ADULT ADHD Presentation -...

What You Don't Know,

You Won't See: Adult ADHD

in the Trenches

Handout for the Neuroscience Education Institute (NEI) online activity:

Learning Objectives

• Explain diagnostic prioritization when

considering treatment for adults with ADHD and

comorbid disorders

• Describe the limitations of neuropsychological

testing that defines executive function

• Evaluate treatment options for adults with ADHD

Copyright © 2014 Neuroscience Education Institute. All rights reserved.

National Comorbidity Survey Replication

• Childhood prevalence in US is 7.8%

- 4.5 million; 56% treated within past year

• Adult prevalence in US is 4.4%

- 9-10 million; <15% treated within past year

• Persistence of retrospectively diagnosed ADHD

into adulthood (ages 18-44) was estimated at

36% (full diagnostic criteria) or 65% by

symptoms and impairments

Kessler et al. Biol Psychiatry 2005;57:1442–1451

Centers for Disease Control 2005

Kessler et al. Amer J Psychiatry 2006

Prevalence Rates of Psychiatric

Disorders in Adults

Kessler RC et al. JAMA. 2003 Jan 18;278(23):3095-105.

Kessler RC et al. Am J Psychiatry. 2006 Apr;63(4):415-24.

Merikangas KR et al. Arch Gen Psychiatry. 2007 May;64(5):543-52.

Regional Differences in Parent-Reported

Current ADHD by State (2011)

Centers for Disease Control

Neurobiology of ADHD

• Receptors

- DAT density differences in striatum

• Cerebral/cerebellum morphology

- Volumetric differences

• Neurodevelopment

- Regional maturational delays

• Neural network activation

- Different activated networks for tasks

Volkow, N; Castellanos X; Shaw; Bush G. Shaw P, Eckstrand K, Sharp W, et al. Attention deficit/hyperactivity

disorder is characterized by a delay in cortical maturation. Proc Natl Acad Sci USA. 2007.

Nov 16:104;19649-19654.

Delayed Brain Growth in ADHD (3 Years) From Shaw, P. et al. (2007). ADHD is characterized by a delay in cortical maturation.

Proceedings of the National Academy of Sciences, 104, 19649-19654.

Greater than 2 years' delay

0 to 2 years' delay

Ns: ADHD=223; Controls = 223 Shaw P, Eckstrand K, Sharp W, et al. Attention deficit/hyperactivity disorder is characterized by a delay in

cortical maturation. Proc Natl Acad Sci USA. 2007. Nov 16:104;19649-19654.

Regions Where Age of Attaining Peak Surface

Area Was Delayed by More Than 1 Year:

ADHD Compared With Typically Developing Participants

Shaw P et al. Development of Cortical Surface Area and Gyrification in Attention-Deficit/Hyperactivity

Disorder. Biol Psychiatry 2012;72:191-197.

R L

Dorsal Anterior Cingulate Cortex

(Cognitive Division) Fails to Activate in ADHD

MGH-NMR Center and Harvard-MIT CITP.

Bush G, et al. Biol Psychiatry. 1999;45(12):1542-1552.

Normal Controls* ADHD*

Counting Stroop (fMRI)

*Group data

Connective Neural Networks

National Institute of Health

Neurocircuitry

• Executive Function - prefrontal (dorsolateral and lateral orbital) regions

• Regulation of affect - orbitofrontal and ventromedial regions

• Attention and inhibitory control - frontostriatal structures (ventrolateral prefrontal cortex, dorsal

anterior cingulate cortex, caudate, and putamen)

Bush et al. Biological Psychiatry 2005;57;1273-1284 Bush G. Biol Psychiatry 2011;69:1160-1167.

Neural Networks

ADHD symptoms

Inattention Impulsivity Hyperactivity Executive Function

Metric Metric Metric Metric

Treatment Treatment Treatment Treatment

Treatment

Biomarkers

Treatment

Biomarkers

Treatment

Biomarkers Treatment

Biomarkers

Outcome Outcome Outcome Outcome

David W. Goodman, M.D.

(Behavioral scales and/or neuropsychological testing)

(ie, Neuroimaging)

Heterogeneity of ADHD

(Functional Scales and/or Quality of Life Scales)

Diagnostic Issues

Diagnostic Differences Between DSM-IV

and DSM-5 for Adult ADHD

DSM-IV DSM-5

Max child age

threshold for

symptoms

< 7 <12

Age for adults ≥18 yo ≥17 yo

Symptom

threshold count

≥6 in IA and/or HI Child: ≥6

Adult: ≥5

Category

designation

Subtypes Presentation

Research protocol

exclusion addition

Autism spectrum

disorder

Diagnostic Difference in DSM-IV and

DSM 5 for Adult ADHD

DSM-IV DSM 5

Impairments

“symptoms that caused

impairment were present

before age 7 years”

“several inattentive or

hyperactive-impulsive

symptoms were present prior

to age 12”

“some impairment in at least

2 settings” before age 7

there is no longer the

requirement that the

symptoms create impairment

by age 12

“clear evidence of clinically

significant impairment in

social, academic, or

occupational functioning’

“several inattentive or

hyperactive-impulsive

symptoms are present in two

or more settings.” “…clear

evidence that the symptoms

interfere with, or reduce the

quality of social, academic, or

occupational functioning.”

ADHD: DSM IV vs DSM 5

SYMPTOMS

AGE 7 12 18 25 32

Child

Diagnosis

Adult

Diagnosis

IMPAIRMENTS

Increasing demands of

Family, Work, Social

Intelligence

Compensatory Skills

Environmental Structure

Impact of ADHD

ADHD Symptom Domains

• Hyperactivity

• Inattention

• Impulsivity

Psychiatric Comorbidities

• Anxiety and mood disorders

• Disruptive behavior disorders

• Substance use disorder

Functional

Impairment Lead to

+ Executive Function Deficits

• Working memory

• Planning and strategy

• On task, shifting, stopping

Case Report (GG)

• 32 yo MWF c/o anxiety because she can't get

all her tasks done; takes longer to finish tasks;

easily distracted; forgetful and loses things;

"zones out" in conversations; can't keep track of

home expenses; husband is on her case

• Worries about getting things done and tries to

recheck her work to avoid careless errors

• Denies panic sxs, hypomania, depression, PMS

• Recalls these sxs back to childhood; teachers

moved her to front of class because of

daydreaming and inattention; denies impulsivity,

hyperactivity, disruptive behavior, moodiness

• Managed to get "decent" grades

• No diagnosis of ADHD as a child

• Patient reports 3 speeding tickets and 2 MVAs

("my fault") before age 19

Case Report (GG)

• No medical history or prescription meds

• Denies h/o alcohol/drugs/caffeine

• HSG, married for 8 years with 2 children (ages 3

and 7)

• Family Hx:

- Mother: similar sxs but never diagnosed

- Her children are too young to assess; no evident

problems

Case Report (GG)

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Inattention

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Hyperactivity / Impulsivity

• ADHD-inattentive type

- With a positive family history for likely ADHD

• Treatment with a long-acting, once-daily

stimulant medication titrated to therapeutic level

Case Report (GG)

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Inattention

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Adult ADHD and

Comorbidities

National Comorbidity Survey Replication:

Mood Disorders in Adult ADHD

Bipolar

Disorder

19.4%

Major

Depression

18.6%

Dysthymia

12.8%

Adult

ADHD Any Mood

Disorder

38.3%

Kessler RC et al. Am J Psychiatry. 2006;163:716-723.

Adult

ADHD PTSD

11.9%

Obsessive-

Compulsive

Disorder

2.7%

Agoraphobia

4%

Generalized

Anxiety

Disorder

8%

Panic

Disorder

8.9%

Social

Phobia

29.3%

Any Anxiety

Disorder

47%



Anxiety Disorders in Adult ADHD


Adult ADHD in Other Psychiatric Disorders

Major Depression Chronic Dysthymia Bipolar Disorder

ADHD

9.4%

ADHD

22.6%

ADHD

21.2%



Adult ADHD in Other Psychiatric Disorders

Anxiety Disorder Substance Abuse ???

ADHD

8.6% ADHD

10.8%

ADHD

???%


Case Report (AA): Patient Presentation

• 17 yo SWF

- High school student

- Oldest of 2 siblings

• Complaints include:

- Depressed mood, irritable/yelling outbursts/angry,

decreased motivation/interest, decreased sense of

pleasure, crying, decreased energy without

change in sleep/appetite, decreased mentation

rate, ruminative

• Denied hopelessness or suicidal ideation

• Symptoms last days to 1 week


• History includes:

- Episodic increased energy, decreased sleep,

improved concentration, increased mentation rate,

impatient, and impulsive

- Symptoms last hours to 2 days

• Denies panic or rituals

• Denies auditory, visual, olfactory, or tactile

hallucinations or delusions

Case Report (AA): Patient History

• Alcohol use started at age 13 years

- Used "occasionally"

• Drug use started at age 13.5 years

- Marijuana more frequently than alcohol

- Used socially

• Cigarette use: 1 pack/day

• Caffeine use: 1 cola/day

• No medical history

Bipolar disorder–rapid cycler


• Complaints

- Chronic symptoms of poor organization, difficulty

finishing tasks, taking longer to do tasks,

procrastination, slow reader, difficulty with deadlines,

difficulty with focus in class, easily distracted, easily

frustrated, inconsistent academic performance,

disruptive in class, forgetful, impulsive, poor

judgment, oppositional, moody

• Although some symptoms worsened when

depressed or agitated, cognitive symptoms

persist when euthymic

Case Report (AA):

Family and Psychiatric History

• Mother

- Past medical history included depression

- No psychiatric medication treatment

• Age 5: tested for and diagnosed with ADHD and LD; started on methylphenidate; used irregularly until age 14

• Age 14: psychiatric admission for 2 weeks for emotional lability and outbursts

• Age 15: diagnosed with bipolar disorder; treated with trials of divalproex, buspirone, risperidone, sertraline

• Age 16: psychiatric care by a national expert; neurological workup was negative

- Involved in weekly psychotherapy

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Inattention (AA) Mother's rating

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Hyperactivity / Impulsivity (AA) Mother's rating

Case Report: Treatment

• December, 2001

- Carbamazepine increased to 600 mg qd

- Valproate was stopped because ineffective for 1

year

• February, 2002

- Citalopram added for angry outbursts; up to 20

mg qd

• May, 2002

- Mixed amphetamine salts XR added for ADHD

• Started at 10 mg qd

• Increased to 20 mg qd

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Mother’s Pre-Tx rating Mother’s Post Tx rating Patient’s Post Tx rating ✔ ✔ ✔

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Mother's Pre-Tx rating Mother's Post-Tx rating Patient's Post-Tx rating ✔ ✔ ✔

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Case Presentation: Diagnostic

Prioritization for Pharmacotherapy

Alcohol and substance abuse

Mood disorders Bipolar and MDD

Anxiety disorders Obsessive-compulsive disorder,

generalized anxiety disorder, panic

ADHD

Goodman D. Treatment and assessment of ADHD in adults. In: Biederman J, ed. ADHD Across the Life

Span: From Research to Clinical Practice—An Evidence-Based Understanding. Hasbrouck Heights, NJ:

Veritas Institute for Medical Education, Inc.2005.

Order of treatment also considers the

severity of the concurrent disorders

Diagnostic Overlap

Intelligence

Learning

Disabilities ADHD

Executive

Function

Neuropsychological

Diagnoses

Behavioral

Diagnosis

Executive Function

• Response inhibition

• Working memory

• Set shifting

• Interference control

Seidman LJ. Neuropsychological functioning in people with ADHD across the lifespan.

Clinical Psychology Review 2006. 26;466-485

30-50% of ADHD patients have executive

dysfunction vs. 5-10% in controls

EF Associated With Other Disorders

Executive Disorder

ADHD

30-50% with EF

Bipolar

Disorder

Autism

Schizophrenia

Learning

Disorders

Chronic SUD

Major

Depression

GAD

Neurological

Disorders

TBI, MCI,

CVA,

CNS Tumors,

Degenerative

Genetic

Disorder

Klinefelter's

Syndrome

(47, XXY)

General

Population 5-10% with EF

Case Report (BB)

• Tom is a 37 yo MWM who was diagnosed

with ADHD-inattentive type at age 19 while

in college

• Having stopped his ADHD medication

"years ago," he now seeks treatment

because of declining work performance after

his promotion 7 months ago

• C/o inattention in meetings, difficulty

finishing paperwork, "things falling through

the cracks", "boss is getting annoyed"

Case Report (BB)

• He completes the Adult Self-Report ADHD Scale (ASRS) (18 items) for baseline symptoms

• You start him on a long-acting stimulant, see him over 2 months, and titrate the dose to reduce symptoms

• He states that his focus, sustained attention, and distractibility are much better

• But he complains that he still can't get organized and that it takes him longer to complete tasks than it should

"Understanding the Cognitive Effects of

Stimulants" Swanson, et al. 2011

In well-controlled studies using batteries, stimulant-

related cognitive enhancements were more

prominent on tasks without an executive function

component (complex reaction time, spatial

recognition memory reaction time, and delayed

matching-to-sample) than on tasks with an

executive function component (inhibition, working

memory, strategy formation, planning, and set-

shifting)

Swanson J et al. Understanding the Effects of Stimulant Medications on Cognition Individuals with

Attention-Defict Hyperactivity Disorder: A Decade of Progress. Neuropsychopharmacology 2011. 36:207-226.

Limitations of "Cold" (Quiet Setting)

Neuropsychological Testing and

Estimates of Deficits

Testing in a Distraction Setting Adult ADHD vs. Controls R

ecall

Accura

cy %

Conditions

*

*

* p>.05

ISE: irrelevant sound effect.

Pelletier MF et al 2013. Characterisation of Attention and Short Term Memory Processes in Adult ADHD

with the Irrelevant Sound Paradigm. Poster Presentation.

Testing in a Distraction Setting Adult ADHD vs. Controls

Pro

port

ion o

f E

rrors

Omissions

*

*

* p>.001 ISE: irrelevant sound effect.

Pelletier MF et al 2013. Characterisation of Attention and Short Term Memory Processes in Adult ADHD

with the Irrelevant Sound Paradigm. Poster Presentation.

Treatment Options

and Medication

Treatment Options

• Diagnoses (what's there, what's not)

• Education (what this is, what it's not)

• Environmental changes (academic,

occupational, social, familial)

• Psychopharm/Psychotherapies

- Behavior, social, individual, family, couples

- Support associations (www.CHADD.org)

International Adult ADHD

Treatment Guidelines

• Canadian Attention Deficit Hyperactivity Disorder

Resource Alliance (CADDRA) (2008)

• National Institute for Health and Clinical

Excellence (NICE) UK (September, 2008)

• European Consensus by the European Network

of Adult ADHD (2010)

• No US guidelines established

v v Storage

vesicle

DA Transporter

Protein

Cytoplasmic DA

MPH and AMPH

inhibit

AMPH is taken up

into cell

Presynaptic Neuron

Synapse

AMPH

AMPH diffuses into

vesicle, causing DA

release into cytoplasm

AMPH blocks

uptake into vesicle

Adapted from Wilens TE, Spencer T. In: Handbook of Substance Abuse: Neurobehavioral Pharmacology.

New York, NY: Plenum Press; 1998:501.

Stimulant Mechanisms of Action

ATOX, DES

AMPH causes release

of DA and NE through

transporter

1. Methylphenidate Preparations

Generic methylphenidate 2-3 hrs tablet

Methylin liquid 2-3 hrs liquid

MPH SR

LA

4 hrs wax matrix

8 hrs beaded

OROS MPH 12 hrs OROS

MPH ER 6-8 hrs beaded

MPH CD 8 hrs beaded

DexMPH

XL

3 hrs tablet

10 hrs beaded

MPH ER liquid 12 hrs liquid

MPH transdermal patch 12 hrs patch

2. Amphetamine Preparations

Preparation Duration of Action

Liquadd 2-3 hrs liquid

Dextrostat 2-3 hrs tablet

Dextroamphetamine

spanules

4 hrs tablet

6 hrs beaded

Mixed AMPH salts

XR

6 hrs tablet

Up to 12 hrs beaded

Lisdexamfetamine Up to 13 hrs prodrug

Nonstimulants

• Atomoxetine

Approved for children/adolescents:

• Guanfacine ER

• Clonidine ER

Off label:

• Bupropion (positive controlled adult trials)

• Desipramine (positive adult trial)

• Modafinil (child study positive, adult study negative)

FDA-Approved Medications for

Adults With ADHD Medication Child

dosing

Adolescent

dosing

Adult

dosing

US

trials

(adult)

Atomoxetine 0.5 mg/kg (<70kg)

max 1.2 mg/kg (max 100

mg)

40 mg

max 100

mg

120 mg

Dexmethylphenidate XR 5 mg

max 20 mg

10 mg

max 20 mg

40 mg

Lisdexamfetamine 30 mg

max 70

mg

30 mg

max 70 mg

30 mg

max 70 mg

70 mg

Mixed amphetamine salts

XR

10 mg

max 30 mg

20 mg

max-none

60 mg

OROS Methylphenidate

HCL

18 mg

max 54

mg

18 mg

max 72 mg

18 or 36

mg

max 72

108 mg

DAILY

No short-acting medication has been

FDA-approved for adults with ADHD

Side Effects With Stimulant Medication

• Insomnia

• GI upset

• Decreased appetite

• Weight loss

• Headaches

• Dry mouth

• Constipation

• Hand tremors

• Jittery

• Research on individual

stimulants has generally

shown no dose

relationship with side

effects in group data1, 2

• Some research has

shown that side effects

may be more likely in

stimulant- naïve patients3

1Weisler RH et al. (2006), CNS Spectr 11(8):625-639; 2Adler L et al. (2005), Presented at the 158th Meeting of

the American Psychiatric Association, May 21-25; 3Goodman DW et al. (2005), CNS Spectr 10(Suppl 20):26-34

CYP450 Inhibitory Effects of

ADHD Medications

0 0 0 0 0 Desipramine

? +++ ? ? ? Bupropion

0 0* 0 0 0 Atomoxetine

0 0 0 0 0 Methylphenidate

0 0 0 0 0 Amphetamine

3A4 2D6 2C19 2C9 1A2 Medication

Cytochrome P450 Isoenzymes

Goodman D. (2006), In: ADHD Across the Life Span: From Research to Clinical Practice—An Evidence-Based Understanding. Biederman J, ed.

Hasbrouck Heights, NJ: Veritas Institute for Medical Education, Inc.; Devane L et al. (2003), Poster presented at the 156th Annual Meeting of the

APA; San Francisco: May 17-22

MPH-Guanfacine XR in Adults

Roesch B et al. Drugs R D 2013. 13:53-61.

35 healthy adult

MPH-Guanfacine XR in Adults

35 healthy adult

Roesch B et al. Drugs R D 2013. 13:53-61.

Complementary and

Alternative Treatments

for ADHD

Alternative ADHD Treatments:

Randomized Controlled Trials

Sonuga-Barke EJS 2013 Nonpharmacological interventions of ADHD Systematic review and meta analyses

of randomized controlled trials of dietary and psychological treatments. Am J Psych 2013 epub 1-15.

Nonpharmacological ADHD Treatments:

Randomized Controlled Trials

ADHD Treatment # Studies Confidence

Interval

P value

Restricted

elimination diets

7 -0.02, 1.04 NS

Artificial food

coloring exclusion

8 0.13, 0.70 p<0.05

Supplementation

with free fatty acids

11 0.01, 0.31 p<0.05

Cognitive training 6 -0.24, 0.72 NS

Neurofeedback 8 -0.02, 0.61 NS

Behavioral

interventions

15 -0.30, 0.34 NS

Sonuga-Barke EJS 2013 Nonpnarmacological interventions of ADHD Systematic review and metaanalyses

of randomized controlled trials of dietary and psychological treatments. Amer J Psych. Epub February 2013.

Accuracy of ADHD Findings by

Newspapers

Gonon F et al. 2012 Why Most Biomedical Findings Echoed by Newspapers Turn Out to be False:

the Case of Attention Deficit Hyperactivity Disorder. PLOS ONE Sept 2012:7(9)

• Collected 47 scientific publications on ADHD in the 1990s that generated 347 newspaper articles

• Picked the top 10 most echoed publications

• Then collected all relevant subsequent studies until 2011

Of the top 10 echoed publications:

Average publication impact factor: 17.1 vs. 6.4 (p<.0001)

7 were initial studies; 6 were later refuted or strongly attenuated; 1 was not confirmed or refuted

3 were not initial studies; 2 were confirmed; 1 was attenuated

Safety Concerns

Medical Illness Considerations

• Hypertension

• Hypo- or hyperthyroidism

• Diabetes mellitus

• Cardiac: post-MI, post-stent placement,

arrythmias, electrical/structural abnormalities

• Seizure disorder

• Substance use: caffeine, alcohol, illicit drugs

• Pregnancy

Comorbid Medical Conditions:

Heart Disease and ADHD Treatment

• Possible causes for concern

- History of palpitations or arrhythmia

- Recent myocardial infarction

- Syncopal episodes, dizziness

- Multiple risk factors, such as smoking, high body mass index, hypertension, metabolic syndrome

• Maximize cardiac medications and address risk factors; patients with ADHD may find it difficult to make necessary lifestyle changes

• Introduce ADHD medication at a low dose and titrate up slowly

• Monitor symptoms, blood pressure/heart rate regularly

• Longer-term effects of ADHD medications on cardiovascular status unclear

Gutgesell et al. Circulation. 1999;99(7):979-982.


Hypertension and ADHD Treatment

• Evaluate blood pressure/pulse prior to initiating

ADHD treatment

• Address hypertension before treating ADHD

• Once hypertension is controlled, treat ADHD and

monitor blood pressure

• Stimulants have a clinically insignificant effect on

blood pressure in treated, normotensive adults

Wilens et al. J Clin Psychiatry. 2006;67:696-702.

Pliszka et al. J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921.

Nutt et al. J Psychopharmacol 2007, 21:10-41.

Jain U, Hechtman L, Quinn D, et al. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance

(CADDRA): Canadian ADHD Practice Guidelines, edn Toronto: CADDRA; 2006.


Diabetes and ADHD Treatment

• Studies of stimulants and nonstimulants on blood sugar regulation in diabetes mellitus unclear

• Longer-term studies do not show glucose dysregulation associated with stimulant or nonstimulant treatment in nondiabetic children, adolescents, or adults

• Stimulants and nonstimulants to a lesser extent may cause appetite suppression and rebound binge eating

• ADHD patients may find lifestyle modifications difficult

• Get ADHD stabilized before trying to get tight control of diabetes

• Monitor for symptoms or evidence of glucose dysregulation with ADHD treatment

Satterfield et al. J Dev Behav Pediatr. 1980;1(3):102-107.

Pregnancy and Stimulants

• Category C

- Amphetamines, methylphenidate,

atomoxetine

- Animal reproduction studies have shown an

adverse effect on the fetus, and there are no

adequate and well-controlled studies in

humans, but potential benefits may warrant

the use of the drug in pregnant women

despite potential risks

Available at www.fda.gov. Accessed January 15, 2008

Breastfeeding and Amphetamines

• Amphetamine

- Detectable in breast milk

- Amphetamine in infants' urine

• Methylphenidate

- Detectable in breast milk

• American Academy of Pediatrics considers

amphetamines and methylphenidate

contraindications for breastfeeding

1Ilett KF et al. (2007), Br J Clin Pharmacol 63(3):371-375; 2Steiner E et al. (1984), Eur J Clin Pharmacol 27:123-124

Spigset O, Brede WR et al. (2007), Am J Psychiatry 164(2):348;

Hackett LP, Kristensen JH et al. (2006). Ann Pharmacother 40(10):1890-1891

Psychotherapies

Comprehensive Role of the Therapist

History of Failure

Symptom

Impairments

Mood Disturbance

Behavioral Avoidance

Lost Opportunity for Skill Development

Medication

Dysfunctional Outcome

Cognitive Distortions

Presentation Treatment Outcome

Organization Techniques

Cognitive Therapy

Behavioral Therapy

Life Skills Building

Improved Social Interactions

Change Behavior Frequency

Improved Productivity

Modified Schema

Symptom Reduction

Goodman D. Treatment and assessment of ADHD in adults. In: Biederman J, ed. ADHD Across the Life

Span: From Research to Clinical Practice—An Evidence-Based Understanding. Hasbrouck Heights, NJ:

Veritas Institute for Medical Education, Inc. 2006

Psychotherapies for ADHD

• Education

- Patients and family members

- Books and Web sites

• Cognitive behavior therapy

- Structure routines

- Audio and visual cues

- Consistent consequences for behavior

• Individual

- Self-esteem issues

- Social skills and relationship issues

- Academic and occupational accommodations

Brain Training

Abcnews.go.com

When to Refer

• Presenting with symptoms of a major mental illness, serious mood disorder, substance dependence, or other complex comorbid psychiatric symptoms that are beyond your level of clinical competence and/or comfort level

• Confused about the patient's presentation, unsure about ADHD, and uncomfortable about the idea of prescribing ADHD medication for the patient

• Suspect drug-seeking behavior

• Patient not responding to medications or expresses sensitivity to drug side effects

• Treatment seems to require multiple psychiatric medications

Summary

ADHD is highly prevalent in both children and

adults; screen regardless of age

Diagnostic accuracy is enhanced by considering:

• Presenting symptoms

• Age of onset

• Longitudinal course: chronic, pervasive, impairing

• Family psychiatric history

Use symptom checklists for baseline target

symptoms and change with treatment

Look for psychiatric comorbidities and prioritize

accordingly

Education, behavioral changes, and cognitive

therapies are effective

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