Adult ADHD in Specific Patient Groups 

For this patient group, the basic approach to care is to:

• Evaluate the symptoms, their severity, and impact using adult centered assessment approach; inform patients directly about the outcome of this assessment
• Evaluate if medication is still required
• Monitor side effects and adverse effect of treatments
• Assess physical health
• Identify and manage co-existing conditions
• Identify and provide appropriate non-pharmacologic treatments
• Mitigate risks, provide education, and assist with support and skill-building services
• Facilitate shared-care arrangements between primary and secondary care services for the prescription and monitoring of ADHD medications

Resources for Teens & Young Adults

• CHADD -- Teens & Young Adults: Trusted sources of evidence-based information for teens and young adults, their parents and family members and health providers. 
• Young Men's Health: An overview of ADHD for young men.
• Attention Deficit Disorder Association: Resources for college students with ADHD.

Women

ADHD in women and girls is not well studied, despite the fact it significantly affects adults of both sexes. The evidence shows that the rates of ADHD are similar between males and females in adulthood. The higher rate of ADHD between young boys and girls is partially attributed to developmental differences, different presentation of symptoms and other facts that are not yet clearly understood about ADHD in females. 

Inattentive type ADHD is thought to be more common in girls and women than it is in boys and men. In females, ADHD may present as more subtle or internal problems (e.g., anxiety, inattention, inability to finish tasks, daydreaming), and less external problems (e.g., aggression, challenging behavior). 

Women with undiagnosed or untreated ADHD are at higher risk to experience divorce, be a single parent, be undereducated, be underemployed or unemployed, suffer from insomnia, and have constant stress due to difficulty in managing the demands of daily life expected of them from society. They may also have a lower life expectancy than those treated for ADHD due to accidents. Girls with undiagnosed or untreated ADHD are also more likely to commit suicide than their neurotypical peers. Pregnancy and motherhood bring additional challenges to women with ADHD.

In addition to timely diagnosis and medications, females with ADHD can also benefit from therapeutic interventions such as:

• Building self-esteem 
• Physical activity, healthy nutrition and promoting healthy habits 
• Learning time and stress management techniques
• Family therapy 
• Peer support groups
• Monitoring for and managing co-existing conditions such as depression, eating disorders, substance use disorders, and sleep problems

Pregnancy and Stimulants

Stimulant medications are all considered “Category C” medications: 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 use of the drug in pregnant women despite potential risks.

Evidence in humans is insufficient to confirm safety of stimulants in pregnancy.  There is a very low risk of having a baby born with birth defects after taking ADHD medicine but more research is needed to determine the safest treatment options for managing symptoms of ADHD during pregnancy. Women should talk with their healthcare providers about options for managing ADHD symptoms before and during pregnancy.

Breastfeeding and Stimulants

Limited information is available on breastfeeding and stimulant use. Amphetamine type stimulant drugs are thought to concentrate in breast milk and may cause irritability and disturbed sleep in babies. The long-term effects of this exposure are unknown. Nursing infants exposed to stimulants should be monitored for insomnia, poor appetite, weight loss, and irritability; however, none of the existing studies have reported these complications. To minimize infant exposure to stimulants via breast milk, feeding should occur just prior to or as long as possible after the dose. 

Stimulants and Milk Production

All stimulants increase dopamine activity. In addition to its effects as a neurotransmitter, dopamine also acts as a hormone to lower levels of another hormone, prolactin. As a result, stimulants may lower prolactin levels and thereby lower breast milk production.

Resources for Women

• CHADD -- Women & Girls: trusted source of evidence-based resources for women and girls with ADHD
• The Queens of Distraction: an online group coaching for women with ADHD.
• Attention Deficit Disorder Association - Women: Resources for women with ADHD.

Substance Use

Substance use, in particular the use of tobacco, alcohol, and cannabis, is found to be more common among individuals with ADHD. Current evidence on the relationship between medical stimulant use and illicit drug use is inconclusive. The following should be considered in managing ADHD with concomitant substance use:

• In cases of chaotic and uncontrolled patterns of drug/alcohol use, stimulants are not recommended
• Stimulant medications need to be used with caution in patients with previous substance use
• It is advisable to use longer-acting stimulant formulations 
• Patients with substance use should be referred to substance use treatment programs
• Monitoring for substance use and drug-seeking behavior is recommended
• All patients should be educated, warned and reminded about legal ramification of diversion and non-medical use of stimulants at the time of stimulant prescription

Resources for Substance Use Management & Support

• Opioid Response Network: Request assistance with substance use managements and support

Co-existing Mental Health Conditions

For patients with co-existing ADHD and mental health disorders such as depression, bipolar or anxiety disorder, it is recommended to provide medication treatment for non-ADHD disorder first. Non-pharmacological treatments for ADHD and co-existing conditions can be initiated concurrently. The goal is to reduce the severity of non-ADHD symptoms. Medication management of ADHD with co-existing mental disorders may require caution in selecting a treatment regiment, as stimulants can cause mood cycling and insomnia, and can worsen anxiety. Careful, ongoing monitoring of treatment effects and side effects is recommended.

Forensic Populations

Adults with ADHD may have traits that result in poor judgment and criminal acts with consequences. It is estimated that the prevalence of ADHD in prison populations is between 25% and 40%. However, it is important to underscore that most people with ADHD never commit criminal acts. Efforts should be made to evaluate for and treat ADHD in the prison populations, as it is shown to reduce the risk of future criminal offences.

ADHD and Seniors

Limited information is available on ADHD in adults over 60 years of age. Some emerging studies show that symptoms of ADHD continue into senior years and can be mistakeably confused with signs of aging or cognitive decline. Studies show that the motor hyperactivity in adults often presents as “inner” hyperactivity in the form of restlessness, excessive fidgeting and talking, inability to relax, and difficulty to sit quietly for long periods. Impulsivity in adulthood manifests as outbursts of anger, impatience, careless driving, and making decisions without thinking. Signs of inattention may include disorganization, forgetfulness, poor performance in planning and completion of tasks, task shifting, and time management. Because of this developmental change in symptom expression, many adults will not fully exhibit the criteria for the diagnosis, while still remaining significantly impaired. There is a lack of research on diagnosis and treatment of ADHD in older adults. Individualized therapy and risk-benefit assessment for each elderly patient should be recommended.