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Clinical Care Guidelines: Attention-Deficit/Hyperactivity Disorder (ADHD) for Adults

An estimated 8.7 million adults in the U.S. have ADHD. (1) While many individuals are diagnosed in childhood, ADHD symptoms can evolve with numerous factors impacting the age of diagnosis, including symptom severity, environmental support, and changes in task demands. Because of increased awareness of ADHD in the adult population, psychiatric providers are likely to see more adults seeking treatment.  

 

This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of ADHD in adults. 

 

Diagnostic Considerations for ADHD in Adults

 

For the previous six months (or longer), has your client been experiencing a persistent pattern of inattention that may include 5 (17 years and older)  of the following:

  • Difficulty attending to details
  • Challenges staying focused
  • Frequently distracted when listening to others
  • Difficulty staying organized 
  • Forgetful
  • Avoidance of tasks that require sustained mental energy
  • Does not follow through on instructions and fails to finish tasks
  • Loses things necessary for tasks/activities
  • Easily distracted by external stimuli

 

AND/OR

 

For the previous six months (or longer), has your client been experiencing a persistent pattern of  Hyperactivity and impulsivity that may include 5 (17 years and older) of the following:

  • Constant Fidgeting 
  • Feeling restless
  • Difficulty engaging in activities quietly
  • Hyperverbal
  • Frequent interrupting
  • Challenges with waiting 
  • Is always “on the go”
  • Leaves seat when should be remain seated i.e. office or workplace
  • Often blurts out answers before the question can be completed 



Key Points for Assessing and Treating ADHD in Adults:

  • Early Onset: ADHD is a neurodevelopmental disorder and symptoms must be present before age 12, although full criteria may be met later.  It is important to ask our patients about symptoms in childhood. 
    • Have the above symptoms been present in the patient’s life before age 12?  
  • Functional Impairments: Diagnosis requires impairments in at least two domains, which can begin at any age. 
    • Have the above symptoms negatively impacted the patient’s ability to function in important areas of life, such as in relationships, at work, at school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc)?
  • Medication Requests: Requesting stimulant medications as “performance enhancers” does not qualify for an ADHD diagnosis.
  • Comorbid Conditions: Other psychiatric diagnoses should be identified and treated before confirming an ADHD diagnosis. It’s important to note that the above symptoms and experiences may also be attributable to several alternative conditions, such as thyroid disease, mood disorders, anxiety, trauma, or the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining if ADHD is the clinically indicated diagnosis. 
  • Collateral Reports: These can be helpful, particularly to verify symptoms before age 12.
  • Rating Scales: These are available and can assist in diagnosis and monitoring.

 

For complete diagnostic criteria of Attention Deficit/Hyperactivity Disorder, consult the Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787.

 

When documenting care, be sure to include the specific symptoms of ADHD experienced by the patient including functional impairment and age of onset (including childhood symptoms). This ensures your note reflects alignment with the diagnosis and demonstrates the medical necessity for the service.  
 

Symptom Screening and Monitoring

 

The use of Measurement-informed care is a critical component of treating ADHD in adults, as it supports the establishment of a diagnosis, determination of treatment targets, and evaluation of treatment response. The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist. (2) can be used to screen for ADHD in adult patients, as well as support symptom monitoring throughout treatment. The checklist takes about 5 minutes to complete, and the eighteen questions in the ASRS-v1.1 are consistent with DSM-IV-TR criteria and address the manifestations of ADHD symptoms in adults.  You can access the ASRS-v1.1 in your note within the EHR. There are other helpful screening tools available including but not limited to BAARS BAARS-ADHD, DIVA-5 DIVA_5_Diagnostic Interview for Adult ADHD-No PW.pdf, CAARS caars - Conners' Adult ADHD Rating Scales.

 

Before considering medication for ADHD, specifically stimulants, certain medical screening questions need to be asked. 

  1. Does the patient have a family medical history of sudden cardiac death or Wolff Parkinson’s white symptoms?
  2. Does the patient have any cardiac conditions that would need closer follow-up i.e. HTN?
  3. Does the patient have any comorbid conditions including depression, anxiety, trauma, mania/hypomania, psychosis, or substance use? Consider treating any comorbid psychiatric conditions such as anxiety, depression, bipolar, or SUD prior to starting a stimulant medication. Are there any psychiatric conditions that are contraindicated with stimulants i.e. psychosis?

 

Monitoring Patients with ADHD who are on stimulants and non-stimulant medications:

  1. Monitor the CURES report before starting and throughout care when prescribing stimulant medications.
  2. If the patient is going to be prescribed a stimulant, ensure that the patient gets a copy of the stimulant medication agreement. After verbally reviewing it with the patient, you can attach it to the note in AMD. 

Please be sure to document that stimulant consent was verbally reviewed and agreed upon. 

  • You can view this agreement by clicking here.
  1. Obtain PCP information and an ROI so that we can obtain medical records.
  2.  Assess and document if initial symptoms of ADHD are improving by providing examples from their day-to-day experience. 
  3. Monitor/Document the patient’s blood pressure and heart rate at the visit (ask the patient to purchase a BP cuff so that we can measure this for their safety)-get a baseline before starting medication and reassess regularly.
  4. If the patient has a hx of substance use check regularly on current use and discuss with the patient the monitoring plan which may include random or initial UDS.
  5. Assess for and document medication side effects including but not limited to restlessness, anxiety, tremors, decreased appetite, decreased sleep, psychosis, exacerbation of tics, and tachycardia/palpitations.
  6. HEDIS (Healthcare Effectiveness Data Information Set) is a set of performance measures in the managed care industry. This is to ensure best practices with evaluation and follow-up with patients. For ways to improve the HEDIS score click here
    1. Initiation phase: following up with a psychiatric provider 30 days after the first stimulant prescription has been dispensed. 
    2. Continuation/Maintenance Phase: described as patients that continue on ADHD medications for at least 9 months and have had 2 follow-up appointments within that time frame. 

 

Evidence-Based Approaches to Treatment 

 

Identifying and treating adult ADHD can have a dramatic and rapid improvement in the lives of the patient, as well as in the lives of those around them. Research has demonstrated that a complementary combination of medication and targeted behavioral therapy for adults with ADHD is the gold standard of treatment and can lead to significant improvements in symptoms. (3) (4)

 

Psychotherapy

Cognitive Behavioral Therapy (CBT) has the most scientific evidence proving its efficacy in the treatment of adult ADHD, as it provides concrete strategies and skills for coping with the core symptoms of ADHD (inattention, hyperactivity, impulsivity) and associated impairment in functioning. Components of CBT for ADHD include psychoeducation, training in organization/planning and time management, problem-solving skills, techniques for increasing attention span, and cognitive restructuring, particularly around situations that cause distress. Additional therapeutic approaches that may be of clinical benefit include:

  • Mindfulness-based cognitive therapy (MBCT)
  • Dialectical Behavioral Therapy (DBT)
  • Holistic therapies and practices  (Interpersonal therapy, music therapy, art therapy, exercise, yoga, etc) focus on helping patients learn skills and structure their environments to reduce the negative impact of ADHD on their lives.

Medication

Currently, two classes of FDA-approved medications are used for the treatment of ADHD: stimulants and non-stimulants. (AAFP) (5) Please look at this guide for more in-depth practicing guidelines Stimulant and Non-Stimulant Guide.

 

Stimulants: Methylphenidate (such as Ritalin and Concerta) and amphetamine (such as Adderall and Vyvanse.)

 

Non-Stimulants: Atomoxetine (Strattera), and Viloxazine (Qelbree) are currently the two non-stimulants approved by the FDA for the treatment of ADHD in adults. We can also use Bupropion (Wellbutrin), Guanfacine (Intuniv), and Clonidine if the provider feels this is the best option. 

 

 

As a reminder, it is important to consider all aspects when deciding what medication to prescribe to the patient. We must take into consideration medical history, family history, substance use history, and comorbid disorders i.e. anxiety/depression/bipolar/SUD, etc before making a decision on medication management with stimulants vs. non-stimulants. 

 

What resources are available to our patients? 

 

If your patient is not already in therapy, it may be helpful to refer them to a therapist who can provide CBT and/or ADHD skills therapy to help improve outcomes. ADHD medications have shown to be efficacious in most patients; however, it is helpful for patients to learn skills to manage their time, learn how to organize, and problem-solving skills. If your patient is experiencing a partial response or would like this additional support, please refer them to a therapist. 

 

It is important to give support/resources to our patients to help them understand and manage their diagnosis. Here are some resources that could be considered for your patients:

 

When should I refer my client to neurological psychiatric testing for ADHD?

In general, we do not require our patients to be sent for neuro-psych testing for the diagnosis of ADHD as there are limitations including cost/insurance as well as availability. If the psychiatric provider feels that the patient would benefit from more in-depth testing due to comorbid conditions or patient disagreement with the psychiatric providers' clinical judgment, then neuro-psych testing can be referred out; however, please keep in mind the cost and availability limitations. For patients that have Kaiser insurance, psychiatric providers may send them back to Kaiser for more in-depth tests which include computerized testing. 



Assessing Risk and  Higher Level of Care Needs

 

The Journal of Clinical Psychiatry found that adults with ADHD are at greater risk than the general population to experience other comorbid mental health conditions including elevated rates of depression, anxiety, substance abuse, and self-harm. Persistent ADHD has also been associated with poor social outcomes, impacting emotional support and leading to higher rates of unemployment or disengagement from education. (6) Psychiatric providers need to engage in (and document) regular assessment of risk, completion of a safety plan, and referral for additional services (such as IOP, PHP, Group therapy, etc) if clinically indicated. 

 

Rula’s team of care coordinators is available to help your patient access these additional clinical services outside of Rula. Click here

to learn more about how to refer your client easily for a Higher Level of Care (HLOC).
 

Cultural Considerations  

 

Cultural and social perspectives often play a significant role in the diagnosis of ADHD in adults. The expression of symptoms is often influenced by cultural contexts, including perceptions of symptoms, culture, gender, racial and religious identification values, and stigma. Moreover, in many cases adults with ADHD may have learned throughout their lives to compensate for ADHD symptoms and may appear to function well, however, they may expend excessive amounts of energy to overcome impairments, leading to marked distress and often accompanying mental health concerns. (7) As a result, it is important always to consider the social and cultural contexts of a patient's treatment needs as part of the diagnostic process. 

 

When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes. (NAMI)



Tools/Resources for adult ADHD:

 

 

To learn more about children/adolescent treatment of ADHD click below

References

1. Journal of Managed Care and Specialty Pharmacy. Schein J, Adler LA, Childress A, et al. Economic burden of attention-deficit/hyperactivity disorder among adults in the United States: a societal perspective. Journal of Managed Care Specialty Pharmacy. 2022;28(2):168–179. https://pubmed.ncbi.nlm.nih.gov/34806909/

2. Word Health Organization. https://www.apaservices.org/practice/reimbursement/health-registry/self-reporting-sympton-scale.pdf

3. National Institute of Health.  Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909688/pdf/nihms213647.pdf

4. Cleveland Clinic. A new paradigm for adult ADHD: A focused strategy to monitor treatment. https://www.ccjm.org/content/ccjom/90/7/413.full.pdf

5. American Academy of Family Physicians. https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/adhd-toolkit/treatment-and-management.html (AAFP)

6. Journal of Clinical Psychiatry (via Psychiatrist.com) https://www.psychiatrist.com/news/study-reveals-the-most-accurate-estimate-of-adult-adhd-to-date/

7. Journal of Attention Disorders https://journals.sagepub.com/doi/10.1177/1087054711435360














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