What are the symptoms and treatment options for Adult Attention Deficit Hyperactivity Disorder (ADHD)?

Adult ADHD: Symptoms and Treatment Options

Stimulant medications are the first-line treatment for adult ADHD due to their superior efficacy compared to non-stimulants, with psychotherapy as an important adjunctive treatment. 1

Symptoms of Adult ADHD

Adult ADHD presents with two primary symptom clusters:

Inattentive Symptoms

• Lack of attention to details/careless mistakes
• Difficulty sustaining attention
• Poor listening skills
• Failure to follow through on tasks
• Poor organization
• Avoidance of tasks requiring sustained mental effort
• Frequently losing things
• Easy distractibility
• Forgetfulness in daily activities 2

Hyperactive-Impulsive Symptoms

• Fidgeting/squirming
• Difficulty remaining seated
• Inappropriate restlessness
• Difficulty engaging in quiet activities
• Often "on the go"
• Excessive talking
• Blurting out answers
• Difficulty waiting turn
• Frequently interrupting others 2

For an adult ADHD diagnosis, symptoms must cause functional impairment across multiple settings, with approximately 2.5% of adults affected 3. Adults typically experience less hyperactivity but more problems with inattentiveness, restlessness, and executive dysfunction 4.

Treatment Algorithm

First-Line Pharmacotherapy

1. Stimulant Medications
   • Methylphenidate-based medications (effect size ~1.0)
   • Amphetamine-based medications (particularly effective for adults)
   • Start at low doses and titrate based on response
   • Target dose for optimal efficacy: individualized based on response 1

Second-Line Pharmacotherapy (if stimulants contraindicated or ineffective)

1. Atomoxetine (Strattera)

   • Starting dose: 40mg daily for adults >70kg
   • Target dose: 80mg daily, may increase to maximum 100mg daily
   • Effect size ~0.7 (less than stimulants) 1, 2

2. Extended-release guanfacine (Intuniv)

   • Starting dose: 1mg daily 1

3. Extended-release clonidine (Kapvay)

   • Starting dose: 0.1mg daily 1

4. Bupropion

   • Alternative for adults with comorbid depression 5

Special Considerations

• For comorbid anxiety: Consider atomoxetine or alpha-2 agonists 1
• For history of substance abuse: Consider atomoxetine as first-line 1
• For tic disorders: Consider atomoxetine 1
• For partial response: Combination therapy (stimulant + alpha-2 agonist) may be beneficial 1

Psychosocial Treatments

• Cognitive-behavioral therapy (CBT): Focuses on time management, organization, planning, emotional regulation, and impulse control 1
• Mindfulness-based interventions: Particularly helpful for inattention symptoms and emotional regulation 1
• Behavioral therapy: Helps address functional impairments in work and relationships 6

Monitoring and Follow-up

• Regular assessment of blood pressure, heart rate, and weight
• Monitor for side effects:
  • Stimulants: appetite loss, insomnia, cardiovascular effects
  • Atomoxetine: initial somnolence, gastrointestinal symptoms, liver function, suicidal ideation 1

Common Pitfalls and Caveats

1. Misdiagnosis: Adult ADHD is often misdiagnosed as atypical depression, mixed affective disorder, or personality disorders 6
2. Untreated comorbidities: ADHD frequently co-occurs with anxiety, depression, and substance use disorders 7
3. Medication diversion: Consider controlled substance agreements and prescription drug monitoring programs for stimulant medications 7
4. Inadequate dose optimization: Insufficient dosing can lead to treatment failure
5. Neglecting psychosocial interventions: Medication alone may not address all functional impairments 1

If left untreated, adult ADHD can significantly impair quality of life, affecting educational achievement, employment status, relationships, and increasing risk of substance misuse 3, 4.