1. ADHD is one of the most common childhood disorders, with 30-60% of cases persisting into adulthood. It is caused by dysfunction in brain circuits involving catecholamines like dopamine and norepinephrine. 2. Adult ADHD presentations do not always neatly match the DSM criteria, which were developed for children. Evaluations require assessing specific symptoms, impairment levels, psychiatric history, and collateral information. 3. Effective treatment involves stimulant medications like methylphenidate and amphetamines, which work by increasing dopamine and norepinephrine levels. Screening tools can aid diagnosis, but labs and cardiac screening are also important aspects of the assessment process.

1. ADHD in Adults: Dx & Rx Implications
Cynthia Garza, JD, MD
&
Frank W Meissner, MD, RDMS, RCDS
Staff Psychiatrist’s - Project Vida

2. I was trying to daydream but my mind kept wandering.
Steve Wright
Without deviation from the norm, progress is not possible.
Frank Zappa
They say a cluttered desk is a sign of a cluttered mind.
What then is an empty desk a sign of?
Albert Einstein

4. Epidemiology
One of the most common disorders of childhood
30-60% persistence of symptoms into adulthood
Prevalence of 4.4% among 18 to 44 year olds1
Genetics
1° relatives of patients with ADHD have a 3-5 fold increased risk
1Am J Psychiatry. 2006;163(4):716.

7. Dysfunction of brain circuits that use catecholamines
Hypoactive dopamine & nor-epinephrine in frontal subcortical
circuits
Modulation of emotion & cognition through behavior & movement
Vigilance, perceptual-motor speed, working memory, verbal
learning, processing speed, and response inhibition
J clin Psychopharmacol. 2008 Jun;28(3 Suppl 2): 539-45
ADHD Pathogenic Concepts

9. Clinical Features
Adult ADHD evaluations are difficult
There is usually a lot of background noise clinically
Presentations in adults does not usually match up neatly with DSM criteria
DX criteria were developed for children
‘You don’t grow out of ADHD, you just get better @ coping with it
Secondary gain is a significant consideration

10. Case Example.
–John is a 21 y/o college student referred for evaluation of ADHD.
Reports a hx/o ADHD diagnosed at age 8, never Rx’ed.
Currently struggling to maintain passing GPA.
Suffers from procrastination, poor attention, & endemic distractibility.
He ‘says what he has on his mind’ - result this gets him into trouble at work & school
In adult persistent ADHD, as crippling as can be the cognitive dysfunctions, the social impact of never
learning the kindergarten lesson’s of rules for getting in the sandbox, and how to successfully play
cooperatively or take your turn in conversations are often the most profound & most difficult things to
change!

11. Assessment
Specific symptoms of inattention, including onset, severity, frequency, situational specificity, & duration.
Functional assessment that covers school history, employment history, and performance
Real vs perceived impairment
Past Psychiatric & medical history
Family history
Social history
Collateral Hx is vital

12. Adult Dx Criteria
A persistent pattern of inattention &/or impulsivity present in more than one setting that interferes with functioning
Hyperactivity is rare in the adult, and marked hyperactivity more likely to represent hypomania than ADHD in the adult
ADHD is not all or nothing in its adult manifestation
Adults with ADHD can pay attention, exercise self control, complete tasks - IF:
faced with a deadline
the task is highly rewarding & interesting to complete
or under close scrutiny
The key to Dx is determining wether symptoms are typically present & are more pronounced when there is less external structure &
demand

13. Clinical features
Key features
inattention
hyperactivity (rare)
Impulsivity
Executive dysfunction
Emotional dysregulation

14. Clinical features
Children Adults
inattention <=========> inattention
Can’t pay close attention in class or complete homework Has difficulty concentrating @ work/ finishing tasks
Forgetful: chores, errands school work Forgetful: returning calls, paying bills, keeping appointments
Loses things: pencils, paper, homework Loses things: wallet, keys, cell phone
athognomonic): Child more often than not, if he does his homework, forgets to put his/her name

15. Clinical features
Inattention
Overlooks details or work is inaccurate
Trouble sustaining attention (lengthy readings, conversations, etc)
Starts tasks but easily gets side-tracked
Difficulty with organization
Avoids activities requiring sustained attention
Loses important things
Easily distracted
Forgetful in daily activities

16. Clinical features
Children Adults
Hyperactivity <=========> Restlessness
Can’t sit still, always on the go Easily distracted, fidgety, impatient
Climbs or runs at inappropriate times Mood swings, relationship troubles
Children Adults
Physical Impulsivity <=========> Verbal Impulsivity
Does things that result in injuries Says the ‘wrong thing’ or speaks out of turn
Interrupts, completes other’s sentences

17. Clinical features
Executive dysfunction: the ability to conceptualize all facets of an activity & translate that into appropriate &
effective behavior
Struggles with time management & have poorly organized lives
Emotional dysregulation: mood lability, anger outbursts, low frustration tolerance
Real world consequences of unRxed Adult ADHD
twice as likely to be arrested
twice as likely to be divorced
twice as likely to have dropped out of HS
twice as likely to have held 6 or more jobs in the past 10 years

19. DSM-5 Dx
Symptom criteria have not changed from DSM-IV
5 or more inattentive symptoms, and/or 5 or more of 9
hyperactive/impulsive symptoms
interfere with social, academic, or occupational fun
Symptom onset prior to age 12 (rather than 7, in DSM-IV) and in 2 or
more settings

20. Screening Instruments
Adult ADHD self-report scale
Current symptom check list based on frequency
18 items pulled from DSM-IV
Shown to be effective in Primary Care settings

22. Conners’ Adult ADHD Rating Scale
Long (66 questions rating frequency), costly Self report and observer
reports
Standardized scores against 9 domains

23. Wender Utah ADHD Rating Scale

24. Diagnostic Features
Basic labs: TSH, chemistry panel, CBC, UDS
Cardiac workup pre-stimulant prescription
Stimulants of sudden cardiac death
Cardiac examination in all patient’s
EKG in patients older than 40, or with a hx/o dz, or Fix of structural HD or
SCD
Monitor blood pressure & pulse
JAMA. 2011,306(24):2673

25. Treatment
Stimulants: methylphenidate & amphetamines
Work by increasing levels of dopamine & norepinephrine
Randomization trials have shown that stimulants outperform (& non-
stimulant medications), especially in short term trials
Multiple formulations & delivery systems

26. Thank You! For Your Attention!