Adult ADHD: Recognition and Treatment Approaches

Recognizing that ADHD can persist beyond childhood is a first step in ensuring necessary care for individuals with this underdiagnosed condition.

Attention-deficit/hyperactivity disorder is commonly perceived as a condition that is manifested, diagnosed, and treated in childhood. However, an estimated 5% of adults worldwide have the disorder, and long-term follow-up studies suggest that it persists into adulthood in half of those diagnosed in childhood.1,2

The number of diagnoses of attention-deficit/hyperactivity disorder (ADHD) is climbing overall, in part because of an increase in the number of adult cases. It often coexists with other conditions—including depression, anxiety, and substance use disorder—and with smoking, which is twice as common among adults with ADHD as in the general population.1

Attention difficulties tend to predominate in adults. Adults who seek help for what eventually is identified as ADHD will express these difficulties as “spinning my wheels” and “barely keeping my head above water,” according to John Mitchell, PhD, psychologist and assistant professor in the Duke University ADHD Program.

Mitchell told Psychiatry Advisor that clinicians do not typically see as much hyperactivity in their adult patients as in youth; the condition might manifest instead as adults being “more verbally tangential and impulsive.” The most significant challenge for adults is inattention, which is, according to Mitchell, the “difficulty with focusing, distraction, organization, forgetfulness, losing things, and time management.”

Susan Sprich, PhD, director of the Cognitive Behavioral Therapy (CPT) Program and of Postgraduate Psychology Education at Massachusetts General Hospital, told Psychiatry Advisor in an email that adults presenting in their clinic often recognize ADHD symptoms in themselves after their child is diagnosed, or the adult has undergone an evaluation suggesting an executive function issue.

She noted that the requirement that the symptoms were present in childhood is critical. “If an adult says that, looking back, he or she can see that he has struggled with these symptoms for many years, ADHD may be more likely,” she wrote. “If the symptoms have emerged recently, one might suspect other psychiatric or medical causes for the symptoms.”

That rule-out is important, especially given the predominance of inattention in adult ADHD. According to a 2010 study by Kessler et al,2 some adults who meet most criteria for adult ADHD lack the key criterion of symptoms in childhood. As a result, the authors urge caution when making a diagnosis because inattention is “strongly associated” with other mental disorders.

Impairment in executive function, a facet of attentional control, is a consistent standout feature of adult ADHD, and one that Kessler and colleagues reported as an important predictor of ADHD in adults.2 According to a 2014 study by Grane and associates,3 difficulties in executive function emerged again as a prominent feature of adult ADHD, with the authors noting that this result confirms many earlier studies finding “significant impairment” in executive function in this patient population.

To address impairment in executive function and other symptoms associated with ADHD, Mitchell said that the most empirically based approaches would use some form of stimulant coupled with CBT. “Those are the two that we typically recommend in our clinic,” he said, “and we try to go by what the science says about what works.”

Because of the prominence of executive function difficulties in adults with ADHD, much of CBT focuses on this facet. Other targets of CBT are negative thoughts and, perhaps surprisingly, positive thoughts that can interfere with function.

CBT also is used for the more frequent comorbid conditions with ADHD. “If the clinician judged that the difficulties with organization or concentration were due to a comorbid condition, such as depression or anxiety, he or she would likely focus on the strategies to address these symptoms […] in addition to the skills to address the ADHD symptoms,” Sprich said.

“Generally, we talk with the adult patients about ‘layering in’ strategies to help them cope with their tendencies to have challenges with attention, concentration, organization, and procrastination,” said Sprich, describing the general CBT approach for patients with ADHD.