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Attention-Deficit/Hyperactivity Disorder in Adults

Amanda E. Olagunju, DO
Faraz Ghoddusi, MD

American Family Physician. 2024;110(2):157-166.

Author disclosure: No relevant financial relationships.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder involving functionally disruptive inattentive and/or hyperactive/impulsive behaviors, such as being easily distracted, regularly failing to follow through on tasks, being restless, or often interrupting others. ADHD diagnosed in childhood often persists into adulthood, with 14.6% of U.S. adults meeting the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria for ADHD. When evaluating for adult ADHD, other mental disorders should be included in the differential diagnosis due to the substantial overlap of symptoms and ADHD concurrence with anxiety/stress, mood, personality, impulse control, and substance use disorders. An ADHD diagnosis requires a comprehensive clinical history and evaluation, patient symptom and function assessment (e.g., Adult ADHD Self-Report Scale, Conners Adult ADHD Rating Scales), and gathering of collateral information. Clinical guidelines recommend a subset of amphetamine and methylphenidate stimulants as first-line pharmacotherapy, which may be more effective when combined with psychotherapy. For adults unable to take stimulants or with concurrent anxiety/depression, options include atomoxetine, viloxazine, and bupropion. To monitor for patient misuse or diversion of stimulants, physicians should consider employing controlled substance agreements and prescription drug monitoring programs.

Adult attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder of executive function associated with inattention, disorganization, and/or hyperactive/impulsive behaviors occurring in people 17 years or older.1 Adult ADHD is a continuance of childhood symptoms, with 29% of cases persisting into adulthood.2–4 Although some studies have suggested that a late-onset ADHD subtype can occur that is not a continuance from childhood, more data are needed, and this theory is not considered in the current diagnostic criteria.5,6 Adults with ADHD are at higher risk of unemployment, educational underachievement, financial difficulties, substance misuse, criminality, divorce, motor vehicle crashes, workplace accidents, and overall mortality compared with the general population.2,7,8

WHAT’S NEW ON THIS TOPIC

Adult Attention-Deficit/Hyperactivity Disorder
The prevalence of attention-deficit/hyperactivity disorder in U.S. adults rose from 4.4% in 2006 to 14.6% in 2022.
In 2021, more than 3.4 million people 18 years and older in the United States misused prescription stimulants, most commonly amphetamines. An estimated 66% of people who misuse prescription stimulants get the medications from family or friends with prescriptions, and 20% obtain prescriptions themselves by presenting to clinicians with exaggerated or fabricated symptoms.
Rates of overdose deaths from noncocaine stimulants have been exponentially increasing in the United States since 2012, with more than 32,500 deaths in 2021.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Validated diagnostic tools and history should be used to confirm DSM-5 criteria for ADHD in adults.1,19 C Expert opinion and consensus guideline in the absence of clinical trials
Neuropsychological testing may increase diagnostic accuracy for adult ADHD when collateral information such as childhood history and observer reports is lacking, malingering is suspected, or confounding mental comorbidities are present.29,30 C Expert opinion and consensus guideline in the absence of clinical trials
Nonpharmacologic therapies recommended for adult ADHD include cognitive behavior therapy, mindfulness, dialectical behavior therapy, and hypnotherapy.35 B Systematic review of studies with inconsistent evidence, which was weakest for dialectical behavior therapy and hypnotherapy
Stimulants are first-line pharmacologic therapy for adult ADHD.37 A Systematic review with consistent evidence from RCTs showing improved executive functioning
Nonstimulant medications (e.g., atomoxetine, viloxazine [Qelbree], bupropion) are indicated for adult ADHD when stimulants are contraindicated, not tolerated, or ineffective.37,38 B Systematic review and small RCTs; bupropion is not approved by the U.S. Food and Drug Administration for ADHD

ADHD = attention-deficit/hyperactivity disorder; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

AMANDA E. OLAGUNJU, DO, is a primary care physician at JenCare Senior Medical Center, Newport News, Va., and a physician and major in the 113th Air National Guard, Andrews Air Force Base, Md.

FARAZ GHODDUSI, MD, is associate chief health information officer and an assistant professor in the Department of Family Medicine and Department of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University, Portland.

Address correspondence to Amanda E. Olagunju, DO, at aeolagunju90@gmail.com.

Author disclosure: No relevant financial relationships.

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