Clinical Recommendations in Current

Practice Guidelines for Diagnosis and

Treatment of ADHD in Adults
Christopher Gibbins, PhD, and Margaret Weiss, MD, PhD

Corresponding author
Christopher Gibbins, PhD
Department of Psychiatry, Box 178, Childrens and
Womens Health Centre, 4500 Oak Street,
Vancouver, British Columbia V6H 3N1, Canada.
E-mail: cgibbins@cw.bc.ca
Current Psychiatry Reports 2007, 9:420426
Current Medicine Group LLC ISSN 1523-3812
Copyright 2007 by Current Medicine Group LLC

Attention-deficit/hyperactivity disorder (ADHD) is a

lifelong neurodevelopmental disorder in which approximately two thirds of patients experience impairment
in adulthood. Although some adults with ADHD were
diagnosed as children, many are first diagnosed as
adults. This poses particular challenges given the limited familiarity with ADHD of many adult mental health
services. As a result, several organizations, including the
Canadian ADHD Resource Alliance, the American Academy of Child and Adolescent Psychiatry, the National
Institutes of Health, and the British Association for Psychopharmacology, have developed practice guidelines
for the assessment and treatment of adults with ADHD.
This article reviews those guidelines in order to examine
current best practices in adult ADHD. There is considerable agreement among these guidelines, which should
be a critical part of moving from emerging knowledge
to patient care, although both empirical evaluation and
ongoing updates as new knowledge emerges will be
important for their future development.

Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a
neurodevelopmental disorder that has the potential to
cause impairment throughout the lifespan [1]. At any particular point of development, symptom presentation will
be dependent on the demands of the environment, coping strategies, supports, and the presence or absence of
comorbid conditions. By definition, ADHD first manifests
in childhood, but residual symptoms and impairment continue into adolescence and adulthood for approximately
two thirds of patients [1]. The prevalence of ADHD in

adults is estimated at 4.4%, of which only a small minority have been diagnosed and treated [2].
Adults with ADHD are identified in several different
ways. There has been considerable interest in ADHD in
the media; thus, awareness has been raised both in the
public and among physicians. Parents of children with
ADHD often report that they had and continue to have
the same problems as their offspring. Adolescents who are
stable on treatment require continued care after age 18
years and seek ongoing treatment at that point.
An effective assessment for ADHD in an adult
requires a good developmental history, use of collateral
informants, a review of school performance, and a retrospective mental status, as well as a review of current
functioning and current mental status. This is essentially
a typical assessment as would be done by a child psychiatrist, with the exception that the patient is an adult,
and familiarity with adult-onset disorders is required.
It is helpful to obtain collateral information on current
symptoms, both for ADHD and for the range of comorbid
disorders that may be present [3]. Comorbidity and differential diagnosis are critical and require knowledge of
both developmental disorders (eg, ADHD, oppositional
defiant disorder, conduct disorder, Tourettes syndrome,
learning disabilities, autism) and of disorders commonly
seen in adults (eg, anxiety and affective disorders, personality disorders) [4].
Several different working groups, including the Canadian ADHD Resource Alliance (CADDRA) [5], the
American Academy of Child and Adolescent Psychiatry
(AACAP) [6], the National Institutes of Health [7], and
the British Association for Psychopharmacology (BAP)
[8], have organized practice guidelines for assessment
and treatment of adults with ADHD so as to provide
appropriate standards of care for clinicians interested in
helping these patients. In this article, the authors review
and summarize these guidelines with a view toward
providing an overview of current best practices in the
assessment and treatment of ADHD in adults.
Over the last 5 years, there has been a rapid accumulation
of evidence on the epidemiology, diagnosis, presentation,
and treatment of ADHD in adults, as well as publication of

Current Practice Guidelines for ADHD in Adults Gibbins and Weiss 421

review articles in popular journals [4,914]. Rating scales

to assist clinicians in taking a history, review of symptoms
of ADHD from the patient and a collateral informant
[1517], and review of childhood symptoms of ADHD [18]
and to assess differential diagnosis and comorbidity have
been developed. New stimulant [1921] and nonstimulant [22] medications have been tested and launched as a
result of clinical trials demonstrating that the disorder is as
treatment responsive in adults as it is in children. Psychotherapies have been developed and tested to assist adults
with ADHD in developing useful coping strategies [2327].
Research has demonstrated that ADHD in adults is associated with significant impairment in work [28,29], education
[30], parenting [31], driving [32,33], financial management,
and social relationships [34,35]. Taken together, this new
body of research has identified a significant new treatment
opportunity: ADHD in adults is a common, chronic, and
impairing condition that is highly treatment responsive.
Practice guidelines are critical to assuring that we translate
this new knowledge into actual practice. Adult psychiatrists
and family doctors require documentation of the procedures
for assuring diagnostic reliability and safe treatment so that
they are confident in proceeding with learning how to care
for these patients [4].
Setting up service delivery for adults with ADHD
has been particularly problematic in that this is an adult
disorder best serviced in adult settings, but expertise in
ADHD traditionally has been found in pediatric units.
Practice guidelines can provide pediatric clinicians with
awareness of the unique skills required to extend care
into adult life and provide adult psychiatrists with the
know-how to work with developmental disorders. This
article summarizes the guidelines developed to date and
the anticipated difficulties with implementation; it also
outlines appropriate procedures for future development
of evidence-based guidelines and evaluation of the effectiveness of such guidelines in establishing a recognized
minimal standard of care.

Screening
Recognition of ADHD in adults is particularly important
because the majority of clinicians are unfamiliar with how
ADHD presents. As a result, they may not know which
patients are at risk or how to screen patients to identify
those patients who are presenting for another problem but
in fact are impaired by ADHD as a primary or comorbid
condition. Both Canadian and British practice guidelines
have delineated the clinical cues and appropriate screening questions to assure that the clinician identifies those
patients who require full assessment. The World Health
Organization, in collaboration with Harvard University,
New York University, and Eli Lilly and Co., developed
a well-validated six-item screener with high sensitivity
and specificity that is in the public domain and readily
available [36]. These six items can be used as a screener

on their own, but many clinicians prefer to use the full

18-item scale, as it provides more information on the full
nine items of attention problems and nine items of hyperactive/impulsive symptoms.

Assessment
All practice guidelines recommend a comprehensive
assessment that includes child and adult mental status;
a developmental history; rating scales completed by
multiple informants; and a thorough clinical interview
to review the history, medical problems, psychiatric history, family psychiatric history, background, and mental
status. The CADDRA guidelines are unique in providing empirical criteria for what is meant by the DSM-IV
requirement that the patient have impairment in two or
more settings. Several studies now have demonstrated
that although there is a significant correlation between
symptom severity and functional impairment, they are by
no means so redundant that one can be substituted for the
other. The CADDRA guidelines use the Weiss Functional
Impairment Rating Scale Self Report (WFIRS-S) as a
cost-effective method of identifying those areas in which
the patient experiences significant impairment.
The rating scales for ADHD have been developed
based on the model of practice inherited from child centers
in which collateral informants are critical to assessment.
This method was an absolute necessity in pediatric practice, as children are poor self-raters, and correlations
between teacher and parent ratings are moderate at best.
More recent research is demonstrating that self-ratings
in adults are reasonable [3]. However, in practice, given
the risk of false-positive diagnosis (eg, in patients who are
drug seeking) or false-negative diagnosis (patients who
lack insight), continued collection of information from
second informants when possible provides a useful crosscheck on the pervasiveness of symptoms across settings
and treatment response.
A number of symptom scale questionnaires exist. The
Wender Utah Rating Scale [18] is a reliable way to measure
the presence of ADHD in childhood. The World Health
Organization Adult Self Report Scale [37] is a reliable
method of screening, measuring symptom severity, and
evaluating outcome. Other measures of ADHD symptom
severity include the Conners [16], the Brown [15], and the
Barkley [38] DSM checklists.
Clinicians unfamiliar with what needs to be incorporated into a diagnostic interview may benefit from the
publication of structured assessment forms, diagnostic
interviews, and ADHD scales developed by Brown [15],
Conners et al. [16,39,40], and Barkley [38].
Assessment of the full spectrum of possible comorbid
or differential diagnoses assumes that the clinician can
do a competent mental status for both child- and adultonset conditions. This is one of the challenges faced by
both family doctors and general psychiatrists doing evalu-

422 Attention-deficit Disorder

ations for ADHD in adults for the first time. Symptom

checklists that review the DSM criteria for most common
disorders presenting with ADHD (including personality disorders) are a useful way for clinicians in practice
to assure that they do not miss an important diagnosis
other than ADHD. The Adult Symptom Inventory and the
Adult Self Report Inventory [41] are also useful ways of
assuring that the clinician does not miss other conditions
that require treatment in their own right. This is especially important where the comorbid condition constitutes
a relative contraindication to stimulant treatment, such as
bipolar disorder or substance abuse.
The typical symptom presentation in adults tends to
differ from that of children in some respects. Symptoms
of ADHD tend to diminish in both patients and normals
developmentally, although patients still remain more
symptomatic than their age-matched norms. Even more
important is that as we get older, the need for executive function, attention, self-directed activity, functional
independence, and risk avoidance increases. Residual
symptoms can be more impairing to an adult than full
symptom criteria are to a child.
Hyperactivity in adults most often manifests as restless
and driven activity and inability to slow down or relax.
Sometimes this is channeled into overwork or intense
sports. Hyperactivity is an umbrella concept that also covers behaviors such as logorrhea, racing thoughts, speeding
in cars, and racing on skis or boats. In adults, there is
less gross motor hyperactivity but continued fine motor
expression of the internal push of driven-like behavior.
Impulsivity may be less obvious and less common
in adults but not necessarily more benign. Adults with
ADHD may have impulsivity in cognition, affect, sexual
activities, and life events. A single impulsive action may
have much more salience in causing enduring damage in
an adult who is autonomous than in a child who is supervised. Common impulsive behaviors such as quitting a job,
impulsive aggression, binge drinking, dangerous driving,
substance use, and leaving school are not frequent, but
they cause damage.
Attention in adults is evident as a diminished capacity for forced effort, working memory, information
processing, conceptualizing consequences, planning for
the future, ability to tune out irrelevant distractions, and
prioritizing. The patients complaint in the doctors office
may be procrastination and lack of motivation. Adults
require a high level of each of these skills to be able to
function. Impaired attention in adults makes it difficult to
work, attend school, care for others, stay out of trouble,
plan for the financial future, organize a household, and
do many of the other routine activities that we take for
granted in adulthood.
The BAP guidelines make the point that diagnostic
standards for ADHD in the DSM-IV-TR and hyperkinetic
disorder in the ICD-10 are primarily child based and on
a predominantly male sample. Thus, it is possible that

the predominance of males with ADHD may be due to

gendered markers rather than an increased risk in males.
As a result, if markers of ADHD in girls are not fully
identified, an emphasis on symptomatology in childhood
may underestimate rates of ADHD in adult women. The
BAP suggests that epidemiologic guidelines indicate that
an appropriate threshold for adults may be four or five
symptoms out of nine present at a severe level, as opposed
to the six-symptom threshold for children.
In contrast to the DSM-IV, which divides ADHD into
primarily inattentive, primarily hyperactive/impulsive,
and combined types, the ICD-10 differentiates based on
the presence or absence of conduct symptoms in defining
hyperkinetic disorder. As a result, symptoms that would
be considered indicative of a comorbid disorder under
the DSM are core symptoms under the ICD-10. The
ICD-10 definition of hyperkinetic disorder is also more
constrained to forms of disorder that include prominent
hyperactivity, impulsivity, and disinhibition, as well as a
higher rate of severity. The ICD-10 currently does not have
a corresponding diagnosis parallel to the DSM-IV-TR
predominantly inattentive type of ADHD.
The clinicians index of confidence in making a diagnosis of ADHD increases with consistency among the
different parts of the family history. If the developmental
history, family psychiatric history, current complaints,
self-report symptoms, collateral symptoms, psychological testing, and functional impairment are all typical of
ADHD, the diagnosis is much easier than if the pattern of
presentation is unusual. A patient who presents with a long
history of misbehavior and underachievement at school,
who could never do homework, and who now is at risk of
losing his job because he is so often late and whose selfand collateral reports are well over the diagnostic threshold
can be diagnosed with confidence. A patient in whom the
child history, the informants, or the pattern of impairment
are inconsistent with each other is more complex.

Developmental History
Following initial screening, a full developmental history is
necessary to investigate the lifelong pattern of impairment
characteristic of ADHD. As a result, it is important for
clinicians to be familiar with the presentation of ADHD
in childhood. Whereas adults with ADHD by definition
must have shown impairment in childhood, the majority
of adult patients with ADHD are first diagnosed as adults
and may not have a prior diagnosis of ADHD, even when
they have received mental health services in the past. A
variety of sources of information may be helpful to clarify
the patients developmental history, including retrospective rating scales completed by the patient and/or parents,
academic documents such as report cards, and results of
formal testing during childhood. Given the possibility of
recall biases, primary sources such as school records and
testing during childhood are of particular value, especially

Current Practice Guidelines for ADHD in Adults Gibbins and Weiss 423

if they contain narrative descriptions of the students learning, behavior, and productivity. Even report cards that
document the grades a student receives may be revealing
of either the underachievement or the variability in performance that is the hallmark of ADHD. It should be noted
that psychoeducational testing completed in childhood
may or may not show evidence of an attention problem.
When there is evidence of problems with attention, working memory, or timed tests, this adds supportive evidence
to the clinicians index of confidence in the diagnosis.
When no problem is evident on psychological testing, this
does not rule out ADHD. ADHD is a context-sensitive
disorder in which patients may be symptomatic in unstructured situations and attentive to structured, interesting,
and supervised activities such as a testing situation.
As ADHD leads to impairment relative to an individuals potential, primarily inattentive students or those with
few externalizing behavior problems may not be seen as
impaired in the classroom, as their strengths allow them
to achieve at a level similar to that of typical students of
average ability. Psychological testing may be particularly
useful in identifying such discrepancies, both at the level
of relative delays in actual academic skills and in academic
underperformance due to poor organization, difficulties
with test taking, failures to complete work, problems with
written output, or erratic performance.

Assessment of Functioning, Quality of Life,

and Development
Assessment of the patients past and current functioning
as an adult similarly must be multifaceted. Clinicians
rely on validated rating scales to provide patients with
feedback as to whether the difficulties they have with
attention and hyperactive/impulsive symptoms are within
the norm or of varying severity outside the norm. These
scales accuracy in accomplishing this task has been noted
to be approximately 70%, although the manuals suggest
that it is much higher [42].
Assessment of symptoms is part of and not a substitute for evaluation of impact on the patients functioning
and quality of life. There remains considerable confusion in the literature between these concepts. Symptoms
identify those states or traits that group together to allow
clinicians to identify a particular syndrome. Functioning
is evidence of the way in which those symptoms impact
on the patients capacity to perform in activities of daily
living, learning, socialization, and work and to maintain
adequate and autonomous self-care. Quality of life is by
definition a hybrid concept that includes symptoms, functioning, and patient satisfaction with life. Recently it has
become common practice to recognize that improvement
in symptoms without improvement in either functioning or
quality of life is of dubious merit as a measure of improved
well-being. In other words, both the patient and the
disorder need to improve for a treatment to be considered

effective. A specific measure of functioning appropriate

to ADHD adults is the WFIRS-S [5]. Generic measures
of quality of life such as the 36-item Short Form Health
Survey may underestimate impact, as they fail to address
difficulties specific to the disorder and emphasize other
problems that may be less relevant in ADHD.
Some of the functional deficits most common in
ADHD include poor organization; messiness; missed
appointments; lateness; anger outbursts; marital conflict;
difficulties with the instrumental tasks of parenting;
impaired driving; avoidance of paperwork; and difficulties with paying bills, taxes, and financial management.
College students often have problems with attendance,
early morning classes, taking notes, interpreting what
the teacher expects, and planning assignments to submit
them on time.

Associated Symptoms
The DSM-IV diagnostic criteria have been noted to have
limitations [43], including reliance on establishing onset
before age 7 yearssomething that is impossible to
ascertain in many adults who were never aware of their difficulties at that time, never mind in retrospect many years
later. However, an equally significant limitation of the DSM
core items is that although they are a reasonable method
of identifying patients who suffer from ADHD, they do
not adequately address the breadth of actual symptoms of
which patients may complain. As a result, a variety of other
symptoms have been noted to be common and impairing in
this population. Associated symptoms that lie outside the
core 18 items described in the DSM are well described by
Wender [44] and Brown [45]. Examples of such symptoms
include procrastination, lack of motivation, dysregulation
of affect, insomnia, and poor sense of time. These aspects
of ADHD may be the presenting complaint and must be
both acknowledged and assessed. The practice guidelines
cited previously all have acknowledged the importance of
looking at the breadth of patient symptoms beyond those
required to assess the diagnostic criteria.

Differential Diagnosis and Comorbidity

More than 87% of adults with ADHD present with
comorbidities, and more than one half have at least two
other conditions in addition to ADHD [2,46]. A thorough
assessment of comorbidities is important, as these may
determine outcome as much as or more than the patients
ADHD-specific symptoms. It is the authors experience
that this is the most challenging part of assessment of
ADHD in adults. It is not difficult to identify who does and
does not have ADHD. It is difficult to accurately identify
ADHD in the context of another disorder and to determine
whether treatment for ADHD is appropriate given the
patients other problems. For example, we do not routinely
proceed with treatment of ADHD until serious concurrent

424 Attention-deficit Disorder

mood disorders or substance abuse are under control or in

patients with borderline personality with quasi-psychotic
perceptions and recent suicide attempts. Clinicians in practice often do not have the time to rule out these disorders
by doing a structured diagnostic interview, and many such
interviews do not include some of the most relevant comorbidities. We do not believe that the practice guidelines to
date have effectively addressed and provided guidelines for
dealing with this issue. We have developed a user-friendly
DSM-IV checklist in the public domain to assist clinicians
in distinguishing ADHD from disorders with overlapping
symptoms (bipolar disorder, borderline personality disorder) and to assure that the identification of ADHD includes
both associated symptoms and recognition of other disorders unfamiliar to clinicians and less widely known in
adult psychiatry, such as oppositional defiant disorder,
conduct disorder, autism spectrum, learning disabilities,
and Tourettes syndrome. This checklist is easy to complete
and forms a platform for the clinician to be aware of DSM
algorithms and to pursue further elaboration of the mental
status to rule in or rule out other problems.

Psychiatric History
Adult patients typically have a long psychiatric history,
not only for ADHD, but for other problems as well. Many
have received a variety of different interventions as they
stumbled through various resources attempting to assist
them with maladaptive behaviors. Taking a past psychiatric history becomes a painstaking but necessary endeavor
and assures that the patient understands how previous
assessments may have missed or misunderstood the presentation of ADHD. Furthermore, it is our experience
that an assessment that puts the patients full history into
context provides psychoeducation and reframing and is in
and of itself therapeutic.

Medical Assessment
All practice guidelines recognize the need for a recent
physical examination to check for medical homologues of
ADHD, such as thyroid conditions; seizures; migraines;
head trauma; or adverse medical effects of medications
such as antihistamines, theophylline, sympathomimetics,
or steroids. Adults with ADHD may have neglected their
health and yet have been found to be more accident prone
and liable to increased medical costs [47]. Furthermore,
adults may be at increased risk of hypertension and cardiovascular risks from medication, requiring the family
doctor to monitor medication on an ongoing basis.

Treatment
Adults presenting with ADHD have, by definition, a
chronic and persistent condition; thus, it is reasonable to
anticipate that ongoing supports will be needed. The lack

of services to assist these patients has meant that in most

countries with adult ADHD clinics (United States, England, Holland, Germany, Canada), a shared care model
in which experts provide assessment and recommendation
and ongoing maintenance is done by the patients local
family doctor is used. CADDRA, BAP, and AACAP all
suggest combination treatment including the following
five components: psychoeducation, an initial medication
trial followed by titration to find the individuals ideal
dose, an assessment of residual symptoms, and long-term
community follow-up.
The BAP guidelines note that although diagnosis may
explain the pattern of underachievement experienced by
many adults with ADHD, gaining greater insight into
the nature and extent of their difficulties also may lead
to at least a short-term reduction in self-esteem, a finding
also suggested by research into group psychoeducational
therapy for adults with ADHD. Informing patients of
the natural history and prognosis of ADHD may help to
reduce unrealistic expectations for treatment effectiveness
and provide a more supportive perspective on their personal history. Many adults in our clinic show a history of
imperfect but impressive attempts to cope with their difficulties; commendable and determined efforts to achieve
their goals; and, not infrequently, success in reaching their
most highly valued objectives in educational, occupational,
or social domains, although at the cost of great efforts and
at times relative neglect of other areas of functioning.
Psychoeducation and feedback are most useful when
the patient comes to a better understanding not only of
why things have been difficult, but also in identifying his
or her strengths. Initiation of medication treatment often
is accompanied by high expectations and needs to be
tempered with a realistic understanding that even when
symptoms improve dramatically, an adult is not easily
normalized if he or she carries a lifetime of past scars,
lost opportunities, limited education, and difficulties in
the workplace. Thus, medication most often still needs
to be a beginning to a process of rehabilitation. Current
research [10,24,25] suggests that whereas core symptoms
improve to a sizeable degree in many adults, augmentation
with skills-building individual and group therapy often is
critical to obtaining a new level of functioning and crossing the threshold to a new developmental level.

Conclusions
There are three different practice guidelines for assisting
clinicians interested in the diagnosis and management of
ADHD in adults. There is considerable agreement among
these guidelines, indicating that there is good agreement
by experts in the field working in different cultural contexts. Although a great deal of new research exists to add
to our evidence base in the area of ADHD in adults, the
guidelines themselves have not been tested to evaluate the
process of their development or their impact on practice.

Current Practice Guidelines for ADHD in Adults Gibbins and Weiss 425

Furthermore, review of the guidelines makes it quite clear

that although we know much more than we once did,
many of our recommendations are based on clinical consensus rather than evidence. We anticipate that guidelines
nonetheless will be a critical cornerstone to the translation
of knowledge in this new area into the provision of actual
patient service. Furthermore, given the pace of new assessment scales, diagnostic interviews, medication options,
and psychological treatments, guidelines will need to be
updated frequently. The impact of these guidelines is most
apparent in establishing that ADHD in adults is no longer
something that can be dismissed or ignored in mainstream
and evidence-based care.

Acknowledgments
Dr. Gibbins has received an honorarium from Shire BioChem, Inc. for a workshop presentation. Dr. Weiss has
served as a paid consultant and received research support
and honoraria from Eli Lilly and Co., Shire BioChem, Inc.,
Janssen Pharmaceutica, Circa Dia BV, and Purdue Pharma.

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