Over the past 2 decades, a

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1 Primary Care Evaluation and Management of Attention Deficit Hyperactivity Disorder in Adults Matthew F. Hollon, MD, MPH ABSTRACT Increasingly, primary care physicians who care for adults are evaluating and managing patients with attention deficit hyperactivity disorder (ADHD), one of the most recognized genetic psychiatric conditions. Because the disorder, by definition, always begins in childhood, understanding its natural history is critical to understanding the disorder in adults. Persistence into adulthood is often accompanied by other psychiatric comorbidities. Ruling out ADHD in adulthood can be easy, but diagnosing the disorder when it has gone unrecognized in childhood is more difficult. Small studies have demonstrated a number of effective pharmacologic therapies for ADHD in adults. This article summarizes the natural history of ADHD and the strategies for evaluating the disorder in adults. It also reviews current therapy for adults. (Adv Stud Med. 2004;4(2):79-86) BEHAVIORAL MEDICINE Over the past 2 decades, a body of evidence supporting the persistence of attention deficit hyperactivity disorder (ADHD) into adulthood has led experts to revise upward the estimates of the prevalence of the disorder in adults. More recently, ADHD in adults has received significant exposure in the mass media. 1 Increasingly, primary care physicians caring for adults have had to evaluate and treat patients for this disorder. Any discussion of ADHD in adults must begin with the epidemiology of the disorder in children since ADHD, by definition, always begins in childhood. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, (DSM IV-TR), some impairment caused by the core symptoms of inattention, hyperactivity, and impulsivity must be present prior to the age of 7 years (Table 1). 2,3 ADHD is the most common neurobehavioral disorder of childhood. 3 Researchers estimate that there are millions of children with the disorder. Estimates of current prevalence rates among school-age children range from 4% to 12% 4 ; experts typically quote prevalence rates at the lower end of this range. 5 NATURAL HISTORY What becomes of these millions of children? Unfortunately, no definitive, large-scale study of the natural history of ADHD exists. Yet, understanding this natural history is critical to understanding the disorder in adults. From small studies of the clinical course of ADHD diagnosed in children, researchers have advanced 3 principal models of the natural history. Dr Hollon is Acting Assistant Professor, Division of General Internal Medicine, University of Washington, Seattle, Washington. Dr Hollon reports having no financial or advisory relationships with corporate organizations related to this activity. Off-Label Product Discussion: The author of this article includes information on off-label use of bupropion, desipramine, and venlafaxine for ADHD. Correspondence to: Matthew F. Hollon, MD, MPH, Box , 4245 Roosevelt Way NE, Seattle, WA mfhollon@u.washington.edu. Advanced Studies in Medicine 79

2 BEHAVIORAL MEDICINE Early research suggested that ADHD, thought at that time to occur only in childhood, would disappear once a person reached maturity. 6,7 Data highlighted that in up to 37% of cases, remission occurred within 9 months of diagnosis. 8 As reports emerged in the early 1980s of the persistence of symptoms into adulthood in some cases, 9 a second model suggesting that a steady decline in the prevalence of ADHD over time replaced the original model positing the disappearance of the disorder by adulthood. In 1996, Hill and Schoener substantiated this model of steady decline by analyzing 9 prospective studies in which researchers had reexamined 4 to 16 years after diagnosis cohorts who had been diagnosed with ADHD in childhood. 10 The report from this study included a model of the natural history of the disorder, which predicted a 50% decline in prevalence every 5 years and an estimated prevalence at age 50 years of 1 in However, other ADHD experts summarily criticized this report as soon as it emerged. 11 The experts who criticized the Hill and Schoener study are mostly those who have spent their careers investigating ADHD and, in general, evaluating and treating the most severe cases. Over the past decade they have, on the basis of reasonable evidence, steadily argued that the natural history of ADHD for the majority of people is one of Table 1. Criteria for Diagnosis of Attention Deficit Hyperactivity Disorder A. Either (1) or (2): (1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b)often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d)often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e)often has difficulty organizing tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (eg, toys, school assignments, pencils, books, or tools) (h)is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities (2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) often fidgets with hands or feet or squirms in seat (b)often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d)often has difficulty playing or engaging in leisure activities quietly (e)is often on the go or often acts as if driven by a motor (f) often talks excessively Impulsivity (g) often blurts out answers before questions have been completed (h)often has difficulty awaiting turn (i) often interrupts or intrudes on others (eg, butts into conversations or games) B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (eg, at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (eg, Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). American Psychiatric Association. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision Copyright Vol. 4, No. 2 February 2004

3 ATTENTION DEFICIT HYPERACTIVITY DISORDER persistence. They highlight persistence rates as high as 60% and conclude that ADHD among adults is very common. 6,11,12 According to a third model of the natural history of the disorder, ADHD in childhood serves as a precursor to other psychopathologic conditions in adulthood. The less consistent response of adults with ADHD to stimulant therapy compared with that of children with ADHD (described below) has highlighted the heterogeneity of the disorder in adults and served to substantiate this model. 6,9 The principal contribution of this model to our understanding of ADHD in adults is to emphasize the frequency with which other psychiatric conditions arise in the setting of ADHD. It is now understood, however, that comorbid conditions arise but rarely replace core ADHD symptoms and that these comorbid conditions likely blunt the expected treatment response in adults. Indeed, comorbidity in the setting of both childhood and adulthood ADHD is common, with about 75% of adults having a co-morbid condition. 7,13 The comorbidities in adulthood include anxiety disorders in up to 50% of patients; substance abuse disorders, including nicotine abuse in 27% to 46% of patients; mood disorders in 30% of patients; and antisocial personality disorder in 12% to 27% of patients. 6,14,15 The reality in clinical practice is that all 3 models of natural history are operational. 16 For approximately 30% to 50% of children with ADHD, symptoms either abate entirely prior to reaching adulthood or decrease in severity over time so that the symptoms no longer produce functional impairment. For another 30% to 50%, the symptoms continue to produce functional impairment into adulthood, often accompanied by significant comorbidity. For a small percentage, the symptoms of ADHD may abate but the symptoms of a comorbid condition may persist. Although researchers do not clearly understand the risk factors for persistence, it is thought that comorbidity, genetic factors, and psychosocial factors all play a role. 8 CLINICAL EVALUATION The primary care physician encounters ADHD in adults in 2 clinical scenarios. The first, and generally easier scenario, occurs when the physician assumes the care of an adult patient with established ADHD (ie, ADHD that was diagnosed in childhood). The second scenario occurs when assuming the care of an adult in whom ADHD went unrecognized during childhood. ESTABLISHED ADHD When a physician assumes the care of an adult who was diagnosed with ADHD during childhood, the first step is to ensure that the diagnosis is accurate. Clinical guidelines, physician experience, and mass media attention have improved the recognition and diagnosis of ADHD during childhood. However, the classic triad of hyperactivity, inattention, and impulsivity characterizing childhood ADHD often gives way in adulthood to symptoms of disorganization and inattention. 7 Experts recognize that other symptom clusters are also present in adults with ADHD, including confusion, irritability, forgetfulness, and procrastination. 1 These symptoms can be exhibited as underachievement, difficulty maintaining a job, marital difficulties, and unsafe driving. 1,7,17 The second step in caring for an adult patient diagnosed with ADHD as a child is to determine whether patient functioning continues to be impaired across 2 or more domains. This, in turn, determines whether pharmacotherapy continues to be indicated. There are no clear predictors of the natural history of ADHD for an individual patient. Because a significant percentage of patients will adapt to the symptoms or experience an abatement or a decline in the severity of symptoms, a carefully timed holiday from medication can be useful for assessing the presence, range, and severity of symptoms. PREVIOUSLY UNDIAGNOSED ADHD Like depression and other psychiatric conditions, the diagnosis of ADHD is challenging because it is a purely behaviorally defined disorder without a specific biological marker. 18 As with diagnosing depression, experience is likely the critical factor contributing to skill in diagnosing ADHD in adults. Until a primary care physician has gained this experience, consultation with a specialist is often helpful. Nevertheless, a possible diagnosis of ADHD in adulthood can come to the attention of the patient or physician in several ways. For example, the disorder should be suspected in an adult patient who failed to succeed in school or who has had difficulty maintaining a job, has a history of tumultuous relationships or a poor driving record, especially if the patient complains of the constellation of symptoms discussed earlier (confusion, irritability, forgetfulness, and procrastination). ADHD should also be suspected in patients with recognized comorbid conditions, such as anxiety or mood disorders, who are not responsive to standard treatment. Alternatively, an adult patient may directly suggest ADHD as a possible diagnosis by reporting to the physician that a family member, such as Advanced Studies in Medicine 81

4 BEHAVIORAL MEDICINE a son or daughter, has been diagnosed with the disorder. 19 A family history of ADHD deserves special attention, given the genetics of ADHD. The disorder is one of the most recognized genetics-based disorders in psychiatry. 20 When a child is diagnosed with ADHD, there is a 30% chance that 1 of the parents has the disorder. 19 In either situation, the key to diagnosing ADHD in adults is establishing the lifelong, persistent, and pervasive nature of the disorder. If the symptoms are consistent with ADHD and are not caused by another psychiatric disorder, such as substance abuse, but are neither lifelong nor cause significant impairment in 2 or more domains (pervasive), the disorder is not ADHD. 1,13 For the primary care physician, excluding ADHD on this basis is relatively easy. Diagnosing ADHD in adults not diagnosed during childhood, however, is harder. In addition to establishing an unremitting course since childhood that has produced global impairment, the clinician must catalog the patient s current behaviors and symptoms and be confident that another psychiatric diagnosis or medical condition does not account for the symptoms. Several validated diagnostic assessment tools are available, including the Adult ADHD Self-Report Scale (ASRS), which was developed in conjunction with the World Health Organization. 11,13,21 When using the ASRS, patients should first complete the new 6-item symptom checklist, which is also called the screening version ( nyu.edu/psych/training/adhdscreener. pdf). 22 This checklist contains questions about 6 of the 18 symptom domains from the DSM-IV-TR criteria for ADHD and is shown on page 85. Researchers have found these 6 questions to be the most predictive of symptoms consistent with a diagnosis of ADHD. If the patient reports having significant symptoms for 4 of the 6 items, the physician should ask the patient to complete the 18-question symptom checklist, which contains questions about all 18 symptom domains listed in the DSM-IV-TR ( nyu.edu/psych/training/adhdscreen18.pdf). The challenges of establishing the presence of symptoms since childhood an unremitting course have been highlighted in a study by Mannuzza and colleagues. 23 Therefore, if the physician suspects, based on the results of the 18-question symptom checklist, that the patient has ADHD, it is worthwhile seeking the opinion of a specialist to confirm the presence of the disorder before initiating treatment. Once the primary care physician gains significant experience recognizing ADHD in adults, consulting with a specialist may be optional. TREATMENT The mainstay of treatment options for established ADHD in both children and adults is pharmacologic. Nonpharmacologic options in adults, such as a cognitive remediation program, have had some success. 24 In general, though, the most useful nonpharmacologic step is to encourage patients to participate in a support group. 7,17,20 Patients can be referred to the Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Web site at Other important psychosocial aspects of treatment include medication adherence (a substantial challenge for those who have ADHD, which emphasizes the value of medication with once-daily dosing); avoidance of drugs of abuse; and attention to marriage, family, and work relationships. When considering pharmacologic therapy, it is critical to recognize that all studies in adults are limited by small sample sizes, highly selected subjects, and extremely short duration of evaluation. Indeed, there are no published studies longer than 10 weeks and, thus, no studies that measure any significant functional outcomes. 25 Historically, the mainstay of pharmacologic treatment has been stimulants (Table 2). Researchers have studied methylphenidate extensively in children, completing more than 150 controlled studies that consistently yield a 70% response rate for short-term efficacy. 8 In contrast, fewer than 10 controlled trials have been completed in adults. The most robust study of methylphenidate screened 85 subjects referred to a highly specialized adult psychopharmacology center in Boston and enrolled 25 of them. 26 The study yielded a therapeutic response rate (30% reduction in symptoms score) of 78% for methylphenidate compared with 4% for placebo. Other studies have yielded response rates ranging as low as 25%, with a weighted mean response from meta-analysis of 57%. 8,17 The data on amphetamine stimulants are limited to 2 published studies of short duration, with a weighted mean response of 58%. 17,27,28 Because of the limited data and the prospects of indefinite treatment, long-term risks and side effects of stimulants are a serious concern. The risk for abuse of stimulants is not accurately quantified although it is thought to be low. 5,29,30 Side effects of these medications include anorexia, unintentional weight loss, insomnia, edginess, and gastrointestinal upset. 20,27 Of more concern is the long-term risk of causing or exacerbating hypertension. 20 Lastly, the short half-life of the drugs requires multiple doses per day although this has largely been circumvented by the development of extended-release formulations Vol. 4, No. 2 February 2004

5 ATTENTION DEFICIT HYPERACTIVITY DISORDER Some antidepressants are a good alternative to stimulants. These include antidepressants with norepinephrine or dopamine effects, including tricyclic antidepressants and bupropion. Researchers have studied venlafaxine in 2 open-label trials that reveal evidence of possible efficacy. 31,32 Both of these uncontrolled trials were small. The first trial enrolled 11 subjects and documented a clinical response in 8 subjects. The second trial enrolled 10 subjects, 9 of whom completed the 4-week trial, and documented a clinical response in 7 subjects. Notably, selective serotonin reuptake inhibitors are not effective in the treatment of ADHD. 10,20 In a placebo-controlled study of 41 patients, Wilens and colleagues found the tricyclic Table 2. Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder in Adults Medication Doses Initial Maximum Potential (Proprietary Name) Available Schedule Dose Dose Adverse Effects First line agents Atomoxetine 10 mg, 18 mg, once daily 40 mg/d 100 mg/d Gastrointestinal (Strattera ) 25 mg, 40 mg, effects, including 60 mg/d anorexia Methylphenidate* 5 mg, 10 mg, 20 mg 3 times daily 30 mg/d 80 mg/d (generic) Methylphenidate 20 mg 2 times daily 20 mg/d 60 mg/d Restlessness, anorexia, (Ritalin SR )* possible hypertension, Methylphenidate 20 mg, 30 mg, once daily 20 mg/d 60 mg/d possible exacerbation of tics (Ritalin LA )* 40 mg Methylphenidate 18 mg, 27 mg, once daily 18 mg/d 54 mg/d (Concerta )* 36 mg, 54 mg Methylphenidate 10 mg, 20 mg 2 times daily 20 mg/d 60 mg/d (Metadate ER )* Methylphenidate 10 mg, 20 mg, once daily 20 mg/d 60 mg/d (Metadate CD )* 30 mg Bupropion 75 mg, 100 mg 3 times daily 225 mg/d 450 mg/d (generic) Bupropion 100 mg, 150 mg, 2 times daily 200 mg/d 400 mg/d Agitation, tremor, (Wellbutrin SR ) 200 mg possible seizures Bupropion 150 mg, once daily 150 mg/d 450 mg/d (Wellbutrin XL ) 300 mg Second line agents Desipramine 25 mg, 50 mg, 75 mg, once daily 100 mg/d 300 mg/d Anticholinergic side effects, 100 mg, 150 mg possible arrhythmias Venlafaxine 25 mg, 37.5 mg, 2 to 3 times daily 75 mg/d 225 mg/d Gastrointestinal side (Effexor ) 50 mg, 75 mg, effects including nausea, 100 mg insomnia, sweating Venlafaxine 37.5 mg, 75 mg, once daily 75 mg/d 225 mg/d (Effexor SR ) 150 mg Dextroamphetamine* 5 mg, 10 mg, 15 mg 2 times daily 10 mg/d 40 mg/d Anorexia, insomnia, Amphetamine/ 5 mg, 10 mg, 2 times daily 10 mg/d 40 mg/d unintentional weight loss, dextroamphetamine 15 mg, 20 mg, hypertension, possible abuse (Adderall )* 30 mg Amphetamine/ 5 mg, 10 mg, once daily 10 mg/d 40 mg/d dextroamphetamine 15 mg, 20 mg, (Adderall XR )* 30 mg *SCHEDULE II AGENT Note: The journal customarily uses only generic drug names; however, due to the different dosing regimens for the long-acting formulations, the trade names of certain drugs have been supplied to avoid confusion. Advanced Studies in Medicine 83

6 BEHAVIORAL MEDICINE desipramine, at a targeted dose of 200 mg per day, significantly more effective than a placebo. In this study, 68% of subjects had a therapeutic response (30% reduction in symptoms score) to desipramine, a response similar to that seen with stimulants. 33 Using the same methodology in another study, Wilens and colleagues also found bupropion significantly more effective than placebo. 34 Of the 40 subjects included in the study, 52% had a therapeutic response. In a follow-up study that directly compared bupropion, methylphenidate, and placebo using the same measure of therapeutic response, Kuperman et al documented a response in 64% of subjects treated with bupropion, 50% of subjects treated with methylphenidate, and 27% of subjects treated with placebo. 35 The differences in this study did not reach statistical significance partly because of the limited power of the study (30 subjects randomized). The anticholinergic side effects and arrhythmogenic potential of tricyclic antidepressants are the principal barriers to their use. Bupropion is contraindicated in patients with a history of seizures and can cause tremor and agitation. Atomoxetine is a new agent recently approved by the Food and Drug Administration (FDA) for adult ADHD. It is attractive because it has no known abuse potential. It is the most studied pharmacologic agent in adults after methylphenidate. In an initial placebo-controlled study of 22 subjects, atomoxetine had a therapeutic response rate of 52% compared with 10% for placebo. 36 In the same paper, 2 studies of more than 250 subjects each found that atomoxetine was superior to placebo in the reduction of ADHD symptoms. 25 The efficacy of atomoxetine has not been compared directly with stimulants or other agents. A summary of available pharmacologic treatments for ADHD is provided in Table 2. At this time, no authoritative recommendation for therapy can be made given the lack of substantial, compelling, long-term data on functional outcomes. Fortunately, the dearth of rigorous studies and published data on treatment for ADHD in adults (particularly when compared with other conditions primary care physicians treat, such as hypertension, hyperlipidemia, and depression) is being remedied. The recent studies of atomoxetine and recent presentations at national meetings exemplify this change. 21 In the author s opinion, the following are reasonable recommendations for primary care physicians. For patients already receiving effective therapy, it is probably most reasonable to continue that therapy. Otherwise, most primary care physicians have extensive experience with antidepressants. Therefore, given the prospect of lifelong therapy and the worrisome lack of data regarding long-term side effects of stimulants, it is reasonable to consider a trial of antidepressants prior to one of stimulants when initiating or changing therapy in adults. 37 This is particularly true if there is a concomitant mood disorder or tobacco dependence. Some experts favor bupropion over tricyclic antidepressants, citing anecdotal reports of poor clinical response to desipramine. Atomoxetine is proving to be a good alternative to stimulant therapy as well and can be considered a first-line agent based on the strength of available data. The clinical response of patients with ADHD to nonstimulant therapy may be slower. The rating scales highlighted above and patients self-reports can be used to assess clinical response. The risks of stimulant therapy should not preclude prescribing it for the adult who fails to respond to other therapies and whose symptoms cause functional impairment. The apparent lower risk of abuse with methylphenidate would favor prescribing methylphenidate over amphetamine stimulants. It is expected that additional data regarding the long-term effects of stimulants will be published in the coming years. 21 Lastly, since symptoms either lessen in severity or abate over time for many patients with ADHD, some experts consider it prudent to initiate an intermittent 1-month holiday from medication every 1 to 3 years. 13 (Drug holidays also can be an opportunity to change therapy should untoward side effects develop.) While there is no compelling evidence to support this strategy, it is a reasonable recommendation given the apparent natural history of the disorder and the fact that patients with ADHD who are treated in the primary care setting will typically be less severely affected. For patients with more severe ADHD, a drug holiday may be unwarranted. If symptoms continue to impair patient functioning in 2 or more domains after a drug holiday, ongoing medication is warranted. SUMMARY ADHD is a psychiatric disorder that surfaces in childhood and may persist into adulthood in up to 50% of cases. Small-scale studies and the opinions of researchers represent the current knowledge base for the evaluation and management of the disorder in adults. While it is challenging to extrapolate these data to primary care settings, a few general points are noteworthy and may facilitate caring for affected adults. ADHD in adults can be effectively ruled out if symptoms of the disorder have not been present since 84 Vol. 4, No. 2 February 2004

7 ATTENTION DEFICIT HYPERACTIVITY DISORDER childhood and are not causing functional impairment in 2 or more domains of the patient s life. Because diagnosing ADHD in adults is more challenging, seeking the opinion of a specialist is helpful. For patients with established ADHD, ongoing pharmacologic therapy is the best treatment option. Stimulants have been the mainstay of therapy in children, and there is some evidence that they are useful in adults. Given the experience that primary care physicians have with prescribing antidepressants and with the long-term effects of these drugs, antidepressants may be more reasonable first-line therapy than stimulants when initiating treatment of ADHD in adults, particularly if comorbidity is present. Atomoxetine, which has been approved by the FDA for the treatment of ADHD in adults, is an attractive new agent. Unlike tricyclic antidepressants, it is not associated with adverse effects on cardiac conduction and, unlike stimulants, it has no known abuse potential. Finally, physicians should consider suggesting that adult patients take a periodic break from medication to assess the persistence and severity of symptoms. With this knowledge about ADHD in adults, primary care physicians can begin to be as confident and comfortable as their pediatric counterparts in evaluating and treating the majority of their adult patients with this disorder. Meanwhile, physicians and researchers await the results of larger cohort studies of the natural history of the disorder and larger, long-term, randomized therapeutic studies that include measures of functional improvement. REFERENCES 1. Feifel D. Attention-deficit hyperactivity disorder in adults. Postgrad Med. 1996;100: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; Are you living with Adult ADHD? The questions below can help you find out. Many adults have been living with Adult Attention-Deficit/Hyperactivity Disorder (Adult ADHD) and don't recognize it. Why? Because its symptoms are often mistaken for a stressful life. If you've felt this type of frustration most of your life, you may have Adult ADHD a condition your doctor can help diagnose and treat. The following questionnaire can be used as a starting point to help you recognize the signs/symptoms of Adult ADHD but is not meant to replace consultation with a trained healthcare professional. An accurate diagnosis can only be made through a clinical evaluation. Regardless of the questionnaire results, if you have concerns about diagnosis and treatment of ADHD, please discuss your concerns with your physician. Adult Self-Report Scale-V1.1 (ASRS-V1.1) Screener Check the box that best describes how you have felt and conducted yourself over the past 6 months. Please give the completed questionnaire to your healthcare professional during your next appointment to discuss the results. 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Add the number of checkmarks that appear in the darkly shaded area. Four (4) or more checkmarks indicate that your symptoms may be consistent with Adult ADHD. It may be beneficial for you to talk with your healthcare provider about an evaluation. This screening tool is intended for people age 18 years or older and contains the 6 questions found to be the most predictive of symptoms consistent with a diagnosis of ADHD. ASRS-V1.1 Screener. Copyright 2003 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved. Never Rarely Sometimes Often Very Often Advanced Studies in Medicine 85

8 BEHAVIORAL MEDICINE 3. American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000;105: Brown RT, Freeman WS, Perrin JM, Stein MT, Amler RW, Feldman HM, et al. Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings. Pediatrics. 2001;107:E National Institutes of Health. Diagnosis and treatment of attention deficit hyperactivity disorder. NIH Consens Statement Online. November 16, 1998;16(2):1-37. Available at: nih.gov/cons/110/110_statement.htm. Accessed December 25, Spencer T, Biederman J, Wilens TE, Faraone SV. Adults with attention-deficit/hyperactivity disorder: a controversial diagnosis. J Clin Psychiatry. 1998; 59(suppl 7): Pary R, Lewis S, Matuschka PR, Rudzinskiy P, Safi M, Lippmann S. Attention deficit disorder in adults. Ann Clin Psychiatry. 2002;14: Biederman J. Attention-deficit/hyperactivity disorder: a life-span perspective. 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