Adults and Attention-Deficit /

Hyperactivity Disorder (ADHD):

Diagnostics, Treatments, Challenges
Edward Thomas Lewis III, M.D.
Clinical Assistant Professor
Attending Physician, Institute of Psychiatry
Associate Director, Forensic Psychiatry Fellowship

Medical University of South Carolina

Department of Psychiatry and Behavioral Sciences
Division of Community and Public Safety Psychiatry
 Acknowledgments &
Disclosures
• Addiction Psychiatry background

• Not subspecialty trained in child and adolescent

psychiatry

• No relevant financial disclosures

 Goals and Objectives
• Explore background information about
ADHD

• Diagnosing ADHD in Adults

• Discuss common treatments for ADHD

• Understand challenges in working with

adults who present with ADHD
symptoms
 What is ADHD?
Consistent pattern of inattention
and/or hyperactivity-impulsivity
that interferes with functioning
and/or development.

Inattention

Hyperactivity

Impulsivity
 Inattention
Wandering off task

Lacking persistence

Difficulty sustaining focus

Disorganized
 Not due to defiance or lack of
comprehension
 Hyperactivity
Excessive motor activity

Fidgeting

Tapping

Talkativeness

Extreme restlessness (in adults)

 Frustrating peers due to elevated
activity
 Impulsivity
Hasty actions that occur in the
moment
 Minimal forethought

High potential for harm to the

individual

Social Intrusiveness

Major Life Decisions

 ADHD: How Common?
Global population surveys suggest
ADHD occurs in about 5% of
children and 2.5% of adults.

More frequent in males than females

 2:1 M:F in children
 1.6:1 M:F in adults

50% of children with ADHD will

experience attenuation of symptoms
as they progress into adulthood
 Adult ADHD: How Common?
2.5 – 4.0% of the population

Hyperactive / Impulsive
presentation is more common in
males

Adults with ADHD have 4 – 9x

higher prevalence of comorbid
mental health diagnoses
 Bipolar Disorder
 Anxiety Disorders
 ADHD: Risk Factors
Very low birth weight

Smoking during pregnancy

History of child abuse, neglect,

multiple foster placements,
neurotoxin, infection, or alcohol
exposure in utero

First degree biological relative with

ADHD
 ADHD: Progression of Symptoms

Begins in childhood

Hyperactivity predominates in
preschool-aged children

Most often identified in elementary

school
 Inattention is often predominant
 ADHD: Progression of Symptoms
Hyperactivity may improve into
adolescence and adulthood, but
restlessness, inattention, poor
planning, and impulsivity persist

Substantial number of children

with ADHD will remain relatively
impaired into adulthood
 Negative Consequences of ADHD
Reduced educational performance
Social rejection
Poorer occupational performance
Higher probability of unemployment
Interpersonal conflict
More likely to be injured
Traffic accidents
Obesity
Incarceration
Conduct Disorder
Substance Use Disorders
Diagnosing Adult ADHD

https://www.advancingadhd.com/diagnosis
Diagnosing Adult ADHD

https://www.advancingadhd.com/diagnosis
 Emotional Dysregulation (ED)
Deficiency in executive or cognitive
management of emotions
 Self-regulation of frustration, impatience, anger

Emotional Impulsivity
 Mesolimbic Circuitry (“Bottom Up”)

Deficient Emotional Self-Regulation

 Prefrontal Cortex (“Top Down”)

Not in DSM-5

35-70% adults with ADHD experience ED

Testing for ADHD: Behavior Rating
Scales

https://www.jaacap.org/article/S0890-8567(09)62182-1/fulltext
Testing for ADHD: Behavior Rating
Scales

https://www.jaacap.org/article/S0890-8567(09)62182-1/fulltext
 Adult ADHD: Scales and Testing
Role for Neuropsychological
Testing
 Continuous Performance Test (CPT)

World Health Organization

(WHO) Adult ADHD Self-Report
Scale (ASRS)

Brown Attention-Deficit Disorder

Scale (BADDS)
 Adult ADHD: ASRS
Six question scale

Designed for community samples

Positive results require follow-up

diagnostic assessment by trained a
clinician
 Score of four or greater is positive
Adult ADHD: ASRS

https://www.hcp.med.harvard.edu/ncs/asrs.php
Adult ADHD: ASRS

https://www.hcp.med.harvard.edu/ncs/asrs.php
 Adult ADHD: BADDS
40-item screening instrument

Designed for primary/preschool,

school-age, adolescent, and adult
populations

Based on Thomas Brown’s model of

cognitive impairment in ADHD
Treating Adult ADHD: Pharmacotherapy
Stimulant medications are front-line management
 National Comorbidity Survey Replication (NCS-R)

FDA approved medications for Adult ADHD

 Extended release mixed amphetamine salts (Adderall
XR)
 Lisdexamfetamine dimesylate (Vyvanse)
 Atomoxetine (Strattera)

Bupropion (Wellbutrin)
 Treating Adult ADHD: Psychosocial
Treatments
CBT
 Negative Thoughts
 Perfectionism
 Over-estimation of one’s
competence
 Comorbid Depression, Anxiety

Organizational Skills Training

Data for CBT in children vs. adults http://namirockland.org/cbt.html

with ADHD
Treating Adult ADHD: Substance Use
Disorders (SUD)
 Neurobiology of Addiction

https://www.google.com/search?q=hijacking+of+limbic+system&source=lnms&tbm=isch&sa=X&ved=0ahUKEwj3t97R9IvfAhWoTd8KHckaCl0Q_AUIDigB&biw=1920&bih=934#imgrc=-V6hjWyv2C_tUM:&spf=1544123599719
 Neurobiology of Addiction:
Hijacking of Limbic System

https://www.google.com/search?q=hijacking+of+limbic+system&rls=com.microsoft:en-US:IE-Address&source=lnms&tbm=isch&sa=X&ved=0ahUKEwimnp_M-ovfAhVikuAKHbQlCaQQ_AUIDigB&biw=1920&bih=934#imgrc=UDv2lr0cOu8gXM:&spf=1544125201097
Neurobiology of Addiction

Needing
Liking Wanting

Repeated use over time

 Treating Adult ADHD: Substance Use
Disorders (SUD)
ADHD has a prevalence of 22% in adults
with SUD
 More severe disease burden
 Higher comorbidity

Dopamine System
 Reward Pathways
 Prefrontal Cortex

Medication Management
 Strategies

Psychotherapy
 Treating Adult ADHD: Psychiatric
Comorbidities

Bipolar Disorder

Anxiety Disorders

Depressive Disorders
 References
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arlington, VA: Author.

• Faraone, S. V., & Antshel, K. M. (2008). Diagnosing and treating attention-deficit/hyperactivity disorder in
adults. World psychiatry : official journal of the World Psychiatric Association (WPA), 7(3), 131–136.

• Giulio Perugi, Alessandro Pallucchini, Salvatore Rizzato, Vito Pinzone & Pietro De Rossi (2019) Current and
emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD), Expert
Opinion on Pharmacotherapy, DOI: 10.1080/14656566.2019.1618270

• Lopez PL, Torrente FM, Ciapponi A, Lischinsky AG, Cetkovich‐Bakmas M, Rojas JI, Romano M, Manes FF.
Cognitive‐behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane
Database of Systematic Reviews 2018, Issue 3. Art. No.: CD010840. DOI: 10.1002/14651858.CD010840.pub2.

Scrandis, Debra. Diagnosing and treating ADHD in adults. The Nurse Practitioner. 43(1):8–10, JANUARY
15, 2018 DOI: 10.1097/01.NPR.0000527741.90830.97. PMID: 29240618.

Van der Burg, D., Crunelle, CL, Matthys, F, Van den Brink, W. diagnosis and treatment of patient with
comorbid substance use disorder and adult attention-deficit and hyperactivity disorder: a review of
recent publications. Curr Opin Psychiatry. 2019 Jul;32(4):300-306.
 Questions?

Contact: Lewiset@musc.edu