Diagnosing and Treating Adult ADHD: A Guide

Introduction

Attention-deficit/hyperactivity disorder (ADHD) has historically been thought of as a childhood illness. Therefore, it may surprise you to learn that up to 50% of childhood cases of ADHD persist into adulthood.^[1] A conservative estimate is that 2.5% of adults have ADHD.^[2] For these individuals, symptoms are persistent and infiltrate all aspects and areas of daily life.

Although relatively common, ADHD in adults can be very difficult to diagnose and manage. Some of the challenges and barriers we face when diagnosing and treating ADHD in adults are obvious. For example, providers have concerns when prescribing stimulants, which are controlled substances. Other challenges are less obvious and require more skill to overcome, including newly updated diagnostic criteria, patients' utilization of compensatory mechanisms, and the subjective nature of the symptoms.

In that light, I recently came across a very thorough article on the treatment of adult ADHD in Psychiatric Times. "Adult ADHD: A Review of the Clinical Presentation, Challenges, and Treatment Option" by Jennifer Reinhold, PharmD,^[3] highlights four specific challenges that I will use as the framework for this article. In addition, I will provide my clinical experience and discuss how I overcome these challenges in my practice.

Lack of Validated Diagnostic Criteria

Before the recent release of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the diagnostic criteria were designed for children and adolescents and had not been validated in adults. The DSM-5 updated the nomenclature for more adult-specific situations and decreased the number of symptoms needed for adults to fulfill criteria. Now validated for use with adults, patients 17 years of age or older need to have five of the nine criteria, whereas children and adolescents continue to need six.^[2]

When I suspect that a patient may have ADHD, I utilize a validated and reliable screening tool to begin my evaluation. One such tool is the Adult ADHD Self-Report Scale. Patients can complete the measure themselves at home or in the waiting room. However, I prefer to go through the criteria and fill them out with my patient because I use the tool initially to establish my patient's baseline degree of symptoms and to individualize my treatment plan, and then again later to monitor for symptom improvement and as an outcome measure. By filling the scale out with my patient, I can better understand how the symptoms of ADHD are specifically affecting their lives in a way that I cannot fully understand by grading their answers on self-reported tool.

After establishing that my patient has the current symptomatology needed to meet criteria for ADHD, I then inquire about the historical nature of the symptoms and their pervasiveness across multiple facets of his or her life. To be diagnosed with ADHD, as per the DSM-5, patients must have had the symptoms before 12 years of age, and the symptoms must be present in two settings^[2]—for example, at home and at work/school or with both family/friends and colleagues/classmates.

It is important to clarify that patients do not have to be diagnosed with ADHD before age 12 years. However, their symptoms should have manifested in childhood. Therefore, I inquire about childhood symptoms and their impact during grade school. I also recommend, with the patient's consent, speaking with a family member who probably has a better memory of the patient's childhood development. Parents are much more likely to remember school performance, difficulties, and compensatory mechanisms (which will be discussed later) that can help solidify your diagnosis of ADHD.