Adult attention deficit hyperactive disorder

Adult attention deficit hyperactivity disorder (ADHD) also known as attention deficit disorder (ADD) in the past, is a common neurobehavioral disorder or a mental health disorder that is thought to be persistence of childhood ADHD ¹. Adult attention deficit hyperactivity disorder (ADHD) presents with difficulty paying attention, impulsive behavior and hyperactivity that persist into adulthood. Adult attention deficit hyperactivity disorder (ADHD) is characterized primarily by inner restlessness rather than hyperactivity; impatience; sensation seeking and excessive spending rather than impulsivity; inattention; and functional impairment with underachievement and disorganization, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. About 75% of adults with ADHD will have at least one other mental health disorder such as anxiety and mood disorders, substance use disorders, and suicidality (serious thoughts about taking one’s own life, suicide plans and suicide attempts), personality disorder and other neurodevelopmental conditions ², ³. Adults diagnosed with ADHD had the greatest likelihood of death compared with patients diagnosed with ADHD in childhood and adolescence ⁴. A prospective cohort study in Denmark found a twofold increased mortality rate ratio in children, adolescents, and adults diagnosed with ADHD compared with those without ADHD ⁴. Of those with ADHD who died, 25 were from natural causes and 54 were from unnatural causes or accidental deaths compared with those without ADHD ⁴. Mortality rate ratio is a ratio between the observed number of deaths in an study population and the number of deaths would be expected, based on the age- and sex-specific rates in a standard population and the population size of the study population by the same age/sex groups ⁵.

Attention deficit hyperactive disorder (ADHD) affects the brain’s executive functioning — the ability to self-regulate and control thoughts, words, actions and emotions.

There are 3 types of ADHD:

1. Inattention means a person may have difficulty staying on task, sustaining focus, and staying organized or easily distractible or inattentive but isn’t hyperactive or impulsive, and these problems are not due to defiance or lack of comprehension.
2. Hyperactive-impulsive means a person has symptoms of impulsivity and hyperactivity.
   1. Hyperactivity means a person may seem to move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks. In adults, hyperactivity may mean extreme restlessness or talking too much.
   2. Impulsivity means a person may act without thinking or have difficulty with self-control. Impulsivity could also include a desire for immediate rewards or the inability to delay gratification. An impulsive person may interrupt others or make important decisions without considering long-term consequences.
3. Combined means a person has a mixture of symptoms including hyperactivity, inattention and impulsivity.

Attention deficit/hyperactivity disorder (ADHD) is commonly affecting children ages 6 to 17 years. However, ADHD does not always resolve after adolescence ⁶. Longitudinal studies with a combination of parent, self-reporting, and structured interviews found that 60% of children with ADHD continued to have persistent symptoms into young adulthood and 41.1% met adulthood ADHD criteria for persistent symptoms and impairment ⁷. In the general population in the United States about 4% to 4.5% of adults have ADHD and 10% to 20% of adults with a common mental health disorder have ADHD ⁸. In the national comorbidity survey for patients with adult ADHD, the prevalence was higher in men, non-Hispanic whites, and the unemployed ². Risk factors for ADHD include genetic mutation and variants, family history of ADHD, comorbid psychiatric conditions, brain injuries, and exposure to cigarette smoke and alcohol in utero ³.

Attention deficit hyperactive disorder (ADHD) is a disorder that begins in childhood and continues into adulthood. In order to diagnose adult attention deficit hyperactive disorder, it needs to be established that the symptoms began in childhood. Adult attention deficit hyperactivity disorder (ADHD) diagnosis can be made in either adulthood or childhood before the age of 12 (age limit increased in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition [DSM-5] to 12 years).

To make a diagnosis of ADHD, a specialist will need to follow strict criteria. These include that the ADHD symptoms:

• began before the age of 7 and have persisted for 6 months or more
• are present in more than one setting (for example, both school and home)
• have caused significant impairment, at school, home or socially
• are unusual for the child’s age and developmental level
• are not better explained by another mental or physical condition, family circumstances or stress

As adults, they currently experience at least five persistent symptoms of inattention and/or five persistent symptoms of hyperactivity-impulsivity. These symptoms must be present in two or more settings (for example, home, work, or school; with friends or relatives; in other activities) and interfere with, or reduce the quality of, social, school, or work functioning. Among those diagnosed with ADHD as children, by age 25 years only 15% retain the full ADHD diagnosis, although a much larger proportion (65%) fulfill the Diagnostic and Statistical Manual of Mental Disorders criteria for ADHD in partial remission. Functional impairment is a criterion for diagnosis.

About 75% of adults with attention deficit hyperactive disorder will have at least one other mental health disorder, often anxiety, mood disorders, personality disorder, substance misuse, and other neurodevelopmental conditions.

Furthermore, stress, other mental health conditions, and physical conditions or illnesses can cause similar symptoms to those of ADHD. Therefore, a thorough evaluation by a health care provider or mental health professional is necessary to determine the cause of the symptoms and identify effective treatments. During this evaluation, the health care provider or mental health professional will examine factors including the person’s mood, medical history, and whether they struggle with other issues, such as alcohol or substance misuse.

A thorough evaluation also includes looking at the person’s history of childhood behavior and school experiences. To obtain this information, an individual’s health care provider may ask for permission to talk with partners, family members, close friends, and others who know the individual well. A health care provider or mental health professional may use standardized behavior rating scales or ADHD symptom checklists to determine whether an adult meets the criteria for a diagnosis of ADHD. An individual may complete psychological tests that look at working memory, executive functioning (abilities such as planning and decision-making), visual and spatial (related to space), or reasoning (thinking) skills. Such tests can help identify psychological or cognitive (thinking-related) strengths and challenges and can be used to identify or rule out possible learning disabilities.

Standard treatments for adult attention deficit hyperactive disorder typically involve medication, education, skills training and psychological counseling. A combination of these is often the most effective treatment. These treatments can help manage many symptoms of ADHD, but they don’t cure it. It may take some time to determine what works best for you.

Adult attention deficit hyperactivity disorder (ADHD) key points ⁶:

• An estimated 4% to 4.5% of adults in the United States have attention deficit hyperactive disorder (ADHD)
• Many adults with attention deficit hyperactive disorder (ADHD) are underdiagnosed or misdiagnosed
• About 60% of children with ADHD continue to have persistent symptoms into adulthood
• About 75% of adults with ADHD will have at least one other mental health disorder such as anxiety and mood disorders, substance use disorders, and suicidality (serious thoughts about taking one’s own life, suicide plans and suicide attempts), personality disorder and other neurodevelopmental conditions ², ³
• Adults diagnosed with ADHD had the greatest likelihood of death compared with patients diagnosed with ADHD in childhood and adolescence ⁴
• Treatment for adult ADHD is similar to treatment for childhood ADHD. Adult ADHD treatment includes medications, psychological counseling (psychotherapy) and treatment for any mental health conditions that occur along with ADHD.

How does ADHD affect adults?

Some adults who have attention deficit hyperactive disorder (ADHD) don’t know they have it. These adults may feel it is impossible to get organized, stick to a job, or remember to keep appointments. Daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with undiagnosed ADHD. These adults may have a history of problems with school, work, and relationships. Adults with attention deficit hyperactive disorder (ADHD) may seem restless and may try to do several things at the same time—most of them unsuccessfully. They sometimes prefer quick fixes rather than taking the steps needed to gain greater rewards.

A person may not be diagnosed with ADHD until adulthood because teachers or family did not recognize the condition at a younger age, they had a mild form of ADHD, or they managed fairly well until they experienced the demands of adulthood, especially at work. Sometimes, young adults with undiagnosed ADHD have academic problems in college because of the intense concentration needed for college courses.

It is never too late to seek a diagnosis and treatment for ADHD and any other mental health condition that may occur with it. Effective treatment can make day-to-day life easier for many adults and their families.

How do I know if I need an evaluation for adult attention deficit hyperactive disorder?

Most adults who seek an evaluation for adult attention deficit hyperactive disorder experience significant problems in one or more areas of living. The following are some of the most common problems:

• Inconsistent performance in jobs or careers; losing or quitting jobs frequently
• History of academic and/or career underachievement
• Poor ability to manage day-to-day responsibilities, such as completing household chores, maintenance tasks, paying bills or organizing things
• Relationship problems due to not completing tasks
• Forgetting important things or getting upset easily over minor things
• Chronic stress and worry due to failure to accomplish goals and meet responsibilities
• Chronic and intense feelings of frustration, guilt or blame

A qualified mental health professional can determine if these problems are due to ADHD, some other cause or a combination of causes. Although some ADHD symptoms are evident since early childhood, some individuals may not experience significant problems until later in life. Some very bright and talented individuals, for example, are able to compensate for their ADHD symptoms and do not experience significant problems until high school, college or in pursuit of their career. In other cases, parents may have provided a highly protective, structured and supportive environment, minimizing the impact of ADHD symptoms until the individual has begun to live independently as a young adult.

Who is qualified to diagnose adult attention deficit hyperactive disorder?

For adults, an ADHD diagnostic evaluation should be conducted by a licensed mental health professional or a physician. These professionals include clinical psychologists, physicians (psychiatrist, neurologist, family doctor or other type of physician) or clinical social workers.

Whichever type of professional is chosen, it is important to ask about their training and experience in working with adults with attention deficit hyperactive disorder (ADHD). Many times the professional’s level of knowledge and expertise about adult attention deficit hyperactive disorder is more important for obtaining an accurate diagnosis and effective treatment plan than the type of professional degree. Qualified professionals are usually willing to provide information about their training and experience with adults with ADHD. Reluctance to provide such information in response to reasonable requests should be regarded with suspicion and may be an indicator that the individual should seek out a different professional.

How do I find a professional qualified to diagnose ADHD?

Ask your personal physician for a referral to a mental health care professional in your community who is qualified to perform ADHD evaluations for adults. It may also be helpful to call a local university-based hospital, a medical school or a graduate school in psychology for recommendations. If there is an ADHD support group in your area, it may be very helpful to go there and talk with the people attending the group. Chances are that many of them have worked with one or more professionals in your community and can provide information about them. Most insurance plans list professionals by specialty and can assist those who participate in their plans to find a health care professional. Finally, there are many internet sites that list providers of ADHD services.

The following adult-specific ADD/ADHD-specific resources may be particularly helpful:

• CHADD (https://chadd.org) is an organization that provides information and resources on ADHD/ADD, including treatment options, and provides in person and adult online support communities. Their information line can be reached at (800) 233-4050, Monday-Friday, 1:00 – 5:00 PM EST.
• Attention Deficit Disorder Association (https://add.org) provides information and resources on ADD for adults living with the disorder, including support groups and workshops and an “Ambassadors” program to provide ADD adults an opportunity to talk with others living with the disorder. The ADDA can be reached at (800) 939-1019.
• UK: Call ADDISS (http://www.addiss.co.uk) at 020 8952 2800 or consult a list of support groups from AADD-UK (https://aadduk.org/help-support/support-groups).
• Australia: Call the Health Direct 24-hour advice line at 1800 022 222 or find a list of ADHD Australia support groups (https://www.adhdaustralia.org.au/resources/support-groups).
• Canada: Find a support group in your area CADDAC (https://caddac.ca)
• India: Call the Vandrevala Foundation Helpline at 1860 2662 345 or 1800 2333 330 (https://www.vandrevalafoundation.com)

How can I help myself?

Psychotherapy and medication are the most effective treatments for ADHD. In addition to these treatments, other strategies may help manage symptoms:

• Exercise vigorously and regularly, especially when you’re feeling hyperactive or restless. Exercise helps work off excess energy and aggression in a positive way while soothing and calming the body.
• Eat regular, healthy meals. Eat a wide variety of healthy foods and limit sugary foods in order to even out mood swings.
• Get plenty of sleep. When you’re tired, it’s even more difficult to focus, manage stress, stay productive, and keep on top of your responsibilities. Support yourself by turning off screens at least one hour before bed and getting between 7-9 hours of sleep every night.
• Work on time management and organization. Set deadlines for everything, even for seemingly small tasks. Use timers and alarms to stay on track. Take breaks at regular intervals. Avoid piles of paperwork or procrastination by dealing with each item as it comes in. Prioritize time-sensitive tasks and write down assignments, messages, appointments, and important thoughts.
• Connect with people and maintain relationships. Schedule activities with friends, particularly supportive people who understand your challenges with ADHD.
• Create a supportive work environment. Make frequent use of lists, color-coding, reminders, notes-to-self, rituals, and files. If possible, choose work that motivates and interests you. Notice how and when you work best and apply these conditions to your working environment as best you can. It can help to team up with less creative, more organized people—a partnership that can be mutually beneficial.
• Practice mindfulness. While difficult for some people with ADHD to even contemplate, regular mindfulness meditation can help you calm your busy mind and gain more control over your emotions. Try meditating for a short period and increase the time as you become more comfortable with the process.
• Blame the ADHD, not yourself. Adults diagnosed with ADHD often blame themselves for their problems or view themselves in a negative light. This can lead to self-esteem issues, anxiety, or depression. But it’s not your fault that you have ADHD and while you can’t control how you’re wired, you can take steps to compensate for your weaknesses and learn to flourish in all areas of your life.
• Take medications as directed, and avoid use of alcohol, tobacco, and drugs.

Where can I turn if I feel alone in my diagnosis of ADHD?

Adults with attention deficit hyperactive disorder (ADHD) may gain social support and better coping skills by talking with family, friends, and colleagues about their diagnosis. If the people in your life are aware of your diagnosis, they will better understand your behavior. Psychotherapy for families and couples can help relationship problems and teach everyone involved about ADHD. There are also support groups for adults with ADHD.

The following adult-specific ADD/ADHD-specific resources may be particularly helpful:

• CHADD (https://chadd.org) is an organization that provides information and resources on ADHD/ADD, including treatment options, and provides in person and adult online support communities. Their information line can be reached at (800) 233-4050, Monday-Friday, 1:00 – 5:00 PM EST.
• Attention Deficit Disorder Association (https://add.org) provides information and resources on ADD for adults living with the disorder, including support groups and workshops and an “Ambassadors” program to provide ADD adults an opportunity to talk with others living with the disorder. The ADDA can be reached at (800) 939-1019.
• UK: Call ADDISS (http://www.addiss.co.uk) at 020 8952 2800 or consult a list of support groups from AADD-UK (https://aadduk.org/help-support/support-groups).
• Australia: Call the Health Direct 24-hour advice line at 1800 022 222 or find a list of ADHD Australia support groups (https://www.adhdaustralia.org.au/resources/support-groups).
• Canada: Find a support group in your area CADDAC (https://caddac.ca)
• India: Call the Vandrevala Foundation Helpline at 1860 2662 345 or 1800 2333 330 (https://www.vandrevalafoundation.com)

Attention deficit hyperactivity disorder symptoms in adults

Though it’s called adult attention deficit hyperactive disorder (ADHD), symptoms start in early childhood and continue into adulthood. In some cases, attention deficit hyperactive disorder (ADHD) is not recognized or diagnosed until the person is an adult. Adult attention deficit hyperactive disorder symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity may decrease, but struggles with impulsiveness, restlessness and difficulty paying attention may continue.

Some people with attention deficit hyperactive disorder have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with their daily functioning. In adults, the main features of attention deficit hyperactive disorder (ADHD) may include difficulty paying attention, impulsiveness and restlessness. Symptoms can range from mild to severe.

Many adults with attention deficit hyperactive disorder aren’t aware they have it — they just know that everyday tasks can be a challenge. Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger.

Adult attention deficit hyperactive disorder symptoms may include:

• Impulsiveness
• Disorganization and problems prioritizing
• Poor time management skills
• Problems focusing on a task
• Trouble multitasking
• Excessive activity or restlessness
• Poor planning
• Low frustration tolerance
• Frequent mood swings
• Problems following through and completing tasks
• Hot temper
• Trouble coping with stress

Signs of inattention may include challenges with:

• Paying close attention to details or making seemingly careless mistakes at work or during other activities
• Sustaining attention for long tasks, such as preparing reports, completing forms, or reviewing lengthy papers
• Listening closely when spoken to directly
• Following instructions and finishing duties in the workplace
• Organizing tasks and activities and managing time
• Engaging in tasks that require sustained attention
• Losing things such as keys, wallets, and phones
• Being easily distracted by unrelated thoughts or stimuli
• Being forgetful in daily activities, such as paying bills, keeping appointments, or returning calls

Signs of hyperactivity and impulsivity may include:

• Experiencing extreme restlessness, difficulty sitting still for extended periods, and/or wearing others out with one’s activity
• Fidgeting with or tapping hands or feet or squirming in seat
• Being unable to engage quietly in leisure activities
• Talking excessively
• Answering questions before they are asked completely
• Having difficulty waiting one’s turn, such as when waiting in line
• Interrupting or intruding on others

If any of the symptoms and signs listed above continually disrupt your life, talk to your doctor or a mental health professional about whether you might have ADHD.

ADHD is diagnosed only when symptoms are severe enough to cause ongoing problems in more than one area of your life. These persistent and disruptive symptoms can be traced back to early childhood.

Adults with symptoms of attention deficit hyperactive disorder (ADHD) classically present with educational underachievement, relationship difficulties, sleep disturbances, engaging in risky behaviors, emotional lability, and employment difficulties due to developmentally inappropriate levels of hyperactive, impulsive, and inattentive behaviors ⁹. When impulsivity and hyperactivity continue into adulthood, they can be impairing, and often are seen in the lives of adults who engage in high-risk behavior and those with substance abuse disorders ¹⁰. Hyperactivity and impulsivity in adults typically manifest as overtalkativeness, fidgeting, restlessness, difficulty sitting still or relaxing, often feeling impatient, and finding it hard to wait one’s turn without becoming angry or short-tempered ⁹.

Although hyperactivity and impulsivity are core characteristic traits in childhood, these fundamental symptoms tend to decline during the transition from childhood to young adulthood, while inattention typically persists ¹¹. In adulthood, inattention typically presents as forgetfulness, unfocused thoughts, poor self-organization, difficulty in planning, and chronic lateness. Inattention also can present as difficulty in preparing, starting, and finishing tasks ⁹.

Adult attention deficit hyperactivity disorder cause

While the exact cause of adult attention deficit hyperactive disorder is not clear, research efforts continue. Factors that may be involved in the development of adult attention deficit hyperactive disorder include:

• Genetics. Attention deficit hyperactive disorder (ADHD) can run in families, and studies indicate that genes may play a role. Researchers are currently working on identifying which genes are involved.
• Environment. Certain environmental factors also may increase risk, such as lead exposure as a child. Some studies have shown that pre-schoolers who were exposed to lead (in certain types of paint or plumbing) had a higher risk of developing ADHD.
• Problems during development. Problems with the central nervous system at key moments in development may play a role.
• Neurophysiology. People with ADHD have differences in brain anatomy, electrical activity and metabolism.
• Drug use during pregnancy. Research has linked ADHD to smoking, alcohol and cocaine use during pregnancy.
• Brain injury. Some children with brain injuries show behaviour that resembles ADHD; however, most children with ADHD have no history of brain injury.
• Lack of early attachment. If a child did not bond with a parent or caregiver as a baby, they can develop inattention and hyperactivity.
• Early childhood trauma. Children who experience trauma in early childhood are more likely to show features consistent with ADHD, but most children with ADHD have not experienced early childhood trauma.

Risk factors for developing adult attention deficit hyperactive disorder

Risk of adult attention deficit hyperactive disorder may increase if:

• You have blood relatives, such as a parent or sibling, with attention deficit hyperactive disorder (ADHD) or another mental health disorder
• Your mother smoked, drank alcohol or used drugs during pregnancy
• As a child, you were exposed to environmental toxins — such as lead, found mainly in paint and pipes in older buildings
• You were born prematurely

Adult attention deficit hyperactivity disorder pathophysiology

The exact pathophysiology of attention deficit hyperactive disorder (ADHD) is not completely understood ⁶. However, studies have shown evidence of a genetic basis with serotonin and dopamine variants, as well as evidence of neuropathophysiology ¹², ⁸. Neuroimaging and neuropsychologic studies have shown a correlation between executive function and attention deficit hyperactive disorder (ADHD) ¹². Executive function is responsible for higher cognitive processes that are predominantly in the prefrontal cortex. These cognitive processes include inhibitory control, planning, organizational strategies, emotion, behavior, working memory, flexible thinking, self-control over irrelevant information, and initiating tasks. Magnetic resonance imaging (MRI) scans of adults with attention deficit hyperactive disorder (ADHD) show a reduction in the gray matter of the frontal cortices and decreased activity in the prefrontal cortex ¹³.

Dopamine and noradrenaline are heavily concentrated in the prefrontal cortex and are the two main neurotransmitters implicated in adult attention deficit hyperactive disorder. Dopamine is responsible for attention, memory, mood, problem solving, emotional decision-making, and motor activity ¹⁴. Noradrenaline also plays a role in motivation and executive function, specifically working memory and inhibitory control ¹⁵. Dopamine receptors and activity are decreased in patients with attention deficit hyperactive disorder (ADHD) ¹⁶. Dysregulation of noradrenaline can cause attention deficit hyperactive disorder (ADHD) symptoms, but the mechanism of noradrenaline in ADHD remains elusive.

Adult attention deficit hyperactive disorder complications

Adult attention deficit hyperactive disorder can make life difficult for you. Adult attention deficit hyperactive disorder has been linked to:

• Poor school or work performance
• Unemployment
• Financial problems
• Trouble with the law
• Alcohol or other substance misuse
• Frequent car accidents or other accidents
• Unstable relationships
• Poor physical and mental health
• Poor self-image
• Suicide attempts

Coexisting mental conditions

Although attention deficit hyperactive disorder (ADHD) doesn’t cause other psychological or developmental problems, other disorders often occur along with ADHD and make treatment more challenging. These include:

• Mood disorders. Many adults with attention deficit hyperactive disorder (ADHD) also have depression, bipolar disorder or another mood disorder. While mood problems aren’t necessarily due directly to ADHD, a repeated pattern of failures and frustrations due to ADHD can worsen depression.
• Anxiety disorders. Anxiety disorders occur fairly often in adults with attention deficit hyperactive disorder. Anxiety disorders may cause overwhelming worry, nervousness and other symptoms. Anxiety can be made worse by the challenges and setbacks caused by ADHD.
• Other psychiatric disorders. Adults with attention deficit hyperactive disorder are at increased risk of other psychiatric disorders, such as personality disorders, intermittent explosive disorder and substance use disorders.
• Learning disabilities. Adults with attention deficit hyperactive disorder may score lower on academic testing than would be expected for their age, intelligence and education. Learning disabilities can include problems with understanding and communicating.

Attention deficit disorder diagnosis in adults

Diagnosis of attention deficit hyperactive disorder in adults can be difficult because certain attention deficit hyperactive disorder symptoms are similar to those caused by other conditions, such as anxiety or mood disorders ¹⁰. And many adults with attention deficit hyperactive disorder also have at least one other mental health condition, such as depression or anxiety.

Other conditions can resemble adult attention deficit hyperactive disorder. Some medical conditions or treatments may cause signs and symptoms similar to those of ADHD include:

• Mental health disorders, such as depression, anxiety, conduct disorders, learning and language deficits, or other psychiatric disorders
• Medical problems that can affect thinking or behavior, such as a developmental disorder, seizure disorder, thyroid problems, sleep disorders, brain injury or low blood sugar (hypoglycemia)
• Drugs and medications, such as alcohol or other substance misuse and certain medications

Signs and symptoms of attention deficit hyperactive disorder in adults can be hard to spot. However, core symptoms start early in life — before age 12 — and continue into adulthood, creating major problems.

Although there is no single medical, physical, or genetic test for adult attention deficit hyperactive disorder, a diagnostic evaluation can be provided by a qualified mental health care professional or physician who gathers information from multiple sources. These sources include ADHD symptom checklists, standardized behavior rating scales, a detailed history of past and current functioning, and information obtained from family members or significant others who know the person well. Some practitioners will also conduct tests of cognitive ability and academic achievement in order to rule out a possible learning disability. ADHD cannot be diagnosed accurately just from brief office observations or simply by talking to the person. The person may not always exhibit the symptoms of ADHD during the office visit, and the diagnostician needs to take a thorough history of the individual’s life. A diagnosis of ADHD must include consideration of the possible presence of co-occurring conditions.

Making the diagnosis will likely include:

• Physical exam, to help rule out other possible causes for your symptoms. A medical examination does not confirm ADHD but is extremely important in helping to rule out other conditions or problems.
• Information gathering, such as asking you questions about any current medical issues, personal and family medical history, and the history of your symptoms
• ADHD rating scales or psychological tests to help collect and evaluate information about your symptoms

Attention deficit hyperactive disorder (ADHD) is commonly diagnosed during a patient’s primary school years because order and attentiveness are necessities in school. Therefore, children with excessive impulsiveness, hyperactivity, and irritability become more obvious because their behaviors can disturb the classroom ¹⁷. On the other hand, a clear diagnosis is not common for adults presenting with ADHD because the signs and symptoms of ADHD can become clouded; as patients mature and learn how to manage their symptoms, the clinical manifestations of attention deficit hyperactive disorder (ADHD) change ¹¹. In many of these high-functioning patients, a diagnosis of adult attention deficit hyperactive disorder may be more easily overlooked, which can lead to poor social outcomes ¹¹. This points to the importance of clinicians knowing how to recognize and diagnose attention deficit hyperactive disorder in adults.

Screening should be the first method used in identifying and ultimately diagnosing adult attention deficit hyperactive disorder ¹⁰. When done properly, screening helps the initiation of prompt and appropriate diagnostic and treatment interventions, preventing further major impairments in life activities for patients ¹⁰. Screening also helps reduce treatment costs that can arise from underdiagnosis of adult attention deficit hyperactive disorder. Costs also can be elevated due to treatment of other psychiatric disorders, such as substance use disorder, that can otherwise be alleviated with proper treatment of the patient’s ADHD ¹⁰.

The World Health Organization (WHO) has a validated Adult ADHD Self-Report Scale version 1.1 (Figures 1 and 2) that is a standardized tool used for assessing ADHD symptoms in patients age 18 years and older ¹⁸. The tool has two versions—one with six questions and one with 18. The six-question version is widely used because it has a greater sensitivity, specificity, and classification accuracy when assessing adults with attention deficit hyperactive disorder (Figure 1) ¹⁸. Although these tools are both sensitive and specific, clinicians should still have a high awareness for bias that may occur when patients are self-reporting their symptoms, as most tend to underreport or underestimate their symptoms ¹⁰.

According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria, patients with adult attention deficit hyperactive disorder may exhibit 18 possible symptoms—nine of hyperactivity-impulsivity, and nine for inattention ¹⁹. To meet the diagnostic criteria, patients older than age 17 years should exhibit five or more symptoms in either sphere. The symptoms also must be inappropriate with the patient’s presumed developmental level.

Figure 1. Adult attention deficit hyperactive disorder Self-Report Scale-V1.1 (ASRS-V1.1) Screener

[Source ²⁰ ]

Figure 2. Adult attention deficit hyperactive disorder self-report symptoms checklist

[Source ²¹ ]

Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for diagnosising ADHD

Clinical guidelines for a diagnosis of ADHD are provided by the American Psychiatric Association in the diagnostic manual Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). These established guidelines are widely used in research and clinical practice. During an evaluation, the clinician will try to determine the extent to which these symptoms currently apply to the adult and if they have been present in childhood. In making the diagnosis, adults should have at least five of the symptoms present. These symptoms can change over time, so adults may fit different presentations from when they were children.

The DSM-5 lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive and Combined. The symptoms for each are adapted and summarized below.

ADHD predominantly inattentive presentation

• Fails to give close attention to details or makes careless mistakes
• Has difficulty sustaining attention
• Does not appear to listen
• Struggles to follow through with instructions
• Has difficulty with organization
• Avoids or dislikes tasks requiring sustained mental effort
• Loses things
• Is easily distracted
• Is forgetful in daily activities

ADHD predominantly hyperactive-impulsive presentation

• Fidgets with hands or feet or squirms in chair
• Has difficulty remaining seated
• Runs about or climbs excessively in children; extreme restlessness in adults
• Difficulty engaging in activities quietly
• Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor
• Talks excessively
• Blurts out answers before questions have been completed
• Difficulty waiting or taking turns
• Interrupts or intrudes upon others

ADHD combined presentation

The individual meets the criteria for both inattention and hyperactive-impulsive ADHD presentations.

A diagnosis of ADHD is determined by the clinician based on the number and severity of symptoms, the duration of symptoms and the degree to which these symptoms cause impairment in various areas of life, such as home, school or work; with friends or relatives; or in other activities. It is possible to meet diagnostic criteria for ADHD without any symptoms of hyperactivity and impulsivity. The clinician must further determine if these symptoms are caused by other conditions, or are influenced by co-existing conditions.

Several of the symptoms must have been present prior to age 12. This generally requires corroboration by a parent or some other informant. It is important to note that the presence of significant impairment in at least two major settings of the person’s life is central to the diagnosis of ADHD. Impairment refers to how ADHD interferes with an individual’s life. Examples of impairment include losing a job because of ADHD symptoms, experiencing excessive conflict and distress in a marriage, getting into financial trouble because of impulsive spending, failure to pay bills in a timely manner or being put on academic probation in college due to failing grades. If the individual exhibits a number of ADHD symptoms but they do not cause significant impairment, s/he may not meet the criteria to be diagnosed with ADHD as a clinical disorder.

Treatment of attention deficit hyperactivity disorder in adults

Treatments for adult attention deficit hyperactive disorder include psychostimulants, psychotherapy, and nonstimulants (Table 1) ²², ⁸. Clinicians should be aware of the pharmacokinetic profiles of the different medications to ensure that the treatment is effective for the patient ²³. Medication adverse reactions should be closely monitored in the patient’s notes and if adverse reactions become intolerable, consider reducing the dosage ²³. Many adults with attention deficit hyperactive disorder have comorbid illnesses, and clinicians should treat the most debilitating illness first ²⁴.

Consider nonpharmacologic treatment for patients who are unable to tolerate medication adverse reactions or those who may be nonadherent due to finances or reluctance to take medications ¹⁷. The goals for psychological therapies (psychotherapy) for adult attention deficit hyperactive disorder are to help patients understand the disorder and challenge negative beliefs they may hold that affect their function and self-esteem ²⁵. Therapies include ADHD-tailored cognitive behavioral therapy (CBT), psychoeducation for patients and their families, attention deficit hyperactive disorder coaching, and exercise and conditioning.

Adult attention deficit hyperactive disorder medications

Medication does not cure ADHD; when effective, it eases ADHD symptoms during the time it is active. Medications that most effectively improve the core symptoms of ADHD seem primarily and directly to affect certain neurotransmitters (brain molecules that facilitate the transmission of messages from one neuron [brain cell] to another). The neurotransmitters involved are dopamine and norepinephrine. Both neurotransmitters appear to play a role in the attentional and behavioral symptoms of ADHD. Doctors cannot know in advance what drug will work best for a particular patient without trying them. Doctors will use a medication trial to figure out which medicine works best for each individual and at what dosage. The trial usually begins with a low dose that is gradually increased at 3–7 day intervals until clinical benefits are achieved.

Talk with your doctor about the benefits and risks of any medications. Stimulant medications (methylphenidate, amphetamine derivatives) are first-line treatment and nonstimulant medications, including atomoxetine, form second-line management.

1. Stimulants or psychostimulants, such as products that include methylphenidate or amphetamine, are typically the most commonly prescribed medications for attention deficit hyperactive disorder, but other medications may be prescribed. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters.
2. Other medications used to treat attention deficit hyperactive disorder include the nonstimulant atomoxetine and certain antidepressants such as bupropion. Atomoxetine and antidepressants work slower than stimulants do, but these may be good options if you can’t take stimulants because of health problems or if stimulants cause severe side effects.

The right medication and the right dose vary among individuals, so it may take time to find out what’s right for you. Tell your doctor about any side effects.

The first-line treatment for adult attention deficit hyperactive disorder are psychostimulants, which typically are safe and well tolerated ²⁶. To improve adherence, start low and quickly titrate up to the target dose ²⁶. Long-acting formulations of stimulant therapies generally are preferred because they are less prone to abuse or diversion and allow once-daily treatment, resulting in greater medication adherence ²². Recent inclusive studies have found that amphetamines are the most efficacious pharmacologic treatment for adult attention deficit hyperactive disorder as reported by clinicians and by patient self-report ²⁷.

Nonstimulants generally are considered second-line therapy, and are used for patients with contraindications to stimulants or comorbid depression and/or anxiety ²². Atomoxetine is considered the first-line nonstimulant treatment for adults with attention deficit hyperactive disorder ²⁶. Patients on medications such as methylphenidate and atomoxetine generally showed marked improvement with their symptoms during weeks 4 to 5 and 8 to 10 of use ²⁸.

Atomoxetine is considered first-line for adults with attention deficit hyperactive disorder and comorbidities such as substance abuse, comorbid tic disorders, and anxiety.24 For adults with comorbid depression, bupropion is recommended; however, it is not FDA-approved for ADHD ²⁹. Both stimulants and atomoxetine should be considered once the mood disorder is stabilized ³⁰.

Selected antidepressants, including bupropion, tricyclic antidepressants (TCAs) and selective norepinephrine reuptake inhibitors (SNRI), have a much smaller evidence base as ADHD therapy ²⁹. These antidepressants promote noradrenergic and dopaminergic actions in the prefrontal cortex, which align with the pathophysiology of ADHD and mirror the studied effects of stimulant therapy ²⁹. Alpha2 adrenergic agonists such as guanfacine and clonidine have shown some benefit in treating adult attention deficit hyperactive disorder, but typically are only used as adjunctive therapy or to treat ADHD-related sleep disturbance ¹⁹.

Table 1. Common medications used to treat adult attention deficit hyperactive disorder

[Source ⁶ ]

Psychological therapies

Psychological therapies, including cognitive behavior therapy (CBT), metacognitive therapy, and dialectic behavior therapy, can be effective in reduction of symptoms in combination with medication.

Counseling for adult attention deficit hyperactive disorder generally includes psychological counseling (psychotherapy), education about the disorder and learning skills to help you be successful.

Psychotherapy may help you:

• Improve your time management and organizational skills
• Learn how to reduce your impulsive behavior
• Develop better problem-solving skills
• Cope with past academic, work or social failures
• Improve your self-esteem
• Learn ways to improve relationships with your family, co-workers and friends
• Develop strategies for controlling your temper

Common types of psychotherapy for attention deficit hyperactive disorder include:

• Cognitive behavioral therapy (CBT). This structured type of counseling teaches specific skills to manage your behavior and change negative thinking patterns into positive ones. It can help you deal with life challenges, such as school, work or relationship problems, and help address other mental health conditions, such as depression or substance misuse.
• Marital counseling and family therapy. This type of therapy can help loved ones cope with the stress of living with someone who has attention deficit hyperactive disorder and learn what they can do to help. Such counseling can improve communication and problem-solving skills.

Working on relationships

If you’re like many adults with attention deficit hyperactive disorder, you may be unpredictable and forget appointments, miss deadlines, and make impulsive or irrational decisions. These behaviors can strain the patience of the most forgiving co-worker, friend or partner.

Therapy that focuses on these issues and ways to better monitor your behavior can be very helpful. So can classes to improve communication and develop conflict resolution and problem-solving skills. Couples therapy and classes in which family members learn more about attention deficit hyperactive disorder may significantly improve your relationships.

Lifestyle and home remedies

Because ADHD is a complex disorder and each person is unique, it’s hard to make recommendations for all adults who have attention deficit hyperactive disorder. But some of these suggestions may help:

• Make a list of tasks to accomplish each day. Prioritize the items. Make sure you’re not trying to do too much.
• Break down tasks into smaller, more manageable steps. Consider using checklists.
• Use sticky pads to write notes to yourself. Put them on the fridge, on the bathroom mirror, in the car or in other places where you’ll see the reminders.
• Keep an appointment book or electronic calendar to track appointments and deadlines.
• Carry a notebook or electronic device with you so that you can note ideas or things you’ll need to remember.
• Take time to set up systems to file and organize information, both on your electronic devices and for paper documents. Get in the habit of using these systems consistently.
• Follow a routine that’s consistent from day to day and keep items, such as your keys and your wallet, in the same place.
• Ask for help from family members or other loved ones.

Alternative medicine

There’s little research to indicate that alternative medicine treatments can reduce attention deficit hyperactive disorder symptoms. However, studies indicate that mindfulness meditation may help improve mood and attention in adults who have attention deficit hyperactive disorder, as well as those who don’t have attention deficit hyperactive disorder.

Before using alternative interventions for ADHD, talk with your doctor about risks and possible benefits.

Coping and support

While treatment can make a big difference with attention deficit hyperactive disorder, taking other steps can help you understand ADHD and learn to manage it. Some resources that may help you are listed below. Ask your health care team for more advice on resources.

• Support groups. Support groups allow you to meet other people with attention deficit hyperactive disorder so that you can share experiences, information and coping strategies. These groups are available in person in many communities and also online.
• Social support. Involve your spouse, close relatives and friends in your attention deficit hyperactive disorder treatment. You may feel reluctant to let people know you have ADHD, but letting others know what’s going on can help them understand you better and improve your relationships.
• Co-workers, supervisors and teachers. ADHD can make work and school a challenge. You may feel embarrassed telling your boss or professor that you have attention deficit hyperactive disorder, but most likely he or she will be willing to make small accommodations to help you succeed. Ask for what you need to improve your performance, such as more in-depth explanations or more time on certain tasks.

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