Adult ADHD Workup and Treatment
The recommended workup for adult ADHD requires comprehensive diagnostic assessment including standardized rating scales, clinical interviews, and evaluation of comorbidities, followed by a multimodal treatment approach with FDA-approved medications (stimulants as first-line) combined with Cognitive Behavioral Therapy for optimal outcomes. 1
Diagnostic Workup
Initial Assessment
- Use standardized ADHD rating scales (such as CAARS - Conners Adult ADHD Rating Scale) 1, 2
- Conduct comprehensive clinical interview assessing:
- Childhood history of symptoms (must have started before age 12)
- Current symptoms across multiple settings
- Functional impairment in academic, occupational, and social domains
- Family history of ADHD (high heritability) 3
Corroborating Information
- Obtain information from family members, partners, or close friends 4
- Review school records when available (especially for evidence of childhood symptoms)
- Assess executive function deficits in:
- Working memory (visuospatial and verbal)
- Inhibitory control
- Vigilance and attention
- Planning and organization
- Reward regulation 3
Differential Diagnosis and Comorbidity Assessment
- Screen for common comorbidities:
- Mood disorders (depression, bipolar disorder)
- Anxiety disorders
- Substance use disorders (present in many adults with ADHD) 5
- Sleep disorders
- Learning disabilities
Medical Considerations
- Assess for cardiac disease (family history, physical exam) before medication initiation 6
- Screen for history of tics or Tourette's syndrome 6
- Consider baseline vital signs (BP, HR) before stimulant therapy
Treatment Approach
Pharmacological Treatment (First-line)
Stimulant Medications
Methylphenidate-based medications:
Amphetamine-based medications:
- Similar efficacy to methylphenidate
- Titrate according to response
- Monitor for side effects including cardiovascular effects 1
Non-Stimulant Medications (for patients with contraindications to stimulants)
Atomoxetine (Strattera):
Other non-stimulant options:
Psychosocial Interventions
Cognitive Behavioral Therapy (CBT):
- Most effective non-pharmacologic treatment 1
- Addresses executive functioning deficits
- Targets comorbid depression and anxiety
- Focuses on time management, organization, and planning skills
Psychoeducation:
- Essential component of treatment
- Helps patients understand ADHD as a chronic neurodevelopmental disorder
- Addresses misconceptions about the condition 3
Combined Approach
- Combination of medication and CBT shows superior outcomes compared to either treatment alone 1, 2
- For optimal results with atomoxetine, combine with CBT 1
Monitoring and Follow-up
- Schedule follow-up within 2-4 weeks after medication initiation 1
- Regular assessment of:
- ADHD symptoms using standardized scales
- Blood pressure and heart rate
- Weight and appetite changes
- Sleep patterns
- Mood changes
- Suicidal ideation (particularly when initiating treatment) 1
Important Considerations
- Substance use disorders: Screen carefully as ADHD increases risk; consider atomoxetine or extended-release stimulants with close monitoring 5
- Cardiovascular risk: Assess cardiac status before stimulant therapy; monitor BP and HR regularly 6
- Medication abuse potential: Be aware of stimulant diversion risk; consider non-stimulants for patients with history of substance abuse 6
- Medication timing: For adults with insomnia, administer last stimulant dose before 6 PM 6
Treatment Pitfalls to Avoid
- Failing to assess for childhood onset of symptoms (required for diagnosis)
- Overlooking common comorbidities that may complicate treatment
- Inadequate dosing of medications (many patients require higher doses than initial)
- Not combining pharmacotherapy with psychosocial interventions
- Infrequent monitoring of medication effects and side effects
- Discontinuing treatment prematurely (ADHD is a chronic condition requiring ongoing management)