Attention Deficit Hyperactivity Disorder in Adults

At tention deficit
hyperactivity
disorder in adults
Straight to the point of care
Last updated: Jan 04, 2023

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 5
Pathophysiology 6
Case history 7
Diagnosis 8
Approach 8
History and exam 10
Risk factors 12
Investigations 14
Differentials 15
Criteria 18
Screening 21
Management 22
Approach 22
Treatment algorithm overview 25
Treatment algorithm 26
Emerging 41
Primary prevention 41
Secondary prevention 41
Patient discussions 41
Follow up 43
Monitoring 43
Complications 44
Prognosis 46
Guidelines 47
Diagnostic guidelines 47
Treatment guidelines 48
Online resources 50
Evidence tables 51
References 57
Disclaimer 68
At tention deficit hyperactivity disorder in adults Overview
Summary
Adult attention deficit hyperactivity disorder (ADHD) is a common adult disorder, thought to be persistence of
childhood ADHD. Prevalence of 2% to 5% in the general population and 10% to 20% in those with a common
OVERVIEW
mental health disorder.
Characterised primarily by inner restlessness rather than hyperactivity; impatience; sensation seeking and
excessive spending rather than impulsivity; inattention; and functional impairment with underachievement
and disorganisation.
Among those diagnosed with ADHD as children, by age 25 years only 15% retain the full ADHD diagnosis,
although a much larger proportion (65%) fulfil the Diagnostic and Statistical Manual of Mental Disorders
criteria for ADHD in partial remission.
Diagnosed by clinical history. Self-report should not be the main source of information. Collateral history is
extremely useful. Neuropsychological testing can be of use in some cases.
About 75% of adults with ADHD will have at least one other mental health disorder, often anxiety, mood
disorders, personality disorder, substance use disorder, and other neurodevelopmental conditions.
ADHD as a primary condition is most clearly diagnosed when mood or anxiety disorders are not active. Treat
obvious psychiatric disorders as normal and assess the effects of that treatment on cognition (attention,
concentration, memory) carefully.
Stimulant medications (methylphenidate, amfetamine derivatives) are first-line treatment and non-stimulant
medications, including atomoxetine, form second-line management.
Psychological therapies including cognitive behaviour therapy, metacognitive therapy, and dialectical
behaviour therapy can be effective in reduction of symptoms in combination with medication.
Definition
ADHD is a neurodevelopmental disorder characterised by persistent inattention, hyperactivity, and
impulsivity.[1] It has a chronic course with symptoms that begin in early childhood but often persist into
adult life.[1] Diagnosis of ADHD in adulthood requires ancillary information supporting onset of symptoms
in childhood (before 12 years of age).[1] Another key element of the definition is that symptoms manifest in
two or more settings, for example both at home and in work.[1] Symptoms interfere with, or reduce the quality
of, social, academic, or occupational functioning. Impulsivity may remain problematic in adults even when
hyperactivity has diminished.[1] Comorbid disorders are present in more than 75% of adult cases.
This topic covers the management of ADHD in adults only. See also ADHD in children .
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BMJ Best Practice topics are regularly updated and the most recent version of the topics
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At tention deficit hyperactivity disorder in adults Theory
Epidemiology
Prevalence:
THEORY
• Studies in different populations have found similar prevalence estimates. In the UK, prevalence of
ADHD in adults is estimated at 3% to 4%.[2] In Canada, the prevalence has been estimated at 3% to
6%; in the US, 4.4%, and in France, 4% to 5%.[3] [4] [5] Another large study stratified the prevalence
of ADHD (in people aged 18-44 years) across low- and high-income countries. With an overall average
of 3.4% (range 1.2% to 7.3%), the study found a lower prevalence in lower-income countries (1.9%)
compared with higher-income countries (4.2%).[6] A study of college students found the prevalence of
ADHD among this population to be 4%.[7] A meta-analysis estimated the rate between 2% and 5%.[8]
• In a 2014 survey in England, using a self-report scale, 1 in 10 adult respondents screened positive
for ADHD (meaning they required a fuller assessment). While the actual prevalence of ADHD will
be lower than 1 in 10, these findings suggest that ADHD characteristics are widespread in the adult
population.[9]
• In one study of electronic health records in California from 2007 to 2016 the prevalence of ADHD in
adults doubled over a decade from 0.43% to 0.96%.[10]
• Studies have found that primary care physicians may be less likely than psychiatrists to diagnose adult
ADHD.[7]
Presentations:
• According to a phone population screen of adults in the US, combined and hyperactive-impulsive
presentations of ADHD are less common among adults than inattentive ADHD.[7]
Comorbidity:
• Most patients with adult ADHD have other psychiatric disorders and also frequently demonstrate
features of other neurodevelopmental disorders including autism spectrum disorder, dyslexia,
dyscalculia, and dyspraxia. Anxiety, mood (depression and bipolar disorder), and substance use
disorders are the most common co-occurring psychiatric conditions.[10] [11] [12]
Sex disparities:
• In children, ADHD is diagnosed far more commonly in boys than girls with a ratio of 5:1; in the
adult population, while the diagnosis remains positively associated with being male, the rate is less
skewed.[13] More recent studies report a male-to-female ratio closer to 3:1, maybe as a result of
better diagnosis in females by clinicians.[14] Among adults, the male-to-female ratio is reported to be
approximately 3:2.[4] A US national survey for DSM-IV disorder prevalence identified 61.6% of adults
with ADHD as men.[4] Girls with ADHD demonstrate more inattentive-type symptoms with a later onset
of impairment. It is also suggested that girls with ADHD may internalise their problems more and,
therefore, go undiagnosed.
Ethnic disparities:
• In the US, adult ADHD is most prevalent among non-Hispanic white people.[4] [10]
Class differences:
• Adult ADHD is more common among those previously married and those who are unemployed or
disabled.[4]
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 04, 2023.
• In general, adults with ADHD have lower levels of academic attainment and poorer career prospects
than those without ADHD.[1]
Obesity:
THEORY
• There is evidence for a significant association between the presence of ADHD and obesity/being
overweight.[15]
Aetiology
Genetic predisposition:
• Childhood twin studies report ADHD to be approximately 70% heritable.[16] Twin studies conducted
among adults, however, report much lower heritability rates, ranging from 0.29 to 0.37. It is assumed
that this is an experimental error related to inadequate self-reporting and change of symptoms from
childhood to adulthood.[17] [18] [19]
• Genetic studies are looking at the difference between those ADHD cases that persist from childhood
to adulthood and those which do not. It is suggested that persistence is related to enduring subcortical
dysfunction whereas remission is dependant on maturational changes in executive control.[20]
• The D2 dopamine receptor gene, the dopamine beta-hydroxylase gene, the D5 dopamine receptor
gene, the D4 dopamine receptor gene, the dopamine transporter gene (DAT1), the SNAP-25
(synaptosome-associated protein) gene, the ANKK1 (ankyrin repeat and kinase domain containing)
gene, the low-density lipoprotein receptor-related protein genes LRP5 and LRP6, the ADGRL3
(adhesion G protein-coupled receptor) gene, the BAIAP2 (BAR/IMD domain containing adaptor
protein) gene, the serotonin transporter gene (5-HTT), and the dopamine beta-hydroxylase gene
(DBH) have all been implicated in the aetiology of ADHD.[21]
• Research on copy number variants (CNVs) has identified an increased number of large CNVs in
children with ADHD, along with other neurodevelopmental and mental health disorders, suggesting
possible overlap with other disorders and a strong genetic linkage.[22]
• A genome-wide study from the United States, Europe, Scandinavia, China, and Australia confirmed a
polygenic cause for most ADHD with many genetic risk variants, each having a small effect, combining
to increase risk for the disorder.[23]
• There is some evidence that a proportion of genes do not affect ADHD symptoms until later in life,
while others have an effect on ADHD throughout life.
Environmental factors:
• Childhood adversity is strongly associated with ADHD symptoms[24], as are non-shared

environmental factors, especially sibling interaction, parental treatment, and peer group characteristics.
• The England-Romanian adoptive studies have demonstrated that, for those Romanian orphans within
care for more than 6 months, the rate of ADHD is double that in the general population.[25]
• Low birth weight, pregnancy, and delivery complications have been associated with the development
of ADHD. While maternal smoking was linked with the onset of ADHD, it is now believed to reflect
genetic effects rather than direct toxic effects of nicotine.[26]
• Antenatal antidepressant use in mothers seems to be associated with an increased risk of ADHD
in offspring, but the risk also appears to be raised in children whose mothers used antidepressants
before conception and among those with psychiatric illness who did not use antidepressants,
suggesting that the increased risk can be at least partly explained by the pre-existing maternal
psychiatric condition.[27]
5
• In a large Danish study prenatal use of the anticonvulsant drug valproate was associated with a 50%
increased risk of ADHD, there was no link with other anticonvulsant drugs.[28]
Brain neurochemistry and structural changes seen in adults and children with ADHD include:
THEORY
• Whole brain volume reduction.

• Downregulation of neurotransmitters (dopamine and noradrenaline).
• Decreased volumes of frontal cortical (especially right), subcortical, caudate, corpus callosum, and
cerebellar structures.[16]
• There is some evidence of an increase in volume in the corpus striatum following treatment with
stimulants that is not seen in other affected areas.
• PET scanning shows abnormal cerebral glucose metabolism in pre-frontal and pre-motor areas of the
frontal lobe in adults with ADHD.[29]
• Single-photon emission computed tomography scanning has demonstrated hypoperfusion and
hypofunction in the pre-frontal and striatal regions of children and adults with ADHD.[30]
• Genomic convergence studies have shown 44 of the 85 identified genes in ADHD are associated with
neurite outgrowth.[31]
• Frontostriatal and frontocortical tracts remain abnormal in people with ADHD throughout life despite
treatment.
• According to the maturational lag model, children with ADHD have neurodevelopmental profiles
representative of healthy children at younger ages,[32] possibly as a result of delay in cortical
development (by as much as 2-3 years) depending upon the specific cortical region.[33]
Pathophysiology
The hyperactive-impulsive and inattentive symptoms of adult ADHD are associated with reduced
inhibitory functioning of the prefrontal cortex, an apparent result of noradrenaline receptor downregulation.
Neuroimaging and positron emission tomography studies demonstrate reduced glucose metabolism in the
premotor cortex and the superior prefrontal cortex, and inhibited activation of the anterior cingulate in adults
with ADHD.[16]
A number of executive functional impairments occur in adults with ADHD, similar to findings in children with
the disorder. These include reductions in vigilance, motor inhibition, organisation, problem solving, verbal
learning, and non-verbal memory.
The corpus striatum is physiologically responsible for movement moderation, and also for filtration of
perceived stimuli and linking this with a response from the frontal lobes via the frontostriatal pathway. The
corpus striatum also seems to have an effect on the willingness to work in order to achieve a reward. It is
the main centre of dopamine activity within the brain. It is likely that reduction in its function, associated with
the findings of reduced volume, are related to an abnormal response to stimuli resulting in distractibility,
emotional response to stimuli, and motivation.
The immediate response of ADHD patients to stimulants would appear to be via activation of dopamine
pathways within the corpus striatum and catecholamine/dopamine activation within the frontal lobes. Children
who have been treated with stimulants may show an increase in growth of the structure, although no
maturational effect is seen on the frontal lobes or the frontostriatal pathway.
Other brain regions such as the parietal cortex, inferior parietal lobe, superior temporal sulcus, and reticular
activating system have been implicated in the executive function and attentional impairments characteristic of
ADHD.[16]
THEORY
Case history
Case history #1
A 26-year-old man presents with difficulty functioning at work, leading him to recently lose his job. He was
treated for ADHD in childhood, beginning at 12 years of age. He could not focus at school and got into
trouble for talking loudly, leaving his desk, and bothering his peers during class. His teachers commented
that he was not achieving according to his abilities. With methylphenidate treatment, his schoolwork and
behaviour improved and he was able to finish school with results that allowed him to enter university.
However, at the age of 18 his medication treatment was stopped because he felt he didn't need it now
that he was an adult. After 6 months at university, he started fearing he would not be able to finish the
year. His academic performance deteriorated, he started to procrastinate, and he was not able to organise
himself to attend lectures or complete his coursework on time.
Case history #2
A 54-year-old man presents as his current partner threatens to terminate their relationship due to his
volatile and chaotic behaviour. The patient is a successful professional man who does not seem to have
any problems. His partner, however, who gave a collateral history of inability to focus, impulsive behaviour,
inability to finish off projects, disorganisation, and forgetfulness, has a grandchild who was recently
diagnosed with ADHD and saw much resemblance in his presentation. The patient had an educational
history characterised by difficulty in sitting in the classroom, daydreaming, bad time management, inability
to revise for lessons, and underachievement. He found it difficult to maintain employment when employed
by others due to feeling constrained, so he set up his own business where he was able to manage
his working hours and conditions. As the business grew, he hired people who helped him to organise
himself because, for example, he would file accounts late and get penalised. His impulsive behaviour was
problematic as he would speak without thinking and as a result lose lucrative contracts. He insisted that if
he was not an 'airhead' he would have done much better with his work.
7
At tention deficit hyperactivity disorder in adults Diagnosis
Approach
The diagnosis of ADHD is clinical and based on the collection of relevant information through screening
questionnaires and clinical history, not psychological testing.[21] ADHD symptom severity scales can identify
current attentional impairment, but this impairment is not itself diagnostic of adult ADHD.
Clinical history
When specific attentional impairment is identified in an adult, the history of such impairment in childhood
should be investigated, as it is essential to the diagnosis. The patient's own report is not usually sufficient
for such history; a living parent or sibling should be identified to provide such history because patients
over-report childhood symptoms of inattention compared with the parent report in about 40% of cases.[35]
Written documentation from school reports may also help. If no third party is available to provide relevant
data, confidence in the possible adult ADHD diagnosis is correspondingly weakened.
If current attentional impairment is present and childhood impairment (prior to 12 years of age) is
identified, including a third-party report, the time course of such impairment should be assessed relative
to any other comorbid psychiatric symptoms (most commonly mood and anxiety symptoms). If mood
and/or anxiety symptoms are found to correlate with attentional symptoms, then the diagnosis of adult
ADHD should be placed lower on the differential tree. The specific mood or anxiety disorder should then
be identified and treated first, with the adult ADHD diagnosis deferred until those comorbid conditions are
resolved, if possible.
ADHD-related symptoms
These include:[34]
• Inattention and hyperfocus
• May be slow to think and formulate due to distractions

• May formulate things in a long-winded and tangential way, getting lost in detail, and having
difficulty making decisions
DIAGNOSIS
• May also over-concentrate and ‘hyperfocus’, often when engaged in an activity of interest; in
this scenario, concentration may last for hours on end
• Hyperactivity
• Adults do not typically present in the same way as children; hyperactivity often presents as a
subjective feeling of inner restlessness and agitation, rather than overt hyperactivity
• May also present as excessive talking, ceaseless mental activity, not being able to relax
properly, or needing drugs/alcohol to relax and/or sleep
• Hyperactivity may be temporarily relieved with sporting activities which may be pursued to
excess, resulting in sustained injuries
• Impulsivity
• May act without thinking, or blurt out things that inadvertently cause distress to others
• There are frequently negative consequences for relationships with family, friends, colleagues
and employers
• There may be impulsive spending or eating
• Closely related to impulsivity are ‘sensation seeking’ behaviours when patients may seek out
excitement from novel or thrilling stimuli - this may result in reckless driving, sexual risks, and
provocative behaviour leading to fights
• Excessive mind wandering
• Adults with ADHD frequently report a distractible mental state and multiple unrelated
thoughts that are constantly on the go and which jump from one to another
• There is no abnormality of content of thought in comparison to other mental health disorders
e.g. depression
• Emotional dysregulation
• There is difficulty in self-regulating emotional states such as irritability, frustration and anger
• This is different to episodic symptoms seen in altered mood states such as depression or
mania; in ADHD, emotional symptoms tend to reflect short-lived exaggerated changes, often
in response to daily events, with rapid return to baseline within a few hours
Impact on patients and their families

ADHD may contribute towards difficulties for patients across the lifespan, including learning difficulties,
school or university dropout, underachievement at work, financial problems, problematic gambling and
internet use, relationship problems, intimate partner violence, addiction, sexual risk taking including
teenage pregnancy and sexually transmitted infections, suicidality, self-harm, and criminal justice system
involvement.[13] [36] [37] [38] [39] [40] [41]
ADHD may present differently in girls and women than in boys and men; there may be lower levels
of hyperactive/impulsive symptoms and less disruptive behaviour in females.[34] In girls and women,
there are high levels of co-occurring symptoms/disorders such as low self-esteem, anxiety and affective
disorders; symptoms of ADHD may be mistakenly attributed to comorbidities.[42] Females with ADHD
may also be more effective at masking symptoms, although masking may become less effective during
life transitions such as leaving school or starting work. Women with ADHD appear particularly vulnerable
DIAGNOSIS
to mental health difficulties, compared with controls; this includes insomnia, suicidal ideation, generalised
anxiety disorder and risky sexual behaviour.[43] [44]
High-functioning adults with ADHD of both sexes may not present with a typical pattern of functional
impairment in daily life due to adaptive or compensatory skills which may mask core features of ADHD.
Some people may excel in certain areas of life (e.g. work) but are impaired in others (e.g. paying bills,
household tasks, social relationships, etc.). These people may experience subjective distress from
symptoms such as mental/physical restlessness, sleep problems, and emotional instability. Some people
with ADHD may self-medicate with drugs such as cannabis or alcohol to reduce unpleasant or distressing
symptoms.[34]
Psychological and medical tests

For diagnostic assessment, use a semi-structured diagnostic interview, in combination with clinical
assessment.[34] Clinical assessment should consider all items of the diagnostic criteria.[1] Examples
of semi-structured diagnostic interviews include the Conners Adult ADHD rating scale, Brown Attention
Deficit Disorder Scale and World Health Organization Adult ADHD Self-Report Scale.[45] [46] [47]
9
Patients with adult ADHD report clear cognitive problems, which can be attentional and/or related to
impairment in executive functioning. These can be assessed by experts using neuropsychological
batteries, which may reveal abnormalities in:
• Matching of familiar figures (impulsivity)

• Verbal fluency
• Continuous performance tests/word-finding (sustained attention)
• Set shifting (dividing and shifting attention)
• Word recall (working memory).
Findings of more generalised cognitive impairment often occur with exaggeration of abnormality in
attentional and working-memory areas.
Neuropsychological testing is not diagnostic, and its main utility is in identifying the presence of isolated
attentional and working-memory impairment, compared with the normal population.
For example, although attentional impairment can be present, the diagnosis may be ADHD, but it is not
definitively so until the clinical history is further assessed.
Medical testing can be used to assess for conditions that, suggested by history, may account for, or at
least contribute to, difficulties with attention and organisation/planning. These can include urine drug
screening to evaluate for substance use, blood screening for hyperthyroidism, electroencephalogram
to evaluate for seizure disorder, polysomnography to evaluate for a sleep disorder, and brain imaging in
cases of head trauma (whether a recent or distant event).[48]
Assessment of psychiatric/neurodevelopmental comorbidity is another essential facet of diagnosis of

ADHD (e.g. mood, anxiety, substance use, eating, sleep, and autistic spectrum disorders). Identify all
comorbidities before beginning treatment, in order to determine the best order of treatment; consider all
items of the relevant diagnostic criteria during this.[1] [34]
History and exam

DIAGNOSIS
Key diagnostic factors

presence of risk factors (common)
• Risk factors include male sex, family history of ADHD, psychosocial adversity, and environmental
factors.
onset prior to age 12 years (common)

• Several inattentive or hyperactive-impulsive symptoms must have been present prior to age 12 years.
Hyperactive symptoms are typically most prominent at preschool age, with inattention becoming more
prominent during elementary school.[1]
•
• In addition to a self-report, a secondary report given by a parent to assess validity can be helpful in
identifying age of onset.
past or present academic dysfunction (common)
• Underachievement, low grades, disciplinary problems, reading disabilities, lower levels of completed
education, longer periods of time spent pursuing degrees.[7] [16]
present or past occupational dysfunction (common)

• Multiple work placements, with evidence of work termination as a result of poor work performance and
problems with authority.
familial and relationship dysfunction (common)

• Family rifts and multiple short sexual relationships.
drug and alcohol use disorders (common)

• Up to 23% of patients attending a substance use disorder clinic suffer from ADHD.[49] A history of
amfetamine use giving an abnormal calming effect may be elicited. The prescription of long-acting
stimulants is unlikely to exacerbate substance use disorders as the pharmacokinetic and dynamic
properties do not lend themselves to misuse. Treatment of the underlying ADHD may reduce addictive
behaviour.[50]
thrill-seeking behaviour (common)

• Patients are prone to thrill-seeking actions.
driving accidents (common)

• Driving accidents are increased in young adults with ADHD as a result of being distracted, impulsive,
and having an increased need for stimulation.[51] Road rage is more common.
unable to pay at tention to details resulting in ‘careless’ mistakes at work,

school, etc. (common)
• DSM-5-TR diagnostic criteria for inattention.[1]
has difficulty maintaining at tention in tasks (common)
DIAGNOSIS
seems not to listen when being spoken to (common)

does not follow instructions and does not finish duties and assigned tasks
(not due to misunderstanding or oppositional behaviour) (common)
has organisational difficulties (common)

avoids, dislikes, or is reluctant to engage in tasks that require maintaining

mental effort (common)
11
frequently loses things needed for tasks or activities (common)
frequently forget ful in daily activities (common)

fidgets often with hands or feet and moves in seat (common)

• DSM-5-TR diagnostic criteria for hyperactivity and impulsivity.[1]
frequently leaves situations, rises from chair when remaining seated is

expected (common)
often feels restless (common)

has difficulty engaging in leisure activities quietly (common)

often 'on the go', acting as if 'driven by a motor' (common)

often talks excessively (common)

often interrupts with answers before questions have been completed

(common)
often has difficulty waiting for his/her turn (e.g., while waiting in line)
DIAGNOSIS
(common)
often interrupts or intrudes on others (e.g., interrupting conversations)

(common)
increased criminal justice system involvement (uncommon)

• Criminal justice system involvement is more common in adults with ADHD than a general population
sample. People with ADHD are also more likely to be apprehended, convicted, and incarcerated.[52]
distracted easily by surroundings and external stimuli (uncommon)

Risk factors
Strong
family history of ADHD
• Family history is a strong determinant of ADHD with twin studies reporting about 70% heritability.[16]
However, most of these twin studies have been conducted among children. Adult heritability studies
are often retrospective and, therefore, less reliable. More replication is needed to determine the
strength of this association in the adult ADHD population. Heritability in families with autism, dyslexia,
and bipolar disorder is also increased.
male sex
• A national survey for DSM-IV disorder prevalence identified 61.6% of adults with ADHD as men.[4]
Among adults, the male-to-female ratio is reported to be approximately 3:2 and in other studies there is
still male predominance.[4] Under-diagnosis in girls and women is considered likely, due to differences
in presentation and under-recognition by healthcare professionals.[34]
Weak
psychosocial adversity
• Lower socioeconomic status, dysfunctional parent-child relationships, spousal separation, parental
psychopathology and parental stress, multiple life failures, and legal violations are all correlated with
ADHD.[16] [26]
other environmental factors

• Low birth weight, pregnancy and delivery complications, and childhood lead exposure have been
linked to ADHD.[26]
DIAGNOSIS
13
Investigations
1st test to order
Test Result
Conners Adult ADHD Rating Scale normal or score
suggesting presence of
• Should not be used alone to make ADHD diagnosis. It is only
ancillary to the clinical history and can be utilised to evaluate for other ADHD
psychiatric diagnoses that can cause ADHD-like symptoms.[35]
Brown At tention Deficit Disorder Scale normal or score
World Health Organization Adult ADHD Self-Report Scale normal or score
Wender Utah Rating Scale normal or score
neuropsychological testing normal or with
impairment in executive
• Neuropsychological testing is not used to diagnose ADHD, but can
be used to identify processing deficits, intelligence level, and learning functions and/or other
areas of cognitive
disabilities.[7]
processing suggestive of
ADHD
Other tests to consider

DIAGNOSIS
Test Result
urine drug screen positive or negative for
substances misuse
• May be useful in differential diagnosis.
electroencephalogram normal or with findings
suggestive of seizure
disorder
brain imaging (CT or MRI) normal or with findings

suggestive of head trauma
polysomnography normal or with findings
suggestive of obstructive
sleep apnoea
computer-based programme impairment in domains

of inat tentiveness,
• May be used to provide qualitative behaviour measurements.
hyperactivity, impulsivity
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Depression in adults • Significant, sustained • Diagnosis based on DSM-5-
depressed mood; loss of TR criteria.
interest in usual activities. • Medical testing (e.g., CBC,
• Excessive guilt. thyroid function tests) is
• Hopelessness, suicidal done to exclude causative
ideation. medical conditions.
Bipolar disorder in adults • Significant mood instability: • Diagnosis based on DSM-5-

irritability, euphoria, TR criteria.
depression. • Medical testing (e.g., CBC,
• Rapid speech, increased thyroid function tests) is
energy, decreased need for done to exclude causative
sleep. medical conditions.
• Poor judgement: spending
sprees, hypersexuality,
getting into arguments/fights.
• Delusions (fixed false
beliefs)/ hallucinations with
more severe illness.
• Suicidal ideation.
Generalised anxiety and • Excessive anxiety and worry. • Diagnosis based on DSM-5-
other anxiety disorders • Panic states with autonomic TR criteria.
arousal. • Medical testing (e.g., thyroid
• Obsessive thoughts/ function tests) is done to
compulsive behaviours. exclude causative medical
• Muscle tension. conditions.
Psychosis • Delusions (fixed false • Diagnosis based on DSM-5-

beliefs). TR criteria.
DIAGNOSIS
• Hallucinations (most usually • Medical testing is done to
auditory). exclude causative medical
• Odd or strange ideas. conditions.
Specific learning disorder • Circumscribed difficulties • Standardised testing in

with reading, mathematics, reading, mathematics, or
or written expression. written expression.
• Learning problems
significantly interfere with
academic achievement or
activities of daily living.
• School dropout, poor work
performance.
Language disorder • Circumscribed difficulties • Standardised testing in

with language expression or expressive, receptive
comprehension. language or specialised
• Language problems functional assessment of
significantly interfere with language abilities.
academic achievement or
activities of daily living.
15

symptoms
• Limited vocabulary, poorly
organised speech.
• Pronunciation difficulties,
stuttering, lisping, erratic
speech rhythm.
• Difficulties understanding
words/specific types of
words (spatial terms),
sentences.
Intellectual disability • Known IQ of ≤70. • IQ testing: score of ≤70.

• Deficits in numerous areas • Adaptive behaviour
of adaptive functioning: scales (Vineland Adaptive
communication, self- Behaviour Scales and the
care, home living, social/ American Association on
interpersonal skills, use Mental Retardation Adaptive
of community resources, Behaviour Scale).
self-direction, functional
academic skills, work,
leisure, health, and safety.
Seizure disorder • Observer report of sudden • Brain MRI: usually normal

loss of consciousness in primary generalised
followed by tonic-clonic epilepsy; may demonstrate
motor activity. a variety of lesions in partial
• Observer report of altered epilepsy.
state of consciousness • Electroencephalogram
accompanied by simple or (EEG): during a generalised
complex motor activity and/ seizure, EEG demonstrates
or vocalisations. bilateral synchrony in the
• Patient report of loss of epileptiform activity. In partial
consciousness, awakening epilepsy, a focal region
with muscle aches and/or of spike and sharp wave
DIAGNOSIS
incontinence. activity may be detected

• Patient report of periods interictally.
of lost time, disorientation/
confusion.
Traumatic brain injury • Accident/trauma history with • CT or MRI of the head may
head involvement. miss subtle traumatic brain
• Headaches. injuries.
• Studies have found single
photon emission computed
tomography to be more
sensitive than CT or MRI in
the diagnosis of traumatic
brain injury.[55]
• Neuropsychological testing
battery.
Medication side effects • Recent initiation of • Urine and/or serum drug

prescribed medication and/or screening positive according
over the counter medication to medications administered.
use. • Cautions with false-positive
and false-negative results.

symptoms
Substance use disorder • Report of recent excessive • Urine and/or serum drug
alcohol use, illicit drug use screening positive.
or misuse of prescribed • Caution in interpreting drug
medications; patients screen results as false-
may not be forthcoming in positive and false-negatives
providing history. are not uncommonly
• Accidents, fights. encountered. Confirmatory
testing with a more sensitive
test may be necessary if
the initial testing result is
suspect.
Sleep disorder • Snoring history (patient or • Sleep studies/

bed partner report). polysomnography
• Sudden loss of muscle tone (physiological/ respiratory
(cataplexy). monitoring, eye movements,
• Leg muscle soreness. electromyogram,
• Observer report of electroencephalogram) may
sleepwalking. show patterns consistent
• Excessive daytime with sleep disorder.
sleepiness.
Hypothyroidism • Tiredness. • Thyroid-stimulating hormone

• Poor ability to tolerate cold. levels elevated in primary
• Weight gain. hypothyroidism.
Perimenopause • Fatigue. • Follicle-stimulating hormone

• Hot flushes. (FSH) levels may be
• Breast tenderness. elevated (note: testing for
• Worsening of premenstrual FSH early in perimenopause
syndrome. may not be of diagnostic
• Irregular menstrual pattern. value because of variability
in levels from day to day
DIAGNOSIS
and during the menstrual
cycle. After several months
of amenorrhoea, an elevated
FSH level may be more
predictive of impending
menopause).
Age-related cognitive • Normal ageing is • Diagnosis involves excluding

decline accompanied by a decline of MCI or dementia.
cognitive abilities over time, • Cognitive screening tests
and executive skills may be such as the Mini-Mental
affected selectively. State Examination indicate
• It presents with memory increased probability of
impairment (e.g., forgetting cognitive impairment.
appointments, misplacing • Further testing, such as
items, memory lapses) serum B12, may indicate
that is not part of mild specific aetiologies, such as
cognitive impairment (MCI) B12 deficiency.
or dementia.
17
Criteria
Diagnostic and Statistical Manual of Mental Disorders, 5th edition,
Text Revision (DSM-5-TR)[1]
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or

development, as characterised by (1) and/or (2):
1. Inattention: 6 (or more) of the following symptoms have persisted for at least 6 months to a degree that
is inconsistent with developmental level and that negatively impacts directly on social or academic/
occupational activities. Note: the symptoms are not solely a manifestation of oppositional behaviour,
defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age
17 years and older), at least 5 symptoms are required.
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work,
or during other activities (e.g., overlooks or misses details, work is inaccurate).
• Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining
focused during lectures, conversations, or lengthy reading).
• Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the
absence of any obvious distraction).
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in
the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
• Often has difficulty organising tasks and activities (e.g., difficulty managing sequential tasks;
difficulty keeping materials and belongings in order; messy, disorganised work; has poor time
management; fails to meet deadlines).
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing
forms, reviewing lengthy papers).
• Often loses things necessary for tasks and activities (e.g., school materials, pencils, books,
DIAGNOSIS
tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include
unrelated thoughts).
• Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents
and adults, returning calls, paying bills, keeping appointments).
2. Hyperactivity-impulsivity: 6 (or more) of the following symptoms have persisted for at least 6 months
to a degree that is inconsistent with developmental level and that negatively impacts directly on social
or academic/occupational activities. Note: the symptoms are not solely a manifestation of oppositional
behaviour, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and
adults (age 17 years and older), at least 5 symptoms are required.
• Often fidgets or taps with hands or feet, or squirms in seat.

• Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place
in the classroom, in the office or other workplace, or in other situations that require remaining in
place).
• Often runs about or climbs excessively in situations where it is inappropriate (for adolescents or
adults, may be limited to feeling restless).
• Often unable to play or engage in leisure activities quietly.
• Is often 'on the go', acting as if 'driven by a motor' (e.g., is unable to be or uncomfortable being
still for extended time, as in restaurants, meetings; may be experienced by others as being
restless or difficult to keep up with).
• Often talks excessively.
• Often blurts out an answer before a question has been completed (e.g., completes other
people's sentences; cannot wait in turn in conversation).
• Often has difficulty waiting his or her turn (e.g., while waiting in line).
• Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may
start using other people's things without asking or receiving permission; for adolescents and
adults, may intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in 2 or more settings (e.g., at home,
school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or
occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder
and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative
disorder, personality disorder, substance intoxication or withdrawal).
Criteria from sections A, B, C, D, and E must be met for a diagnosis to be given.
Specify whether:
• Combined presentation: if both criterion A1 (inattention) and criterion A2 (hyperactivity-impulsivity) are

met for the past 6 months.
• Predominantly inattentive presentation: if criterion A1 (inattention) is met but criterion A2 (hyperactivity-
impulsivity) is not met for the past 6 months.
DIAGNOSIS
• Predominantly hyperactive/impulsive presentation: if criterion A2 (hyperactivity-impulsivity) is met and
criterion A1 (inattention) is not met for the past 6 months.
Also specify current severity:
• Mild: few, if any, symptoms in excess of those required to make the diagnosis are present, and
symptoms result in no more than minor impairments in social or occupational functioning.
• Moderate: symptoms or functional impairment between 'mild' and 'severe' are present.
• Severe: many symptoms in excess of those required to make the diagnosis, or several symptoms
that are particularly severe, are present, or the symptoms result in marked impairment in social or
occupational functioning.
Patients may be classified as being 'in partial remission' if full criteria were previously met, fewer than the full
criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic,
or occupational functioning.
International Classification of Diseases 11th revision (ICD-11)[56]
19
Hyperkinetic disorder in ICD 10th revision (ICD-10) has been replaced with ADHD in ICD-11. ADHD has also
been moved from 'Disruptive behaviour or dissocial disorders' to 'Neurodevelopmental disorders' to avoid
stigma and reflect that individuals with ADHD are not intentionally disruptive.
In ICD-11, ADHD is characterised by a persistent pattern (e.g., at least 6 months) of inattention symptoms
and/or a combination of hyperactivity and impulsivity symptoms that is outside the limits of normal variation
expected for age and level of intellectual development. Symptoms vary according to chronological age and
disorder severity.
Inattention
• Several symptoms of inattention that are persistent, and sufficiently severe that they have a direct
negative impact on academic, occupational, or social functioning. Symptoms are typically from the
following clusters:
• Difficulty sustaining attention to tasks that do not provide a high level of stimulation or reward or
require sustained mental effort; lacking attention to detail; making careless mistakes in school or
work assignments; not completing tasks.
• Easily distracted by extraneous stimuli or thoughts not related to the task at hand; often does not
seem to listen when spoken to directly; frequently appears to be daydreaming or to have mind
elsewhere.
• Loses things; is forgetful in daily activities; has difficulty remembering to complete upcoming
daily tasks or activities; difficulty planning, managing and organising schoolwork, tasks and
other activities.
• Inattention may not be evident when the individual is engaged in activities that provide intense
stimulation and frequent rewards.
Hyperactivity/impulsivity
• Several symptoms of hyperactivity/impulsivity that are persistent, and sufficiently severe that they
have a direct negative impact on academic, occupational, or social functioning. These tend to be most
DIAGNOSIS
evident in structured situations that require behavioural self-control. Symptoms are typically from the
following clusters:
• Excessive motor activity; leaves seat when expected to sit still; often runs about; has difficulty
sitting still without fidgeting (younger children).
• Difficulty engaging in activities quietly; talks too much.
• Blurts out answers in school, comments at work; difficulty waiting turn in conversation, games,
or activities; interrupts or intrudes on others conversations or games.
• A tendency to act in response to immediate stimuli without deliberation or consideration of risks
and consequences (e.g., engaging in behaviours with potential for physical injury; impulsive
decisions; reckless driving)
• Evidence of significant inattention and/or hyperactivity-impulsivity symptoms prior to age 12, though
some individuals may first come to clinical attention later in adolescence.
• Manifestations of inattention and/or hyperactivity-impulsivity must be evident across multiple situations
or settings (e.g., home, school, work, with friends or relatives), but are likely to vary according to the
structure and demands of the setting.
• Symptoms are not better accounted for by another mental disorder (e.g., an anxiety or fear-related
disorder or a neurocognitive disorder such as delirium).
• Symptoms are not due to the effects of a substance (e.g., cocaine) or medication (e.g.,
bronchodilators, thyroid replacement medication) on the central nervous system, including and
withdrawal effects, and are not due to a disease of the nervous system.
Specifiers
• The characteristics of the current clinical presentation should be described using one of the following
specifiers, which are meant to assist in recording the main reason for the current referral or services.
Predominance of symptoms refers to the presence of several symptoms of either an inattentive or
hyperactive/impulsive nature with few or no symptoms of the other type.
• Predominantly inattentive presentation: all diagnostic requirements for ADHD are met and
inattentive symptoms predominate.
• Predominantly hyperactive-impulsive presentation: all diagnostic requirements for ADHD are
met and symptoms of hyperactivity-impulsivity predominate.
• Combined presentation: all diagnostic requirements for ADHD are met and both hyperactive-
impulsive and inattentive symptoms are clinically significant aspects of the current clinical
presentation, with neither clearly predominating.
Screening
Rating scales used in diagnosis
Appropriate adult ADHD rating scales include:
• Barkley ADHD Behavior Checklist for Adults[57]

• Conners Adult ADHD Rating Scale (CAARS)[54]
• Brown Attention Deficit Disorder Scale (BrownADDScales)[58]
DIAGNOSIS
• World Health Organization Adult ADHD Self-Report Scale[53]
• [Adult ADHD Self-Report Scale (ASRS-v1.1) symptom checklist - 18 item] (https://add.org/wp-

content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf)
• [Adult ADHD Self-Report Scale (ASRS-v1.1) Screener - 6 item] (http://
www.hcp.med.harvard.edu/ncs/ftpdir/adhd/6Q_ASRS_English.pdf)
• Wender Utah Rating Scale.[59] [60] [61] [62]
Screening adults for ADHD is appropriate when: 1) there is a family or childhood history of ADHD, 2)
problems attending to information and/or poor planning and organisational skills are noted in the presenting
history, 3) an adult being treated for a mood, anxiety, or substance use disorder does not respond optimally
to standard treatments for those disorders, 4) in substance use disorder clinics, 5) in those in frequent
contact with the criminal justice system.[34] [63] Rating scale results are combined with the results of patient
interview and assessment, information from secondary sources, and additional testing (psychological,
medical), as applicable, in evaluating the adult patient for the diagnosis of ADHD.[64]
21
At tention deficit hyperactivity disorder in adults Management
Approach
Treatment often follows a multi-modal approach, incorporating elements of psychoeducation, medication and
psychological therapy e.g. cognitive behavioural therapy (CBT).[34] Treatment recommendations for adult
ADHD may differ between countries and healthcare settings; for example in some locations, such as the UK,
either pharmacotherapy or psychological therapy may be offered in isolation.[2]
Psychoeducation
Psychoeducation, if available, is a recommended first step following diagnosis according to some
treatment guidelines.[34] Structured psychoeducation programmes offer information about ADHD as well
as support to patients and their families, and may include aspects of cognitive behavioural therapy. There
is preliminary evidence to suggest structured psychoeducation programmes may increase psychological
well-being, improve relationship quality and increase knowledge of ADHD.[65] [66]
ADHD without concomitant mood disorder or anxiety

Medication
Where adult ADHD symptoms persist without comorbid symptoms, a trial with lisdexamfetamine or
methylphenidate is recommended as first-line pharmacological treatment.[2] [34] [Evidence B] It is
suggested that amfetamines are better tolerated in adults than methylphenidate.[21] [68] Consider
dexamfetamine for adults whose ADHD symptoms are responding to lisdexamfetamine but who cannot
tolerate the longer effect profile.[2] [Evidence B]
Use of medication should last for as long as there is clinical benefit. Treatment response can be
monitored by use of a symptom rating scale such as the Adult ADHD Investigator Symptom Rating Scale
or the World Health Organization Adult ADHD Self-Report Scale.[69] [53] [Adult ADHD Self-Report
Scale (ASRS-v1.1) symptom checklist - 18 item] (https://add.org/wp-content/uploads/2015/03/adhd-
questionnaire-ASRS111.pdf) [Adult ADHD Self-Report Scale (ASRS-v1.1) Screener - 6 item] (http://
www.hcp.med.harvard.edu/ncs/ftpdir/adhd/6Q_ASRS_English.pdf) With stimulant medications, benefits
can be seen quite soon after initiation, often within the first 2 to 3 days of use.
When considering stimulant medication treatment, a careful cardiac history, including family history of
sudden death or arrhythmia and symptoms of syncope and dyspnoea with exertion, should be obtained.
In cases where there are cardiac symptoms of concern or a history of such symptoms, an ECG and/or a
cardiology consultation should be obtained prior to starting a stimulant.
Stimulants are also associated with adverse effects such as sleep problems and decreased appetite, and
ongoing monitoring is warranted.[68]
Prescribers should note that there are differences in long-acting formulations of methylphenidate in terms
of dosing frequency, administration with food, amount and timing of the modified-release component,
and overall clinical effect. It is important to follow specific dosage recommendations for each formulation
and to use caution if switching from one to another long-acting preparation of methylphenidate, including
MANAGEMENT
a careful discussion with the patient. Follow specific prescribing guidance on methylphenidate relevant
to your location of practice; for example, there may be the recommendation to prescribe long-acting
formulations of methylphenidate by specifying the brand name or by using the generic drug name and
name of the manufacturer.[70]
Psychosis has been associated with stimulants. In one study of adolescents and young adults (13 to
25 years old) who started taking prescription stimulants for ADHD, amfetamines were associated with a
greater risk of new-onset psychosis than methylphenidate.[71] One population-based cohort study found
no evidence that methylphenidate increases the risk of psychotic events in adolescents and young adults
with ADHD.[72]
Physician vigilance for any pattern of medication misuse is a necessary part of prescribing these
medications.
If a trial of stimulant medication does not provide benefit or is not well tolerated, change to an alternative
formulation, or atomoxetine (a selective noradrenaline-reuptake inhibitor without stimulant properties) is
recommended as the next agent.[34] [73] Atomoxetine may not be well tolerated in adults with ADHD, a
meta-analysis showed a 40% greater discontinuation rate compared with placebo.[21] As with stimulant
medication, an adequate trial would last for as long as there is clinical benefit. For patients who do not
respond adequately to these treatments, seek advice from a tertiary ADHD service.[2]
The following treatments should only be initiated under specialist guidance.[2] Atypical antipsychotics may
be offered in addition to stimulants for people with ADHD and co-existing pervasive aggression, rages, or
irritability. Physicians should be vigilant for potential serious side effects of antipsychotics.[74] Additional
experimental and adjunct treatments may be useful, including bupropion for core symptoms, venlafaxine,
and risperidone (an atypical antipsychotic often used for aggressive behaviour).[75] Bupropion is an
antidepressant with dopaminergic effects. Treatment over several weeks may be needed to evaluate
efficacy for reduction of attentional and other cognitive symptoms. Bupropion is contraindicated in patients
with seizure disorders or conditions that increase the risk of seizure disorders, and in patients with
anorexia/bulimia.
If benefit is obtained with either non-stimulant or stimulant treatment, the prescribed agent can be
continued for several months, with subsequent evaluations weighing the need for ongoing treatment.[76]
Psychological therapy
As an adjunct to medication, it is recommended that psychological therapy be available in all clinical

adult ADHD settings as a viable treatment option.[34] [77] There is evidence that cognitive-behavioural-
based treatments may be beneficial for treating adults with ADHD in the short term both in terms of core
symptoms and associated symptoms such as depression and anxiety.[21] [78] [79] [80] One review
found that reductions in core symptoms of ADHD were fairly consistent when cognitive behavioural
therapy (CBT) was used in addition to pharmacotherapy versus pharmacotherapy alone and in CBT
versus waiting list.[80] Alternative psychological therapies include dialectical behaviour therapy and
metacognitive therapy.[81] [82] There is insufficient evidence for meditation-based therapies.[83]
Occupational therapy focusing on organisation skills, enhancing social interaction/awareness, stress
management techniques and sensory regulation can be helpful although further evidence is required to
assess the effectiveness of different interventions.[84]
ADHD with concomitant mood disorder (depression, bipolar

disorder) or anxiety
MANAGEMENT
Medication
Mood and anxiety disorders can occur with adult ADHD and when they do, the treatment becomes more
complicated.[85] The symptoms of the comorbid disorders can have a spill-over effect into the ADHD
23
symptoms, so inattentiveness, impulsivity, and hyperactivity can appear worse than they would be in the
absence of comorbidity. Treating the comorbid condition(s) first may help lessen the symptomatology
attributed to ADHD.
In addition, since common side effects of stimulant treatment may include mania, weight loss, and
insomnia, once stimulant treatment is begun it may be difficult to assess whether such symptoms
are stimulant side effects or are the symptoms of untreated, comorbid conditions. When treating the
comorbidities first, the least potentially harmful drugs are used first.
For patients presenting with symptoms of a mental health disorder such as depressive, bipolar, or
anxiety disorder, in addition to adult ADHD symptomatology, the first step is to provide treatment for the
non-ADHD condition(s). Psychological therapy participation may be initiated concurrently, based on
assessment of the severity of the ADHD symptomatology and patient preference. Mood symptoms may
necessitate treatment with antidepressants and/or mood-stabilising agents, while anxiety symptoms can
benefit from treatment with anxiolytics, antidepressants (and occasionally benzodiazepines). The goal is
to reduce the severity of the non-ADHD symptoms, which may lead to significant lessening of reported
attentional and cognitive deficits that would have otherwise been attributed to ADHD.
If careful evaluation does reveal the persistence of ADHD disorders, despite adequate treatment of the
mood/anxiety disorders, consideration of medication treatment aimed at reduction of the persisting ADHD
symptoms is indicated.
This treatment may require significant expertise with psychopharmacologic agents for those patients
requiring multiple medications for non-ADHD symptom stability. Patients with mood (depression and
bipolar disorder) and/or anxiety disorders may require a regimen that includes antidepressant medication.
In patients with bipolar disorder, caution is recommended with use of antidepressants and closely
related agents (such as atomoxetine) due to the risk of such agents inducing mood cycling. Stimulant
medication (methylphenidate or amfetamine salt preparation) treatment is not contraindicated with
concurrent antidepressant or mood-stabiliser treatment. Stimulant use also carries risk of mood-cycling
induction, so caution is recommended, particularly with use in patients with bipolar illness. Stimulants can
additionally worsen anxiety and cause insomnia. Any of these effects could be detrimental to the patient
with significant mood and/or anxiety symptoms, and careful, ongoing monitoring for the emergence of
such medication effects would be prudent.
Psychological therapy
There is evidence that CBT may also improve common secondary disturbances in adults with ADHD,
such as depression, anxiety, and anti-social behaviour.[78] [86] [87]
Treatment in patients with previous substance use disorder

Stimulant medication can be used with caution in this group. It is advisable to use longer-acting stimulants
as they have less potential to be misused, particularly for some formulations.[49] Simultaneous and
integrated treatment of ADHD and substance use disorder, using a combination of pharmaco- and
psychotherapy, is recommended.
MANAGEMENT
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Ongoing ( summary )
ADHD without concomitant mood
disorder or anxiety
1st psychoeducation + stimulant therapy ±

psychological therapy
2nd atomoxetine ± psychological therapy
3rd alternative experimental treatments

including antidepressants and
antipsychotic medication ± psychological
therapy
ADHD with depression (with or

without prominent anxiety)
1st antidepressants + psychological therapy
persistent ADHD- adjunct psychoeducation + ADHD medication

like symptoms treatments ± psychological therapy
despite euthymia on
antidepressants
persistent anxiety adjunct anxiolytic therapies

symptoms despite
euthymia on
antidepressants
ADHD with bipolar disorder (with or

1st mood stabilisers + psychological therapy
persistent ADHD-like adjunct psychoeducation + ADHD medication

symptoms despite treatments ± psychological therapy
euthymia on mood
stabilisers

symptoms despite
euthymia on mood
stabilisers
ADHD with anxiety disorder alone
1st anxiolytics + psychological therapy

MANAGEMENT

controlled anxiety on
anxiolytics
25
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Ongoing
ADHD without concomitant mood
disorder or anxiety
1st psychoeducation + stimulant therapy ±

psychological therapy
Primary options
» methylphenidate: consult product literature

for guidance on dose
OR
» lisdexamfetamine: 30-70 mg orally once

daily in the morning
Secondary options
» dexamfetamine: 5-60 mg/day orally given in

2-4 divided doses
» Psychoeducation, if available, is a
recommended first step following diagnosis
according to some treatment guidelines.[34]
Structured psychoeducation programmes offer
information about ADHD as well as support to
patients and their families, and may include
aspects of cognitive behavioural therapy. There
is preliminary evidence to suggest structured
psychoeducation programmes may increase
psychological well-being, improve relationship
quality, and increase knowledge of ADHD.[65]
[66]
» The dose of methylphenidate and amfetamine

preparations needs to be titrated. Dose should
always be started low and increased gradually
according to response.
» Extended-release methylphenidate is
reported to provide better symptom control
than immediate- or sustained-release
formulations. However, a Cochrane review
found 'very low' certainty of evidence to support
symptom improvement with extended-release
methylphenidate versus placebo in adults with
MANAGEMENT
ADHD.[88]
» It is suggested that amfetamines are better

tolerated in adults than methylphenidate.[21] [68]
Ongoing
» Consider dexamfetamine for adults
whose ADHD symptoms are responding to
lisdexamfetamine but who cannot tolerate the
longer effect profile.[2] [Evidence B]
» If there has been any substance use in the

last year, stimulant medication can be used
with caution. It is advisable to use longer-acting
stimulants, as they have less potential to be
misused.[49]
» A careful cardiac history, including family

history of sudden death or arrhythmia, symptoms
including syncope and dyspnoea with exertion,
should be obtained. In cases where there
are symptoms of concern or a history of
such symptoms, an ECG and/or a cardiology
consultation should be obtained prior to starting
a stimulant.
» Stimulants are associated with adverse effects

such as sleep problems and decreased appetite,
and ongoing monitoring is warranted.[68]
» Prescribers should note that there are

differences in long-acting formulations of
methylphenidate in terms of dosing frequency,
administration with food, amount and timing
of the modified release component, and
overall clinical effect. It is important to follow
specific dosage recommendations for each
formulation and to use caution if switching
from one to another long-acting preparation of
methylphenidate, including a careful discussion
with the patient. Follow specific prescribing
guidance on methylphenidate relevant to your
location of practice; for example, there may
be a recommendation to prescribe long-acting
formulations of methylphenidate by specifying
the brand name or by using the generic drug
name and name of the manufacturer.[70]
» Psychosis has been associated with

stimulants. In one study of adolescents
and young adults (13 to 25 years old) who
started taking prescription stimulants for
ADHD, amfetamines were associated with
a greater risk of new-onset psychosis than
methylphenidate.[71] One population-
based cohort study found no evidence that
methylphenidate increases the risk of psychotic
events in adolescents and young adults with
MANAGEMENT
ADHD.[72]
» Use of stimulant medication should last for

as long as there is clinical benefit. It should be
stopped when side effects appear to outweigh
benefits.
27
Ongoing
» Psychological therapy (e.g. CBT) should be
available as an adjunct to pharmacotherapy in all
clinical adult ADHD settings.[34] [89] Treatment
recommendations for adult ADHD may differ
between countries and healthcare settings; for
example, in some locations, such as the UK,
either pharmacotherapy or psychological therapy
may be offered in isolation.[2]
2nd atomoxetine ± psychological therapy
Primary options
» atomoxetine: 40-120 mg/day orally given in

1-2 divided doses
» Atomoxetine is a selective noradrenaline-

reuptake inhibitor.
» Treatment over several weeks may be needed

to evaluate efficacy for reduction of attentional
and other cognitive symptoms.
» Dose should always be started low and

increased gradually according to response.
» Medication should be stopped if side effects

appear to outweigh benefits. Atomoxetine may
not be well tolerated in adults with ADHD,
a meta-analysis showed a 40% greater
discontinuation rate compared with placebo.[21]
» Psychological therapy should be available

in all clinical adult ADHD settings as a viable
treatment option.
3rd alternative experimental treatments
including antidepressants and
antipsychotic medication ± psychological
therapy
Primary options
» bupropion: 100 mg orally (sustained-

release) once daily in the morning, increase
gradually to 200 mg twice daily, maximum
400 mg/day
OR
» venlafaxine: consult specialist for guidance

on dose
OR
MANAGEMENT
» risperidone: consult specialist for guidance

on dose
Ongoing
» The following treatments should only be
initiated under specialist guidance (e.g.
from a tertiary ADHD service).[2] Additional
experimental and adjunct treatments may be
useful, including bupropion for core symptoms,
venlafaxine, and risperidone (an atypical
antipsychotic often used for aggressive
behaviour).[75]
» Bupropion is an antidepressant with

dopaminergic effects. Treatment over several
weeks may be needed to evaluate efficacy for
reduction of attentional and other cognitive
symptoms. Bupropion is contraindicated in
patients with seizure disorders or conditions that
increase the risk of seizure disorders, and in
patients with anorexia/bulimia.

» If benefit is obtained with either non-stimulant

or stimulant treatment, the prescribed agent
can be continued for several months, with
subsequent evaluations weighing the need for
ongoing treatment.[76]

treatment option.
ADHD with depression (with or
ADHD with depression (with or 1st antidepressants + psychological therapy

» The aim of treatment in both initial treatment
and treatment resistance is to achieve euthymia
with antidepressant treatments, unrelated to
specific treatment for ADHD.
» In the case of suboptimal response to initial

antidepressant therapy (treatment resistance),
ongoing ADHD-like symptoms would be seen as
part of the resistant depression.[85] ADHD-like
symptoms should not be specifically treated.
» Specialist (psychopharmacologist) referral

should be considered for complex cases.
» Patients who are prescribed a selective

serotonin-reuptake inhibitor (SSRI) should be
informed about the possibility of increased risk of
MANAGEMENT
suicidality associated with SSRI use.

treatment option.
29
Ongoing
» See Depression in adults (Treatment
algorithm) .
persistent ADHD- adjunct psychoeducation + ADHD medication
like symptoms treatments ± psychological therapy
despite euthymia on
Treatment recommended for SOME patients in
antidepressants
selected patient group
Primary options

OR

Secondary options

2-4 divided doses
OR

1-2 divided doses
Tertiary options

400 mg/day
OR

on dose
» Psychoeducation, if available, is
a recommended first step following
diagnosis of ADHD according to some
treatment guidelines.[34] Structured
psychoeducation programmes offer information
about ADHD as well as support to patients
and their families, and may include aspects
of cognitive behavioural therapy. There is
preliminary evidence to suggest structured
psychoeducation programmes may increase
psychological well-being, improve relationship
MANAGEMENT
quality, and increase knowledge of ADHD.[65]

[66]
» Medication dose needs to be titrated. Dose

should always be started low and increased
gradually according to response.[85]
Ongoing
ADHD.[88]

tolerated in adults than methylphenidate.[68]


misused.[49]
» A careful cardiac history, including a family

history of sudden death or arrhythmia, including
symptoms of syncope and dyspnoea with
exertion, should be obtained. In cases where
there are symptoms of concern or a history of
a stimulant.
» Stimulants are also associated with

adverse effects such as sleep problems and
decreased appetite, and ongoing monitoring is
warranted.[68]

formulation, and to use caution if switching
location of practice; for example, there may be
the recommendation to prescribe long-acting
MANAGEMENT


31
Ongoing
ADHD.[72]

benefits.

reuptake inhibitor. Treatment over several
symptoms. Medication should be stopped
if side effects appear to outweigh benefits.
Atomoxetine may not be well tolerated in adults
with ADHD, a meta-analysis showed a 40%
greater discontinuation rate compared with
placebo.[21]
» Other treatments may be useful, including

bupropion for core symptoms[75] and
venlafaxine.[85]

dopaminergic effects. Treatment over several

example in some locations, such as the UK,
symptoms despite
euthymia on
antidepressants
» Anxiolytic therapies include both medication
MANAGEMENT
and psychotherapies.
» Medication treatments include

antidepressants, and occasionally,
benzodiazepines..
Ongoing
» Psychotherapies include cognitive behavioural
therapy, which has shown efficacy for patients
with obsessive-compulsive disorder and panic
disorder.[90] [91] Mindfulness-based cognitive
therapy may help patients with generalised
anxiety disorder.[92]
» Benzodiazepines pose risks of addiction,

tolerance and withdrawal, possibly including
withdrawal seizures.

serotonin-reuptake inhibitor should be informed
about the possibility of increased risk of
suicidality associated with their use.
» See Generalised anxiety disorder (Treatment

algorithm) .
ADHD with bipolar disorder (with or
ADHD with bipolar disorder 1st mood stabilisers + psychological therapy

(with or without prominent
anxiety) » If the comorbid mood disorder is bipolar
disorder, the aim in initial treatment and
treatment-resistant patients is to achieve
euthymia with mood-stabiliser treatments,
unrelated to specific treatment for ADHD.[85]

mood-stabiliser therapy (treatment resistance),
ongoing ADHD-like symptoms may be seen as
part of the resistant bipolar disorder. ADHD-like
symptoms should not be specifically treated.

should be considered for complex cases, where
stimulant or alternative ADHD medication may
be initiated.

treatment option.
» See Bipolar disorder in adults (Treatment

algorithm) .
euthymia on mood
stabilisers
MANAGEMENT
Primary options

OR
33
Ongoing
Secondary options

2-4 divided doses
OR

1-2 divided doses
Tertiary options

400 mg/day
of ADHD according to some treatment
guidelines.[34] Structured psychoeducation
programmes offer information about ADHD
as well as support to patients and their
families, and may include aspects of cognitive
behavioural therapy. There is preliminary
evidence to suggest structured psychoeducation
programmes may increase psychological well-
being, improve relationship quality, and increase
knowledge of ADHD.[65] [66]
» Medication dose needs to be titrated.

» All of these agents carry some risk of

inducing mood cycling in patients with bipolar
disorder.[85]
ADHD.[88]

MANAGEMENT

Ongoing
a stimulant.



ADHD.[72]

benefits.

reuptake inhibitor. Medication should be stopped
MANAGEMENT

placebo.[21]

dopaminergic effects.[75] Treatment over several
35
Ongoing

symptoms despite
euthymia on mood
stabilisers
» Anxiolytic therapies include both medication
and psychotherapies.

benzodiazepines.
» Psychotherapies include cognitive behavioural

therapy, which has shown efficacy for patients
with obsessive-compulsive disorder and panic
disorder.[90] [91] Mindfulness-based cognitive
therapy may help patients with generalised
anxiety disorder.[92]

tolerance, and withdrawal, possibly including

serotonin-reuptake inhibitor should be informed
about the possibility of increased risk of
suicidality associated with their use.

algorithm) .
ADHD with anxiety disorder alone
ADHD with anxiety disorder 1st anxiolytics + psychological therapy

alone
» Anxiolytic therapies for initial treatment and
treatment-resistant patients can be either
medication or psychotherapies.
MANAGEMENT

benzodiazepines.
Ongoing
» Psychotherapies can include cognitive
behavioural therapy: in particular, for obsessive-
compulsive disorder and panic disorder.[90] [91]
Mindfulness-based cognitive therapy may help
with generalised anxiety disorder.[92]

anxiolytic therapy (treatment resistance),
ongoing ADHD-like symptoms may be seen as
part of the resistant anxiety disorder.[85] ADHD-
like symptoms should not be specifically treated.

should be considered for complex cases.

tolerance, and withdrawal, possibly including
» Patients who are prescribed an SSRI should

be informed about the possibility of increased
risk of suicidality associated with their use.

treatment option.

algorithm) .
controlled anxiety on
anxiolytics
Primary options

OR

Secondary options

2-4 divided doses
OR
MANAGEMENT

1-2 divided doses
Tertiary options
37
Ongoing
400 mg/day
OR
» risperidone: 1 mg orally once or twice daily
OR

on dose
of ADHD according to some treatment
guidelines.[34] Structured psychoeducation
programmes offer information about ADHD
as well as support to patients and their
families, and may include aspects of cognitive
behavioural therapy. There is preliminary
evidence to suggest structured psychoeducation
programmes may increase psychological well-
being, improve relationship quality, and increase
knowledge of ADHD.[65] [66]
» Medication dose needs to be titrated. Dose

should always be started low and increased
gradually according to response.[85]
» Treatment over several weeks may be needed

to evaluate efficacy for reduction of attentional
and other cognitive symptoms.
ADHD.[88] [66]


MANAGEMENT

misused.[49]
Ongoing
a stimulant.



ADHD.[72]

benefits.

reuptake inhibitor. Treatment over several
MANAGEMENT
symptoms. Medication should be stopped

placebo.[21]
39
Ongoing
» The following treatments should only be
initiated under specialist guidance (e.g. from
a tertiary ADHD service).[2] Other treatments
may be useful, including bupropion for core
symptoms, venlafaxine, and risperidone (an
atypical antipsychotic often used for aggressive
behaviour).[75]

dopaminergic effects.[75] Treatment over several

MANAGEMENT
Emerging
Viloxa zine
Viloxazine is a selective noradrenaline-reuptake inhibitor that was initially developed as an antidepressant in
the 1970s. An extended-release formulation of viloxazine was approved for the treatment of ADHD in children
aged 6 to 17 years in the US in 2021. It has now also been approved for the treatment of ADHD in adults,
and is the first novel non-stimulant option to be approved in the US for ADHD in adults in 20 years. In phase
3 clinical trials, viloxazine improved ADHD symptoms compared to placebo and was generally well tolerated.
Somnolence, decreased appetite, and headache were the most commonly reported adverse events.[93] [94]
[95] [96] Based on clinical study data, viloxazine is associated with an increased risk of suicidal thoughts and
behaviour compared to placebo. Patients treated with viloxazine therefore need to be closely monitored for
clinical worsening, and for emergence of suicidal thoughts and behaviours. Viloxazine is not approved or
available in Europe.
Primary prevention
Given that relatively common environmental factors (poverty, poor prenatal care, maternal smoking, spousal
separation, a stressful academic environment, and parental stress) are associated with the development
of ADHD, a broad array of social, educational, and family-based interventions could potentially reduce the
incidence of childhood ADHD, and later persistence into adulthood.
Secondary prevention
Secondary preventive measures include scheduling patient follow-up visits to: 1) address the status of ADHD
symptomatology, 2) assess for emergent psychiatric symptoms/worsening of existing psychiatric disorder(s),
and, 3) assess for any substance use concerns (including prescribed medication misuse) in a timely manner.
Patients can also be directed to appropriate treatment (e.g., family/marital counselling) or vocational or social
service agencies to address deterioration in marital or other important relationships, job performance, or
financial status.
Patient discussions
Physician instruction to patients should address the following issues:
• Education regarding the importance of adherence to prescribed medication and/or therapy groups
• Advice on the higher incidence of road traffic accidents in people with ADHD and the fact that
effective treatment appears to reduce this risk.[37] [99] [100]
• Advice on structuring activities with planning, reminders, and memory aids and avoidance of
settings that may provide excessive environmental stimuli
• Advice to get enough rest and eat well to maintain cognitive vigilance with sleep hygiene advice
• Education on the risks of excessive alcohol use, any substance use, and misuse of prescribed
medication
• Use of a mentor.
MANAGEMENT
• [Children and adults with attention-deficit/hyperactivity disorder (CHADD)] (http://

www.chadd.org)
• [Helpguide.org: adult ADD/ADHD] (https://www.helpguide.org/articles/add-adhd/adhd-
attention-deficit-disorder-in-adults.htm)
41
• [National Institute of Mental Health (NIMH): attention deficit hyperactivity disorder (ADHD)]
(http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/
index.shtml)
MANAGEMENT
At tention deficit hyperactivity disorder in adults Follow up
Monitoring
Monitoring
FOLLOW UP
The patient should attend regularly scheduled physician visits, weekly or every other week initially,
extending to monthly or quarterly once stability is achieved. This will allow for close follow-up of patient
status. At the visits, clinical interviewing and examination can accomplish the following:
• Monitoring of medication use and its continued effectiveness

• Assessment of psychiatric status for emergence of any significant changes in mood or anxiety state
• Monitoring for any substance use or misuse of prescribed medication, especially stimulants
• Monitoring of cardiovascular status measured by blood pressure and pulse.
43
Complications
Complications Timeframe Likelihood

FOLLOW UP
stimulant-induced mania short term low
Stimulants should be stopped if mania occurs.
obesity long term medium
A Swedish national register study of over 2.5 million people found ADHD patients had a threefold greater
risk of obesity relative to their non-ADHD siblings and cousins. A meta-analysis found that compared with
typically developing people, adults with unmedicated ADHD almost 50% more likely to be overweight or
obese (9 studies, over 45,000 participants).[21]
Obesity in adults
type 2 diabetes mellitus long term medium
Type 2 diabetes mellitus has been found to be more common in adults with ADHD compared with age-
and sex-matched controls.[21]
Type 2 diabetes in adults
sleep problems variable high
Insomnia and general sleep disorders are 50-60% higher than the general population, with self-reported
increased difficulty in falling asleep and frequency of night awakenings, moderately worse sleep quality,
greater daytime sleepiness, and feeling less rested at wake up.[97]
Insomnia
stimulant-induced weight loss variable medium
Dose should be minimised and patient should be assessed for eating disorder. Weight loss often occurs
in clinical practice, and under such circumstances high protein/energy drinks can be helpful (care should
be taken as certain energy drinks contain caffeine, which may exacerbate issues with blood pressure,
pulse, palpitations, or tremor), otherwise medication may have to be stopped. It is a potentially serious
complication, although likelihood is not high.
stimulant-induced insomnia variable medium
Possible management may include the following: dose of stimulants should be minimised or alternative
formulation prescribed; hypnotics can be prescribed; and patient can be switched to a shorter-acting agent
or take the medication earlier in the day. Can switch to atomoxetine or alternative therapy. Melatonin,
alpha-agonists, or sedative antidepressants may also be used in addition to regular therapy.
substance use disorder variable medium
People with ADHD are around twice as likely to develop a drug or alcohol use disorder than those without
ADHD.[21]
Overview of substance use disorders and overdose
Complications Timeframe Likelihood

sexually transmit ted infection variable medium
FOLLOW UP
Adolescents and young adults are more than three times more likely to develop sexually transmitted
infections compared with age- and sex-matched controls.[21]
Overview of sexually transmitted infections
accidental injury variable medium
People with ADHD have been found to be at greater risk of accidental injury including road traffic
accidents and minor traumatic brain injury.[21]
stimulant-related substance use disorder variable low
Atomoxetine should be used first line. If adjunct stimulants are needed, a long-duration formulation is
recommended. Stimulants should be stopped if they are misused.
stimulant-induced cardiac events variable low
Stimulants should be stopped if arrhythmia occurs. A careful cardiac history (including family history of
sudden death or arrhythmia, symptoms including syncope, dyspnoea with exertion) should be obtained. In
cases where there are symptoms of concern or a history of such symptoms, ECG/cardiology consultation
should be obtained prior to starting a stimulant.
Cardiovascular effects of long-term extended-release mixed amfetamine salts (≤60 mg/day) are not
expected in otherwise healthy adults with ADHD.
atomoxetine-induced cardiac events variable low
Approximately 6%-12% of adults and children experience clinically relevant changes in heart rate (20 bpm
or greater) and blood pressure (15-20 mmHg or greater). It is recommended that heart rate and blood
pressure are measured and recorded on a centile chart before treatment is started and, during treatment,
after each adjustment of dose; and then at least every 6 months to detect possible clinically important
increases.
suicidal beahviours variable low
ADHD is associated with an increase in suicidal attempts (OR 2.37, 95% CI 1.64 to 3.43), suicidal
ideations (OR 3.53, 95% CI 2.94 to 4.25), suicidal plans (OR 4.54, 95% CI 2.46 to 8.37), and completed
suicide (OR 6.69, 95% CI 3.24 to 17.39).[98]
Suicide risk management
premature death variable low
Mostly due to accidental death or suicide.[21]
45
Prognosis
FOLLOW UP
Treatment response of ADHD occurring in adults to a satisfactory quality of life and treated with stimulant
medication is about 60%. Where comorbid mood and anxiety conditions occur, they are also highly
treatable. In resistant cases of ADHD with mood or anxiety disorder, ADHD psychopharmacology should
be considered. Psychological therapy participation and training in planning and time-structuring skills can
provide patients with coping strategies for ongoing use and enhance the benefits of ADHD medication
treatment.
At tention deficit hyperactivity disorder in adults Guidelines
Diagnostic guidelines
United Kingdom
At tention deficit hyperactivity disorder: diagnosis and management (ht tps://

www.nice.org.uk/guidance/ng87)
Published by: National Institute for Health and Care Excellence Last published: 2019
ADHD in adults: good practice guidelines (ht tps://

www.rcpsych.ac.uk/docs/default-source/members/divisions/scotland/
adhd_in_adultsfinal_guidelines_june2017.pdf?sfvrsn=40650449_2)
Published by: Royal College of Psychiatrists in Scotland Last published: 2017
Europe
GUIDELINES
Updated European consensus statement on diagnosis and treatment of adult
ADHD (ht tps://www.sciencedirect.com/science/article/pii/S0924933818301962?
via%3Dihub)
Published by: European Network Adult ADHD Last published: 2019
International
World Federation of ADHD International consensus statement (ht tps://

www.adhd-federation.org/publications/international-consensus-
statement.html)
Published by: World Federation of ADHD Last published: 2021
North America
Canadian ADHD practice guidelines (4th ed) (ht tps://adhdlearn.caddra.ca/

purchase-guidelines)
Published by: Canadian ADHD Resource Alliance Last published: 2020
Diagnostic and statistical manual of mental disorders, 5th edition, text

revision (DSM-5-TR) (ht tps://www.psychiatry.org/psychiatrists/practice/dsm)
Published by: American Psychiatric Association Last published: 2022
Africa
The South African Society of Psychiatrists/Psychiatry Management Group

management guidelines for adult at tention-deficit/hyperactivity disorder
(ht tps://sajp.org.za/index.php/sajp/article/view/1060/842#7)
Published by: South African Society of Psychiatrists; Psychiatry Last published: 2017
Management Group
47
Treatment guidelines
United Kingdom
Recommendations for occupational therapy interventions for adults with

ADHD: a consensus statement from the UK Adult ADHD Network (ht tps://
www.ukaan.org/papers)
Published by: UK Adult ADHD Network Last published: 2021
At tention deficit hyperactivity disorder: diagnosis and management (ht tps://

www.nice.org.uk/guidance/ng87)
Published by: National Institute for Health and Care Excellence Last published: 2019
ADHD in adults: good practice guidelines (ht tps://

www.rcpsych.ac.uk/docs/default-source/members/divisions/scotland/
GUIDELINES
adhd_in_adultsfinal_guidelines_june2017.pdf?sfvrsn=40650449_2)
Published by: Royal College of Psychiatrists in Scotland Last published: 2017
Europe
Updated European consensus statement on diagnosis and treatment of adult

ADHD (ht tps://www.sciencedirect.com/science/article/pii/S0924933818301962?
via%3Dihub)
Published by: European Network Adult ADHD Last published: 2019
International
World Federation of ADHD International consensus statement (ht tps://

www.adhd-federation.org/publications/international-consensus-
statement.html)
Published by: World Federation of ADHD Last published: 2021
North America
Canadian ADHD practice guidelines (4th ed) (ht tps://adhdlearn.caddra.ca/

purchase-guidelines/)
Published by: Canadian ADHD Resource Alliance Last published: 2020
Africa
The South African Society of Psychiatrists/Psychiatry Management Group

management guidelines for adult at tention-deficit/hyperactivity disorder
(ht tps://sajp.org.za/index.php/sajp/article/view/1060/842#7)
Published by: South African Society of Psychiatrists; Psychiatry Last published: 2017
Management Group
GUIDELINES
49
At tention deficit hyperactivity disorder in adults Online resources
Online resources
1. Adult ADHD Self-Report Scale (ASRS-v1.1) symptom checklist - 18 item (https://add.org/wp-content/
uploads/2015/03/adhd-questionnaire-ASRS111.pdf) (external link)
2. Adult ADHD Self-Report Scale (ASRS-v1.1) Screener - 6 item (http://www.hcp.med.harvard.edu/ncs/

ftpdir/adhd/6Q_ASRS_English.pdf) (external link)
3. Children and adults with attention-deficit/hyperactivity disorder (CHADD) (http://www.chadd.org)

(external link)
4. Helpguide.org: adult ADD/ADHD (https://www.helpguide.org/articles/add-adhd/adhd-attention-deficit-

disorder-in-adults.htm) (external link)
5. National Institute of Mental Health (NIMH): attention deficit hyperactivity disorder (ADHD) (http://
www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml) (external
link)
ONLINE RESOURCES
At tention deficit hyperactivity disorder in adults Evidence tables
Evidence tables
What are the effects of lisdexamfetamine or methylphenidate as first-line
EVIDENCE TABLES
pharmacological treatments for adults with at tention deficit hyperactivity
disorder (ADHD)?[67]
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review)
that focuses on the above important clinical question.
View the full source guideline (https://www.nice.org.uk/guidance/ng87)
Evidence B * Confidence in the evidence is moderate or low to moderate where GRADE has
been performed and the intervention may be more effective/beneficial than the
comparison for key outcomes.
Population: Adults with ADHD

Intervention: Lisdexamfetamine or methylphenidate ᵃ
Comparison: Placebo ᵃ
† ‡
Outcome Effectiveness (BMJ rating) Confidence in evidence (GRADE)
Immediate-release methylphenidate versus placebo
Treatment response (follow-up Favours intervention Moderate

3-6 weeks) ᵇ
ADHD symptoms (Conners’ No statistically significant Low

Adult ADHD Rating Scales - difference
inattention subscale [CAARS]
or Barkley Adult ADHD Rating
Scale - final values; follow-up:
3-4 weeks)
ADHD symptoms (ADHD- No statistically significant Very Low

Rating Scale [ADHD-RS] - difference
change scores; follow-up: 7
weeks)
Clinical Global Impression No statistically significant Moderate

(CGI) score of 1 or 2 (follow- difference
up: 7 weeks)
Discontinued due to adverse Occurs more commonly High

events (follow-up: 3-7 weeks) with immediate-release
methylphenidate compared with
placebo (favours comparison)
51
† ‡
Controlled-release methylphenidate versus placebo

EVIDENCE TABLES
Quality of life (Quality-of-Life No statistically significant High

Enjoyment and Satisfaction difference
Questionnaire)
Treatment response (follow-up Favours intervention Moderate

6-8 weeks) ᶜ
ADHD total symptoms Favours intervention Moderate to Low

(investigator or self-rated;
multiple scales including
CAARS and ADHD-RS total
scores; up to 13 week's follow-
up)
ADHD inattention symptoms Favours intervention Moderate to Low

(investigator or self-rated;
CAARS; up to 8 weeks' follow-
up)
ADHD inattention symptoms No statistically significant Low

(investigator rated; CAARS); difference
change scores; at 13 weeks'
follow-up)
ADHD hyperactivity symptoms No statistically significant Low

(investigator or self-rated; difference
CAARS or ADHD-RS
hyperactivity subscale; up to
13 weeks' follow-up)
ADHD hyperactivity symptoms Favours intervention Low

(investigator rated; CAARS
hyperactive subscale; change
scores; at 5-8 weeks' follow-
up)
CGI score of 1 or 2 (follow-up: Favours intervention High

8 weeks); 7-13 weeks
Discontinued due to adverse Occurs more commonly High

events (follow-up: 6-13 weeks) with controlled-release
methylphenidate compared with
† ‡
Lisdexamfetamine versus placebo
EVIDENCE TABLES
Quality of life (Adult ADHD Favours intervention Very Low
Quality-of-Life Questionnaire);
10 weeks
ADHD total symptoms Favours intervention Moderate

investigator rated (ADHD-RS
total scores); change scores
reported; 4-10 weeks
ADHD inattention symptoms Favours intervention Low

investigator rated (ADHD-
RS inattention subscale); 10
weeks
ADHD hyperactivity symptoms Favours intervention Low

investigator rated (ADHD-RS
hyperactivity subscale); 10
weeks
CGI score of 1 or 2 (follow-up: Favours intervention Moderate

4 weeks)
Discontinuation due to adverse Occurs more commonly with Low

events (follow-up 4-6 weeks) lisdexamfetamine compared with
Recommendations as stated in the source guideline

The National Institute for Health and Care Excellence (NICE) 2019 guideline update on Attention deficit
hyperactivity disorder: diagnosis and management makes the following recommendation:
Offer lisdexamfetamine or methylphenidate as first-line pharmacological treatment for adults with

ADHD. Note that this is an off-label use of lisdexamfetamine for some adults, and some preparations of
methylphenidate.
Note
• The overall rating in this table is based upon outcomes which have been deemed critical for decision
making by the guideline development group. Please see the full text guideline for additional information
on outcomes classified as important
• The guideline committee noted that the drugs that showed a most convincing clinically important
benefit from the evidence were methylphenidate, lisdexamfetamine, dexamfetamine, atomoxetine, and
guanfacine.
• The committee discussed that stimulant medications (e.g., methylphenidate, lisdexamfetamine)

generally have a faster onset compared to non-stimulant medications (e.g., atomoxetine, guanfacine).
53
Therefore, they felt that it is better to use a stimulant medication as first-line treatment to allow more
rapid assessment of whether a person is responsive.
• Lisdexamfetamine is a pro-drug of dexamfetamine. The committee agreed, based on consensus,

EVIDENCE TABLES
that dexamfetamine should only be prescribed when someone has responded very well to
lisdexamfetamine but is unable to tolerate its longer effect profile.
ᵃ The guideline considered the evidence for other pharmacological treatments for ADHD in adults including
atomoxetine, guanfacine, venlafaxine, and modafinil. In addition to placebo, they also looked at active
comparisons (different medications versus each other). See guideline for more information.
ᵇ Two studies, defined at a 30% decrease in ADHD investigator symptom rating scale (AISRS) and Clinical
Global Impression Scale-Improvement (CGI-I) of 1 or 2; or a decrease of at least 2 points on CGI-Severity
scale and a 30% reduction on DSM-IV rating scale.
ᶜ Three studies, defined as CGI-I of 1 or 2 and a 30% reduction on the AISRS (2 studies), or a 30% reduction
on Wender-Reimherr Adult Attention Deficit Disorder Scale.
What are the effects of dexamfetamine compared with placebo for adults with
at tention deficit hyperactivity disorder (ADHD)?[67]
EVIDENCE TABLES
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review)
that focuses on the above important clinical question.
View the full source guideline (https://www.nice.org.uk/guidance/ng87)
Evidence B * Confidence in the evidence is moderate or low to moderate where GRADE has
been performed and the intervention may be more effective/beneficial than the
comparison for key outcomes.
Population: Adults with ADHD

Intervention: Dexamfetamine
Comparison: Placebo
† ‡
ADHD symptoms (follow-up: Favours intervention Moderate

6-7 weeks)
ADHD symptoms: inattentive Favours intervention Moderate

subscale (follow-up: 6-7
weeks)
ADHD symptoms: hyperactive Favours intervention Moderate

subscale (follow-up: 6-7
weeks)
Clinical Global Impression- Favours intervention Moderate

Improvement score of 1 or 2
(follow-up: 6 weeks)
Recommendations as stated in the source guideline

The National Institute for Health and Care Excellence (NICE) 2019 guideline update on Attention deficit
hyperactivity disorder: diagnosis and management makes the following recommendation:
Consider dexamfetamine for adults whose ADHD symptoms are responding to lisdexamfetamine but who
cannot tolerate the longer effect profile. Note that this is an off-label use.
Note
Lisdexamfetamine is a pro-drug of dexamfetamine. The guideline committee agreed, based on consensus,
that dexamfetamine should only be prescribed when someone has responded very well to lisdexamfetamine
but is unable to tolerate its longer effect profile.
55
* Evidence levels
The Evidence level is an internal rating applied by BMJ Best Practice. See the EBM Toolkit (https://
bestpractice.bmj.com/info/evidence-tables/) for details.
EVIDENCE TABLES
Confidence in evidence
A - High or moderate to high

B - Moderate or low to moderate
C - Very low or low
† Effectiveness (BMJ rating)

Based on statistical significance, which demonstrates that the results are unlikely to be due to chance, but
which does not necessarily translate to a clinical significance.
‡ Grade certainty ratings
High The authors are very confident that the true

effect is similar to the estimated effect.
Moderate The authors are moderately confident that
the true effect is likely to be close to the
estimated effect.
Low The authors have limited confidence in the
effect estimate and the true effect may be
substantially different.
Very Low The authors have very little confidence in
the effect estimate and the true effect is
likely to be substantially different.
BMJ Best Practice EBM Toolkit: What is GRADE? (https://bestpractice.bmj.com/info/toolkit/learn-ebm/what-
is-grade/)
At tention deficit hyperactivity disorder in adults References
Key articles
• American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed, text
REFERENCES
revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.
• National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis
and management. September 2019 [internet publication]. Full text (https://www.nice.org.uk/guidance/
NG87)
• Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD International
Consensus Statement: 208 evidence-based conclusions about the disorder. Neurosci Biobehav
Rev. 2021 Sep;128:789-818. Full text (https://www.adhd-federation.org/publications/international-
consensus-statement.html) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/33549739?
tool=bestpractice.bmj.com)
References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed, text
revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.
2. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis
and management. September 2019 [internet publication]. Full text (https://www.nice.org.uk/guidance/
NG87)
3. Kates N. Attention deficit disorder in adults. Management in primary care. Can Fam Physician. 2005
Jan;51(1):53-9. Full text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479568) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/15732222?tool=bestpractice.bmj.com)
4. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the
United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006
Apr;163(4):716-23. Full text (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859678) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/16585449?tool=bestpractice.bmj.com)
5. Rollini M, Baud P. Pharmacological treatment of attention-deficit/hyperactivity disorder in adults

[in French]. Rev Med Suisse. 2008 Jul 16;4(165):1638-43. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/18767289?tool=bestpractice.bmj.com)
6. Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult

attention-deficit hyperactivity disorder. Br J Psychiatry. 2007 May;190:402-9. Full text (http://
bjp.rcpsych.org/content/190/5/402.long) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/17470954?
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8. Simon V, Czobor P, Bálint S, et al. Prevalence and correlates of adult attention-deficit
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69
Contributors:
// Authors:
Marios Adamou, MD, MSc, LL.M, MA, MBA, PhD, FRCPsych, FFOM
Consultant Psychiatrist
South West Yorkshire NHS Partnership Foundation Trust, University of Huddersfield, Huddersfield, UK
DISCLOSURES: MA has provided consultancy to Takeda the manufacturer of Elvanse.
// Acknowledgements:
Professor Marios Adamou would like to gratefully acknowledge Dr Bridget Craddock, Dr S. Nassir Ghaemi,
and Dr Elizabeth A. Whitham, the previous contributors to this topic.
DISCLOSURES: BC declares that she has no competing interests. SNG has received research grants
from Pfizer, served on the speakers' bureaus of Astra Zeneca and Pfizer, and received honoraria from
Bristol Myers Squibb. Neither SNG nor his family hold equity positions in pharmaceutical corporations. EAW
declares that she has no competing interests.
// Peer Reviewers:
Gianni Faedda, MD
Lucio Bini Mood Disorders Center
New York, NY
DISCLOSURES: GF has been reimbursed by Astra Zeneca, the manufacturer of Seroquel, for attending
several conferences.
David W. Goodman, MD
Assistant Professor
Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD
DISCLOSURES: DWG has received research grants from Shire Pharmaceuticals. DWG has received
speaking fees from Neuroscience Education Institute, Temple University, American Professional Society
of ADHD and Related Disorders, Medscape, and WebMD. DWG has been a paid consultant to American
Physician Institute for Advanced Professional Studies, Prescriber's Letter, Consumer Reports, Thomson
Reuters, GuidePoint Global, Shire Pharmaceuticals, McNeil Pediatrics, Cephalon, Teva Pharmaceuticals,
Lundbeck, Otsuka Pharmaceuticals, and Novartis.

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At tention deficit

Last updated: Jan 04, 2023

• Childhood adversity is strongly associated with ADHD symptoms[24], as are non-shared

• Whole brain volume reduction.

• Inattention and hyperfocus

• May be slow to think and formulate due to distractions

Impact on patients and their families

Psychological and medical tests

• Matching of familiar figures (impulsivity)

Assessment of psychiatric/neurodevelopmental comorbidity is another essential facet of diagnosis of

History and exam

Key diagnostic factors

onset prior to age 12 years (common)

present or past occupational dysfunction (common)

familial and relationship dysfunction (common)

drug and alcohol use disorders (common)

thrill-seeking behaviour (common)

driving accidents (common)

unable to pay at tention to details resulting in ‘careless’ mistakes at work,

has difficulty maintaining at tention in tasks (common)

seems not to listen when being spoken to (common)

has organisational difficulties (common)

avoids, dislikes, or is reluctant to engage in tasks that require maintaining

frequently forget ful in daily activities (common)

fidgets often with hands or feet and moves in seat (common)

frequently leaves situations, rises from chair when remaining seated is

often feels restless (common)

has difficulty engaging in leisure activities quietly (common)

often 'on the go', acting as if 'driven by a motor' (common)

often talks excessively (common)

often interrupts with answers before questions have been completed

often interrupts or intrudes on others (e.g., interrupting conversations)

increased criminal justice system involvement (uncommon)

distracted easily by surroundings and external stimuli (uncommon)

other environmental factors

Other tests to consider

brain imaging (CT or MRI) normal or with findings

computer-based programme impairment in domains

Condition Differentiating signs / Differentiating tests

Bipolar disorder in adults • Significant mood instability: • Diagnosis based on DSM-5-

Psychosis • Delusions (fixed false • Diagnosis based on DSM-5-

Specific learning disorder • Circumscribed difficulties • Standardised testing in

Language disorder • Circumscribed difficulties • Standardised testing in

Condition Differentiating signs / Differentiating tests

Intellectual disability • Known IQ of ≤70. • IQ testing: score of ≤70.

Seizure disorder • Observer report of sudden • Brain MRI: usually normal

incontinence. activity may be detected

Medication side effects • Recent initiation of • Urine and/or serum drug

Condition Differentiating signs / Differentiating tests

Sleep disorder • Snoring history (patient or • Sleep studies/

Hypothyroidism • Tiredness. • Thyroid-stimulating hormone

Perimenopause • Fatigue. • Follicle-stimulating hormone

Age-related cognitive • Normal ageing is • Diagnosis involves excluding

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or

tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Often fidgets or taps with hands or feet, or squirms in seat.

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.