Expert provides effective strategies for treating adult ADHD

Several psychopharmacological and psychotherapeutic interventions can help treat adult ADHD, according to a presenter at the NEI Max virtual conference.

“ADHD is predicated on childhood and adolescent presentation of ADHD symptoms, but there's also the term called late-onset ADHD,” David W. Goodman, MD, FAPA, assistant professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, said in a presentation at NEI Max.

“That means [the patient] had no symptoms prior to age 12 but developed symptoms between the ages of 12 and 18, or maybe 21. There is also adult-onset, where there were no symptoms in childhood and adolescence and all of a sudden, at ages 25 or 31, [the patient is] starting to complain of cognitive difficulties.”

According to Goodman, no guidelines currently exist in the United States for treating adults with ADHD; however, international guidelines or consensus statements include the ADHD International Consensus Statement from the World ADHD Federation, the European Consensus by the European Network of Adult ADHD, the Canadian ADHD Resource Alliance and the guidance from the National Institute for Health and Clinical Excellence. Goodman noted that he guides his adult patients with ADHD through understanding what their diagnosis entails and what it doesn’t; educates them on the specifics of this disorder; details environmental changes related to the disorder, such as academic, occupational, social and familial; and presents available psychopharmacological and psychotherapeutic interventions.

Results of a study of more than 25,000 adults with ADHD suggested that those who used ADHD medication exhibited a significant decrease in criminality rates, as well as a lower risk for STSs. Other study findings showed that those with ADHD who received psychostimulant treatment exhibited lower risk for substance use disorder vs. those who did not receive the treatment. Further results demonstrated that those with ADHD who received methylphenidate treatment had fewer total self-reported ADHD and inattentive symptoms, were at lower risk for exhibiting risk-driving behaviors and had fewer collisions vs. those without this treatment.

Goodman highlighted results of a systematic review and meta-analysis that found when accounting for safety and efficacy, evidence supported methylphenidate among children and amphetamines among adults as first choice at the group level.

Regarding medication and dosage options for adults with ADHD, Goodman noted the following:

• atomoxetine 40 mg, with a max of 100 mg;

• dexmethylphenidate XR 10 mg, with a max of 20 mg;

• triple bead mixed amphetamine salts 12.5 mg, with a max of 50 mg;

• mixed amphetamine salts XR 20 mg, with no recommended max;

• OROS methylphenidate HCL 18 or 36 mg, with a max of 72 mg; and

• triple bead MPH 25 mg, with a max of 85 mg.

According to Goodman, adverse events related to stimulant medication use include insomnia, gastrointestinal upset, decreased appetite, weight loss, headaches, dry mouth, constipation, hand tremors and jitteriness. Research on individual stimulants has generally shown no dose relationship with adverse events in group data, Goodman said.

Alpha agonists for adult ADHD include guanfacine XR, which was more effective than placebo, and clonidine. Psychotherapy options for adult ADHD include cognitive behavioral therapy, as well as individual therapy that focuses on self-esteem issues, social skills and relationship issues and academic and occupational accommodations.

“The differential diagnosis and the diagnostic prioritization, a thoughtful sequence of medications, the combination of medications used with patients who are not ultimately responsive, inquiring about and treating side effects aggressively and education about behavioral changes, cognitive therapies and incredible websites are critical to effective treatment,” Goodman said.