Anthony L. Rostain, MD, MA

Mr. B, age 50, dreams of becoming a computer programmer but fears he will embarrass himself—as he has in many classrooms before. He is seeking evaluation because his teenage son was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD), and he recognizes similar symptoms in himself.

Mr. B received a college degree with great difficulty, putting off assignments until the last minute and “squeaking by.” For years he has changed occupations often, never progressing beyond entry level, and now works as a personal care provider and limousine driver. He reports problems keeping up with work and managing time.

His history includes early childhood hyperactivity, difficulty sitting through classes, sloppy handwriting, disorganization, short attention span, and distractibility. He is restless, fidgety, and has trouble staying on topic. His disorganization has caused marital difficulties, for which he has sought counseling.

After careful evaluation, you determine that Mr. B meets criteria for ADHD, combined type, and for anxiety disorder not otherwise specified. His treatment goals are to increase his ability to focus; procrastinate less; improve his planning, prioritizing, and self-esteem; and to become less sensitive to criticism and less anxious about handling work demands.

Like Mr. B, adults with ADHD need treatment for the disorder’s core symptoms as well as its psychiatric comorbidities and psychosocial consequences. Comprehensive treatment with medications, cognitive-behavioral therapy (CBT), and environmental adaptations is usually recommended.

Comorbidity rules

Core symptoms. ADHD is a lifespan disorder with multiple behavioral, cognitive, and emotional manifestations that impair relationships and academic and vocational functioning. ADHD-like symptoms are seen in other conditions such as mood disorders or substance abuse, but complaints of inattention, distractibility, procrastination, restlessness, and impulsivity—particularly when pervasive and chronic—are highly indicative of ADHD.

In treating adults with ADHD, we have noticed common behavioral patterns that contribute to their psychosocial problems (Table 1). Dysfunctional coping behaviors have short-term advantages, but patients readily admit they would rather accomplish tasks through greater thought and planning.

Chronic frustrations—often associated with deep shame—are typical of adult ADHD. Many patients have maladaptive core beliefs of failure, self-mistrust, and inadequacy (Table 2).

Table 1

Common dysfunctional behavioral patterns in adults with ADHD

Table 2

5 common maladaptive core beliefs of adults with ADHD

Psychiatric comorbidity is the rule in adults with ADHD (Table 3). For example, among 43 patients who received combined medication and CBT at the University of Pennsylvania Adult ADHD Treatment and Research Program, 75% reported at least one comorbid condition, including:

• 27 (63%) with mood disorder
• 23 (54%) with anxiety disorder
• 5 (12%) with substance abuse.¹

Other treatment studies have reported similar comorbidity rates in adults with ADHD.^2-4

Table 3

Psychiatric comorbidity in adult ADHD

Making the diagnosis

Diagnosis of adult ADHD is based on a comprehensive assessment, including:

• careful history of presenting complaints
• thorough review of educational, occupational, and family history
• standardized rating scales (such as the Barkley ADHD Behavior Checklists, the Conners’ Adult ADHD Rating Scale, or the Brown Attention Deficit Disorder Scales)
• collateral information
• assessment of mood, anxiety, substance use, and learning/organizational skills. For details, consult references on adult ADHD.^5-8

Case continued: Self-fulfilling prophesies

On standardized rating scales, Mr. B meets criteria for combined ADHD for childhood and current symptoms. Information from his wife and brother also confirms the ADHD diagnosis.

He is motivated, resilient, optimistic, and has a good support system. However, his negative automatic thoughts about his ability to succeed in school and to handle increasing time demands suggest deeper beliefs of inadequacy and failure.

Mr. B struggled academically. Without guidance about how to change his approach to difficult situations, he has repeated old thinking and behavior patterns. Believing he will embarrass himself and fail to learn required material, Mr. B procrastinates and avoids doing assignments. In class, his feelings of inadequacy make him self-conscious, which causes him to lose focus and have trouble concentrating.

See the world through the patient’s eyes

Understanding your patient. Before you start treatment, we recommend that you conceptualize how ADHD has influenced your patient’s life, including:

• developmental experiences
• family-of-origin issues, such as conflicts with parents stemming from ADHD symptoms or reciprocal interactions with an ADHD parent
• world view (“schemata”)
• patterns of coping with (or avoiding) stress
• attitudes toward self and important others
• readiness to change.

Developing a working case conceptualization is a dynamic, collaborative process. You talk with patients, and encourage them to reflect on how ADHD affects their view of themselves and their important relationships. The conceptualization takes shape as you:

• observe patients’ behaviors
• elicit how they think and feel
• assess with them the relevance and accuracies of their belief systems and response patterns.

Seeing the world “through their eyes” prepares you to help them accept the diagnosis and learn to manage ADHD symptoms. Then, by providing a blueprint to manage what patients may see as uncontrollable responses, you can help them take charge of their automatic reactions.

Psychoeducation. To set the stage for treatment, encourage patients to learn about ADHD by reading articles and books and consulting Web sites for adults with ADHD (see Related resources). Psychoeducation helps patients:

• review possible treatment approaches, including organizational (environmental) management, medication, and psychotherapy (individual or group)
• become informed participants in setting treatment goals.

Explain the relative contribution of each treatment component. For example, medications can reduce distractibility and improve attention, organizational strategies can reduce disorganization and improve time management, and structured psychotherapy can help the patient develop more effective coping skills.

Case continued: Planning combined treatment

You discuss diagnosis and treatment options with Mr. B, and he agrees to start the methylphenidate compound Concerta, initially at 18 mg/d, and weekly CBT sessions. You recommended a stimulant based on efficacy studies and your clinical experience in treating adults with ADHD. Mr. B wants a medication that will help him focus while working or studying, and he says Concerta has improved his son’s ADHD symptoms.

You instruct Mr. B to increase the dosage by 18 mg each week until he reaches 72 mg/d. You also tell him to keep a medication response log and to note any positive changes and side effects.

If an adult with ADHD expresses preference for a particular medication, we usually prescribe that one first. Most patients to whom we offer both medication and psychotherapy agree to this “top-down” and “bottom-up” approach. “Top down” means giving patients new ways of thinking to help them understand and modify their responses. “Bottom up” refers to the medication reducing their impulsivity, distractibility, and inattentiveness.

CBT for adult ADHD

Medications can ameliorate key symptoms of adult ADHD, but adjunctive interventions are needed to improve functioning and quality of life. Evidence supporting psychosocial treatment for adults with ADHD is limited, but CBT has been studied the most.^1,9-13 Safren et al¹³ found a four-fold greater therapeutic response when patients received adjunctive CBT for residual ADHD symptoms, compared with patients who received medication alone.

We usually provide CBT weekly for 12 weeks and then taper to 8 additional sessions over 3 months (total 20 sessions). We may extend CBT with additional sessions to address complicated issues. CBT helps adults with ADHD to:

• identify dysfunctional thinking, feeling, and behaving patterns
• recognize contexts in which patterns arise
• systematically change these patterns.

CBT can reduce ADHD-associated anxiety and depression and improve coping skills and sense of well-being.^1,9,11 Its flexibility allows you to address family issues with patients’ partners, children and other relatives to improve communication, reduce conflict, and develop healthier interactions.

We focus CBT sessions on finding alternate coping strategies. We might try role playing, rehearsing, creating “thought experiments,” and anticipating and preparing to modify typical patterns of avoidance. These approaches have been described elsewhere.^10,11,14

We adopt an active stance during therapy to keep ADHD patients’ distractibility from disrupting our conversation. For example, we set the therapeutic agenda, provide feedback about patients’ behaviors, and encourage them to clarify rewards and consequences of using (or avoiding) problem-solving strategies.

Although we typically assign between-session homework, we expect patients to have difficulty completing it. We remain nonjudgmental and collaborative, viewing incomplete assignments as opportunities to learn about patients’ unproductive problem solving and to help them develop more-effective patterns.

Challenging maladaptive beliefs. A strong therapeutic relationship allows adults with ADHD to discuss their chronic frustrations, which often are associated with deep shame. We then shift CBT’s focus to deeper ADHD-related schemata that perpetuate dysfunctional patterns.

We work with patients to elucidate and challenge their maladaptive core beliefs and encourage new ways to view themselves and others. Allowing patients to grieve about the limitations ADHD imposes on their lives also helps to reduce chronic negative self-esteem.

Case continued: ‘less frenetic’

Mr. B achieves good results within 3 weeks of an increasing titration of stimulant medication, reporting significantly less restlessness and greater concentration without significant side effects. His wife confirms that he is less frenetic, can converse without interruptions, and is better at managing his complicated work schedule.

Which medications?

Drug therapy for adult ADHD is not as well-studied as in children and adolescents, but American Academy of Child and Adolescent Psychiatry guidelines and others^15-18 recommend stimulant and nonstimulant medications. Your choice depends on the patient’s clinical profile (including risk factors and comorbid conditions), past medication use, treatment goals, preferred medication effects and dosing patterns (once-daily versus multiple times), and potential side effects. Stimulants or atomoxetine are first-line choices for adult ADHD without psychiatric comorbidity.

Stimulants work quickly and are cleared relatively rapidly from the brain without causing euphoria or dependency. They are effective (80% to 90% response rate) and well-tolerated, though long-term effects have not been studied in adults (Table 4).

Stimulants’ effect size of 0.9 is considered substantial. Effect size—a statistical method of reporting an intervention’s effect across different studies—is typically rated as:

• <0.32 very small
• 0.33 to 0.54, moderate
• >0.55, significant or very strong.

When choosing a medication, we usually try methylphenidate and amphetamine first, one after the other. We explain to the patient how stimulants work in the brain and the need for a comparative trial to determine which might work best for him or her. If the patient has tried a stimulant and found it helpful, we start with that class. Similarly, if he/she has not had good results with one type, we start with the other. Approximately one-third of our patients respond equally well to methylphenidate or amphetamine, one-third respond better to methylphenidate, and one-third respond better to amphetamine.

To determine the optimal dosage, we usually titrate up from 10 to 30 mg per dose of an immediate-release preparation. We begin with this form to help patients notice the medication’s onset and duration of action. After we find the optimal dosage, we switch to a longer-acting preparation.

Insomnia, mood instability, and euphoria are unacceptable stimulant side effects, although many patients welcome others such as appetite suppression and weight loss. Closely monitor cardiovascular effects, and review potential interactions with other medications, such as antihypertensives or bronchodilators. Because sudden death has been reported with stimulants in persons with structural cardiac lesions,¹⁹ obtain a cardiology consultation for patients with a history of heart disease.

We encourage patients to keep daily medication logs (Box), which we review at each visit and use to make dosing or medication changes. Dosing guidelines resemble those used for children and adolescents, although adults usually tolerate higher maximum dosages (such as methylphenidate, 80 to 100 mg/d).

Because of stimulants’ potential for recreational misuse and abuse, remain wary about choosing stimulants for patients with whom you lack a solid doctor-patient relationship.

Table 4

Stimulant dosages used in treating adult ADHD

Atomoxetine, a nonstimulant, norepinephrine re-uptake inhibitor, is approved for ADHD in adults.^20-22 In two double-blind, controlled, randomized trials totalling 536 adults, Michaelson et al²⁰ found significantly reduced ADHD symptoms after 10 weeks of atomoxetine treatment. Effect sizes of 0.35 and 0.40 were reported, with 10% of patients discontinuing because of side effects.

Atomoxetine has a long duration of action (>12 hours) but a more gradual onset (4 to 6 weeks) than that of stimulants. Approximately 60% of patients respond to atomoxetine, though effect sizes are less than those of stimulants. We have found atomoxetine works well for patients who:

• do not tolerate or are uncomfortable with taking stimulants
• are highly anxious
• report emotional dysregulation as a major target symptom.

To reduce risk of common side effects (nausea, GI upset, headache, sedation, reduced sex drive), we start with low dosages (such as 25 mg bid) and increase weekly by 25 mg to a target of 80 to 100 mg/d.

Treating complicated ADHD

Bupropion or tricyclic antidepressants are reasonable options for ADHD with depression. Atomoxetine, a tricyclic, or a stimulant plus a selective serotonin reuptake inhibitor (SSRI) can provide good symptom relief for adults with ADHD and comorbid anxiety and/or depression.

Bupropion. Approximately 50% of adults with ADHD respond to bupropion,^23,24 with a treatment effect size of 0.6. Bupropion’s efficacy in smoking cessation adds value for those trying to quit.

We usually start extended-release bupropion at 150 mg/d and increase after 2 weeks to 300 mg/d if response is suboptimal. Headache, dry mouth, insomnia, and nausea are the most common adverse effects. Agitation or irritability is sometimes serious enough to warrant stopping bupropion.

Combining medications. Using SSRIs with stimulants can help adults with ADHD and comorbid anxiety or depression. Any SSRI can be safely combined with stimulants, though we tend to pick:

• more-sedating agents such as paroxetine or sertraline when patients report difficulty with insomnia or overactivation
• less-sedating compounds such as fluoxetine or citalopram when patients complain of being too tired or underactive.

When patients taking SSRIs seek help for ADHD, adding a stimulant usually reduces inattention, distractibility, impulsivity, and/or subjective feelings of restlessness. We prescribe usual dosages because stimulants and SSRIs do not interact. We have not seen serious side effects, but some patients report feeling oversedated.

Tricyclics. We use tricyclics when a stimulant/SSRI combination does not relieve symptoms satisfactorily or a patient complains of side effects. We usually have good results with desipramine or imipramine, 150 to 300 mg/d, or nortriptyline, 50 to 150 mg/d. Spencer et al have reported a response rate of 68% with nortriptyline or desipramine in a retrospective chart review²⁵ and a prospective placebo-controlled trial²⁶ of adults with ADHD.

Case continued: Closer to dream job

After 6 months of combined treatment, Mr. B reports much-improved ADHD symptoms, with minimal stimulant-related side effects. He has made some realistic plans for computer programming school and is taking preliminary courses. Keeping a schedule book has reduced his tardiness and tendency to procrastinate.

He is more comfortable in the classroom and better able to challenge self-critical thinking. When routine difficulties arise, he is using more-adaptive coping strategies. To maintain gains achieved in therapy, he chooses to continue periodic CBT booster sessions.

Long-term treatment

Even with medication and CBT, patients may require referral for organizational coaching, academic counseling, school or workplace accommodations, vocational counseling, cognitive remediation, group therapy, or social skills classes. You can help them obtain quality adjunctive care by collaborating with professionals who offer these services.

No studies have examined long-term care of adults with ADHD. In our experience, ongoing medication and intermittent therapy can sustain symptom control and coping skills for years. Most patients are initially skeptical about staying on medication, but after they experience the benefits most seem willing to continue as long as the medication helps.

Most of our patients sustain changes in thinking, feeling, and behaving that they learn through BT. They may seek additional sessions to meet a challenge, such as a new job or starting a family.

Related resources

Books

• Kolberg J, Nadeau K. ADD-friendly ways to organize your life. New York: Brunner-Routledge; 2002.
• Hallowell EM, Ratey JJ. Driven to distraction. New York: Touchstone; 1994.
• Hallowell E, Ratey J. Delivered from distraction. New York: Ballantine Books; 2005.

Organizations

• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on AD/HD. www.chadd.org.
• Attention Deficit Disorder Association (ADDA). Resources and membership organization for adults with ADHD. www.add.org.

Drug brand names

• Amphetamine • Adderall, Dexedrine
• Atomoxetine • Strattera
• Bupropion • Wellbutrin
• Desipramine • Norpramin
• Imipramine • Tofranil
• Methylphenidate • Concerta, Focalin, Metadate, Ritalin
• Nortriptyline • Aventyl, Pamelor

Disclosures

Dr. Rostain is a consultant to Shire Pharamaceuticals Group and a speaker for Eli Lilly & Co. and Ortho-McNeil Pharmaceutical

Dr. Ramsay reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Mr. B, age 50, dreams of becoming a computer programmer but fears he will embarrass himself—as he has in many classrooms before. He is seeking evaluation because his teenage son was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD), and he recognizes similar symptoms in himself.

Mr. B received a college degree with great difficulty, putting off assignments until the last minute and “squeaking by.” For years he has changed occupations often, never progressing beyond entry level, and now works as a personal care provider and limousine driver. He reports problems keeping up with work and managing time.

His history includes early childhood hyperactivity, difficulty sitting through classes, sloppy handwriting, disorganization, short attention span, and distractibility. He is restless, fidgety, and has trouble staying on topic. His disorganization has caused marital difficulties, for which he has sought counseling.

After careful evaluation, you determine that Mr. B meets criteria for ADHD, combined type, and for anxiety disorder not otherwise specified. His treatment goals are to increase his ability to focus; procrastinate less; improve his planning, prioritizing, and self-esteem; and to become less sensitive to criticism and less anxious about handling work demands.

Like Mr. B, adults with ADHD need treatment for the disorder’s core symptoms as well as its psychiatric comorbidities and psychosocial consequences. Comprehensive treatment with medications, cognitive-behavioral therapy (CBT), and environmental adaptations is usually recommended.

Comorbidity rules

Core symptoms. ADHD is a lifespan disorder with multiple behavioral, cognitive, and emotional manifestations that impair relationships and academic and vocational functioning. ADHD-like symptoms are seen in other conditions such as mood disorders or substance abuse, but complaints of inattention, distractibility, procrastination, restlessness, and impulsivity—particularly when pervasive and chronic—are highly indicative of ADHD.

In treating adults with ADHD, we have noticed common behavioral patterns that contribute to their psychosocial problems (Table 1). Dysfunctional coping behaviors have short-term advantages, but patients readily admit they would rather accomplish tasks through greater thought and planning.

Chronic frustrations—often associated with deep shame—are typical of adult ADHD. Many patients have maladaptive core beliefs of failure, self-mistrust, and inadequacy (Table 2).

Table 1

Common dysfunctional behavioral patterns in adults with ADHD

Table 2

5 common maladaptive core beliefs of adults with ADHD

Psychiatric comorbidity is the rule in adults with ADHD (Table 3). For example, among 43 patients who received combined medication and CBT at the University of Pennsylvania Adult ADHD Treatment and Research Program, 75% reported at least one comorbid condition, including:

• 27 (63%) with mood disorder
• 23 (54%) with anxiety disorder
• 5 (12%) with substance abuse.¹

Other treatment studies have reported similar comorbidity rates in adults with ADHD.^2-4

Table 3

Psychiatric comorbidity in adult ADHD

Making the diagnosis

Diagnosis of adult ADHD is based on a comprehensive assessment, including:

• careful history of presenting complaints
• thorough review of educational, occupational, and family history
• standardized rating scales (such as the Barkley ADHD Behavior Checklists, the Conners’ Adult ADHD Rating Scale, or the Brown Attention Deficit Disorder Scales)
• collateral information
• assessment of mood, anxiety, substance use, and learning/organizational skills. For details, consult references on adult ADHD.^5-8

Case continued: Self-fulfilling prophesies

On standardized rating scales, Mr. B meets criteria for combined ADHD for childhood and current symptoms. Information from his wife and brother also confirms the ADHD diagnosis.

He is motivated, resilient, optimistic, and has a good support system. However, his negative automatic thoughts about his ability to succeed in school and to handle increasing time demands suggest deeper beliefs of inadequacy and failure.

Mr. B struggled academically. Without guidance about how to change his approach to difficult situations, he has repeated old thinking and behavior patterns. Believing he will embarrass himself and fail to learn required material, Mr. B procrastinates and avoids doing assignments. In class, his feelings of inadequacy make him self-conscious, which causes him to lose focus and have trouble concentrating.

See the world through the patient’s eyes

Understanding your patient. Before you start treatment, we recommend that you conceptualize how ADHD has influenced your patient’s life, including:

• developmental experiences
• family-of-origin issues, such as conflicts with parents stemming from ADHD symptoms or reciprocal interactions with an ADHD parent
• world view (“schemata”)
• patterns of coping with (or avoiding) stress
• attitudes toward self and important others
• readiness to change.

Developing a working case conceptualization is a dynamic, collaborative process. You talk with patients, and encourage them to reflect on how ADHD affects their view of themselves and their important relationships. The conceptualization takes shape as you:

• observe patients’ behaviors
• elicit how they think and feel
• assess with them the relevance and accuracies of their belief systems and response patterns.

Seeing the world “through their eyes” prepares you to help them accept the diagnosis and learn to manage ADHD symptoms. Then, by providing a blueprint to manage what patients may see as uncontrollable responses, you can help them take charge of their automatic reactions.

Psychoeducation. To set the stage for treatment, encourage patients to learn about ADHD by reading articles and books and consulting Web sites for adults with ADHD (see Related resources). Psychoeducation helps patients:

• review possible treatment approaches, including organizational (environmental) management, medication, and psychotherapy (individual or group)
• become informed participants in setting treatment goals.

Explain the relative contribution of each treatment component. For example, medications can reduce distractibility and improve attention, organizational strategies can reduce disorganization and improve time management, and structured psychotherapy can help the patient develop more effective coping skills.

Case continued: Planning combined treatment

You discuss diagnosis and treatment options with Mr. B, and he agrees to start the methylphenidate compound Concerta, initially at 18 mg/d, and weekly CBT sessions. You recommended a stimulant based on efficacy studies and your clinical experience in treating adults with ADHD. Mr. B wants a medication that will help him focus while working or studying, and he says Concerta has improved his son’s ADHD symptoms.

You instruct Mr. B to increase the dosage by 18 mg each week until he reaches 72 mg/d. You also tell him to keep a medication response log and to note any positive changes and side effects.

If an adult with ADHD expresses preference for a particular medication, we usually prescribe that one first. Most patients to whom we offer both medication and psychotherapy agree to this “top-down” and “bottom-up” approach. “Top down” means giving patients new ways of thinking to help them understand and modify their responses. “Bottom up” refers to the medication reducing their impulsivity, distractibility, and inattentiveness.

CBT for adult ADHD

Medications can ameliorate key symptoms of adult ADHD, but adjunctive interventions are needed to improve functioning and quality of life. Evidence supporting psychosocial treatment for adults with ADHD is limited, but CBT has been studied the most.^1,9-13 Safren et al¹³ found a four-fold greater therapeutic response when patients received adjunctive CBT for residual ADHD symptoms, compared with patients who received medication alone.

We usually provide CBT weekly for 12 weeks and then taper to 8 additional sessions over 3 months (total 20 sessions). We may extend CBT with additional sessions to address complicated issues. CBT helps adults with ADHD to:

• identify dysfunctional thinking, feeling, and behaving patterns
• recognize contexts in which patterns arise
• systematically change these patterns.

CBT can reduce ADHD-associated anxiety and depression and improve coping skills and sense of well-being.^1,9,11 Its flexibility allows you to address family issues with patients’ partners, children and other relatives to improve communication, reduce conflict, and develop healthier interactions.

We focus CBT sessions on finding alternate coping strategies. We might try role playing, rehearsing, creating “thought experiments,” and anticipating and preparing to modify typical patterns of avoidance. These approaches have been described elsewhere.^10,11,14

We adopt an active stance during therapy to keep ADHD patients’ distractibility from disrupting our conversation. For example, we set the therapeutic agenda, provide feedback about patients’ behaviors, and encourage them to clarify rewards and consequences of using (or avoiding) problem-solving strategies.

Although we typically assign between-session homework, we expect patients to have difficulty completing it. We remain nonjudgmental and collaborative, viewing incomplete assignments as opportunities to learn about patients’ unproductive problem solving and to help them develop more-effective patterns.

Challenging maladaptive beliefs. A strong therapeutic relationship allows adults with ADHD to discuss their chronic frustrations, which often are associated with deep shame. We then shift CBT’s focus to deeper ADHD-related schemata that perpetuate dysfunctional patterns.

We work with patients to elucidate and challenge their maladaptive core beliefs and encourage new ways to view themselves and others. Allowing patients to grieve about the limitations ADHD imposes on their lives also helps to reduce chronic negative self-esteem.

Case continued: ‘less frenetic’

Mr. B achieves good results within 3 weeks of an increasing titration of stimulant medication, reporting significantly less restlessness and greater concentration without significant side effects. His wife confirms that he is less frenetic, can converse without interruptions, and is better at managing his complicated work schedule.

Which medications?

Drug therapy for adult ADHD is not as well-studied as in children and adolescents, but American Academy of Child and Adolescent Psychiatry guidelines and others^15-18 recommend stimulant and nonstimulant medications. Your choice depends on the patient’s clinical profile (including risk factors and comorbid conditions), past medication use, treatment goals, preferred medication effects and dosing patterns (once-daily versus multiple times), and potential side effects. Stimulants or atomoxetine are first-line choices for adult ADHD without psychiatric comorbidity.

Stimulants work quickly and are cleared relatively rapidly from the brain without causing euphoria or dependency. They are effective (80% to 90% response rate) and well-tolerated, though long-term effects have not been studied in adults (Table 4).

Stimulants’ effect size of 0.9 is considered substantial. Effect size—a statistical method of reporting an intervention’s effect across different studies—is typically rated as:

• <0.32 very small
• 0.33 to 0.54, moderate
• >0.55, significant or very strong.

When choosing a medication, we usually try methylphenidate and amphetamine first, one after the other. We explain to the patient how stimulants work in the brain and the need for a comparative trial to determine which might work best for him or her. If the patient has tried a stimulant and found it helpful, we start with that class. Similarly, if he/she has not had good results with one type, we start with the other. Approximately one-third of our patients respond equally well to methylphenidate or amphetamine, one-third respond better to methylphenidate, and one-third respond better to amphetamine.

To determine the optimal dosage, we usually titrate up from 10 to 30 mg per dose of an immediate-release preparation. We begin with this form to help patients notice the medication’s onset and duration of action. After we find the optimal dosage, we switch to a longer-acting preparation.

Insomnia, mood instability, and euphoria are unacceptable stimulant side effects, although many patients welcome others such as appetite suppression and weight loss. Closely monitor cardiovascular effects, and review potential interactions with other medications, such as antihypertensives or bronchodilators. Because sudden death has been reported with stimulants in persons with structural cardiac lesions,¹⁹ obtain a cardiology consultation for patients with a history of heart disease.

We encourage patients to keep daily medication logs (Box), which we review at each visit and use to make dosing or medication changes. Dosing guidelines resemble those used for children and adolescents, although adults usually tolerate higher maximum dosages (such as methylphenidate, 80 to 100 mg/d).

Because of stimulants’ potential for recreational misuse and abuse, remain wary about choosing stimulants for patients with whom you lack a solid doctor-patient relationship.

Table 4

Stimulant dosages used in treating adult ADHD

Atomoxetine, a nonstimulant, norepinephrine re-uptake inhibitor, is approved for ADHD in adults.^20-22 In two double-blind, controlled, randomized trials totalling 536 adults, Michaelson et al²⁰ found significantly reduced ADHD symptoms after 10 weeks of atomoxetine treatment. Effect sizes of 0.35 and 0.40 were reported, with 10% of patients discontinuing because of side effects.

Atomoxetine has a long duration of action (>12 hours) but a more gradual onset (4 to 6 weeks) than that of stimulants. Approximately 60% of patients respond to atomoxetine, though effect sizes are less than those of stimulants. We have found atomoxetine works well for patients who:

• do not tolerate or are uncomfortable with taking stimulants
• are highly anxious
• report emotional dysregulation as a major target symptom.

To reduce risk of common side effects (nausea, GI upset, headache, sedation, reduced sex drive), we start with low dosages (such as 25 mg bid) and increase weekly by 25 mg to a target of 80 to 100 mg/d.

Treating complicated ADHD

Bupropion or tricyclic antidepressants are reasonable options for ADHD with depression. Atomoxetine, a tricyclic, or a stimulant plus a selective serotonin reuptake inhibitor (SSRI) can provide good symptom relief for adults with ADHD and comorbid anxiety and/or depression.

Bupropion. Approximately 50% of adults with ADHD respond to bupropion,^23,24 with a treatment effect size of 0.6. Bupropion’s efficacy in smoking cessation adds value for those trying to quit.

We usually start extended-release bupropion at 150 mg/d and increase after 2 weeks to 300 mg/d if response is suboptimal. Headache, dry mouth, insomnia, and nausea are the most common adverse effects. Agitation or irritability is sometimes serious enough to warrant stopping bupropion.

Combining medications. Using SSRIs with stimulants can help adults with ADHD and comorbid anxiety or depression. Any SSRI can be safely combined with stimulants, though we tend to pick:

• more-sedating agents such as paroxetine or sertraline when patients report difficulty with insomnia or overactivation
• less-sedating compounds such as fluoxetine or citalopram when patients complain of being too tired or underactive.

When patients taking SSRIs seek help for ADHD, adding a stimulant usually reduces inattention, distractibility, impulsivity, and/or subjective feelings of restlessness. We prescribe usual dosages because stimulants and SSRIs do not interact. We have not seen serious side effects, but some patients report feeling oversedated.

Tricyclics. We use tricyclics when a stimulant/SSRI combination does not relieve symptoms satisfactorily or a patient complains of side effects. We usually have good results with desipramine or imipramine, 150 to 300 mg/d, or nortriptyline, 50 to 150 mg/d. Spencer et al have reported a response rate of 68% with nortriptyline or desipramine in a retrospective chart review²⁵ and a prospective placebo-controlled trial²⁶ of adults with ADHD.

Case continued: Closer to dream job

After 6 months of combined treatment, Mr. B reports much-improved ADHD symptoms, with minimal stimulant-related side effects. He has made some realistic plans for computer programming school and is taking preliminary courses. Keeping a schedule book has reduced his tardiness and tendency to procrastinate.

He is more comfortable in the classroom and better able to challenge self-critical thinking. When routine difficulties arise, he is using more-adaptive coping strategies. To maintain gains achieved in therapy, he chooses to continue periodic CBT booster sessions.

Long-term treatment

Even with medication and CBT, patients may require referral for organizational coaching, academic counseling, school or workplace accommodations, vocational counseling, cognitive remediation, group therapy, or social skills classes. You can help them obtain quality adjunctive care by collaborating with professionals who offer these services.

No studies have examined long-term care of adults with ADHD. In our experience, ongoing medication and intermittent therapy can sustain symptom control and coping skills for years. Most patients are initially skeptical about staying on medication, but after they experience the benefits most seem willing to continue as long as the medication helps.

Most of our patients sustain changes in thinking, feeling, and behaving that they learn through BT. They may seek additional sessions to meet a challenge, such as a new job or starting a family.

Related resources

Books

• Kolberg J, Nadeau K. ADD-friendly ways to organize your life. New York: Brunner-Routledge; 2002.
• Hallowell EM, Ratey JJ. Driven to distraction. New York: Touchstone; 1994.
• Hallowell E, Ratey J. Delivered from distraction. New York: Ballantine Books; 2005.

Organizations

• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on AD/HD. www.chadd.org.
• Attention Deficit Disorder Association (ADDA). Resources and membership organization for adults with ADHD. www.add.org.

Drug brand names

• Amphetamine • Adderall, Dexedrine
• Atomoxetine • Strattera
• Bupropion • Wellbutrin
• Desipramine • Norpramin
• Imipramine • Tofranil
• Methylphenidate • Concerta, Focalin, Metadate, Ritalin
• Nortriptyline • Aventyl, Pamelor

Disclosures

Dr. Rostain is a consultant to Shire Pharamaceuticals Group and a speaker for Eli Lilly & Co. and Ortho-McNeil Pharmaceutical

Dr. Ramsay reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Mr. B, age 50, dreams of becoming a computer programmer but fears he will embarrass himself—as he has in many classrooms before. He is seeking evaluation because his teenage son was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD), and he recognizes similar symptoms in himself.

Mr. B received a college degree with great difficulty, putting off assignments until the last minute and “squeaking by.” For years he has changed occupations often, never progressing beyond entry level, and now works as a personal care provider and limousine driver. He reports problems keeping up with work and managing time.

His history includes early childhood hyperactivity, difficulty sitting through classes, sloppy handwriting, disorganization, short attention span, and distractibility. He is restless, fidgety, and has trouble staying on topic. His disorganization has caused marital difficulties, for which he has sought counseling.

After careful evaluation, you determine that Mr. B meets criteria for ADHD, combined type, and for anxiety disorder not otherwise specified. His treatment goals are to increase his ability to focus; procrastinate less; improve his planning, prioritizing, and self-esteem; and to become less sensitive to criticism and less anxious about handling work demands.

Like Mr. B, adults with ADHD need treatment for the disorder’s core symptoms as well as its psychiatric comorbidities and psychosocial consequences. Comprehensive treatment with medications, cognitive-behavioral therapy (CBT), and environmental adaptations is usually recommended.

Comorbidity rules

Core symptoms. ADHD is a lifespan disorder with multiple behavioral, cognitive, and emotional manifestations that impair relationships and academic and vocational functioning. ADHD-like symptoms are seen in other conditions such as mood disorders or substance abuse, but complaints of inattention, distractibility, procrastination, restlessness, and impulsivity—particularly when pervasive and chronic—are highly indicative of ADHD.

In treating adults with ADHD, we have noticed common behavioral patterns that contribute to their psychosocial problems (Table 1). Dysfunctional coping behaviors have short-term advantages, but patients readily admit they would rather accomplish tasks through greater thought and planning.

Chronic frustrations—often associated with deep shame—are typical of adult ADHD. Many patients have maladaptive core beliefs of failure, self-mistrust, and inadequacy (Table 2).

Table 1

Common dysfunctional behavioral patterns in adults with ADHD

Table 2

5 common maladaptive core beliefs of adults with ADHD

Psychiatric comorbidity is the rule in adults with ADHD (Table 3). For example, among 43 patients who received combined medication and CBT at the University of Pennsylvania Adult ADHD Treatment and Research Program, 75% reported at least one comorbid condition, including:

• 27 (63%) with mood disorder
• 23 (54%) with anxiety disorder
• 5 (12%) with substance abuse.¹

Other treatment studies have reported similar comorbidity rates in adults with ADHD.^2-4

Table 3

Psychiatric comorbidity in adult ADHD

Making the diagnosis

Diagnosis of adult ADHD is based on a comprehensive assessment, including:

• careful history of presenting complaints
• thorough review of educational, occupational, and family history
• standardized rating scales (such as the Barkley ADHD Behavior Checklists, the Conners’ Adult ADHD Rating Scale, or the Brown Attention Deficit Disorder Scales)
• collateral information
• assessment of mood, anxiety, substance use, and learning/organizational skills. For details, consult references on adult ADHD.^5-8

Case continued: Self-fulfilling prophesies

On standardized rating scales, Mr. B meets criteria for combined ADHD for childhood and current symptoms. Information from his wife and brother also confirms the ADHD diagnosis.

He is motivated, resilient, optimistic, and has a good support system. However, his negative automatic thoughts about his ability to succeed in school and to handle increasing time demands suggest deeper beliefs of inadequacy and failure.

Mr. B struggled academically. Without guidance about how to change his approach to difficult situations, he has repeated old thinking and behavior patterns. Believing he will embarrass himself and fail to learn required material, Mr. B procrastinates and avoids doing assignments. In class, his feelings of inadequacy make him self-conscious, which causes him to lose focus and have trouble concentrating.

See the world through the patient’s eyes

Understanding your patient. Before you start treatment, we recommend that you conceptualize how ADHD has influenced your patient’s life, including:

• developmental experiences
• family-of-origin issues, such as conflicts with parents stemming from ADHD symptoms or reciprocal interactions with an ADHD parent
• world view (“schemata”)
• patterns of coping with (or avoiding) stress
• attitudes toward self and important others
• readiness to change.

Developing a working case conceptualization is a dynamic, collaborative process. You talk with patients, and encourage them to reflect on how ADHD affects their view of themselves and their important relationships. The conceptualization takes shape as you:

• observe patients’ behaviors
• elicit how they think and feel
• assess with them the relevance and accuracies of their belief systems and response patterns.

Seeing the world “through their eyes” prepares you to help them accept the diagnosis and learn to manage ADHD symptoms. Then, by providing a blueprint to manage what patients may see as uncontrollable responses, you can help them take charge of their automatic reactions.

Psychoeducation. To set the stage for treatment, encourage patients to learn about ADHD by reading articles and books and consulting Web sites for adults with ADHD (see Related resources). Psychoeducation helps patients:

• review possible treatment approaches, including organizational (environmental) management, medication, and psychotherapy (individual or group)
• become informed participants in setting treatment goals.

Explain the relative contribution of each treatment component. For example, medications can reduce distractibility and improve attention, organizational strategies can reduce disorganization and improve time management, and structured psychotherapy can help the patient develop more effective coping skills.

Case continued: Planning combined treatment

You discuss diagnosis and treatment options with Mr. B, and he agrees to start the methylphenidate compound Concerta, initially at 18 mg/d, and weekly CBT sessions. You recommended a stimulant based on efficacy studies and your clinical experience in treating adults with ADHD. Mr. B wants a medication that will help him focus while working or studying, and he says Concerta has improved his son’s ADHD symptoms.

You instruct Mr. B to increase the dosage by 18 mg each week until he reaches 72 mg/d. You also tell him to keep a medication response log and to note any positive changes and side effects.

If an adult with ADHD expresses preference for a particular medication, we usually prescribe that one first. Most patients to whom we offer both medication and psychotherapy agree to this “top-down” and “bottom-up” approach. “Top down” means giving patients new ways of thinking to help them understand and modify their responses. “Bottom up” refers to the medication reducing their impulsivity, distractibility, and inattentiveness.

CBT for adult ADHD

Medications can ameliorate key symptoms of adult ADHD, but adjunctive interventions are needed to improve functioning and quality of life. Evidence supporting psychosocial treatment for adults with ADHD is limited, but CBT has been studied the most.^1,9-13 Safren et al¹³ found a four-fold greater therapeutic response when patients received adjunctive CBT for residual ADHD symptoms, compared with patients who received medication alone.

We usually provide CBT weekly for 12 weeks and then taper to 8 additional sessions over 3 months (total 20 sessions). We may extend CBT with additional sessions to address complicated issues. CBT helps adults with ADHD to:

• identify dysfunctional thinking, feeling, and behaving patterns
• recognize contexts in which patterns arise
• systematically change these patterns.

CBT can reduce ADHD-associated anxiety and depression and improve coping skills and sense of well-being.^1,9,11 Its flexibility allows you to address family issues with patients’ partners, children and other relatives to improve communication, reduce conflict, and develop healthier interactions.

We focus CBT sessions on finding alternate coping strategies. We might try role playing, rehearsing, creating “thought experiments,” and anticipating and preparing to modify typical patterns of avoidance. These approaches have been described elsewhere.^10,11,14

We adopt an active stance during therapy to keep ADHD patients’ distractibility from disrupting our conversation. For example, we set the therapeutic agenda, provide feedback about patients’ behaviors, and encourage them to clarify rewards and consequences of using (or avoiding) problem-solving strategies.

Although we typically assign between-session homework, we expect patients to have difficulty completing it. We remain nonjudgmental and collaborative, viewing incomplete assignments as opportunities to learn about patients’ unproductive problem solving and to help them develop more-effective patterns.

Challenging maladaptive beliefs. A strong therapeutic relationship allows adults with ADHD to discuss their chronic frustrations, which often are associated with deep shame. We then shift CBT’s focus to deeper ADHD-related schemata that perpetuate dysfunctional patterns.

We work with patients to elucidate and challenge their maladaptive core beliefs and encourage new ways to view themselves and others. Allowing patients to grieve about the limitations ADHD imposes on their lives also helps to reduce chronic negative self-esteem.

Case continued: ‘less frenetic’

Mr. B achieves good results within 3 weeks of an increasing titration of stimulant medication, reporting significantly less restlessness and greater concentration without significant side effects. His wife confirms that he is less frenetic, can converse without interruptions, and is better at managing his complicated work schedule.

Which medications?

Drug therapy for adult ADHD is not as well-studied as in children and adolescents, but American Academy of Child and Adolescent Psychiatry guidelines and others^15-18 recommend stimulant and nonstimulant medications. Your choice depends on the patient’s clinical profile (including risk factors and comorbid conditions), past medication use, treatment goals, preferred medication effects and dosing patterns (once-daily versus multiple times), and potential side effects. Stimulants or atomoxetine are first-line choices for adult ADHD without psychiatric comorbidity.

Stimulants work quickly and are cleared relatively rapidly from the brain without causing euphoria or dependency. They are effective (80% to 90% response rate) and well-tolerated, though long-term effects have not been studied in adults (Table 4).

Stimulants’ effect size of 0.9 is considered substantial. Effect size—a statistical method of reporting an intervention’s effect across different studies—is typically rated as:

• <0.32 very small
• 0.33 to 0.54, moderate
• >0.55, significant or very strong.

When choosing a medication, we usually try methylphenidate and amphetamine first, one after the other. We explain to the patient how stimulants work in the brain and the need for a comparative trial to determine which might work best for him or her. If the patient has tried a stimulant and found it helpful, we start with that class. Similarly, if he/she has not had good results with one type, we start with the other. Approximately one-third of our patients respond equally well to methylphenidate or amphetamine, one-third respond better to methylphenidate, and one-third respond better to amphetamine.

To determine the optimal dosage, we usually titrate up from 10 to 30 mg per dose of an immediate-release preparation. We begin with this form to help patients notice the medication’s onset and duration of action. After we find the optimal dosage, we switch to a longer-acting preparation.

Insomnia, mood instability, and euphoria are unacceptable stimulant side effects, although many patients welcome others such as appetite suppression and weight loss. Closely monitor cardiovascular effects, and review potential interactions with other medications, such as antihypertensives or bronchodilators. Because sudden death has been reported with stimulants in persons with structural cardiac lesions,¹⁹ obtain a cardiology consultation for patients with a history of heart disease.

We encourage patients to keep daily medication logs (Box), which we review at each visit and use to make dosing or medication changes. Dosing guidelines resemble those used for children and adolescents, although adults usually tolerate higher maximum dosages (such as methylphenidate, 80 to 100 mg/d).

Because of stimulants’ potential for recreational misuse and abuse, remain wary about choosing stimulants for patients with whom you lack a solid doctor-patient relationship.

Table 4

Stimulant dosages used in treating adult ADHD

Atomoxetine, a nonstimulant, norepinephrine re-uptake inhibitor, is approved for ADHD in adults.^20-22 In two double-blind, controlled, randomized trials totalling 536 adults, Michaelson et al²⁰ found significantly reduced ADHD symptoms after 10 weeks of atomoxetine treatment. Effect sizes of 0.35 and 0.40 were reported, with 10% of patients discontinuing because of side effects.

Atomoxetine has a long duration of action (>12 hours) but a more gradual onset (4 to 6 weeks) than that of stimulants. Approximately 60% of patients respond to atomoxetine, though effect sizes are less than those of stimulants. We have found atomoxetine works well for patients who:

• do not tolerate or are uncomfortable with taking stimulants
• are highly anxious
• report emotional dysregulation as a major target symptom.

To reduce risk of common side effects (nausea, GI upset, headache, sedation, reduced sex drive), we start with low dosages (such as 25 mg bid) and increase weekly by 25 mg to a target of 80 to 100 mg/d.

Treating complicated ADHD

Bupropion or tricyclic antidepressants are reasonable options for ADHD with depression. Atomoxetine, a tricyclic, or a stimulant plus a selective serotonin reuptake inhibitor (SSRI) can provide good symptom relief for adults with ADHD and comorbid anxiety and/or depression.

Bupropion. Approximately 50% of adults with ADHD respond to bupropion,^23,24 with a treatment effect size of 0.6. Bupropion’s efficacy in smoking cessation adds value for those trying to quit.

We usually start extended-release bupropion at 150 mg/d and increase after 2 weeks to 300 mg/d if response is suboptimal. Headache, dry mouth, insomnia, and nausea are the most common adverse effects. Agitation or irritability is sometimes serious enough to warrant stopping bupropion.

Combining medications. Using SSRIs with stimulants can help adults with ADHD and comorbid anxiety or depression. Any SSRI can be safely combined with stimulants, though we tend to pick:

• more-sedating agents such as paroxetine or sertraline when patients report difficulty with insomnia or overactivation
• less-sedating compounds such as fluoxetine or citalopram when patients complain of being too tired or underactive.

When patients taking SSRIs seek help for ADHD, adding a stimulant usually reduces inattention, distractibility, impulsivity, and/or subjective feelings of restlessness. We prescribe usual dosages because stimulants and SSRIs do not interact. We have not seen serious side effects, but some patients report feeling oversedated.

Tricyclics. We use tricyclics when a stimulant/SSRI combination does not relieve symptoms satisfactorily or a patient complains of side effects. We usually have good results with desipramine or imipramine, 150 to 300 mg/d, or nortriptyline, 50 to 150 mg/d. Spencer et al have reported a response rate of 68% with nortriptyline or desipramine in a retrospective chart review²⁵ and a prospective placebo-controlled trial²⁶ of adults with ADHD.

Case continued: Closer to dream job

After 6 months of combined treatment, Mr. B reports much-improved ADHD symptoms, with minimal stimulant-related side effects. He has made some realistic plans for computer programming school and is taking preliminary courses. Keeping a schedule book has reduced his tardiness and tendency to procrastinate.

He is more comfortable in the classroom and better able to challenge self-critical thinking. When routine difficulties arise, he is using more-adaptive coping strategies. To maintain gains achieved in therapy, he chooses to continue periodic CBT booster sessions.

Long-term treatment

Even with medication and CBT, patients may require referral for organizational coaching, academic counseling, school or workplace accommodations, vocational counseling, cognitive remediation, group therapy, or social skills classes. You can help them obtain quality adjunctive care by collaborating with professionals who offer these services.

No studies have examined long-term care of adults with ADHD. In our experience, ongoing medication and intermittent therapy can sustain symptom control and coping skills for years. Most patients are initially skeptical about staying on medication, but after they experience the benefits most seem willing to continue as long as the medication helps.

Most of our patients sustain changes in thinking, feeling, and behaving that they learn through BT. They may seek additional sessions to meet a challenge, such as a new job or starting a family.

Related resources

Books

• Kolberg J, Nadeau K. ADD-friendly ways to organize your life. New York: Brunner-Routledge; 2002.
• Hallowell EM, Ratey JJ. Driven to distraction. New York: Touchstone; 1994.
• Hallowell E, Ratey J. Delivered from distraction. New York: Ballantine Books; 2005.

Organizations

• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on AD/HD. www.chadd.org.
• Attention Deficit Disorder Association (ADDA). Resources and membership organization for adults with ADHD. www.add.org.

Drug brand names

• Amphetamine • Adderall, Dexedrine
• Atomoxetine • Strattera
• Bupropion • Wellbutrin
• Desipramine • Norpramin
• Imipramine • Tofranil
• Methylphenidate • Concerta, Focalin, Metadate, Ritalin
• Nortriptyline • Aventyl, Pamelor

Disclosures

Dr. Rostain is a consultant to Shire Pharamaceuticals Group and a speaker for Eli Lilly & Co. and Ortho-McNeil Pharmaceutical

Dr. Ramsay reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.