An estimated 8.7 million adults in the US have ADHD. (1) While many individuals are diagnosed in childhood, ADHD symptoms can evolve over time 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, mental health therapists 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:
- Difficulty attending to details
- Challenges staying focused
- Frequently distracted when listening to others
- Difficulty staying organized and finishing tasks
- Forgetful
- Avoidance of tasks that require sustained mental energy
AND/OR
For the previous six months (or longer), has your client been experiencing a persistent pattern of Hyperactivity and impulsivity that may include:
- Constant Fidgeting
- Feeling restless
- Difficulty engaging in activities quietly
- Hyperverbal
- Frequent interrupting
- Challenges with waiting
- Is always “on the go”
Have the above symptoms negatively impacted the client’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)?
It’s important to note that the above symptoms and experiences may also be attributable to a number of alternative conditions, such as thyroid disease, mood disorders, or the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment prior to determining if ADHD is the clinically indicated diagnosis.
For complete diagnostic criteria of Generalized Anxiety 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 the client is experiencing. This ensures your note aligns with the diagnosis and demonstrates the medical necessity for the service. |
Symptom Screening and Monitoring
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 clients, as well as support symptom monitoring over the course of 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 learn more about strategies for incorporating Measurement Informed Care (MIC) into your practice here.
Evidence-Based Approaches to Treatment
Identifying and treating adult ADHD can have a dramatic and rapid improvement in the lives of the client, 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) that focus on helping clients 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: stimulant and non-stimulant. (5)
- Stimulant: Methylphenidate (such as Ritalin and Concerta) and amphetamine (such as Adderall and Vyvanse.)
- Non-Stimulant: Atomoxetine (Strattera) is currently the only non-stimulant approved by the FDA for the treatment of ADHD in adults.
| As a reminder, it is beyond the scope of a psychotherapist to suggest specific medications, groups of medications, specific supplements, or advise on the frequency of taking or stopping medications. These discussions must only be carried out by a medical provider. |
When should I refer my client for psychiatric medication management?
Therapists are not required to give an official diagnosis of ADHD prior to referring for a psychiatric medication management evaluation with a provider at Rula. If your client is presenting with suspected ADHD symptomology, it is a best practice to document your clinical assessment and working diagnosis, upload any completed ADHD-specific screening or assessments to the chart, and discuss with the client the option to engage with a Psych NP or Psychiatrist at Rula to be evaluated further and explore the option of medication management.
If the client does elect to meet with a prescriber for evaluation, it is strongly encouraged for the therapists to also engage in communication directly with the prescriber as well, for continuity of care. You do not need an ROI to speak with a psychiatric provider at Rula. Therapists often have a deeper understanding of the client, history of symptoms, and most prominent treatment needs based on the active therapeutic work with the client, and this clinical information can be highly useful for the prescriber in making determinations related to diagnosis and prescription of medications.
This step-by-step guide walks you through how to easily refer your client for a psychiatric medication management evaluation at Rula.
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) It is important for therapists 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 support your client in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client 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, cultural, gender, racial and religious identification and values and stigma. Moreover, in many cases adults with ADHD may have learned throughout their life 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 to always consider the social and cultural contexts of a clients 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.”(8)
Disclaimer: ADHD in Children and Adolescents
This care guide focuses on best practice guidelines for the treatment of adult ADHD, however, ADHD is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. (AAP). For information on providing effective care for children and adolescents with ADHD, check out the below resources:
- Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (AAP)
- Treatment of ADHD in Children and Adolescents (CDC)
- Treatments for ADHD in Children and Adolescents: A Systematic Review (AAP)
Downloadable Digital Guide
Click HERE for a downloadable digital copy of this guide.
References
- 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/
- Word Health Organization. https://www.apaservices.org/practice/reimbursement/health-registry/self-reporting-sympton-scale.pdf
- 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
- 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
- American Academy of Family Physicians. https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/adhd-toolkit/treatment-and-management.html (AAFP)
- Journal of Clinical Psychiatry (via Psychiatrist.com) https://www.psychiatrist.com/news/study-reveals-the-most-accurate-estimate-of-adult-adhd-to-date/
- Journal of Attention Disorders https://journals.sagepub.com/doi/10.1177/1087054711435360
- National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/