ADHD Screening and Treatment in a 28-Year-Old Male
The recommended approach for ADHD screening in a 28-year-old male involves a comprehensive assessment using standardized rating scales from multiple sources, followed by first-line treatment with stimulant medications such as methylphenidate or amphetamine derivatives if ADHD is diagnosed. 1, 2
Screening and Diagnostic Assessment
Standardized Assessment Tools
- Use validated screening instruments:
Key Diagnostic Criteria
- Must document at least 5 symptoms of inattention and/or hyperactivity-impulsivity for at least 6 months 3, 4
- Symptoms must have been present before age 12 3, 4
- Symptoms must occur in at least two settings (e.g., work, home, social) 4
- Clear evidence of functional impairment in social, academic, or occupational domains 2
Assessment of Inattentive Symptoms
- Difficulty maintaining focus
- Making careless mistakes
- Struggling with following through on instructions
- Poor organization
- Easily distracted
- Forgetful in daily activities 1, 3
Assessment of Hyperactivity/Impulsivity Symptoms
- Feeling restless
- Interrupting others
- Difficulty waiting turn
- Excessive talking
- "On the go" behavior 1, 3
Critical Screening for Comorbidities
Psychiatric Comorbidities
- Screen for:
Bipolar Disorder Screening
- Always screen for personal or family history of bipolar disorder, mania, or hypomania before starting medication 3
- Note key differences:
Feature ADHD Bipolar Disorder Symptom onset Before age 12 Typically after age 12 Course Chronic, persistent Episodic, cyclical Mood symptoms Not primary feature Central to diagnosis Psychotic symptoms Absent May be present
Treatment Approach
Pharmacological Treatment
First-Line Medications
- Stimulants (methylphenidate and amphetamine derivatives) are first-line pharmacotherapy with high strength of evidence 1, 2, 5
- For adults over 70 kg: Start atomoxetine at 40 mg/day, increase after 3 days to target dose of 80 mg/day
- After 2-4 weeks, may increase to maximum of 100 mg if needed
- Can be administered as single morning dose or divided doses (morning and late afternoon) 3
Second-Line Medications
- For patients who cannot tolerate stimulants or have contraindications:
Non-Pharmacological Interventions
- Cognitive-behavioral therapy focused on:
- Organization skills
- Time management
- Emotional regulation 1
Monitoring and Follow-up
Follow-up Schedule
- Monthly visits until symptoms stabilize
- Monitor for:
- Treatment response
- Side effects
- Medication adherence 1
Long-term Management
- Periodically reevaluate the need for continued medication
- Assess for any emerging comorbidities
- Monitor for potential medication diversion or misuse 1, 3
Common Pitfalls to Avoid
- Do not rely solely on self-report - Adults may minimize or exaggerate symptoms 1
- Do not fail to screen for substance use before initiating stimulants 1
- Do not discontinue treatment prematurely - Untreated ADHD increases risk for substance use disorders, depression, and underachievement 1
- Do not overlook the need to screen for bipolar disorder before starting medication 3
- Do not miss the potential for medication diversion - Consider using controlled substance agreements when prescribing stimulants 2
ADHD in adults is a legitimate neurodevelopmental disorder affecting approximately 3-5% of adults, with symptoms that can significantly impact quality of life, occupational functioning, and relationships 2, 6. Proper screening, diagnosis, and treatment can substantially improve outcomes and quality of life.