What is the diagnosis and treatment approach for an adult presenting with symptoms of Attention Deficit Hyperactivity Disorder (ADHD)?

Diagnosis of Adult ADHD

For adults presenting with suspected ADHD, begin screening with the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A, which takes 3-5 minutes and is positive if 4 or more of 6 questions are marked "often" or "very often," then confirm diagnosis through comprehensive clinical interview documenting at least 5 symptoms from either inattentive or hyperactive-impulsive categories present for ≥6 months with onset before age 12 and functional impairment in ≥2 settings. 1

Core Diagnostic Criteria

DSM-5 Requirements for Adults (Age 17+):

• At least 5 symptoms from either inattentive OR hyperactive-impulsive category (not 6 as in children) 1
• Symptoms present for ≥6 months 1
• Symptom onset before age 12 years 1
• Functional impairment in ≥2 settings (work, home, social) 1
• Symptoms not better explained by another mental disorder 1

Clinical Presentation in Adults

Inattentive symptoms predominate in adults and include: 1

• Poor attention to detail 1
• Difficulty concentrating or sustaining attention 1
• Appearing preoccupied 1
• Difficulty completing tasks 1
• Organizational challenges and chronic lateness 1
• Reluctance to engage in sustained mental effort 1
• Forgetfulness in daily activities 1

Hyperactive-impulsive symptoms (less prominent than childhood): 1

• Frequent fidgeting 1
• Difficulty sitting still for prolonged periods 1
• Inner restlessness or agitation 1
• Being loud and disruptive 1
• Always being "on the go" 1
• Talking excessively 1

Critical diagnostic pitfall: Adults with ADHD are notoriously poor self-reporters and often underestimate symptom severity and functional impairment. 1 Collateral information from family, partners, or coworkers is essential. 2

Screening Tools

Primary screening tool: Adult ADHD Self-Report Scale (ASRS-V1.1) Part A 1

• Takes 3-5 minutes to administer 2
• Positive screen: 4 or more of 6 questions marked "often" or "very often" 1

Additional validated assessment tools: 1

• Wender Utah Rating Scales 1, 3
• Brown Attention-Deficit Disorder Scale for Adults 1
• Conners Adult ADHD Rating Scale 1, 4

Mandatory Comorbidity Screening

Screen ALL adults for these high-prevalence comorbidities: 1

• Depression and anxiety (present in ~10% of adults with recurrent depression/anxiety) 1
• Substance use disorders (extremely common; obtain detailed drug/alcohol history and consider urine drug screening) 1
• Bipolar disorder 1
• Personality disorders (especially borderline and antisocial) 1, 5
• Learning disabilities 1
• Sleep disorders (restless leg syndrome, hypersomnolence) 6

Critical point: Treatment of depression/anxiety alone will likely be inadequate without addressing underlying ADHD when both are present. 1 Conversely, misdiagnosis as atypical depression, mixed affective disorder, cyclothymia, or borderline personality disorder is common when ADHD goes unrecognized. 5

Comprehensive Diagnostic Interview Components

Childhood symptom documentation: 3, 2

• Establish presence of ADHD symptoms in childhood (before age 12) 1
• Review school records if available 2
• Interview parents or siblings about childhood behavior 2

Current functional impairment assessment in multiple domains: 1

• Academic/occupational performance 1
• Social relationships 1
• Family functioning 1
• Daily organization and time management 1

Associated features to assess: 1

• Emotional dysregulation 1, 6
• Executive function deficits 6
• Disorganization affecting work and personal life 1
• Chronic lateness and difficulty with time management 1

Differential Diagnosis Considerations

ADHD symptoms overlap substantially with: 4

• Anxiety and stress disorders 4
• Mood disorders (unipolar and bipolar depression) 4, 5
• Personality disorders 4
• Impulse control disorders 4
• Substance use disorders 4

Key distinguishing feature: ADHD symptoms are trait-like, stable characteristics from early childhood, whereas mood/anxiety symptoms typically have episodic onset later in life. 5

Treatment Approach After Diagnosis

First-line pharmacotherapy: Stimulant medications (methylphenidate or amphetamines) 4

• 70-80% response rate 7
• Largest effect sizes among all ADHD medications 7
• Work within days, allowing rapid assessment of response 7

For patients with contraindications to stimulants or concurrent anxiety/depression: 4

• Atomoxetine 4
• Viloxazine 4
• Bupropion 4

Multimodal treatment is essential: 3

• Psychoeducation 6
• Cognitive-behavioral therapy 6
• "Third wave therapies" focusing on emotional regulation 6
• Coaching and organizational skills training 3
• Couples/family therapy when indicated 3

Monitoring requirements: 4

• Controlled substance agreements for stimulants 4
• Prescription drug monitoring programs 4
• Regular assessment for misuse or diversion 4

Common Diagnostic Pitfalls to Avoid

• Do not dismiss ADHD diagnosis because patient has achieved academic/professional success; many adults develop compensation strategies that mask symptoms until demands exceed coping capacity. 1
• Do not rely solely on patient self-report; collateral information is essential given poor self-awareness. 1
• Do not assume comorbid conditions explain all symptoms; ADHD often coexists with and exacerbates other psychiatric disorders. 1
• Do not delay diagnosis in adults presenting with depression/anxiety without first screening for ADHD, as treatment of mood/anxiety alone will be inadequate if ADHD is the underlying condition. 1