Treatment and Management of ADHD in Adults

Evidence-Based Non-Pharmacological Treatments

Cognitive Behavioral Therapy (CBT)

Cognitive Component: Focused on identifying and modifying “thinking errors” or “thought distortions” so that the patient’s thoughts are more aligned with success and confidence.

Behavioral Component: Involves engineering the environment to be more conducive to concentration and focus, and learning what reinforces and maintains problem behaviors, and constructive behaviors so that constructive changes can be implemented that support the patient’s ability to function well. It includes training in skills to promote relaxation and quiet the mind; communication skills training and exposure therapy, which helps a patient, overcome certain fears and avoidance. It also includes behavioral rehearsal, behavioral practice, and role-playing.

Meta-Cognitive Therapy

Metacognitive therapy is as a type of therapy that involves changing how people think rather than what they are thinking about. Metacognitive therapy suggests stepping back from specific thoughts and instead understand one’s own thinking style. Changing one’s own patterns or style of thinking could have a broad impact on how one manages their life. In this way, metacognitive therapy is distinct from cognitive behavioral therapy, which focuses more on the content of people's thoughts. In people with attention deficit hyperactivity disorder (ADHD), problems with metacognition more often encompass difficulty in planning or executing tasks. The goal of metacognitive therapy in ADHD is to improve organization skills, planning, time management, and resolve thinking distortions that lead to negative moods and the perception of limited options.

ADHD and Exercise

There is no research looking at exercise and adults with ADHD, but there is some research showing improvement of ADHD with exercise on children and adolescents. There is not enough research to conclude what type, intensity, or duration is best. Exercise is an important part of a healthy lifestyle, and should be recommended for both health and possible ADHD benefits. When patients fail to get regular exercise, it could be an indication that ADHD is affecting their organizational skills.

Pharmacological Treatments

Currently, two classes of FDA-approved medications are used for ADHD treatment: stimulant and non-stimulant. 

Stimulants

Methylphenidate and amphetamine are the two most commonly used stimulant medications for treatment of ADHD in adults (FDA-Approved Stimulant Medications for Adult ADHD). They both affect dopamine and norepinephrine reuptake in certain parts of the brain and, as a result, increase the amount of these neuro - transmitters to facilitate brain functioning. While methylphenidate and amphetamine have different mechanisms of action in the brain, they generally have a similar effect in terms of improvement of ADHD symptoms.

View a general overview on medication treatments for ADHD and how the medications work.

Non-stimulants

Atomoxetine (Strattera) is currently the only non-stimulant approved by the FDA for the treatment of ADHD in adults (FDA-Approved Non-Stimulant Medications for Adult ADHD). It is a potent selective norepinephrine reuptake inhibitor. It lacks the abuse potential of stimulants and is not a controlled Schedule II drug. The effects of atomoxetine take longer to achieve. Some people report small changes in hyperactivity and impulse control within two weeks, but it may take 4 to 8 weeks for the drug to achieve maximum effectiveness.

Treatment Monitoring

It is suggested that all adults with a new ADHD diagnosis, uncontrolled symptoms or any change in medication should be seen within 30 days and monthly there after until the symptoms and function improve. When symptoms and function improve, visits every 3-6 months are recommended. 

At the follow up visit, consider the following:

• Review target symptoms and function 
• Review medication use and effects, considering any dose or time of administration modifications (inquire about how long the effects last and any changes in symptoms or medications effects during a day)
• Monitor for treatment adherence and side effects
• Monitor vital signs
• Review information from informants (when available)
• Adjust therapy
• Provide patient education and advice 
• Monitor for signs of substance abuse/dependence

Prognosis

About 60% of adults experience improvements in quality of life and symptom reduction in response to treatment. Comorbid conditions such as mood and anxiety disorders are also highly treatable. 

Treatment Discontinuation

There is no evidence from controlled trials to indicate how long the patient with ADHD should be treated with medications. Trials of off medications and “medication holidays” can be used to assess the patient's functioning without pharmacotherapy. Improvement may be sustained when the drug is either temporarily or permanently discontinued. The evidence on effectiveness and safety of these methods is lacking in adults. 

Withdrawal

There is a documented withdrawal syndrome for stimulant medications. The initial phase (crash) of withdrawal syndrome occurs as the stimulant effects wear off. Symptoms may include:

• Prolonged sleeping
• Depressed mood
• Irritability
• Overeating
• Some cravings (not usually severe in this initial phase).

The initial phase may last one to two days and then is followed by a longer period of several days to weeks of dysphoria (unpleasant or negative mood states). This can start within a few hours to several days of stopping use of the stimulant, in addition to at least two of the following symptoms:

• Difficulty sleeping (insomnia) or excessive sleeping (hypersomnia)
• Feelings of fatigue
• Unpleasant and very vivid dreams
• Psychomotor agitation (e.g., jitteriness, nervousness, moving quickly, edginess, etc.) or psychomotor retardation (e.g., slowed reflexes, moving as if one feels they are weighted down, moving like one is in slow motion, etc.)
• Cravings
• Lethargy

Psychotic symptoms may emerge during the first one to two weeks, particularly if they were present during times of use.

Amphetamine withdrawal is largely psychological, but may be difficult to manage, particularly for friends and family members, due to mood swings.

An inpatient setting may be necessary if the patient has significant psychotic symptoms, in which case a referral to mental health services is appropriate.

Medication

No medication has been demonstrated to be effective in alleviating amphetamine withdrawal, but some medications may be useful with some symptoms.

Patients should drink at least 2-3 liters of water per day during stimulant withdrawal. Multivitamin supplements containing B group vitamins and vitamin C are recommended. Symptomatic medications should be offered as required for aches, anxiety and other symptoms

If patients are significantly distressed or agitated, presenting a danger to themselves or others, short-term use of benzodiazepines (diazepam 5 to 10mg QID PRN) and antipsychotics (olanzapine 2.5-5mg BD PRN) for control of irritability and agitation can be helpful, particularly in the inpatient setting. Care should be taken to limit access to large quantities of medications and to avoid development of benzodiazepine dependence. These medications should be prescribed for a maximum of seven to 10 days.

The goal of treatment during withdrawal is supportive care and counselling¹.

Team-based Care and Referrals

Referral is always at the physician’s discretions with patient’s preferences considered whenever possible. During assessment and diagnosis process, consider referral to a psychiatrist or mental/behavioral health professionals in the following several presentations and co-conditions:

• Extreme or severe dysfunction
• Suicidal or homicidal ideationsSubstance use or dependence
• Psychosis
• Extreme psychosocial stressors or recent traumatic events
• Previous treatment failures
• Atypical presentation – if presentation as brand-new symptoms this is not ADHD; even if not diagnosed as a child the symptoms must concur 

During treatment and monitoring, consider referral to a psychiatrist in the following situations:

• Poor or no treatment effect after repeated medication adjustments
• Resistant mood or anxiety disorder
• Active substance use and dependence

View team-based care patient resources

References

1. Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. Geneva: World Health Organization; 2009. 4, Withdrawal Management.