presentations of adhd

ADHD Quick Facts: ADHD Presentations

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Three Possible ADHD Presentations

Children need to exhibit six or more symptoms in two or more settings for a diagnosis; older teens and adults should have at least five of the symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists three presentations of ADHD—Predominantly Inattentive, Hyperactive-Impulsive, and Combined.

Inattentive

• Fails to give close attention to details or makes careless mistakes
• Has difficulty sustaining attention
• Does not appear to listen
• Struggles to follow instructions
• Has difficulty with organization
• Avoids or dislike tasks requiring sustained mental effort
• Loses things
• Is easily distracted
• Is forgetful in daily activities

Hyperactive-impulsive

• Fidgets with hands or feet or squirms in chair
• Has difficulty remaining seated
• Runs about or climbs excessively; extreme restlessness in adults
• Difficulty engaging in activities quietly
• Acts as if driven by a motor; adults will often feel inside as if they are driven by a motor
• Talk excessively
• Blurts out answers
• Difficulty waiting or taking turns
• Interrupts or intrudes upon others
• Meets the criteria for both inattention and hyperactive-impulsive presentations.

To receive a diagnosis, these symptoms need to start before age 12, be present in more than one setting, interfere with functioning at home, school or work, in social settings, and cannot be better explained by another disorder.

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The information provided by CHADD’s National Resource Center on ADHD is supported by Cooperative Agreement Number NU38DD000002 funded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the Department of Health and Human Services (HHS).

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What is ADHD?

Signs and symptoms.

• Managing Symptoms

ADHD in Adults

More information.

ADHD is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.

It is normal for children to have trouble focusing and behaving at one time or another. However, children with ADHD do not just grow out of these behaviors. The symptoms continue, can be severe, and can cause difficulty at school, at home, or with friends.

A child with ADHD might:

• daydream a lot
• forget or lose things a lot
• squirm or fidget
• talk too much
• make careless mistakes or take unnecessary risks
• have a hard time resisting temptation
• have trouble taking turns
• have difficulty getting along with others

Learn more about signs and symptoms

Get information and support from the National Resource Center on ADHD

There are three different ways ADHD presents itself, depending on which types of symptoms are strongest in the individual:

• Predominantly Inattentive Presentation: It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.
• Predominantly Hyperactive-Impulsive Presentation: The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.
• Combined Presentation: Symptoms of the above two types are equally present in the person.

Because symptoms can change over time, the presentation may change over time as well.

 Learn about symptoms of ADHD, how ADHD is diagnosed, and treatment recommendations including behavior therapy, medication, and school support.

Causes of ADHD

Scientists are studying cause(s) and risk factors in an effort to find better ways to manage and reduce the chances of a person having ADHD. The cause(s) and risk factors for ADHD are unknown, but current research shows that genetics plays an important role. Recent studies link genetic factors with ADHD. 1

In addition to genetics, scientists are studying other possible causes and risk factors including:

• Brain injury
• Exposure to environmental risks (e.g., lead) during pregnancy or at a young age
• Alcohol and tobacco use during pregnancy
• Premature delivery
• Low birth weight

Research does not support the popularly held views that ADHD is caused by eating too much sugar, watching too much television, parenting, or social and environmental factors such as poverty or family chaos. Of course, many things, including these, might make symptoms worse, especially in certain people. But the evidence is not strong enough to conclude that they are the main causes of ADHD.

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Deciding if a child has ADHD is a process with several steps. There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, sleep problems, and certain types of learning disabilities, can have similar symptoms. One step of the process involves having a medical exam, including hearing and vision tests , to rule out other problems with symptoms like ADHD. Diagnosing ADHD usually includes a checklist for rating ADHD symptoms and taking a history of the child from parents, teachers, and sometimes, the child.

Learn more about the criteria for diagnosing ADHD

In most cases, ADHD is best treated with a combination of behavior therapy and medication. For preschool-aged children (4-5 years of age) with ADHD, behavior therapy, particularly training for parents, is recommended as the first line of treatment before medication is tried. What works best can depend on the child and family. Good treatment plans will include close monitoring, follow-ups, and making changes, if needed, along the way.

Learn more about treatments

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with ADHD. In addition to behavioral therapy and medication, having a healthy lifestyle can make it easier for your child to deal with ADHD symptoms. Here are some healthy behaviors that may help:

• Developing healthy eating habits  such as eating plenty of fruits, vegetables, and whole grains and choosing lean protein sources
• Participating in daily  physical activity based on age
• Limiting the amount of daily screen time from TVs, computers, phones, and other electronics
• Getting the recommended amount of sleep each night based on age

If you or your doctor has concerns about ADHD, you can take your child to a specialist such as a child psychologist, child psychiatrist, or developmental pediatrician, or you can contact your local early intervention agency (for children under 3) or public school (for children 3 and older).

The Centers for Disease Control and Prevention (CDC) funds the National Resource Center on ADHD , a program of CHADD – Children and Adults with Attention-Deficit/Hyperactivity Disorder. Their website has links to information for people with ADHD and their families. The National Resource Center operates a call center (1-866-200-8098) with trained staff to answer questions about ADHD.

For more information on services for children with special needs, visit the Center for Parent Information and Resources.  To find the Parent Center near you, you can visit this website.

ADHD can last into adulthood. Some adults have ADHD but have never been diagnosed. The symptoms can cause difficulty at work, at home, or with relationships. Symptoms may look different at older ages, for example, hyperactivity may appear as extreme restlessness. Symptoms can become more severe when the demands of adulthood increase. For more information about diagnosis and treatment throughout the lifespan, please visit the websites of the National Resource Center on ADHD  and the National Institutes of Mental Health .

• National Resource Center on ADHD
• National Institute of Mental Health (NIMH)
• Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., . . . Wang, Y. (2021). The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about the disorder. Neuroscience & Biobehavioral Reviews. doi:10.1016/j.neubiorev.2021.01.022

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About the Author

We curate evidence by systematically reviewing the scientific literature to select studies meeting a very high level of evidence. We limit our curation to two types of evidence: meta-analyses and very large studies. Meta-analyses combine

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Distinguished Professor and Vice Chair of Research of Psychiatry and Behavioral Sciences Professor of Neuroscience and Physiology , Professor of Neuroscience Graduate Program

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This set of slides provides an overview of the diagnosis and treatment of ADHD.   It can be used as a presentation meant to be given by someone with prior knowledge of these topics.  Feel free to add or delete slides to this set to accommodate your audience.

La Declaration de Consensus International sur le Trouble Déficit d’Attention Hyperactivité:​Implications pour le Diagnostic et le Traitement

Ces diapositives constituent une introduction à la Déclaration de consensus internationale sur le TDAH. Elles décrivent les méthodes et les résultats les plus pertinents pour le diagnostic et le traitement de ce trouble. Le texte qui accompagne chaque diapositive est la manière dont les diapositives ont été présentées par le Professeur Faraone lors du "Symposium international sur le TDAH".

International Consensus Statement

This set of 370 slides is not meant to be a single presentation.  Instead, it is meant to provide slides that describe the findings reported in the International Consensus Statement of ADHD.  Educators can use these slides to create presentations crafted for their educational goals.

La Declaration de Consensus International sur le Trouble Deficit d’Attention Hyperactivityé:​ Implications pour le Diagnostic et le Traitement

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Attention-Deficit/Hyperactivity Disorder

What is adhd.

Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. People with ADHD experience an ongoing pattern of the following types of symptoms:

• Inattention means a person may have difficulty staying on task, sustaining focus, and staying organized, and these problems are not due to defiance or lack of comprehension.
• Hyperactivity means a person may seem to move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks. In adults, hyperactivity may mean extreme restlessness or talking too much.
• Impulsivity means a person may act without thinking or have difficulty with self-control. Impulsivity could also include a desire for immediate rewards or the inability to delay gratification. An impulsive person may interrupt others or make important decisions without considering long-term consequences.

What are the signs and symptoms of ADHD?

Some people with ADHD mainly have symptoms of inattention. Others mostly have symptoms of hyperactivity-impulsivity. Some people have both types of symptoms.

Many people experience some inattention, unfocused motor activity, and impulsivity, but for people with ADHD, these behaviors:

• Are more severe
• Occur more often
• Interfere with or reduce the quality of how they function socially, at school, or in a job

Inattention

People with symptoms of inattention may often:

• Overlook or miss details and make seemingly careless mistakes in schoolwork, at work, or during other activities
• Have difficulty sustaining attention during play or tasks, such as conversations, lectures, or lengthy reading
• Not seem to listen when spoken to directly
• Find it hard to follow through on instructions or finish schoolwork, chores, or duties in the workplace, or may start tasks but lose focus and get easily sidetracked
• Have difficulty organizing tasks and activities, doing tasks in sequence, keeping materials and belongings in order, managing time, and meeting deadlines
• Avoid tasks that require sustained mental effort, such as homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers
• Lose things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones
• Be easily distracted by unrelated thoughts or stimuli
• Be forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments

Hyperactivity-impulsivity

People with symptoms of hyperactivity-impulsivity may often:

• Fidget and squirm while seated
• Leave their seats in situations when staying seated is expected, such as in the classroom or the office
• Run, dash around, or climb at inappropriate times or, in teens and adults, often feel restless
• Be unable to play or engage in hobbies quietly
• Be constantly in motion or on the go, or act as if driven by a motor
• Talk excessively
• Answer questions before they are fully asked, finish other people’s sentences, or speak without waiting for a turn in a conversation
• Have difficulty waiting one’s turn
• Interrupt or intrude on others, for example in conversations, games, or activities

Primary care providers sometimes diagnose and treat ADHD. They may also refer individuals to a mental health professional, such as a psychiatrist or clinical psychologist, who can do a thorough evaluation and make an ADHD diagnosis.

For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind typical development for their age. Stress, sleep disorders, anxiety, depression, and other physical conditions or illnesses can cause similar symptoms to those of ADHD. Therefore, a thorough evaluation is necessary to determine the cause of the symptoms.

Most children with ADHD receive a diagnosis during the elementary school years. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before age 12.

ADHD symptoms can appear as early as between the ages of 3 and 6 and can continue through adolescence and adulthood. Symptoms of ADHD can be mistaken for emotional or disciplinary problems or missed entirely in children who primarily have symptoms of inattention, leading to a delay in diagnosis. Adults with undiagnosed ADHD may have a history of poor academic performance, problems at work, or difficult or failed relationships.

ADHD symptoms can change over time as a person ages. In young children with ADHD, hyperactivity-impulsivity is the most predominant symptom. As a child reaches elementary school, the symptom of inattention may become more prominent and cause the child to struggle academically. In adolescence, hyperactivity seems to lessen and symptoms may more likely include feelings of restlessness or fidgeting, but inattention and impulsivity may remain. Many adolescents with ADHD also struggle with relationships and antisocial behaviors. Inattention, restlessness, and impulsivity tend to persist into adulthood.

What are the risk factors of ADHD?

Researchers are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other disorders, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors that might raise the risk of developing ADHD and are studying how brain injuries, nutrition, and social environments might play a role in ADHD.

ADHD is more common in males than females, and females with ADHD are more likely to primarily have inattention symptoms. People with ADHD often have other conditions, such as learning disabilities, anxiety disorder, conduct disorder, depression, and substance use disorder.

How is ADHD treated?

While there is no cure for ADHD, currently available treatments may reduce symptoms and improve functioning. Treatments include medication, psychotherapy, education or training, or a combination of treatments.

For many people, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Sometimes several different medications or dosages must be tried before finding the right one that works for a particular person. Anyone taking medications must be monitored closely by their prescribing doctor.

Stimulants. The most common type of medication used for treating ADHD is called a “stimulant.” Although it may seem unusual to treat ADHD with a medication that is considered a stimulant, it works by increasing the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention.

Under medical supervision, stimulant medications are considered safe. However, like all medications, they can have side effects, especially when misused or taken in excess of the prescribed dose, and require an individual’s health care provider to monitor how they may be reacting to the medication.

Non-stimulants. A few other ADHD medications are non-stimulants. These medications take longer to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD. Doctors may prescribe a non-stimulant: when a person has bothersome side effects from stimulants, when a stimulant was not effective, or in combination with a stimulant to increase effectiveness.

Although not approved by the U.S. Food and Drug Administration (FDA) specifically for the treatment of ADHD, some antidepressants are used alone or in combination with a stimulant to treat ADHD. Antidepressants may help all of the symptoms of ADHD and can be prescribed if a patient has bothersome side effects from stimulants. Antidepressants can be helpful in combination with stimulants if a patient also has another condition, such as an anxiety disorder, depression, or another mood disorder. Non-stimulant ADHD medications and antidepressants may also have side effects.

Doctors and patients can work together to find the best medication, dose, or medication combination. To find the latest information about medications, talk to a health care provider and visit the FDA website  .

Psychotherapy and psychosocial interventions

Several specific psychosocial interventions have been shown to help individuals with ADHD and their families manage symptoms and improve everyday functioning.

For school-age children, frustration, blame, and anger may have built up within a family before a child is diagnosed. Parents and children may need specialized help to overcome negative feelings. Mental health professionals can educate parents about ADHD and how it affects a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other.

All types of therapy for children and teens with ADHD require parents to play an active role. Psychotherapy that includes only individual treatment sessions with the child (without parent involvement) is not effective for managing ADHD symptoms and behavior. This type of treatment is more likely to be effective for treating symptoms of anxiety or depression that may occur along with ADHD.

Behavioral therapy is a type of psychotherapy that aims to help a person change their behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a person how to:

• Monitor their own behavior
• Give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting

Parents, teachers, and family members also can give feedback on certain behaviors and help establish clear rules, chore lists, and structured routines to help a person control their behavior. Therapists may also teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

Cognitive behavioral therapy helps a person learn how to be aware and accepting of one’s own thoughts and feelings to improve focus and concentration. The therapist also encourages the person with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.

Family and marital therapy can help family members and spouses find productive ways to handle disruptive behaviors, encourage behavior changes, and improve interactions with the person with ADHD.

Parenting skills training (behavioral parent management training) teaches parents skills for encouraging and rewarding positive behaviors in their children. Parents are taught to use a system of rewards and consequences to change a child’s behavior, to give immediate and positive feedback for behaviors they want to encourage, and to ignore or redirect behaviors they want to discourage.

Specific behavioral classroom management interventions and/or academic accommodations for children and teens have been shown to be effective for managing symptoms and improving functioning at school and with peers. Interventions may include behavior management plans or teaching organizational or study skills. Accommodations may include preferential seating in the classroom, reduced classwork load, or extended time on tests and exams. The school may provide accommodations through what is called a 504 Plan or, for children who qualify for special education services, an Individualized Education Plan (IEP). 

To learn more about the Individuals with Disabilities Education Act (IDEA), visit the  U.S. Department of Education’s IDEA website  .

Stress management techniques can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behavior.

Support groups can help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.

The National Resource Center on ADHD, a program of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD®) supported by the Centers for Disease Control and Prevention (CDC), has information and many resources. You can reach this center online   or by phone at 1-866-200-8098.

Learn more about psychotherapy .

Tips to help kids and adults with ADHD stay organized

Parents and teachers can help kids with ADHD stay organized and follow directions with tools such as:

• Keeping a routine and a schedule. Keep the same routine every day, from wake-up time to bedtime. Include times for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or a bulletin board. Write changes on the schedule as far in advance as possible.
• Organizing everyday items. Have a place for everything, (such as clothing, backpacks, and toys), and keep everything in its place.
• Using homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home necessary books.
• Being clear and consistent. Children with ADHD need consistent rules they can understand and follow.
• Giving praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior and praise it.

For adults:

A professional counselor or therapist can help an adult with ADHD learn how to organize their life with tools such as:

• Keeping routines.
• Making lists for different tasks and activities.
• Using a calendar for scheduling events.
• Using reminder notes.
• Assigning a special place for keys, bills, and paperwork.
• Breaking down large tasks into more manageable, smaller steps so that completing each part of the task provides a sense of accomplishment.

How can I find a clinical trial for ADHD?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage : Information about participating in clinical trials
• Clinicaltrials.gov: Current Studies on ADHD  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country
• Join a Study: Children - ADHD : List of studies being conducted on the NIH Campus in Bethesda, MD

Where can I learn more about ADHD?

Free brochures and shareable resources.

• Attention-Deficit/Hyperactivity Disorder in Children and Teens: What You Need to Know : This brochure provides information about attention-deficit/hyperactivity disorder (ADHD) in children and teens including symptoms, how it is diagnosed, causes, treatment options, and helpful resources. Also available en español .
• Attention-Deficit/Hyperactivity Disorder in Adults: What You Need to Know : This brochure provides information about attention-deficit/hyperactivity disorder (ADHD) in adults including symptoms, how ADHD is diagnosed, causes, treatment options, and resources to find help for yourself or someone else. Also available en español .
• Shareable Resources on ADHD : These digital resources, including graphics and messages, can be used to spread the word about ADHD and help promote awareness and education in your community.
• Mental Health Minute: ADHD : Take a mental health minute to learn about ADHD.
• NIMH Expert Discusses Managing ADHD : Learn the signs, symptoms, and treatments of ADHD as well as tips for helping children and adolescents manage ADHD during the pandemic.

Federal resources

• ADHD   : CDC offers fact sheets, infographics, and other resources about the signs, symptoms, and treatment of children with ADHD.
• ADHD   : (MedlinePlus – also available  en español   .)

Research and statistics

• Journal Articles   : This webpage provides information on references and abstracts from MEDLINE/PubMed (National Library of Medicine).
• ADHD Statistics : This web page provides statistics about the prevalence and treatment of ADHD among children, adolescents, and adults.

Last Reviewed: September 2023

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The Different Presentations of ADHD Explained

by Margaret Paton | Oct 25, 2018

A counselor of the Today Parent Team, Susie Garlick, says : “Our ADHD children are not horrible, undisciplined or unruly children, we have just created a world that no longer allows them to fit inside the box.”

This article explains the three different presentations of this disorder – Predominantly Inattentive ADHD , Predominantly Hyperactive-Impulsive ADHD and ADHD combined.

Diagnosis – the Stats

One in nine children aged between four and 17 in the US have been diagnosed with ADHD – that’s about 6.4 million children, according to the health website , MedicalNewsToday. Age four is the earliest a child can be diagnosed, says the American Academy of Pediatrics. About a third of children diagnosed continue to have the disorder into adulthood, according to a report by Viser and associates. And, it’s more difficult to diagnose ADHD in teenagers.

So, how is it diagnosed? Well, there isn’t a single test for it, so health professionals need to gather much information to make a diagnosis including a typical rating scale with up to 90 questions about the frequency of ADHD type behaviours. And although there’s no cure, there is help.

The authoritative source on this is the American Psychiatric Association. It last updated its information about ADHD five years ago to help clinicians diagnose adults as well as children presenting with the condition. They’ve explained it in their Diagnostic and Statistical Manual of Mental Disorders (DSM-5), that is, the fifth edition .

Symptoms to look for

That manual says those with ADHD: • Present in multiple settings (such as school and home) with a pattern of behaviour that can result in performance issues socially, educationally or at work • Fall into two categories of (1) inattention, and (2) hyperactivity and impulsivity • Have at least six symptoms from either/both of those categories if they’re children (and that these present before age 12) • Have at least five symptoms from either/both of those categories if they’re aged 17+.

And these symptoms would have been happening for at least six months. However, over time symptoms may change and in fact, so can the diagnosis of which type of ADHD. At the time of diagnosis, you’ll usually hear if it’s rated mild, moderate or severe. That’s actually a more accurate indicator of the severity of your condition than the type. But it’s still important to know about the three presentations – formerly known as subtypes.

Three presentations of ADHD

Ok, you might be confused because the DSM talks about ‘two categories’ and in a way, they’re right. There are two categories of inattentive, hyperactive-impulsive, and the third presentation is a combination of those two. Let’s unpack them.

Predominantly Inattentive ADHD

This presentation of ADHD affects females from than males. It means that those diagnosed are easily distracted, find it hard to pay close attention to details, but they don’t exhibit hyperactivity or impulsiveness. They may appear to be daydreaming, seem forgetful about their belongings, make simple mistakes, have trouble following instructions and organizing tasks, get bored easily and don’t like exerting mental effort for prolonged periods. In short, they exhibit poor centration skills and are easily distracted.

Predominantly Hyperactive-Impulsive ADHD

There are two elements here – hyperactivity and impulsivity.

Hyperactivity is shown through constant movement and talking – always being ‘on the go’. Symptoms include not being able to sit down or stay still for long, fidgeting and squirming particularly when it’s inappropriate to do so. They have trouble staying on task.

People with this presentation of ADHD tend to struggle to control powerful emotions so their anger can flare up. That’s the impulsivity part. They can be risk takers who don’t think through their actions, perhaps even jump the gun saying inappropriate things or answering before they’ve heard the whole question. You may find them interrupting others often and not being so great at waiting their turn.

Combined ADHD

ADHD combined includes symptoms of the other two types and it’s the most common and mostly widely researched. As mentioned above, symptoms can change with age and the setting. Such a diagnosis in children typically means they are hyperactive and have difficulty paying attention.

The way forward

Knowing which presentation of ADHD has been diagnosed is a step in the right direction to get treatment and management. ADHD is treated through psychology, behavior therapy, parent training in behavior therapy (also called parent behavior training), behavioral peer interventions, behavioral classroom management, organization training, and psychostimulant medication. Restricting the consumption of food additives, preservatives or sugar, though sometimes helpful, won’t ‘cure’ ADHD either.

And panning out a bit further, another approach (often complementary) is to focus on their strengths, interests and talents – rather than deficits. It’s what the ADDitude magazine calls the ‘abundance model’ as opposed to the ‘deficit model’.

Find out more about Inattentive Attention Deficit Hyperactivity Disorder overall and Gemm Learning’s programs to help get the best out of you or your child – you can check out a free demo here .

Links: American Psychiatric Association’s two-page  factsheet on Attention Deficit/Hyperactivity Disorder (under DSM-5 ‘Updated Disorders’) Consumer health information website , healthline Diagnosing ADHD in Children: Guideline and Information for Parents  factsheet from healthychildren.org. (Also available as an audio file and in Spanish)

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Adult ADHD: A Review of the Clinical Presentation, Challenges, and Treatment Options

The clinical presentation and functional impacts of ADHD in adults vary greatly from their child and adolescent counterparts. Here: latest information on this complex topic.

Table 1 – Stimulant drug therapy options

Table 2 – Nonstimulant drug therapy options

Premiere Date: October 20, 2015 Expiration Date: April 20, 2017

This activity offers CE credits for:

1. Physicians (CME) 2. Other

ACTIVITY GOAL

To recognize the clinical presentation of adult ADHD as well as the associated challenges of assessment and treatment.

LEARNING OBJECTIVES

At the end of this CE activity, participants should be able to:

• Understand the difficulties associated with making an objective assessment of adult ADHD

• Identify the psychiatric conditions frequently comorbid with adult ADHD

• Distinguish which intervention to use when treating an adult patient with a diagnosis of ADHD

TARGET AUDIENCE

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

CREDIT INFORMATION

CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for 1.5 AMA PRA Category 1 Credit™ .

DISCLOSURE DECLARATION

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Jennifer A. Reinhold, PharmD, BCPS, BCPP, has no disclosures to report.

J. Russell Ramsay, PhD, (peer/content reviewer) reports that he is a research consultant for Shire Pharmaceuticals and is on the faculty of the CME Institute of Physicians Postgraduate Press, which is funded in part by a Shire grant.

Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.

UNLABELED USE DISCLOSURE

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

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The inattentive and the hyperactive-impulsive subtypes of ADHD are particularly evident in adults. This inherent heterogeneity complicates the diagnosis and contributes to the lack of uniformly recognized criteria in the adult population. Historically, the diagnostic criteria that were developed based on the traditional childhood presentation have been applied to adult patients. Practitioners have attempted to adapt these criteria to adults in practice, and DSM-5 has also modified some of the qualifiers in order to facilitate the utilization of the criteria in adults. However, the clinical presentation and functional impacts of ADHD in adults vary greatly from their child and adolescent counterparts.

As patients mature and their roles and responsibilities evolve, the functional impairments and symptom presentation evolve in response, thereby presenting a barrier to fulfilling diagnostic criteria. Adults are exposed to a variety of social and professional situations that can provide an opportunity for previously unnoticed symptoms to manifest. Inattentive symptoms may present as difficulty in completing tasks, poor time management, difficulty in sustaining attention in work-related activities, distractibility and forgetfulness, and poor concentration. Occupational performance and professional interpersonal relationships can suffer, and ultimately result in frequent job changes, unemployment, failure to live up to one’s occupational potential, and lower salaries. Moreover, deficits in global performance in the adult patient’s life role, follow-through, and memory can have pervasive effects that extend to those who depend on him or her (eg, children, spouses, employers, friends).

Perhaps the most significant evolution of symptoms occurs in the hyperactivity-impulsivity domain. It is often assumed that these symptoms fade or resolve entirely in adults as they grow older. However, maturation results in a shift in this symptom cluster, and it evolves from behavioral to cognitive-adult patients feel restless as opposed to running around and being disruptive in school. Approximately 90% of adult patients have symptoms of inattention. 1

Challenges in assessing ADHD in adult patients

There are many challenges associated with a diagnosis of ADHD in adults. Objective assessment is difficult because of many factors, including the extensive degree of symptom overlap with other psychiatric diagnoses (eg, psychiatric comorbidities, adaptive compensatory mechanisms, difficulty in assessing functional impact).

Lack of validated diagnostic criteria

The most contemporary multidimensional approach to a relatively objective diagnosis in children and adolescents are DSM-5 criteria, which assess symptoms in all 3 domains. Until the release of DSM-5, there was very little consideration for the assessment of adult patients because DSM criteria had not been validated in the adult population. DSM-5 adapted the previous set of diagnostic criteria to be more accurately applicable to adult symptom presentation. The nomenclature has evolved to reflect more adult-specific situations, such as having difficulty focusing during lectures, avoidance of reviewing lengthy papers, and forgetfulness related to paying bills or keeping appointments.

Revisions that facilitate the application of the criteria to adults are the decrease in the number of required symptoms for adults to fulfill criteria as well as an increase in the age of initial presentation. Previously, adult patients needed to satisfy at least 6 of the 9 inattentive criteria, which is consistent with diagnosis in the pediatric and adolescent population. In DSM-5, adults need to satisfy only 5 of the 9 criteria and children and adolescents still need to satisfy 6 of the 9 inattentive criteria. DSM-IV required that symptoms present before age 7-a challenging retrospective for adult patients who had not previously sought an intervention.

Even with the new criteria, practitioners need to make a retrospective evaluation of the presence of ADHD in childhood in order to establish a diagnosis in adulthood. This was cited as one of the most problematic components of the criteria because many patients could not recall childhood symptoms or they could not produce documentation substantiating a childhood diagnosis. Because ADHD is considered a developmental disorder, the presence of current symptoms as well as a history of previous symptoms (in childhood) needs to be established. Patients with ADHD, however, have impaired short- and long-term memory; therefore, recall bias can affect the accuracy of assessments. The practitioner is faced with the challenge of determining whether this was an established childhood diagnosis, a missed diagnosis in childhood, or a late-onset adult ADHD.

There are a host of validated rating scales for assessing adult patients with suspected ADHD, although each has inherent limitations. The Adult Self-Report Scale (ASRS) is an 18-item screening tool that is based on DSM-IV criteria. Patients rate the items based on the frequency and degree to which they occur. A 6-item version of the ASRS captures abnormalities in the domains related to follow-through, memory, organization, procrastination, restlessness, and hyperactivity.

The Conners Self-Report Scale is a multidimensional assessment scale that both the patient and an observer complete. The long version of this scale has 66 items that assess symptoms consistent with inattention and memory deficits, impulsivity and emotional lability, hyperactivity and restlessness, and problems with self-conceptualization. 2 Having multiple perspectives is ideal in that the observer can contribute critical data that the patient may be either unaware of or not willing to disclose. One of the most significant limitations of self-report scales is that they are generally not sufficient independently to establish a diagnosis in the absence of more objective data or documentation. A 30-item version of the Conners Adult ADHD Self-Report Scale can also be used.

Psychiatric comorbidity and symptom overlap

Another challenge in the evaluation of adult ADHD is the symptom overlap between ADHD and mood and anxiety disorders. Patients with ADHD tend to have high rates of comorbidity with anxiety, depression, and substance abuse disorders, with prevalence rates that are more than double those observed in patients without ADHD. 3-5 In a 2006 study, 87% of adult patients had at least one psychiatric comorbidity and 56% had two. 4 Determining whether ADHD is present alone or whether it is comorbid with another psychiatric disorder is critical-a mood or anxiety disorder may be responsible for the ADHD-like symptoms.

Compared with patients who have a depressive disorder, those with ADHD tend to have more occupational or functional impairment, organizational deficits, and impulsivity issues. The distinction between ADHD and bipolar disorder can be especially challenging, since the manic and hypomanic features of bipolar disorder are similar to the hyperactive and impulsive symptoms associated with ADHD. In patients with ADHD, these symptoms tend to be constant, but in bipolar disorder there is a waxing and waning of manic symptoms interrupted with periods of depression. Patients with bipolar disorder tend to be goal-directed and are usually productive, while patients with ADHD are less able to complete tasks.

Substance use disorders are more common in patients with ADHD, and the clinical course of ADHD tends to be more challenging in this patient population. In patients with an opiate or cocaine addiction, the prevalence of ADHD is as high as 35%; and for alcohol-addicted patients, the ADHD prevalence exceeds 70%. 4,6 Alcohol and certain prescription and illicit drugs can produce symptoms that mirror those of ADHD, which may artificially inflate the prevalence of ADHD in patients with an addiction problem and may not be reflective of the true prevalence.

Compensatory mechanisms

Adult patients may develop and depend on compensatory mechanisms in order to overcome some of the functional impairments associated with ADHD. 4,7 Patients who are highly functioning with higher than average IQs tend to develop useful coping mechanisms to overcome symptoms or to hide them from others. Some patients become compulsive list makers or develop a highly structured daily routine in order to complete tasks and to minimize forgetting details or losing belongings.

6 Challenges in Assessing ADHD in Adult Patients

They may unknowingly rely on coworkers or family members to an inappropriate extent for reminders or assistance in completing tasks or fulfilling responsibilities. Although compensatory mechanisms are generally therapeutic for the patient, they may cloud the clinical picture particularly in cases where the patient does not self-suspect ADHD but rather a family member or the practitioner suspects ADHD.

Engaging in compensatory mechanisms such as relying significantly on others or forgoing sleep to finish tasks may mask the symptoms of ADHD or suggest that a patient is adequately coping when he or she is not. In any case, the use of appropriate compensatory mechanisms should also be taken into consideration when determining whether drug therapy is indicated. Some patients can manage without a clinically significant functional impact by relying on compensatory mechanisms and are able to avoid drug therapy.

Evidence of significant clinical impact

Among the DSM criteria is an item that evaluates the degree of clinical impact of ADHD symptoms on life domains. For a diagnosis of ADHD, there must be clear evidence of significant clinical impact, which can be especially difficult to objectively assess. Failure to demonstrate significant clinical impact precludes a diagnosis of ADHD even if all other criteria are satisfied. Examples of true clinical impact include disciplinary action at work, risk of job loss, relationship discord, or frequent automobile accidents or accidents in the home.

Underdiagnosis vs overdiagnosis

Given the high degree of psychiatric symptom overlap, the realistic possibility of feigning ADHD symptoms, and a general fear of enabling drug addiction or diversion, the underdiagnosis versus overdiagnosis of ADHD in practice has been called into question. There are no available data to quantify this concern, and therefore no support can be lent to the argument of failure to recognize ADHD or misdiagnosis of ADHD. A psychiatric comorbidity and the point of entry into the health care system (primary care versus a psychiatrist) may influence whether ADHD is overdiagnosed or underdiagnosed. The most frequent point of entry into the health care system and the most common place for ADHD to be evaluated and diagnosed is in the primary care setting, where it may be overdiagnosed. However, when patients are seen by a psychiatrist, it usually is the comorbid psychiatric diagnosis that is treated and not ADHD. Thus, ADHD may be underdiagnosed when patients present to a psychiatrist. Given the assertion that ADHD is overdiagnosed in primary care and underdiagnosed by specialists, the true prevalence of ADHD theoretically lies somewhere in between. 8,9

Prescription drug abuse and drug-seeking behavior

According to the most recent survey by the National Institute on Drug Abuse, adults between the ages of 18 and 25 are statistically the most likely to abuse prescription drugs. 10 Adults between the ages of 18 and 22 are the most likely to abuse stimulant medications, with rates in college students double those in non-college students. 11 The majority of adult patients who present with self-suspected ADHD are between the ages of 18 and 24; therefore, the unfortunate but realistic risk of drug seeking must be considered.

A definitive statistic that quantifies the risk and rates of stimulant medication abuse is elusive owing to patient unwillingness to admit abuse or diversion. However, multiple studies have attempted to capture this rate through anonymous surveys and emergency-department visits. Generally stimulants with a rapid onset of effect and shorter half-life are more likely to be abused, since there is a more narrow window between ingesting the drug and realizing the perceived reward. Variability exists within the therapeutic class in terms of abuse potential: rates of abuse of amphetamine salts exceed those of methylphenidate. 12

Establishing a meaningful comparison of the rates of abuse of stimulant medications compared with prescription drugs for other indications is also challenging. Considering the physiologic consequences of abusing stimulants, opioids, or sedative-hypnotics, it may not be surprising that accidental death due to abuse of a prescription drug is by far the highest for the opioids. Prescription opioid-related accidental deaths were more frequent than cocaine, heroin, and stimulant overdoses combined. 13

Treatment modalities

Psychostimulants remain the drug class of choice in treating adults and children with ADHD. Most product formulations available are derived from one of two parent molecules: methylphenidate or amphetamine ( Table 1 ). Pharmacologically, the stimulants inhibit the reuptake of dopamine and norepinephrine, thereby increasing concentrations in the presynaptic cleft. Amphetamines also directly stimulate the release of dopamine and norepinephrine. About 14 products are currently available in the US: some of them are immediate-release and others are extended-release formulations. It is generally recommended that drug therapy, particularly in adults, should consist of an extended-release product in order to maximize compliance and minimize the risk of abuse. Stimulant medications mitigate traditional ADHD symptoms and have demonstrated utility in improving interpersonal relationships, self-esteem, and cognition, as well as alleviating symptoms of comorbid anxiety disorders. 14,15 Stimulants are arguably the most effective in resolving ADHD symptoms and comorbid psychopathology; however, because of the risk of adverse effects and abuse potential, these agents may be underprescribed for adult ADHD. 16

Common, transient adverse effects include sleep disturbance, appetite suppression and associated weight loss, agitation, and nervousness. These are typically minimized by taking the drugs with food and using an extended-release formulation. Serious concerns exist regarding cardiotoxicity. Patients can experience palpitations, tachycardia, and elevations in blood pressure. Serious cardiovascular effects include rhythm disturbances and cardiomyopathy, which precludes use in patients who have an existing cardiovascular abnormality.

Nonstimulants

Owing to their less impressive effectiveness compared with stimulants, the nonstimulant medications tend to be prescribed less frequently among all age groups. Generally, practitioners do not initiate drug therapy with a nonstimulant unless the patient has a contraindication to stimulants (cardiac abnormalities, previous or current substance abuse) or is intolerant to or has failed a trial of a stimulant. Currently, the nonstimulant therapeutic class includes atomoxetine, immediate- and extended-release guanfacine, clonidine, and bupropion (Table 2 ).

Atomoxetine’s efficacy and safety have been demonstrated in adults and children; however, its associated rates of response are less impressive than those of the stimulants. It remains an appropriate option in patients who have contraindications to stimulants or who have a comorbid anxiety disorder, as anecdotal evidence suggests some level of anxiolytic activity.

Bupropion has been evaluated in a small number of studies involving children, adolescents, and adults, in whom its efficacy compared with placebo or with an active stimulant comparator has been established. This is not an approved indication for bupropion in any age group, however. Bupropion may be a therapeutic alternative in adults who have contraindications or are intolerant to stimulant medications, or in patients who have a comorbid depressive illness.

Guanfacine and clonidine are typically reserved for children who also have a hyperactive component. Of the newer extended-release formulations, only extended-release clonidine has an indication for the treatment of adult ADHD.

CASE VIGNETTE

A 42-year-old woman presents to a primary care clinic for an evaluation of her attention issues. Alice’s symptoms became apparent in early grade school, but with extra effort she managed to get good grades throughout elementary school, high school, and college. Lately she has had increasing difficulty in remembering appointments and completing her projects; she has also been losing her belongings, avoiding tasks, getting distracted at meetings, and failing to listen to people when they speak to her. Her direct superior has brought this to her attention and has mentioned possible disciplinary action. Symptoms occur all day, regardless of setting. Her past medical history includes dyslipidemia, anxiety, and gastroesophageal reflux disease. Prescription medications include 20-mg atorvastatin daily, 10-mg escitalopram daily, and 20-mg omeprazole daily. Evaluations for mood and anxiety disorders reveal no additional diagnoses. There is no documented history of or current issues with substance abuse.

Does this patient fulfill DSM-5 diagnostic criteria for ADHD?   Yes . She reports at least 5 symptoms of inattention (remembering appointments, finishing projects, losing belongings, task avoidance, easy distraction, failing to listen to others in conversation). The symptoms (per patient report) began before age 12, occur both at work and at home, and have resulted in functional impairment (evidenced by her supervisor’s threat of disciplinary action). Given her age, it would be difficult to collect collateral supporting information from a teacher or parent, and so the patient report alone will need to be the only account of symptoms. The clinician’s judgment about the validity of these claims will also need to be taken into consideration. If possible, an attempt could be made to discuss these issues with the patient’s husband or work supervisor in order to acquire different perspectives and additional supporting information. Other psychiatric diagnoses and substance abuse issues are ruled out; therefore, the ADHD symptoms are not better explained by another psychiatric disorder.

Is this patient a candidate for a pharmacotherapeutic intervention?   Yes. Current treatment guidelines recommend initiating drug therapy in adults as a first-line treatment.

Is this patient a candidate for non-drug therapy?   Yes, if necessary. There is no treatment guideline that specifically recommends non-drug therapy for adult patients because there is a lack of efficacy data to support it. However, if the patient complains of specific symptoms that may be behavior-mediated (such as time management or procrastination-related symptoms), counseling or other workshop-based interventions may help her to manage these symptoms more effectively and may eventually reduce her dependence on drug therapy for the monotherapy of ADHD.

What pharmacotherapeutic intervention(s) would be most appropriate? Consistent with the domestic guidelines for the management of ADHD in children, the National Institute for Health and Care Excellence guidelines in Europe recommend initiating a stimulant medication as first-line therapy. None of the stimulants are considered superior with regard to safety or efficacy in adults or children. However, a long-acting formulation is generally preferred because of the reduced likelihood of abuse. This patient has no history of substance abuse, but use of longer-acting formulations will minimize any risk.

Longer-acting products tend to have a smoother onset and offset of action compared with immediate-release agents, which produce a noticeable onset in most patients. A longer-acting product will reduce the pill burden and will require less frequent dosing-an advantage for someone who needs coverage throughout the day.

If this patient has a contraindication to stimulants, what is the next most appropriate intervention? Contraindications to stimulants generally include cardiovascular issues such as arrhythmias, uncontrolled hypertension, or concomitant administration of other drugs that can be arrhythmogenic. In the setting of a contraindication, the nonstimulants could be considered. Atomoxetine is generally used first because its efficacy data are more robust than that of clonidine, guanfacine, and bupropion.

If this patient had a comorbid diagnosis of depression or anxiety, how might the treatment plan for ADHD be different? Depending on the severity of symptoms, the practitioner may choose to treat the mood or anxiety disorder first. This depends on which symptoms are most distressing and which are causing the most functional impairment. Improvement in a comorbid mood and/or anxiety disorder may also indirectly improve ADHD symptoms because patients who are euthymic and not anxious may be better equipped to deal with the ADHD symptoms. Assuming that the comorbid diagnosis is depression, a stimulant and an antidepressant could be initiated, but not at the same time in order to gauge which drug resulted in the resolution of which symptoms.

Bupropion might be a possible intervention if a reduction in pill burden is important. Bupropion is not indicated for ADHD, but there is some evidence to support its use. Assuming that the comorbidity is anxiety, the initiation of a stimulant may or may not worsen symptoms. This is highly patient-specific and will depend on whether the anxiety is worsening the ADHD or vice versa. It may be advisable to initiate medication therapy for the anxiety first and once improved or resolved, initiate drug therapy carefully for the ADHD and monitor for worsening of anxious symptoms.

Historically considered a diagnosis of childhood, ADHD persists into adulthood for a vast majority of patients. Secondary to the absence of validated screening tools for adults, the pervasive symptom overlap with other psychiatric illnesses, frequent comorbidity with other psychiatric diagnoses, feigned ADHD, and the risk of drug diversion or abuse, diagnosis in adults has proven to be challenging. However, utilizing the available diagnostic criteria, gathering as much data as possible from as many sources as possible, considering the possible influence of other psychiatric comorbidities, and being diligent in assessing risk of abuse, the diagnosis of ADHD in an adult can be achieved responsibly and with minimal risk.

CME POST-TEST

Post-tests, credit request forms, and activity evaluations must be completed online at www.cmeoutfitters.com/PT (requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required). This Web site supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy, visit www.neurosciencecme.com/technical.asp .

PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR A YEAR AFTER.

Disclosures:

Dr Reinhold is Associate Professor of Clinical Pharmacy in the department of pharmacy practice/pharmacy administration at The Philadelphia College of Pharmacy at the University of the Sciences in Philadelphia.

References:

1. Davidson MA. ADHD in adults: a review of the literature. J Atten Disord . 2008;11:628-641.

2. Taylor A, Deb S, Unwin G. Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): a systematic review. Res Dev Disabil . 2011;32:924-938.

3. Haavik J, Halmøy A, Lundervold AJ, Fasmer OB. Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Rev Neurother . 2010;10:1569-1580.

4. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry . 2006;163:716-723.

5. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry . 2005;162:1621-1627.

6. Levin FR. Diagnosing attention-deficit/hyperactivity disorder in patients with substance use disorders. J Clin Psychiatry . 2007;68(suppl 11):9-14.

7. Santosh PJ, Sattar S, Canagaratnam M. Efficacy and tolerability of pharmacotherapies for attention-deficit hyperactivity disorder in adults. CNS Drugs . 2011;25:737-763.

8. Fayyad J, De Graaf R, Kessler R. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry . 2007;190:402-409.

9. Ginsberg Y, Quintero J, Anand E, et al. Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. Prim Care Companion CNS Disord . 2014;16.

10. US Department of Health and Human Services. National Institute on Drug Abuse. Stimulants . October 2011. http://www.drugabuse.gov/publications/research-reports/prescription-drugs/stimulants . Accessed September 1, 2015.

11. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. 2013.

. Accessed August 31, 2015.

12. Romach MK, Schoedel KA, Sellers EM. Human abuse liability evaluation of CNS stimulant drugs. Neuropharmacol . 2014;87:81-90.

13. Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug Alcohol Depend . 2013;131:263-270.

14. Upadhyaya HP. Managing attention-deficit/hyperactivity disorder in the presence of substance use disorder. J Clin Psychiatry . 2007;68(suppl 11):23-30.

15. Primich C, Iennaco J. Diagnosing adult attention-deficit hyperactivity disorder: the importance of establishing daily life contexts for symptoms and impairments. J Psychiatr Ment Health Nurs . 2012;19:362-373.

16. Greenhill LL, Pliszka S, Dulcan MK, et al. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry . 2002;41(suppl 2):26S-49S.

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The State of Adult ADHD Today

The landscape for researching, evaluating, and treating adhd in adults is shifting rapidly. here are recent and forthcoming developments worthy of our attention..

April 20, 2024

The diagnostic criteria for ADHD are largely based on studies of young white boys. The symptoms spelled out in the DSM-5 — i.e., Is often “on the go” acting as if “driven by a motor” — do not reflect the lived experiences of many adults with the condition. This gap between clinical guidance and real-life symptoms has contributed to a decades-long problem with misdiagnosis, missed diagnoses, and inadequate treatment for individuals who slipped under the ADHD radar in childhood.

ADHD persists into adulthood for up to 90% of children with the condition. Symptoms evolve and change, but they do not magically disappear. In fact, the Centers for Disease Control and Prevention calls ADHD a “public health concern” with long-term repercussions. The longevity of ADHD is confirmed by scientific research, as is the fact that three boys are diagnosed with ADHD for every one girl with the condition. As a result, we now have a surging population of adults seeking a first-time diagnosis for lifelong symptoms of ADHD that may have become more debilitating, or at least distressing, with age.

“It’s not that ADHD symptoms necessarily get worse with age,” said David Goodman, M.D., assistant professor in psychiatry and behavioral sciences at the  Johns Hopkins School of Medicine , during an ADDitude webinar in April 2024. “But when you are younger, ADHD symptoms are disruptive and inconvenient to others; as you age, ADHD symptoms become disruptive and inconvenient to you .”

Pent-up demand for ADHD evaluations among adult patients continues to grow, yet clinicians today have no reliable, standardized metrics for evaluating those symptoms. The DSM-5 contains some guidance for diagnosing adults, but it is controversial and largely considered inadequate. In addition, only 33% of pediatricians, 30% of family practitioners, 25% of nurse practitioners, and 22% of internists said that they received adequate training on ADHD in medical school, according to data presented by the American Professional Society of ADHD and Related Disorders (APSARD) at its 2024 conference.

“ADHD is the second most common psychiatric disorder in adults, but it is rarely focused on” by health care providers, Goodman said during the ADDitude webinar, titled “ ADHD in Older Adults: Clinical Guidance and Implications .” “Older patients should not be easily discounted as having age-related cognitive decline and dismissed.”

First-Ever Adult ADHD Guidelines

APSARD is working to remedy this huge obstacle to care. In 2023, it established a 27-member task force that is devising clinical practice guidelines for the diagnosis and treatment of ADHD in adults . According to Goodman, who is leading the medical subcommittee for the task force, the adult ADHD guidelines have the greatest chance at widespread adoption if they are research based, clinically informed, and patient focused.

However, few research studies exist on adults over the age of 50, women, people of color, and minority populations, such as autistic adults with ADHD. If the APSARD guidelines are built on a framework of scientific research, and little, if any, unbiased scientific research exists on huge populations of patients, how thorough or helpful can those guidelines be?

“I wouldn’t say that we are going to write ‘good’ guidelines,” Goodman said during a presentation at the annual APSARD conference in January 2024, “because ‘good’ is defined in the present as what is supported by evidence. We are setting a basic standard of care… these guidelines will evolve as we learn more.”

Even so, APSARD’s clinical practice guidelines for ADHD in adults stand to impact far more than diagnosis and treatment rates. Some experts believe that formal guidelines based on high-quality scientific evidence will compel insurance companies to fully cover the medical treatment of ADHD in adults, which is seldom the case now. Others believe the guidelines could influence nationwide quotas for Schedule II controlled substances set by the Drug Enforcement Administration (DEA) , opening the door for greater availability of stimulant medications used to treat ADHD. And many advocates are hopeful that adult ADHD guidelines will contribute to greater public awareness, better medical training, less stigma, and improved mental health outcomes for patients.

The adult guidelines, which are slated for release in late 2024 or early 2025, will take into consideration many of ADHD’s major comorbid conditions, according to committee member Frances Levin, M.D., of the Columbia University Irving Medical Center . Levin confirmed that her subcommittee is meeting with subject-matter experts on substance abuse, depression, and bipolar disorder, among other ADHD-related conditions.

For each psychiatric comorbidity diagnosed alongside ADHD, a patient’s risk of premature death rises exponentially, according to Goodman. The risk of premature death is 1.56 times higher for an adult with ADHD compared to one without ADHD, and it is 29.29 times higher for an adult with ADHD and four comorbid conditions, he said, citing a 2019 study published in JAMA Psychiatry . 1

The Concept of Subthreshold ADHD

The notion of “subthreshold” ADHD was introduced by task force members at the APSARD conference as well. Subthreshold ADHD may not meet the necessary DSM-5 criteria for a diagnosis in childhood, but mild symptoms may become severe due to the stress of parenthood or the hormonal swings that accompany menopause, said Maggie Sibley, Ph.D., head of the diagnosis and assessment subcommittee. People with subthreshold ADHD may not exhibit impairing symptoms before age 12, as required in the current DSM-5 for a diagnosis. However, these undiagnosed, untreated adults may experience significant distress later in life and face an elevated risk for substance abuse, burnout, and professional and personal problems as a result, Sibley argued during a presentation at the 2024 APSARD conference.

“People with subthreshold ADHD may be massively impaired even though they don’t quite meet the criteria for a diagnosis,” said Stephen Faraone, Ph.D., a distinguished professor in the Departments of Psychiatry and Neuroscience & Physiology at SUNY Upstate Medical University , during the APSARD presentation.

Citing 2022 research showing that 63.8% of people with ADHD experienced symptom fluctuations throughout their lives, Sibley said, “We need to recognize that ADHD symptoms are not stable; they wax and wane over the lifespan.” 2

Removing or adjusting the DSM requirement that ADHD symptoms must be present before age 12 is one way to improve diagnosis and treatment. Another approach may be to expand the symptom criteria for adult ADHD to include emotional dysregulation, a common and impairing ADHD trait not currently included in the DSM-5 . Some experts like Anthony Rostain, M.D., point out that “other DSM disorders allow ‘suffering’ or ‘distress’” due to persistent symptoms as justification for a diagnosis, “but an ADHD diagnosis requires impairment. Can we use impairment or distress instead?”

Implications for Treatment and Care

Though the APSARD task force is squarely focused on developing clinical practice guidelines for the diagnosis and treatment of ADHD in adults, it will also likely “address the issue of prescriptions for older adults with ADHD,” Goodman said. A primary concern is the safety of stimulant medication use among older adults, and the risk for introducing or exacerbating cardiovascular problems. In 2023, JAMA published a meta-analysis of 19 observational studies, involving 3.9 million participants, that found ADHD medications — both stimulants and non-stimulants — do not place patients of any age at greater risk for cardiovascular events, including heart failure and hypertension. The study found that there was no statistically significant association between  ADHD medications  and cardiovascular disease (CVD), even among middle-aged and older adults. 3 Still, some prescribers hesitate or refuse to prescribe ADHD medications to patients older than age 50.

Perhaps surprisingly, the average duration of treatment for adults with ADHD is currently just seven months, said APSARD Past President Ann Childress, M.D., during a presentation on the topic of treatment barriers for adults with ADHD . More than half of adults stop taking their ADHD medication due to “suboptimal management of ADHD symptoms,” she said, citing a 2022 study published in BMC Psychiatry. 4 

To reverse this trend, Childress suggested greater clinician education regarding the benefits of long-acting stimulant medication for patients who would benefit from symptom control in professional and personal settings. Currently, 48% of adult ADHD patients are taking a short-acting stimulant, said APSARD President Greg Mattingly, M.D., an associate clinical professor at  Washington University School of Medicine . Mattingly reported during an APSARD presentation that long-acting stimulants, sometimes in combination with a non-stimulant medication, are more effective for many of his patients.

APSARD is partnering with Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) to develop clinical tools based on the forthcoming adult ADHD guidelines that clinicians can use to aid the evaluation process, Goodman said.

Mattingly added that ADHD screenings should become a routine part of annual doctors’ visits.

“Five years ago, 20% of pediatricians were screening for depression, and now it is a ubiquitous quality measure,” he said. “ ADHD screening has a higher rate of reliability, and it can be a quality measure, too.”

View Article Sources

1 Sun, S., Kuja-Halkola, R., Faraone, S.V., D’Onofrio, B.M., Dalsgaard, S., Chang, Z., Larsson, H. (2019) Association of Psychiatric Comorbidity With the Risk of Premature Death Among Children and Adults With Attention-Deficit/Hyperactivity Disorder. JAMA Psychiatry. 76(11):1141-1149. https://doi.org/10.1001/jamapsychiatry.2019.1944

2 Sibley, M.H., Arnold, L.E., Swanson, J.M., Hechtman, L.T., Kennedy, T.M., Owens, E., Molina, B.S.G., Jensen, P.S., Hinshaw, S.P., Roy, A., Chronis-Tuscano, A., Newcorn, J.H., Rohde, L.A. (2022). MTA Cooperative Group. Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. https://doi.org/10.1176/appi.ajp.2021.21010032

3 Zhang, L., Yao, H., Li, L., et al. (2022). Risk of Cardiovascular Diseases Associated with Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis.  JAMA Netw Open . https://doi.org/10.1001/jamanetworkopen.2022.43597

3 Schein, J., Childress, A., Cloutier, M., Desai, U., Chin, A., Simes, M., Guerin, A., Adams, J. (2022) Reasons for Treatment Changes in Adults with Attention-Deficit/Hyperactivity Disorder: A Chart Review Study. BMC Psychiatry. https://doi.org/10.1186/s12888-022-04016-9

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ADHD Test For Kids: The Signs And Symptoms Of Childhood ADHD

The Centers for Disease Control and Prevention (CDC) estimate that six million children aged three to 17 have been diagnosed with attention-deficit/hyperactivity disorder (ADHD ). With millions of children living with this disorder, parents may want to know how to determine whether their kids are experiencing symptoms. However, a reliable ADHD test for kids (or at least one that an individual without proper training can administer) may not exist. In addition, a simple ADHD test may not be sufficient for parents to recognize whether their child is experiencing this disorder. Instead, it may be necessary to understand the professional assessment process, as well as the signs and symptoms of ADHD in children. Parents interested in learning whether their children may benefit from the formal diagnostic process may benefit from consulting a licensed therapist in person or online.

ADHD tests for children

While there may be at-home or online tests that claim to test children for ADHD, these tend to be unreliable and incapable of officially diagnosing the disorder. Some tests, such as the Adult ADHD Self-Report Scale (ASRS), may be effective as a preliminary assessment tool for adult ADHD, but this type of assessment may not be accurate for children. 

According to the UK National Health Service, there may not be a simple test to determine whether a child is experiencing ADHD. However, a medical doctor or mental health professional may be able to provide a diagnosis after a detailed assessment. Qualified doctors or professionals may include the following:

• Pediatricians 
• Primary care physicians 
• School psychologists
• Psychiatrists 
• Clinical psychologists
• Social workers
• Licensed professional counselors

Assessments may involve multiple elements, including a physical examination. This examination may be used to determine whether a child is experiencing any physical conditions that could manifest in similar ways to the symptoms of ADHD. 

The physical assessments a doctor uses may vary, but could include CT scans, MRIs, EEGs, blood tests, hearing tests, and eyesight tests. 

A specialist’s ADHD assessment will likely also involve asking the child a series of questions and interviewing significant people in their lives (such as their parents or teachers) to get a better understanding of their behavior. This portion of the assessment may help them rule out other mental health disorders, such as bipolar disorder, autism, sensory processing disorder, and anxiety disorders.

Outside of an official assessment and diagnosis, it may be helpful to watch for the signs and symptoms of childhood ADHD. If you notice that your child is displaying any of these signs or symptoms, it may be beneficial to contact a physician or mental health professional. 

Signs and symptoms of childhood ADHD

According to the CDC, there may be a variety of signs that a child is experiencing ADHD, including the following:

• Trouble paying attention
• Difficulty controlling impulsive behaviors
• Difficulty considering the consequences of their actions
• Frequent daydreaming
• Forgetfulness or frequent loss of items
• Unnecessary risk-taking
• Frequent careless mistakes
• Difficulty resisting temptation
• Struggling to take turns
• Difficulty getting along with others
• A tendency to be overactive, squirm, or fidget

These signs may differ from the diagnostic criteria for ADHD in children. According to the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), children up to age 16 must experience at least six symptoms each of inattention and hyperactivity-impulsivity for a period of at least six months to qualify for an official diagnosis. 

Inattention symptoms for children with ADHD

• Makes careless mistakes or doesn’t give close attention to details in schoolwork, at work, or with other activities
• Often has difficulty organizing activities and tasks
• Has trouble holding attention on play activities or tasks
• Doesn’t follow through on instructions or doesn’t finish schoolwork, chores, or workplace duties
• Is often forgetful during daily activities
• Is often easily distracted
• Does not seem to listen when spoken to directly
• Dislikes, avoids, or is reluctant to do tasks requiring mental effort expended over a long period 
• Loses items that they need for tasks and activities (such as school materials, books, pencils, wallets, keys, eyeglasses, or mobile telephones) 

Hyperactivity-impulsivity symptoms for children with ADHD

• Does not stay seated in situations when remaining in one’s seat is expected
• Taps hands or feet, fidgets, or squirms in their seat
• Climbs or runs about at inappropriate times or in inappropriate settings
• Is often unable to play or take part in quiet leisure activities
• Acts as if “driven by a motor” or is often “on the go”
• Blurts out answers before the question has been completed
• Interrupts or intrudes on others
• Has trouble waiting their turn
• Talks excessively

In general, these symptoms must be present to the extent that they disrupt an individual’s life and are inappropriate for their developmental level. In addition, several symptoms must normally be present before the age of 12 in two or more settings and may not be better explained by another mental health disorder. 

Depending on the symptoms a child is experiencing, they may have one of three specific presentations of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, or combined presentation. 

• Predominantly inattentive: Also known as inattentive type ADHD, the predominantly inattentive presentation of ADHD typically involves difficulty with working memory and higher levels of distractibility. These individuals usually display a higher number of inattentive symptoms.
• Predominantly hyperactive-impulsive: Those with the predominantly hyperactive-impulsive presentation of ADHD tend to have trouble controlling their behavior or staying in one place. These individuals often display a higher number of hyperactivity-impulsivity symptoms. 
• Combined presentation: Combined presentation ADHD can involve a mix of restlessness, difficulty concentrating, and risky behavior. These individuals tend to display a mix of both inattentive and hyperactivity-impulsivity symptoms. 

Understanding the symptoms and presentations of ADHD can be beneficial for those looking to recognize signs of the disorder in their children. However, it may also be helpful to understand the potential causes or reasons that a person may develop ADHD. 

What causes ADHD? 

While the causes of ADHD may still require further research, the CDC has listed several potential causes and risk factors: 

• Low birth weight
• Premature delivery
• Exposure to environmental risks during pregnancy or at a young age
• Alcohol and tobacco use during pregnancy
• Brain injury

Research indicates that genetic factors could also play a role in the development of ADHD. In the World Federation of ADHD International Consensus Statement, numerous studies were used to show that genes and their interaction with the environment could have a significant effect on whether an individual develops ADHD. 

Researchers concluded that, in most cases, the cause of the disorder may not be a single genetic or environmental risk factor, but rather a combination of multiple risk factors. 

No matter the cause, it may be helpful to explore various treatment approaches to alleviate the symptoms of ADHD. While these treatments may vary, one potentially effective approach involves therapy. 

Can therapy help a child with ADHD? 

Research indicates that behavioral therapy often benefits children living with ADHD. One study involved 201 preschoolers diagnosed with ADHD who were split into two groups. One group received biofeedback and was provided with a health education booklet, and the other received interventions that included behavioral therapy. Children were evaluated at the beginning of the study to serve as a baseline and again six months and 12 months after the intervention. Researchers found that improvements in the behavioral intervention group tended to be more significant than those of the other group. 

Parents of children with ADHD may also benefit from seeing a mental health professional. A therapist may be able to introduce parents to valuable strategies to help their children cope with ADHD at school and at home. In addition, individuals can discuss the stress and challenges they may face as parents of children with ADHD. Therapy can also provide a place for parents to discuss their struggles outside of parenting, such as those they may be experiencing at work, in their romantic relationships, or with friends and family. 

While some may prefer to see a therapist in-person, doing so may not always be convenient or accessible. Some areas may not have enough available in-person therapists, which could make it difficult to get an appointment. Other individuals may want to use different communication formats, such as online chat, phone calls, or video conferences. In these cases, it may be beneficial to explore alternative options, such as online therapy . 

Research indicates that online therapy can be as effective as its in-person counterpart. One systematic review looked at 12 randomized controlled trials including 931 total participants in order to compare the efficacy of telehealth and face-to-face delivery of psychotherapy. Researchers found that there were generally no significant differences between telehealth and face-to-face therapy , including when addressing difficulties related to childhood mental health challenges.

While parents may want to determine whether their children are living with ADHD with an at-home or online test, doing so may not be possible. Testing or diagnosing ADHD is generally only possible through a mental health professional or medical doctor, such as a pediatrician, primary care physician, or clinical psychologist. The assessments these professionals administer may seek to rule out other conditions and disorders while also identifying whether the child is experiencing symptoms of ADHD. Parents may also benefit from working with a therapist to learn effective strategies to use with their children and to address any stressors or challenges they may be experiencing themselves.

• The ADHD Questionnaire For Adults: What You Should Know Medically reviewed by April Justice , LICSW
• Successful People With ADHD: Simone Biles, Bill Gates, And More Medically reviewed by Julie Dodson , MA
• Relationships and Relations

2 Overlooked Signs of ADHD

Hyperfocus, urgency, and atypical presentations..

Posted January 28, 2023 | Reviewed by Vanessa Lancaster

• What Is ADHD?
• Find a therapist to help with ADHD
• ADHD was first formally recognized 225 years ago and we still struggle at times to notice the condition.
• Often depicted as haywire and spacey, clinicians, teachers, and parents must be observant for presentations thwarting the stereotype.
• The two core ADHD symptoms, inattentiveness and restlessness may manifest as hyperfocused and overproductive.

Believed to have first been formally recognized in 1798 by Scottish physician Sir Alexander Crichton (Lange et al., 2010), ADHD needs little introduction in modern times. The condition has gone on to be one of the most over-diagnosed and undiagnosed disorders (e.g., Ginsberg et al., 2014; Ford-Jones, 2015; Chung et al., 2019; Kazda et al., 2021).

Anyone working in mental health care or pediatrics knows it is easy, at first glance, for other psychiatric conditions to be mistaken for ADHD (i.e., DSM-5 ). This is often the result of careless history-taking and/or kneejerk diagnosis based on one symptom, as I discussed in "One Symptom Isn't Enough."

Surely you're familiar with cases of a fidgety boy who can't focus and gets irritable who is quickly assigned an ADHD diagnosis, only to discover stimulant medication exacerbated the symptoms. Upon closer evaluation, it is discovered he has a very worried thought process, naturally leading to the "ADHD" presentation, and it was anxiety all along.

Conversely, ADHD can also be entirely missed. As some researchers (e.g., Madsen et al., 2018; Chung et al., 2019; Abdenour et al., 2022; Chronis-Tescano, 2022) have discovered, this is typically correlated to gender and ethnicity . For example, boys tend to be impulsive and restless, drawing fast attention to something awry. Conversely, girls tend to exhibit more inattention, therefore, perhaps being seen as simply "spacey," or assumptions are made that they have a learning disability. Cross-culturally "...tolerance for certain behaviors varies between cultural groups and that, in the specific case of ADHD, the attitudes of parents and relatives, clinicians, and even society at large can influence the diagnosis...of ADHD" (Gomez-Benito, 2019).

Regardless of demographics, it's also possible that chief symptoms have an atypical presentation and thus fly under the radar. The following two items are alternative presentations of the core symptoms of restlessness, poor impulse control, and lack of focus I have encountered over the years.

Two Atypical Presentations of Core ADHD Symptoms

1. Hyperfocus.

"How can she have ADHD?" asked Sam's mother (composite example), "She gets so focused on making her models and playing her guitar. Even some school subjects like science. It's like she gets in a groove. Isn't ADHD where there's no focus?"

Sam, age 12, was being evaluated after getting into trouble at school, where she shoved a teacher who made her discontinue an art project when the bell rang. Her mother said that since age four, Sam could get very irritable if removed from something of interest. They thought she was simply enthusiastic about certain interests.

After assessing for a developmental history congruent with autism, which can also present intense fixation, it was clear Sam wasn't autistic .

Throughout the interviews, her mother shared information about her being absent-minded about where she left things and seeming fidgety when unoccupied, the latter being obvious in Sam's interview.

Further, her mother noticed an air of impatience about Sam, like an urgency to get on to the next thing. She figured Sam was perhaps just a temperamental girl. These details led me to wonder about ADHD; Sam presented what ADHD specialists refer to as a hyper-focused subtype (e.g., Ayers-Glassey, et al., 2021; Drake Institute, 2023).

While the stereotypical ADHD presentation likely conjures images of constantly shifting attention, the attention deficit in those with a proclivity for hyper-focus is that they have trouble shifting attention. It should be noted that this is not the same as a child with ADHD who becomes consumed with video gaming, which holds their attention due to fast-paced, new stimulation.

2. A sense of urgency to complete activities.

As we saw with Sam, a sense of urgency to complete a task in order to get on to the next may also belie ADHD. Though not restless in a "crawling the walls" fashion as popular culture might depict ADHD, it is a more productive restlessness, as if the individual found a way to contain that energy more constructively. Despite often rushing, it doesn't mean the person cannot do a thorough job. Chances are, though, they are already in their head about the next thing to do while working on the current matter as if to maintain momentum.

It should be noted that this trait can also be present in people with generalized anxiety disorder (GAD) or hypomania. In GAD, however, the constant activity is a distraction from worry. Further, worried thought processes will be obvious upon getting to know the patient. There will be muscle tension, edginess, insomnia , irritability, and a lack of focus due to a mill of worried thoughts. In hypomania, it will only surface periodically when the person is in the throes of a hypomanic episode .

For someone with ADHD, it's a baseline trait and may seem as if keeping productively in motion is an end unto itself and, upon evaluation, be discovered to be accompanied by other ADHD symptoms. This doesn't mean ADHD and other disorders with similar symptoms can't co-occur.

Careful clinical attention must be paid to the differentiation process for accurate care. Pharmacologically, if someone suffers from both GAD and ADHD, for instance, stimulant medications might exacerbate the picture. Psychotherapeutically, though ADHD and GAD ostensibly have similar symptoms, it is not enough to address one and not the other. Such a patient is hit doubly hard, as both conditions engender trouble with restlessness and attention. Reducing the worried thoughts driving the GAD, at the least, will reduce edginess and engender better sleep, which is known to positively affect those with ADHD (e.g., Weiss et al., 2015; Surman & Walsh, 2021).

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care from an individual’s provider or formal supervision if you’re a practitioner or student.

To find a therapist, visit the Psychology Today Therapy Directory .

Facebook image: StockLite/Shutterstock

LinkedIn image: Jacob Lund/Shutterstock

Abdelnour, E., Jansen, M.O., & Gold, J.A. (2022). ADHD diagnostic trends: Increased recognition or overdiagnosis? Missouri Medicine, 119 (5), 467-473. PMID: 36337990; PMCID: PMC9616454.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Chronis-Tuscano, A. (2022). ADHD in girls and women: A call to action – reflections on Hinshaw et al. (2021). The Journal of Child Psychology and Psychiatry, 63 (4), 497-499. https://doi.org/10.1111/jcpp.13480

Chung, W., Jiang, S., Paksarian, D., et al., 2019. Trends in the prevalence and incidence of attention-deficit/hyperactivity disorder among adults and children of different racial and ethnic groups. JAMA Netw Open, 2(11). doi:10.1001/jamanetworkopen.2019.14344.

Ford-Jones, P.C., 2015. Misdiagnosis of attention deficit hyperactivity disorder: 'Normal behaviour' and relative maturity. Pediatric Child Health, 20 (4), 200-2. doi: 10.1093/pch/20.4.200. PMID: 26038639; PMCID: PMC4443828.

Gómez-Benito, J., Van de Vijver, F. J. R., Balluerka, N., & Caterino, L. (2019). Cross-Cultural and Gender Differences in ADHD Among Young Adults. Journal of Attention Disorders , 23 (1), 22–31.

Kazda, L., Bell, K., Thomas, R., McGeechan, K., Sims, R., & Barratt, A., 2021. Overdiagnosis of attention-deficit/hyperactivity disorder in children and adolescents: A systematic scoping review. JAMA Network Open, 4 (4).doi:10.1001/jamanetworkopen.2021.5335.

Lange K.W., Reichl S., Lange, K.M., Tucha, L., & Tucha, O., 2010. The history of attention deficit hyperactivity disorder. Attention Deficit Hyperactivity Disorder, 2 (4), 241-55. doi: 10.1007/s12402-010-0045-8. Epub 2010 Nov 30. PMID: 21258430; PMCID: PMC3000907.

Madsen, K.B., Ravn, M.H., Arnfred, J., Olson, J., Ulrikka-Rask, C., & Obel, C., 2018 . Characteristics of undiagnosed children with parent-reported ADHD behaviour. European Child and Adolescent Psychiatry, 27, 149–158. https://doi.org/10.1007/s00787-017-1029-4

Surman, C.B.H., & Walsh, D.M. (2016). Managing sleep in adults with ADHD: From science to pragmatic approaches. Brain Science, 11 (10). doi: 10.3390/brainsci11101361. PMID: 34679425; PMCID: PMC8534229.

Weiss, M.D., Craig, S.G., Davies, G., Schibuk, L., & Stein, M. , 2015 . New research on the complex interaction of sleep and ADHD. Current Sleep Medicine Reports, 1, 114–121. https://doi.org/10.1007/s40675-015-0018-8 .

What is overfocused ADD? (2023). https://www.drakeinstitute.com/what-is-overfocused-add

Anthony Smith, LMHC, has 23 years of experience that includes the roles of therapist, juvenile court evaluator, professor, and counseling supervisor.

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ADHD Diagnosis and Treatment in Children and Adolescents

Comparative Effectiveness Review, No. 267

Investigators: Bradley S. Peterson , M.D., Joey Trampush , Ph.D., Margaret Maglione , M.P.P., Maria Bolshakova , B.S., Ph.D., Morah Brown , M.P.H., Mary Rozelle , P.A., Aneesa Motala , B.A., Sachi Yagyu , M.L.S., Jeremy Miles , Ph.D., Sheila Pakdaman , Ph.D., Mario Gastelum , M.P.H., Bich Thuy (Becky) Nguyen , M.P.H., Erin Tokutomi , M.P.H., Esther Lee , M.P.H. candidate, Jerusalem Z. Belay , M.P.H., Coleman Schaefer , M.P.H., Benjamin Coughlin , M.P.H., Karin Celosse , Psy.D, M.S.C.P., M.P.H., Sreya Molakalapalli , M.P.H., Brittany Shaw , M.P.H. candidate, Tanzina Sazmin , M.P.H., M.B.B.S., Anne N. Onyekwuluje , M.D., M.P.H., Danica Tolentino , M.S., and Susanne Hempel , Ph.D.

• Copyright and Permissions

The systematic review assessed evidence on the diagnosis, treatment, and monitoring of attention deficit hyperactivity disorder ( ADHD ) in children and adolescents to inform a planned update of the American Academy of Pediatrics ( AAP ) guidelines.

Data sources:

We searched PubMed ® , Embase ® , PsycINFO ® , ERIC, clinicaltrials.gov , and prior reviews for primary studies published since 1980. The report includes studies published to June 15, 2023.

Review methods:

The review followed a detailed protocol and was supported by a Technical Expert Panel. Citation screening was facilitated by machine learning; two independent reviewers screened full text citations for eligibility. We abstracted data using software designed for systematic reviews. Risk of bias assessments focused on key sources of bias for diagnostic and intervention studies. We conducted strength of evidence ( SoE ) and applicability assessments for key outcomes. The protocol for the review has been registered in PROSPERO (CRD42022312656).

Searches identified 23,139 citations, and 7,534 were obtained as full text. We included 550 studies reported in 1,097 publications (231 studies addressed diagnosis, 312 studies addressed treatment, and 10 studies addressed monitoring). Diagnostic studies reported on the diagnostic performance of numerous parental ratings, teacher rating scales, teen/child self-reports, clinician tools, neuropsychological tests, EEG approaches, imaging, and biomarkers. Multiple approaches showed promising diagnostic performance (e.g., using parental rating scales), although estimates of performance varied considerably across studies and the SoE was generally low. Few studies reported estimates for children under the age of 7. Treatment studies evaluated combined pharmacological and behavior approaches, medication approved by the Food and Drug Administration, other pharmacologic treatment, psychological/behavioral approaches, cognitive training, neurofeedback, neurostimulation, physical exercise, nutrition and supplements, integrative medicine, parent support, school interventions, and provider or model-of-care interventions. Medication treatment was associated with improved broadband scale scores and ADHD symptoms (high SoE) as well as function (moderate SoE), but also appetite suppression and adverse events (high SoE). Psychosocial interventions also showed improvement in ADHD symptoms based on moderate SoE. Few studies have evaluated combinations of pharmacological and youth-directed psychosocial interventions, and we did not find combinations that were systematically superior to monotherapy (low SoE). Published monitoring approaches for ADHD were limited and the SoE is insufficient.

Conclusion:

Many diagnostic tools are available to aid the diagnosis of ADHD , but few monitoring strategies have been studied. Medication therapies remain important treatment options, although with a risk of side effects, as the evidence base for psychosocial therapies strengthens and other nondrug treatment approaches emerge.

• Collapse All
• Acknowledgments
• Key Informants
• Technical Expert Panel
• Peer Reviewers
• Main Points
• Background and Purpose
• Strengths and Limitations
• Implications and Conclusions
• 1.1. Background
• 1.2. Purpose and Scope of the Systematic Review
• 2.1. Review Approach
• 2.2. Study Selection
• 2.3. Data Extraction
• 2.4. Risk of Bias Assessment
• 2.5. Data Synthesis and Analysis
• 2.6. Grading the Body of Evidence
• 2.7. Peer Review and Public Commentary
• 3. Results: Description of Included Evidence
• 4.1. KQ1, ADHD Diagnosis Key Points
• 4.2. KQ1, ADHD Diagnosis Summary of Findings
• 4.3. Summary ADHD Diagnosis by Tests for All Age Groups
• 4.4. KQ1a. What is the comparative diagnostic accuracy of approaches that can be used in the primary care practice setting or by specialists to diagnose ADHD among individuals younger than 7 years of age?
• 4.5. KQ1b. What is the comparative diagnostic accuracy of EEG, imaging, or approaches assessing executive function that can be used in the primary care practice setting or by specialists to diagnose ADHD among individuals aged 7 through 17?
• 4.6. KQ1c. For both populations, how does the comparative diagnostic accuracy of these approaches vary by clinical setting, including primary care or specialty clinic, or patient subgroup, including age, sex, or other risk factors associated with ADHD?
• 4.7. KQ1d. What are the adverse effects associated with being labeled correctly or incorrectly as having ADHD?
• 4.8. Summary of Findings. KQ1a–d
• 5.1. KQ2, ADHD Treatment Key Points
• 5.2. KQ2, ADHD Treatment Results
• 5.3. Effects by Intervention
• 5.4. KQ2a. How do these outcomes vary by presentation (inattentive, hyperactive/impulsive, and combined) or other co-occurring conditions?
• 5.6. KQ2b. What is the risk of diversion of pharmacologic treatment?
• 5.7. Summary of Findings KQ2a and KQ2b
• 6.1. Key Question (KQ) 3 ADHD Monitoring Key Points
• 6.2. KQ 3 ADHD Monitoring Summary of Findings
• Findings in Relation to the Decisional Dilemma(s)
• Findings in Relation to Existing Research Syntheses and Practice Guidelines
• Implications
• Applicability
• Abbreviations and Acronyms
• Appendix A. Methods
• Appendix B. List of Excluded and Background Studies
• Appendix C. Evidence Tables
• Appendix D. Critical Appraisal and Applicability Tables
• Appendix E. List of Included Studies
• Appendix F. Expert Guidance and Review
• Appendix G. PCORI Checklist

Suggested citation:

Peterson BS, Trampush J, Maglione M, Bolshakova M, Brown M, Rozelle M, Motala A, Yagyu S, Miles J, Pakdaman S, Gastelum M, Nguyen BT, Tokutomi E, Lee E, Belay JZ, Schaefer C, Coughlin B, Celosse K, Molakalapalli S, Shaw B, Sazmin T, Onyekwuluje AN, Tolentino D, Hempel S. ADHD Diagnosis and Treatment in Children and Adolescents. Comparative Effectiveness Review No. 267. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 75Q80120D00009.) AHRQ Publication No. 24-EHC003. PCORI Publication No. 2023-SR-03. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. DOI: https://doi.org/ 10.23970/AHRQEPCCER267 . Posted final reports are located on the Effective Health Care Program search page .

This report is based on research conducted by the Southern California Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00009). The Patient-Centered Outcomes Research Institute ® (PCORI ® ) funded the report (PCORI ® Publication No. 2023-SR-03). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ or PCORI ® , its Board of Governors or Methodology Committee. Therefore, no statement in this report should be construed as an official position of PCORI ® , AHRQ, or the U.S. Department of Health and Human Services.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. Most AHRQ documents are publicly available to use for noncommercial purposes (research, clinical or patient education, quality improvement projects) in the United States, and do not need specific permission to be reprinted and used unless they contain material that is copyrighted by others. Specific written permission is needed for commercial use (reprinting for sale, incorporation into software, incorporation into for-profit training courses) or for use outside of the U.S. If organizational policies require permission to adapt or use these materials, AHRQ will provide such permission in writing.

PCORI ® , AHRQ, or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.

A representative from AHRQ served as a Contracting Officer’s Representative and reviewed the contract deliverables for adherence to contract requirements and quality. AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis, interpretation of data, or preparation or drafting of this report.

AHRQ and PCORI ® appreciate appropriate acknowledgment and citation of their work. Suggested language for acknowledgment: This work was based on an evidence report, ADHD Diagnosis and Treatment in Children and Adolescents, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ) and funded by PCORI ® .

• Cite this Page Peterson BS, Trampush J, Maglione M, et al. ADHD Diagnosis and Treatment in Children and Adolescents [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2024 Mar. (Comparative Effectiveness Review, No. 267.) doi: 10.23970/AHRQEPCCER267
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ADHD Breakthrough

Adhd breakthrough presentation, free google slides theme and powerpoint template.

Have you conducted a study on attention deficit hyperactivity disorder (ADHD) and need to present the results? This template is perfect for you. The background is sober, in gray, and the geometric elements that we have included in all the slides provide the touch of color. The typography of the titles is round and sans serif, which brings modernity and is easily readable. The images of children we have added bring empathy and closeness. Use all the resources at your disposal to personalize your presentation.

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