Optimizing Treatment Strategies for Adult Attention-Deficit Hyperactivity Disorder (ADHD)

Presenter

Matthew V. Rudorfer, M.D. 
Division of Services and Intervention Research 

Goal

The goal of this concept is to encourage the development of evidence-based treatments for adult ADHD that utilize nonstimulant medications, psychosocial interventions, and device-based approaches, in situations where stimulant monotherapy is insufficiently effective, difficult to tolerate, or undesirable.

Rationale

Until recently, ADHD was considered a disorder of childhood and treatments for ADHD were exclusively focused on young people. It is now recognized that while the most visible signs of childhood ADHD, such as motor hyperactivity, diminish by high school age, other symptoms (e.g., difficulty with sustained attention, tendency to lose things, challenges with organization) can follow people into adulthood, impairing relationships, higher education, and work functioning. It is estimated that 4% of adults live with ADHD, compared with 11% in those younger than 18. Many of those with adult ADHD must deal with stigma; co-occurring conditions, including substance use disorders, are common.

Since the development of the amphetamines in the 1930s, stimulants have been the mainstay of ADHD treatment across the lifespan. As with all medications, stimulants do not work equally well for everyone. These controlled drugs, subject of late to sporadic shortages and with a risk of abuse, dependence, misuse, and diversion as well as agitation, insomnia, and other possible adverse effects, may require alternative or complementary approaches. For example, there are now nonstimulant medications that are FDA-approved for treatment of ADHD across the lifespan, while other medications and a device (trigeminal nerve stimulation) are FDA-indicated for young people only but could benefit from study in adults. Other medications that have similar mechanisms of action as stimulants (i.e., action on dopaminergic systems) may also be candidates for treatment. Psychosocial approaches, including individual and group cognitive-behavioral therapy, may also help control symptoms of adult ADHD.

Given that adult ADHD was recognized in the Diagnostic and Statistical Manual of Mental Disorders for the first time only a decade ago, it is not surprising that optimal treatment strategies are yet to be codified, validated, and ranked. This concept encourages research on approaches for individuals with adult ADHD who respond only partially or not at all to stimulant medication, or for whom stimulants are best avoided due to co-existing substance use problems or intolerance to specific effects or adverse effects. Combination treatment approaches may also be of value in augmenting partial response to a stimulant, or as a replacement strategy. Device-based treatments would be welcome subjects of controlled trials, with appropriate FDA consultation. 

Additionally, research aimed at understanding the natural trajectory of ADHD, including the risk factors for continuation of the disorder into adulthood, would help advance the field.