1. Adults and Attention-Deficit / Hyperactivity Disorder (ADHD): Diagnostics, Treatments, Challenges
Edward Thomas Lewis III, M.D.
Clinical Assistant Professor
Attending Physician, Institute of Psychiatry
Associate Director, Forensic Psychiatry Fellowship
Medical University of South Carolina
Department of Psychiatry and Behavioral Sciences
Division of Community and Public Safety Psychiatry

2. Acknowledgments & Disclosures
Addiction Psychiatry background
Not subspecialty trained in child and adolescent psychiatry
No relevant financial disclosures

3. Goals and Objectives Explore background information about ADHD
Diagnosing ADHD in Adults
Discuss common treatments for ADHD
Understand challenges in working with adults who present with ADHD symptoms

4. What is ADHD?
Consistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning and/or development.
Inattention
Hyperactivity
Impulsivity

5. Inattention Wandering off task Lacking persistence
Difficulty sustaining focus
Disorganized
Not due to defiance or lack of comprehension

6. Hyperactivity Excessive motor activity Fidgeting Tapping Talkativeness
Extreme restlessness (in adults)
Frustrating peers due to elevated activity

7. Impulsivity Hasty actions that occur in the moment
Minimal forethought
High potential for harm to the individual
Social Intrusiveness
Major Life Decisions

8. ADHD: How Common?
Global population surveys suggest ADHD occurs in about 5% of children and 2.5% of adults.
More frequent in males than females
2:1 M:F in children
1.6:1 M:F in adults
50% of children with ADHD will experience attenuation of symptoms as they progress into adulthood

9. Adult ADHD: How Common? 2.5 – 4.0% of the population
Hyperactive / Impulsive presentation is more common in males
Adults with ADHD have 4 – 9x higher prevalence of comorbid mental health diagnoses
Bipolar Disorder
Anxiety Disorders

10. ADHD: Risk Factors Very low birth weight Smoking during pregnancy
History of child abuse, neglect, multiple foster placements, neurotoxin, infection, or alcohol exposure in utero
First degree biological relative with ADHD

11. ADHD: Progression of Symptoms
Begins in childhood
Hyperactivity predominates in preschool-aged children
Most often identified in elementary school
Inattention is often predominant

12. ADHD: Progression of Symptoms
Hyperactivity may improve into adolescence and adulthood, but restlessness, inattention, poor planning, and impulsivity persist
Substantial number of children with ADHD will remain relatively impaired into adulthood

13. Negative Consequences of ADHD
Reduced educational performance
Social rejection
Poorer occupational performance
Higher probability of unemployment
Interpersonal conflict
More likely to be injured
Traffic accidents
Obesity
Incarceration
Conduct Disorder
Substance Use Disorders

14. Diagnosing Adult ADHD

15. Diagnosing Adult ADHD

16. Emotional Dysregulation (ED)
Deficiency in executive or cognitive management of emotions
Self-regulation of frustration, impatience, anger
Emotional Impulsivity
Mesolimbic Circuitry (“Bottom Up”)
Deficient Emotional Self-Regulation
Prefrontal Cortex (“Top Down”)
Not in DSM-5
35-70% adults with ADHD experience ED

17. Testing for ADHD: Behavior Rating Scales
Practice Parameter for the Assessment and Treatment of Children and Adolescents with ADHD recommends using behavior rating scales (American Academy of Child and Adolescent Psychiatry)
These behavior rating scales are not helpful for adults
Neuropsychological testing is not effective in diagnosing ADHD due to inherent quite testing environment. Self-report scales are more effective in identifying severity of symptoms. It is not necessary to refer patient for neuropsych testing before diagnosing and treating ADHD in adults.
World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS)
Brown Attention –Deficit Disorder Scale (BADDS)

18. Testing for ADHD: Behavior Rating Scales
Practice Parameter for the Assessment and Treatment of Children and Adolescents with ADHD recommends using behavior rating scales (American Academy of Child and Adolescent Psychiatry)
These behavior rating scales are not helpful for adults
Neuropsychological testing is not effective in diagnosing ADHD due to inherent quite testing environment. Self-report scales are more effective in identifying severity of symptoms. It is not necessary to refer patient for neuropsych testing before diagnosing and treating ADHD in adults.
World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS)
Brown Attention –Deficit Disorder Scale (BADDS)

19. Adult ADHD: Scales and Testing
Role for Neuropsychological Testing
Continuous Performance Test (CPT)
World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS)
Brown Attention-Deficit Disorder Scale (BADDS)
Reference:

20. Adult ADHD: ASRS Six question scale Designed for community samples
Positive results require follow-up diagnostic assessment by trained a clinician
Score of four or greater is positive
Reference:

21. Adult ADHD: ASRS
Reference:

22. Adult ADHD: ASRS
Reference:

23. Adult ADHD: BADDS 40-item screening instrument
Designed for primary/preschool, school-age, adolescent, and adult populations
Based on Thomas Brown’s model of cognitive impairment in ADHD
Brown Attention-Deficit Disorder Scale (BADDS)

24. Treating Adult ADHD: Pharmacotherapy
Stimulant medications are front-line management
National Comorbidity Survey Replication (NCS-R)
FDA approved medications for Adult ADHD
Extended release mixed amphetamine salts (Adderall XR)
Lisdexamfetamine dimesylate (Vyvanse)
Atomoxetine (Strattera)
Bupropion (Wellbutrin)
NCS-R data demonstrated that only 11% of adults with ADHD are treated (NCS-R is National Comorbidity Survey Replication, an epidemiologic study of 9,200 adults ages 18 – 44.
Reference:

25. Treating Adult ADHD: Psychosocial Treatments
CBT
Negative Thoughts
Perfectionism
Over-estimation of one’s competence
Comorbid Depression, Anxiety
Organizational Skills Training
Data for CBT in children vs. adults with ADHD

26. Treating Adult ADHD: Substance Use Disorders (SUD)

27. Neurobiology of Addiction

28. Neurobiology of Addiction: Hijacking of Limbic System

29. Neurobiology of Addiction
Wanting
Liking
Repeated use over time
Needing

30. Treating Adult ADHD: Substance Use Disorders (SUD)
ADHD has a prevalence of 22% in adults with SUD
More severe disease burden
Higher comorbidity
Dopamine System
Reward Pathways
Prefrontal Cortex
Medication Management
Strategies
Psychotherapy
Integrative CBT

31. Treating Adult ADHD: Psychiatric Comorbidities
Bipolar Disorder
Anxiety Disorders
Depressive Disorders

32. References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Faraone, S. V., & Antshel, K. M. (2008). Diagnosing and treating attention-deficit/hyperactivity disorder in adults. World psychiatry : official journal of the World Psychiatric Association (WPA), 7(3), 131–136.
Giulio Perugi, Alessandro Pallucchini, Salvatore Rizzato, Vito Pinzone & Pietro De Rossi (2019) Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD), Expert Opinion on Pharmacotherapy, DOI: /
Lopez PL, Torrente FM, Ciapponi A, Lischinsky AG, Cetkovich‐Bakmas M, Rojas JI, Romano M, Manes FF. Cognitive‐behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD DOI: / CD pub2.
Scrandis, Debra. Diagnosing and treating ADHD in adults. The Nurse Practitioner. 43(1):8–10, JANUARY 15, 2018 DOI: /01.NPR PMID:
Van der Burg, D., Crunelle, CL, Matthys, F, Van den Brink, W. diagnosis and treatment of patient with comorbid substance use disorder and adult attention-deficit and hyperactivity disorder: a review of recent publications. Curr Opin Psychiatry Jul;32(4):

33. Contact: Lewiset@musc.edu
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