Attention deficit hyperactivity disorder (ADHD) is a chronic disorder of attention and/or hyperactivity-impulsivity that is typically diagnosed in children 6 to 9 years of age (Katz, 2018). Approximately, 5 to 10 % of school aged children, primarily males, have ADHD (Katz, 2018). Two to 5 percent of adults have ADHD (Katz, 2018). In the adult population the number, or ratio, of females diagnosed with ADHD is equal to males (Katz, 2018).
“Currently, there is no known neurophysiological or neurochemical basis for the disorder. Imbalances among levels of norepinephrine, dopamine, and epinephrine all seem to be involved” (Dunphy, Winland-Brown, Porter, & Thomas, 2015, p. 1108). Family history, genetics, provides the strongest evidence for etiology of ADHD (Katz, 2018). Having a first-degree relative with ADHD makes an individual 5 times more likely to have ADHD (Katz, 2018). Many times ADHD goes unrecognized throughout childhood, or people with ADHD were able to compensate for their symptoms when they were young, but as their responsibilities increase their symptoms become more apparent, negatively impacting them both professionally and their personal relationships (Smith & Segal, 2017). Unlike children with ADHD, adults with ADHD typically do not have motoric hyperactivity (Katz, 2018). Adults commonly present with complaints of restlessness, edginess, difficulty relaxing, disorganization, boredom, difficulty paying attention or focusing, and difficulty completing tasks (Katz, 2018). Frustration with job and life routines are also common complaints among adults with ADHD (Dunphy et al., 2015).
Assessment and Physical Exam
It is important that clinicians remember that symptoms of ADHD may not be evident during a structured assessment, because symptoms of ADHD are more pronounced in less structured environments such as school or work (Dunphy et al., 2015). Also, people with ADHD are 6 times more likely to have another psychiatric or learning disorder (Smith & Segal, 2017). “The DSM-5 provides guidance for diagnosis of ADHD for individuals aged 17 and older. It may be necessary to review early academic records or report cards for the presence of impulsivity, hyperactivity, and inattentive symptoms during the early school years. Additional questions related to family history of ADHD should be conducted. Adult patients may need to question their parents regarding ADHD behaviors that were evident from childhood. Key areas for questioning relate to complaints of boredom, disorganization or frustration in work, and a tendency for impulsive, impatient, and restless behavior” (Dunphy et al., 2015, p. 1108).
Along with assessing previous history of ADHD and past performance in school, adults should also be assessed for a personal and family history of mental health diagnoses, substance abuse, and current or past medication use (Dunphy et al., 2015). In regard to current symptoms, inquiry should be made about how their symptoms are impacting their current school performance, work, and home life/relationships (Dunphy et al., 2015). “The World Health Organization’s Adult Self-Report Scale (ASRS) v1.1 has good sensitivity and adaptability to the primary care setting” (Katz, 2018, p. 161). The ASRS v1.1 checklist takes about 5 minutes to complete and contains questions that are consistent with the DSM-IV criteria and addresses the manifestations of ADHD symptoms in adults (Adler, Kessler, & Spencer, 2003).
During the physical examination the clinician should investigate for possible medical causes of patient’s symptoms, coexisting conditions, and contraindications to treatment (Katz, 2018). “Special focus should be paid to evaluation of dysmorphic features; neurologic examination, including assessment for neurocutaneous findings; and assessment of hearing and vision” (Katz, 2018, p. 160). Laboratory and imaging studies should only be ordered if indicated by history and physical examination (Katz, 2018).
Treatment Plan and Follow Up
The majority of studies comparing the efficacy of non-pharmacologic versus pharmacologic treatments for ADHD support pharmacologic intervention, specifically stimulants such as Ritalin, Adderall, and Dexedrine (Katz, 2018). These medications have been proven to boost concentration and focus in many people with ADHD (Smith & Segal, 2017). Before and periodically during treatment patients should be evaluated for cardiovascular disease when choosing to prescribe a stimulant (Katz, 2018). Strattera, a non-stimulant, has been shown to be less effective than stimulants, but is an alternative for patients with ADHD who have not responded well to stimulants, or for use in patients with a history of substance abuse (Katz, 2018). “Second line therapies include antidepressants and alpha agonists” (Katz, 2018, p. 161). Antidepressants may be useful if the patient has a coexisting psychiatric disorder (Katz, 2018). Alpha agonists are useful as an adjunct to stimulants in patients who have a partial therapeutic response to stimulants, or patients whose ADHD is successfully treated with stimulants but experience stimulant related side effects such as sleep disturbance or concurrent symptoms of over arousal, irritability, or aggression (Katz, 2018). Lifelong treatment of ADHD is typically necessary for most patients with ADHD (Katz, 2018). “Among adults with persistent ADHD symptoms treated with medication, trials have shown that the use of cognitive behavioral therapy compared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months” (Katz, 2018, p. 161).
Adult patients with ADHD should be instructed to contact their healthcare provider if symptoms worsen after treatment begins; not to self-medicate with drugs or alcohol, or use too much caffeine or sugar; not to increase medication dosages unless instructed by their healthcare provider; to keep their follow-up appointments for evaluation of response to therapy and cardiovascular risk monitoring; and to exercise regularly and try to maintain structure and routine (Katz, 2018).
Adler, L., Kessler, R. C., & Spencer, T. (2003). Adult ADHD Self-Report Scale-V1.1(ASRS-V1.1) Symptoms Checklist from WHO composite international diagnostic interview. Retrieved from: https://www.hcp.med.harvard.edu/ncs//ftpdir/adhd/18Q_ASRS_English.pdf
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis.
Katz, E. (2018). Attention deficit hyperactivity disorder. In F. Ferri (Ed.), 2018 Ferri’s clinical advisor (pp. 160-161). Philadelphia, PA: Elsevier.
Smith, M., & Segal, R. (2017). ADHD in adults. Retrieved from: https://www.helpguide.org/articles/add-adhd/adhd-attention-deficit-disorder-in-adults.htm?pdf=true