Why We Need U.S. Guidelines for Adults with ADHD
Our understanding of adult ADHD is advancing, yet professional, authoritative guidelines for diagnosing and treating adult ADHD are currently unavailable in the U.S. To improve quality of care, APSARD, an organization for ADHD specialists, is developing the first-ever guidelines for the diagnosis and treatment of adult ADHD.
December 27, 2022
U.S. guidelines for diagnosing and treating adult attention deficit hyperactivity disorder (ADHD) are long overdue.
Adult patients with ADHD deserve high-quality care, and providers likewise deserve authoritative resources that outline effective, evidence-based practices for adult ADHD. This is precisely why the American Professional Society of ADHD and Related Disorders (APSARD), the premier professional organization for ADHD specialists in the U.S., is currently establishing guidelines for the diagnosis and treatment of ADHD in adults – the first of its kind in the country – set for release in 2023.
Why Adult ADHD Practice Guidelines are Imperative
In recent years, the number of adults diagnosed with ADHD has risen significantly – thanks, in part, to decades of research that has advanced awareness of ADHD as a lifelong disorder.1 Though ADHD is commonly detected in childhood, later-in-life diagnoses are providing clarity and relief for many adults with once unexplained, misunderstood, or overlooked lifelong struggles. Late-diagnosed ADHD is particularly common in women, minorities, and gifted individuals.
As awareness of adult ADHD increases, so too does clinical recognition that its symptoms are challenging to diagnose and treat in this population. Many adults with ADHD will initially seek treatment for a comorbid condition such as depression or anxiety, so evaluation of adult ADHD warrants a dramatically different approach from pediatric procedures. At the same time, U.S. practice guidelines – and multiple ones at that – currently only exist for childhood ADHD.2,3 This is a gap we must close.
Patient demand for providers who can assess, diagnose, and treat adult ADHD continues to grow. New adult ADHD cases add to a landscape of long-term patients who were diagnosed as children — greatly increasing ADHD patient volume over the last decade. Guidelines that outline effective care protocols for adult patients are needed to meet this demand.
Specialist Supply Can’t Meet Patient Demand
The enduring shortage of traditional ADHD specialists, such as psychiatrists and psychologists, is a pressing problem made more urgent by an upsurge in ADHD patients over the last decade. The shortage was especially evident during the pandemic, when many of these specialists became severely overbooked. Digital health startups have made headlines for joining the ADHD care sector and absorbing some of these patients.
To meet patient demand, primary care practitioners, coaches, social workers, and allied health care workers, without formal training or guidance, have increasingly stepped into unfamiliar territory to assess, diagnose, and treat ADHD in adult patients. Naturally, these providers may want to consult official guidelines at the very least. Unfortunately, they’ve come up empty handed. The result is providers who may feel uncertain about which diagnostic tools to use, how to select and titrate appropriate medications, and when a non-pharmacological approach, like cognitive behavioral therapy (CBT), is warranted.
ADHD Is Inherently Challenging to Diagnose
Because ADHD expresses diversely across patients, there is no single tell-tale sign or symptom to influence a diagnosis. Evaluating for ADHD is a complex process that requires lots of detective work and problem-solving, not to mention evaluations for other mental disorders. Providers often struggle for a few key reasons.
ADHD Symptoms Are Subjective
Most people regularly experience one or two symptoms of ADHD (like forgetfulness, disorganization, or restlessness), especially in highly demanding or stressful situations. Sometimes, it can be difficult for providers to ascertain whether a patient’s symptoms warrant a diagnosis.
Many ADHD symptoms are also internally experienced; difficulty focusing or aversion to mental effort are “invisible” symptoms. As professionals cannot directly observe some of these ADHD symptoms, they must rely on a patient’s description of these internal experiences and consider whether they rise to the level of an ADHD diagnosis. It’s not uncommon for clinicians to interview a patient’s loved ones, who can provide a valuable outside perspective on the severity of a patient’s impairment due to ADHD.
The subjective nature of ADHD symptoms, coupled with a recent surge of misleading information about ADHD on social media platforms like TikTok, makes evaluating for adult ADHD all the more challenging today.4 Some adults, after seeing superficial, inaccurate descriptions of ADHD online, may unintentionally misdiagnose themselves out of genuine confusion. Identifying as a person with ADHD may offer access to a supportive online community or make someone feel like their shortcomings are not their fault.
Many other conditions may cause problems with concentration, like depression and anxiety; drug and alcohol abuse; sleep problems; and hypothyroidism. The list goes on. ADHD is also highly comorbid with many mental conditions. Perhaps the biggest challenge facing new or inexperienced providers is teasing apart ADHD from other and/or co-occurring conditions. Accurate diagnosis matters because each condition is treated using very different methods.
ADHD Treatment Is Multifaceted
ADHD treatment is similarly complicated, especially to the unfamiliar practitioner. It requires a holistic approach that combines patient education — including informing patients on the lifestyle factors that improve and worsen ADHD symptoms — with ongoing monitoring of a patient’s progress in a given treatment, as well as potential comorbid physical and mental health conditions.
Even deciding on an appropriate treatment is a challenge. For one, providers have various medications to choose from, and must consider the effects, risks, and benefits of a medication on a patient’s underlying ADHD symptomatology and on any associated comorbid health conditions. Lifestyle management and routine follow-up, where providers check for vital signs, medication adherence and potential misuse, side effects, and changes in medical and psychiatric comorbidities is essential. What’s more, providers also have non-pharmacological options to integrate into care.
Guidelines would clarify to providers the degree to which various interventions, including non-pharmacological treatments, demonstrate effectiveness for adult ADHD. Ultimately, guidelines would help clinicians deliver holistic, safe, and appropriate care.
Stimulant Prescription Practices
Prescription rates for ADHD medications have surged alongside new diagnoses in recent years. Prescriber patterns vary and include potentially problematic practices, such as over-reliance on formulations with higher abuse potential. In fact, some telehealth companies are under federal investigation for their prescribing practices, highlighting a need for clarity on appropriate practices for the prescription of stimulants – a first-line treatment for ADHD.
APSARD’s forthcoming adult ADHD guidelines will address this urgent need for providers and patients alike — making evaluations more thorough, diagnosis more reliable, and treatment safer.
To learn more about and get involved with APSARD’s plans to develop practice guidelines for adult ADHD, under the leadership of Drs. Thomas Spencer and Frances Levin, please visit https://apsard.org/us-guidelines-for-adults-with-adhd/
Adult ADHD Diagnosis and Treatment: Next Steps
- Free Download: Choosing the Right Professional to Treat ADHD
- Self-Test: ADHD Symptoms in Adults
- Read: I Think I Have ADHD – Adult Symptom & Diagnosis Guide
Margaret H. Sibley, Ph.D. is the current secretary of APSARD, and is a member of the adult ADHD guidelines committee. Ann Childress, M.D., is the current president of APSARD.
View Article Sources
1 Sibley MH, Arnold LE, Swanson JM, Hechtman LT, Kennedy TM, Owens E, Molina BS, Jensen PS, Hinshaw SP, Roy A, Chronis-Tuscano A. Variable patterns of remission from ADHD in the multimodal treatment study of ADHD. American Journal of Psychiatry. 2022 Feb;179(2):142-51. https://doi.org/10.1176/appi.ajp.2021.21010032
2 Wolraich ML, Chan E, Froehlich T, Lynch RL, Bax A, Redwine ST, Ihyembe D, Hagan JF. ADHD diagnosis and treatment guidelines: a historical perspective. Pediatrics. 2019 Oct 1;144(4). https://doi.org/10.1542/peds.2019-1682
3 Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2007 Jul 1;46(7):894-921. https://doi.org/10.1097/chi.0b013e318054e724
4 Yeung A, Ng E, Abi-Jaoude E. TikTok and attention-deficit/hyperactivity disorder: A cross-sectional study of social media content quality. The Canadian Journal of Psychiatry. 2022 Feb 23:07067437221082854. https://doi.org/10.1177/07067437221082854
5 McCabe, S. E., West, B. T., Teter, C. J., & Boyd, C. J. (2014). Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: Connecting the dots. Addictive Behaviors, 39(7), 1176–1182. https://doi.org/10.1016/j.addbeh.2014.03.008
6 Musso, M. W., & Gouvier, Wm. D. (2014). “Why is this so hard?” A review of detection of malingered ADHD in college students. Journal of Attention Disorders, 18(3), 186–201. https://doi.org/10.1177/1087054712441970
7Sollman, M. J., Ranseen, J. D., & Berry, D. T. (2010). Detection of feigned ADHD in college students. Psychological Assessment, 22(2), 325. https://doi.org/10.1037/a0018857