Clinical Review

ADHD in Young Adults

Clinician Reviews. 2008 September;18(9):30-32

References

1. Adler L, Cohen J. Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder. Psychiatr Clin North Am. 2004;27(2):187-201.

2. Wilens TE, Dodson W. A clinical perspective of attention-deficit/hyperactivity disorder into adulthood. J Clin Psychiatry. 2004;65(10):1301-1313.

3. Faraone SV, Spencer TJ, Montano CB, Biederman J. Attention-deficit/hyperactivity disorder in adults: a survey of current practice in psychiatry and primary care. Arch Intern Med. 2004;164(11):1221-1226.

4. Wilens TE, Gignac M, Swezey A, et al. Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. J Am Acad Child Adolesc Psychiatry. 2006;45(4):408-414.

5. Diller LH. Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill. New York, NY: Bantam Books; 1999.

6. Zwi M, Pindoria S, Joughin C. Parent training interventions in attention-deficit/hyperactivity disorder (protocol). Cochrane Database Syst Rev. 2001(2):CD003018.

7. Kliegman RM, Marcdante KJ, Jenson HB, Behrman RE. Nelson Essentials of Pediatrics. 5th ed. Philadelphia, PA: Saunders; 2005.

8. National Institutes of Health Consensus Development Conference Statement: diagnosis and treatment of attention-deficit/hyperactivity (ADHD). J Am Acad Child Adolesc Psychiatry. 2000;39(2):182-193.

9. Adler LA. Clinical presentations of adult patients with ADHD. J Clin Psychiatry. 2004;65 Suppl 3:8-11.

10. Biederman J. Impact of comorbidity in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2004;65 Suppl 3:3-7.

11. Meaux JB, Hester C, Smith B, Shoptaw A. Stimulant medications: a trade-off? The lived experience of adolescents with ADHD. J Spec Pediatr Nurs. 2006;11(4):214-226.

12. Culpepper L. Primary care treatment of attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2006;67 Suppl 8:51-58.

13. McGough JJ, Barkley RA. Diagnostic controversies in adult attention deficit hyperactivity disorder. Am J Psychiatry. 2004;161(11):1948-1956.

14. Arnold LE. Alternative treatments for adults with attention-deficit hyperactivity disorder (ADHD). Ann N Y Acad Sci. 2001;931:310-341.

15. Bradley C. The behavior of children receiving benzedrine. Am J Psychiatry. 1937;94(3):577-585.

16. Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annu Rev Med. 2002;53:113-131.

17. Gau SS, Kessler RC, Tseng WL, et al. Association between sleep problems and symptoms of attention-deficit/hyperactivity disorder in young adults. Sleep. 2007;30(2):195-201.

18. Barkley RA, Fischer M, Smallish L, Fletcher K. Young adult outcomes of hyperactive children: adaptive functioning in major life activities. J Am Acad Child Adolesc Psychiatry. 2006;45(2):192-202.

19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (Text Revision: DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000:85-93.

20. Frances A, First MB, Pincus HA. DSM-IV Guidebook. Arlington, VA: American Psychiatric Publishing Group; 1995.

21. Bowes M. ADHD in adults: definition and diagnosis. Neuropsychiatry Rev. 2001;2(1):22, 24-25.

22. Faraone SV, Biederman J, Spencer T, et al. Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry. 2006;163(10):1720-1729.

23. McCann BS, Scheele L, Ward N, Roy-Byrne P. Discriminant validity of the Wender Utah Rating Scale for attention-deficit/hyperactivity disorder in adults. J Neuropsychiatry Clin Neurosci. 2000;12(2):240-245.

24. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(6):885-890.

25. McCann BS, Roy-Byrne P. Attention-deficit/hyperactivity disorder and learning disabilities in adults. Semin Clin Neuropsychiatry. 2000;5(3):191-197.

26. Conners CK, Erhart D, Sparrow E. Conners’ Adult ADHD Rating Scales, Technical Manual. New York, NY: Multi-Health Systems; 1999.

27. Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry. 2004;65 Suppl 3:12-17.

28. Brown TE. Brown Attention-Deficit Disorder Scales. San Antonio, TX: Psychological Corporation; 1996.

29. World Health Organization. Adult ADHD Self-Report Scale (ASRS-v1.1; 2003). www.med.nyu.edu/psych/assets/adhd screen18.pdf. Accessed August 21, 2008.

30. Robison RH, Reimherr FW, Marchant BK, et al. Gender differences in 2 clinical trials of adults with attention-deficit/hyperactivity disorder: a retrospective date analysis. J Clin Psychiatry. 2008;69(2):213-221.

31. Wilens TE. Mechanism of action of agents used in attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2006;67 Suppl 8:32-38.

32. Volkow ND, Wang GJ, Newcorn J, et al. Brain dopamine transporter levels in treatment and drug naïve adults with ADHD. Neuroimage. 2007;34(3):1182-1190.

33. Spencer TJ, Biederman J, Madras BK, et al. Further evidence of dopamine transporter dysregulation in ADHD: a controlled PET imaging study using altropane. Biol Psychiatry. 2007;62(9):1059-1061.

34. Spencer TJ, Biederman J, Madras BK, et al. In vivo neuroreceptor imaging in attention-deficit/hyperactivity disorder: a focus on the dopamine transporter. Biol Psychiatry. 2005;57(11):1293-1300.

35. Volkow ND, Wang GJ, Fowler JS, Ding YS. Imaging the effects of methylphenidate on brain dopamine: new model on its therapeutic actions for attention-deficit/hyperactivity disorder. Biol Psychiatry. 2005;57(11):1410-1415.

36. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder: Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-1086.

37. Safren SA. Cognitive-behavioral approaches to ADHD treatment in adulthood. J Clin Psychiatry. 2006;67 Suppl 8:46-50.

Treatment
Current treatment recommendations for adult ADHD are almost exclusively pharmacologic. Effective, FDA-approved agents are methylphenidate, dextroamphetamine, and the nonstimulant atomoxetine. Treatment efficacy is determined by patient response, which is far from uniform or predictable. Selecting the optimal drug and dosage for each patient can be a lengthy process. Off-label use of other pharmacologic agents (eg, bupropion, clonidine, modafinil, and the tricyclic antidepressants³¹), combinations of agents, and medication for the ADHD patient with a history of substance abuse are treatments that are best left to a specialist.

Until recently, the role of behavioral therapy for children with ADHD had been somewhat discounted.³⁶ In current research, behavioral therapy appears to help properly motivated adult patients understand their condition and develop appropriate coping skills.³⁷ Self-referred adults with ADHD are usually motivated and compliant with prescribed treatment regimens.³

Currently, few therapeutic options are available for the ADHD-impaired adult who does not meet DSM-IV criteria for stimulant medications. If adults with confirmed ADHD benefit from behavioral therapies, however, their use to treat less impaired, subthreshold ADHD adults (for whom pharmacotherapy may not be warranted) is an intriguing possibility.

Conclusion
Previously considered a childhood-only disorder, ADHD is now known to persist into adulthood in many cases, often causing significant impairment in affected individuals. Ongoing research and brain imaging studies continue to improve our understanding of the neurobiologic basis for ADHD. Since no biomarker has yet been proved valid, diagnosis of ADHD remains subjective and clinical.

No consensus exists regarding the best diagnostic tools for ADHD in the young adult. Applying the DSM-IV criteria for ADHD to the adult patient is controversial. Until more objective data make it possible to modify these criteria, the primary care practitioner must rely on supplemental rating scales and other tools to gather diagnostic information.

Currently, schedule II stimulants and the FDA-approved nonstimulant atomoxetine are the most effective agents known for the adult patient with ADHD. Off-label medication use, combinations of medications, and the addition of behavioral therapy are best handled by a specialist.