Attention Deficit Hyperactivity Disorder (ADHD) in Adults

Last Updated: March 19, 2025

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This tool is designed to support primary care providers in screening, diagnosing and implementing treatment for adult patients (≥ 18 years) with attention deficit hyperactivity disorder (ADHD). ADHD in adulthood can be associated with significant impairment in academic, occupational, social and emotional functioning.1,2 The treatment of ADHD involves pharmacological and non-pharmacological interventions.

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Screening and diagnosis

Consider screening for ADHD in primary care in adults who present with executive function difficulties, including those who do not have a childhood diagnosis of ADHD.

Due to the barriers to accessing specialty care, this tool aims to empower and guide primary care providers in managing adult ADHD within the primary care setting. For additional support see the Canadian ADHD Resource Alliance (CADDRA) and consult specialists across the province at OTN eConsult.

Opportunities for screening

Consider screening your patient who has distress or dysfunction and:2,3,4

  • Pre-existing diagnosis of ADHD
  • Treatment-resistant anxiety and/or depression
  • Family history of ADHD (e.g., parents, siblings or children)
  • Difficulty with transitions in life (e.g., university/college, living independently, work/promotion, parenthood, menopause)
  • Occupational instability (e.g., job loss, difficulty with deadlines, working with others)
  • Perceived underachievement
  • Poor adherence to a healthy lifestyle (difficulty initiating, organizing)
  • High-risk behaviour (e.g., substance misuse, interaction with law enforcement, driving offences)
  • Suicidal behaviour or ideation
  • Emotional dysregulation
  • Family dysfunction
  • Eating issues/fluctuating weight (e.g., binge eating)
  • High caffeine tolerance
  • Atypical response to stimulants (i.e., calming effect on initial use)
High Risk Groups
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High Risk Groups

Clinicians should be aware that people in the following groups may have increased prevalence of ADHD. 3,4

Earliest Factors

  • Close family member with ADHD
  • Prenatal exposure to substances
  • Born pre-term
  • Low birth weight
  • Cared for out of home as a child

Mental Health Conditions

  • Adults with ANY mental health condition
  • History of or current substance misuse
  • Suicidal behaviour or ideation
  • Oppositional defiant disorder or conduct disorder in youth
  • Mood disorder in youth

Neurodevelopmental Disorders

  • Autism spectrum disorder
  • Intellectual disability
  • Tic disorder
  • Language disorders
  • Specific learning disorders

Other Conditions & Scenarios

  • Epilepsy
  • Acquired brain injury
  • Sleep disorders
  • Involvement in the youth or adult criminal justice system

Screening

Use the Adult ADHD self-report scale (ASRS-V1.1) symptom checklist to screen patients for ADHD.6 The ASRS-V1.1 is designed to guide history taking and facilitate dialogue between you and your patient to identify if they have symptoms of ADHD (e.g. prompting the patient to provide specific examples when answering certain questions).2,5 Consider utilizing the first six questions of the ASRS for screening and the full questionnaire if the screen is positive. If the patient has symptoms highly consistent with ADHD in adults, then investigation is warranted using the diagnostic criteria below.6

Diagnosis

To diagnose  ADHD, symptom manifestations of hyperactivity/impulsivity and/or inattention should:4

If possible, ask the patient for permission to consult a third party (a friend or family member) who is close to the patient and can offer further insight into their symptoms.

Categories of impairment2,7,8

The following are examples of impairment that patients with ADHD may experience.

Occupational

Problems with:
• Performing required duties (e.g., low productivity, procrastination)
• Higher likelihood to impulsively quit, change jobs, or be fired

Educational

Problems with:
• Focusing (e.g., disrupting others)
• Meeting deadlines
• Completing assignments (e.g., handing in late or not at all, lower grades than expected)

Family

Problems with:
• Family members
• Parenting (e.g., angry/irritable parent)
• Separation/divorce/marital conflict
• Balancing their needs against those of their family

Life skills

Problems with:
• Insomnia
• Speed of thought
• Financial management
• Maintaining household tasks and organization
• Time management
• Weight control

Self-concept

Feels:
•  Self-regulation of thoughts, emotions
• Low self-esteem
• Frustrated with themselves
• Discouraged, imposter thoughts

Social

Problems with:
• Avoiding arguments
• Interrupting and/or trouble following conversations
• Establishing and maintaining friendships
• Regulating emotions

Risk

Problems with:
• Legal issues
• Aggressive driving
• Substance use
• Higher emergency room visits
• Physical aggression

Adapted from CADDRA and the Weiss functional impairment rating scale (WFIRS-S).

Talking tips
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Talking tips

Look for signs of ADHD and address them with your patient
“I’ve noticed some patterns in what you’ve described that might align with symptoms of ADHD. These symptoms can have many causes, and it’s important to explore all possibilities. Have you ever considered the possibility of ADHD, either in the past or presently?”

Talk to your patient without judgment, stigma or bias
“Many people don’t know that they have been living with ADHD until adulthood. It is a treatable and common condition, affecting 3.4% of adults worldwide.”5

Concerns about self-diagnosis
“It sounds like you’ve been investigating ADHD and how it might relate to your experiences. Let’s work together on an assessment. This will help us understand what’s going on and if ADHD is contributing to the challenges you’re facing.”

Practice point

ADHD can present differently and be under-recognized in girls and women. Girls and women are:3

  • Less likely to be referred for assessment for ADHD.
  • More likely to have inattentive type of ADHD, which often goes undiagnosed until adulthood.
  • Sometimes more likely to receive an incorrect diagnosis of another mental health or neurodevelopmental disorder, such as an anxiety, depression or borderline personality disorder.

Consider how intersecting identities and disparities can impact ADHD presentation, leading to variations in  diagnosis, treatment and care.2

Initiating treatment

Develop a treatment plan with your patient that addresses their psychological, behavioural, occupational and educational needs.4

Take into account:4

  • How symptoms and impairments affect the patient’s daily life activities, including sleep and appetite.4
    • E.g. the potential for stimulant-induced appetite suppression and proactively planning for food and hydration reminders.2
  • The patient’s resilience and protective factors (positive self-esteem, success at school, steady employment, supportive family).4,9
  • Consider incorporating a treatment agreement into the treatment plan, particularly if patient is at high risk or has a Substance Use Disorder (SUD).

Discuss the following with your patient:4

  • How to use the Specific, Measurable, Achievable, Realistic, and Timely (SMART) goals framework to create measurable outcomes for monitoring treatment effect (e.g., if a patient wants to focus more on their studies, be more financially responsible, manage their time better) and improvement (e.g. complete tasks, improving emotional regulation).
  • How other diagnosed mental health or neurodevelopmental conditions might affect their treatment decisions. (see Treatment for patients with comorbid conditions and differential diagnosis)
  • The benefits and risks of non-pharmacological and pharmacological treatments.
  • The importance of adherence to their treatment plan.
  • The risks of not treating ADHD (e.g., mortality, SUD, potential underperformance, relationship difficulty, underachievement in education, employment).
Talking tips
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Talking tips

Reassure patients that their treatment plan can be changed
“This is a shared discussion about your treatment options. Nothing is set in stone. We can always revisit at the next appointment.”

When discussing a diagnosis with a patient, acknowledge and emphasize their positive characteristics, traits and habits. This can help create a more balanced and supportive conversation.

Non-pharmacological treatment options

Non-pharmacological treatment should always be discussed as an adjunct therapy when prescribing medication for ADHD to optimize the effects of the patient’s treatment.2 When available, the following may be helpful:

  • Consider a structured, supportive psychological intervention focused on ADHD, such as cognitive behavioural therapy (CBT). 4
  • Consider referring patients for more information on ADHD (e.g., coaching, counselling, mindfulness, food and nutrition, healthy lifestyle modifications, vocational advice, financial resources and other tips).2,4

For additional support, recommend consulting the Canadian ADHD Resource Alliance (CADDRA) Guide to ADHD psychoeducation for tips on engaging in pyschosocial treatment with your patient.28

Pharmacological treatment options

If a patient has a diagnosis of ADHD, pharmacological and non-pharmacological treatment should be used in parallel.

Considerations when prescribing2,3,4

  • Revisit the patient’s S.M.A.R.T. goal methods to determine when their medication needs to be effective over an extended period. This can help determine if medication is losing effect during the day. 2
  • Evaluate current educational or employment circumstances. 3,4
  • Complete a risk assessment for substance misuse and drug diversion. 3,4
  • Rule out contraindications to medication (e.g., uncontrolled hypertension, cardiovascular disease, uncontrolled epilepsy).2,3,4
  • When prescribing stimulants for ADHD, use long-acting stimulants (see First-line treatment options).4
  • Once stable, reassess the treatment plan every 3-12 months or sooner as dictated by provider or patient preference (see Maintenance and monitoring).2,3,4
  • Document the patient’s blood pressure, heart rate, BMI/weight and ASRS-V1.1 score at baseline and all subsequent visits to measure the effect of treatment for monitoring purposes.2
  • Choose long-acting stimulants . There is an increased potential risk of diversion and misuse associated with immediate-release medications.2
  • Be aware of possible diversion by some patients who may request these medications for cognitive enhancement or appetite suppression2
Talking tips
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Talking tips

Discuss the following when starting pharmacological treatment

“We’re starting a stimulant medication today. For the first few days, it’s common to experience some stimulation, so it’s important to limit caffeine and other substances. When the stimulation settles down after a week, we’ll have a better sense of the medication’s effect, and we will adjust your dosage based on how it feels then.”

“It is important to maintain a routine and to take your medications at the same time every day.”

“Consider reducing or discontinuing alcohol, cannabis and caffeinated beverages while taking stimulants as they could complicate treatment.”

Treatment options

First line treatment
Evidence supports the efficacy of long-acting stimulants (amphetamines or methylphenidate) as first-line pharmacological treatment for adult patients living with ADHD.10

If the first stimulant choice doesn’t work optimally (e.g. significant side effects or intolerance) try an alternate stimulant from the other molecule family.2

  • For significant side effects or intolerance – try an alternate stimulant from the other stimulant family
  • For concerns with duration of action or release mechanism – try switching within the same stimulant family.
    If effects wear off too early in the day, consider switching to a long-acting stimulant with a longer duration of action, a long-acting stimulant with a higher proportion of extended release or adding small dose of the same long-acting stimulant at mid-day. If greater effects are needed in the morning, consider switching to a long-acting stimulant with a higher proportion of immediate-release. See Medications table, for more information. 2

Second line treatment
Offer atomoxetine to adults if:4

  • They cannot tolerate use of a stimulant (i.e., amphetamines or methylphenidate)
  • Their symptoms have not responded to separate six-week trials of amphetamines and methylphenidate, having considered alternative preparations and adequate doses
  • Note: Atomoxetine requires daily administration and may not be discontinued abruptly. Patients should take it every day, including weekends.

Medications3-4,11-27

Titration

Titrate starting at the lowest appropriate dose according to the product monograph, the patient’s symptoms and response until dose optimization is achieved (i.e., the patient experiences reduced symptoms, a positive behaviour change, or improvements in learning, employment, relationships and perceived impairment) while monitoring potential adverse effects.

  • Consider titrating patient dose every 2-4 weeks based on assessment for goals and symptom improvement. Continue their current dose for a longer duration if goals are achieved. Monitor for signs of anxiety, irritability or stimulation. If present, return to previous dose.2 
  • Most patients will notice initial improvement, but it may also take several months for choice of medication and dosage to be in the range that provides optimum benefit to the patient.2
  • Review of ADHD symptoms, impairments and side effects should be discussed. The ASRS-V1.1 can also be used as a scale to follow changes in the patient’s executive function. Inquiry as to how patients are managing with their S.M.A.R.T. goals is also important.2,4
  • Dose titration must be slower and monitored more carefully in patients with co-morbid conditions, neurodevelopment disorders and medical conditions as outlined in Treatment for patients with comorbid conditions and differential diagnosis.
  • Advise patients to avoid self-treating (e.g., caffeine, nicotine, alcohol, cannabis) while titrating medication. Once medication dosages are optimized, consider the utility of gradually reintroducing caffeine, nicotine, alcohol, cannabis as patients see fit. Non-prescription medications and substance use should be reviewed carefully using an individualized approach with the provider.2

Treatment for patients with comorbid conditions and differential diagnosis

Up to 80% of adults with ADHD will have at least one other mental health diagnosis (e.g. anxiety, mood disorder, personality disorder or substance use disorder) or a comorbid neurodevelopmental condition (e.g. autism spectrum disorder or a learning/intellectual disability).3

It is important for treatment to address the most distressing symptoms first. Consultation with an experienced healthcare ADHD professional or psychologist may be required for complex cases.

Note: Medications such as SSRIs and antipsychotics may worsen ADHD symptoms due to relative reduction in norepinephrine and dopamine.

Talking tips
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Talking tips

“We’ll need to treat your other health concerns for you to start feeling better. To do this, we will address the most important issues first.”

Select comorbid condition to view details

For adults with ADHD experiencing an acute psychotic (e.g., hallucinations, delusions and disorganized thinking) or manic episode (e.g., abnormally upbeat, jumpy or wired, increased activity, energy or agitation, decreased need for sleep), review medication and consider its impact on ADHD: 4,28,29

  • Stop stimulant medication for ADHD. Stimulants should not be prescribed for untreated acute psychosis or mania.
  • Resume or start a new ADHD medication after the episode has been treated.2,4

Individuals with untreated ADHD may describe their difficulties with thought and emotional control as anxiety. While both generalized anxiety and ADHD can involve racing thoughts, there are key differences. For patients with ADHD, racing thoughts often revolve around reviewing all tasks and distractions; anxious thoughts are more secondary. In contrast, generalized anxiety is characterized by persistent worries and fears.2

If anxiety is the most distressing symptom, treat it first. If anxiety is well-managed, or treatment resistant, then revisiting an ADHD evaluation is appropriate.2

Patients with co-occurring bipolar disorder and ADHD should be stabilized on a therapeutic dose of a mood-stabilizing medication before treating ADHD with a stimulant.1 In patients with Bipolar Disorder Type 1, think about how effective the specific mood stabilizer is at protecting against manic episode rather than solely Major Depressive Episodes.2 

All patients should be monitored with regular blood pressure and heart rate checks.

  • If a patient has significant cardiovascular disease or a family history of sudden cardiac death, especially in young family members, refer them to a cardiologist prior to treatment.2
  • There is a risk of a slight increase in blood pressure and heart rate with stimulant medications and with atomoxetine with stimulant and non-stimulant medications. 3,4
  • An ECG is recommended for patients at risk of cardiac disease, or taking medications with impact on cardiovascular system, prior to initiating psychostimulants.3,4

People with ADHD often experience depressive symptoms. This can be due to the ongoing challenges of living with ADHD, such as difficulties with focus, organization, and managing emotions. These struggles can lead to feelings of hopelessness and futility, especially when everyday tasks become consistently difficult.2

For patients with ADHD and co-occurring depression, consider combining ADHD treatment with an antidepressant. If depression is the most distressing symptom, treat this first. If depression is well managed, or treatment resistant, then revisiting an ADHD evaluation is appropriate.2

See “Anxiety” above if there are prominent anxiety symptoms coexisting.

Note: Certain medications, as mentioned above, can exacerbate ADHD symptoms.

In adults with ADHD and an active SUD (e.g., alcohol, cannabis, cocaine, nicotine), the SUD is to be acknowledged and ideally stabilized before starting pharmacotherapy for ADHD. Not addressing their ADHD will make it more difficult to address their SUD.1

  • Treatment with atomoxetine may be recommended as it has limited abuse potential1
  • Lisdexamfetamine is recommended as it is a prodrug which makes it difficult to abuse and divert2,30
  • For patients with comorbid nicotine use, methylphenidate may be recommended. 30
  • If urine screening is used, consider limitations of such tests (e.g. false positives/negatives) and interactions with other medications.

Patients with SUD benefit from additional structure with dispensing medication and monitoring patient safety:

  • Consider daily observed doses at the pharmacy.
  • When there are complications of SUD, a patient may benefit from more frequent review and  shorter time between medications (e.g., weekly, bi-weekly or monthly dispensing).2

Maintenance and monitoring

Guidance for conducting follow-up visits with patients

Follow up is recommended 3-12 months after optimizing treatment (i.e. an effective long-term stable dose is obtained), unless clinical indicators warrant the need for an earlier visit. Considerations to address during the follow-up visit include:

  • Ongoing monitoring of the following is recommended2,3,4:
    • Appetite
    • Weight
    • Sleep
    • Cardiovascular function
    • Tics
    • Seizures
    • Sexual function
    • Worsening symptoms
    • Worsening of mood
    • Increased anxiety
    • Risk of stimulant diversion
  • Assess cardiovascular health (e.g., heart rate, blood pressure) after dose changes, and at least every 6 months. Review personal and family history of cardiovascular health changes at each visit.3,4
  • Revisit the patient’s SMART goals for assessing treatment effect by evaluating the patient’s areas of improvement and change.2
  • Ask patient if there’s a time of day they notice the medication wearing off. If so, consider the options:2
    • If the patient is not currently on a long-acting medication, then consider switching to a longer-acting option.
    • If you decide to add a small dose of medication at lunch or early afternoon (noon-2pm), then titrate it as you would the morning dose.
    • Then follow up on the effect of the medication in the evening (e.g. sleep).
  • Monitor and record the effectiveness of the patient’s medication for ADHD by using methods such as conducting the ASR S-V1.1 or patient conversations at each visit to monitor for improvement4
Managing side effects
  • Treatment should be reviewed regularly to evaluate side effects, such as: 11
    • Appetite suppression
    • Headaches
    • Change in weight
    • Stomach aches
    • Blood pressure
  • Encourage the patient to monitor and record the effects associated with their medication, both positive and negative.4
Review of medication and discontinuation
  • Review ADHD medication at least once a year and discuss with the patient whether medication is supported and should be continued. Considerations include3,4:
    • Clinical need
    • Response to impairment (e.g., benefits, adverse effects)
    • Change in cognitive or emotional demand (e.g., kids get older, retired)
    • Effect on existing or new mental health, physical health or neurodevelopmental disorders 
    • Impact on education and employment
    • Effects of missed doses, planned dose reductions and periods of no treatment 
  • Atomoxetine can be stopped at any time without tapering.2, 31,32
  • Tapering for amphetamine or methylphenidate-based stimulants requires a review of patient’s medical history and needs (i.e., if they have prolonged use of a stimulant and/or they are taking another medication in conjunction such as antipsychotics).
    • Tapering is considered after the patient has been stable for more than 6-12 months, if the patient wants to explore lower doses, or is medically necessary due to diagnosis (i.e., schizophrenia, bipolar disorder, SUD) or medical status changes where risks outweigh benefits. 2,32
  • Continue to document patient factors to monitor treatment effects at follow-up visits.

References

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    UpToDate. Approach to treating attention deficit hyperactivity disorder in adults. 2019. [cited 2019 November 13].

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    Expert opinion

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    Australasian ADHD Professionals Association (AADPA). Australian Evidence-Based Clinical Practice ADHD Guideline. 2022. Available from: https://adhdguideline.aadpa.com.au/

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    National Institute for Health and Care Excellence (NICE). Attention deficit hyperactivity disorder: diagnosis and management. 2018. Available from https://www.nice.org.uk/guidance/ng87

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    Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist Instructions. [cited 2019 November 15]. Available from: https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf

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    Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practice guidelines. 2020. Available from: https://adhdlearn.caddra.ca/purchase-guidelines/

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    Government of Canada. Risk and protective factors. 2015. [cited 2020 February 20]. Available from https://www.publicsafety.gc.ca/cnt/cntrng-crm/crm-prvntn/fndng-prgrms/rsk-fctrs-en.aspx

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    UpToDate. Pharmacotherapy for attention deficit hyperactivity disorder in adults. 2019. [cited 2020 February 19].

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    Volkow ND, Wang GJ, Telang F, Fowler JS, Alexoff D, Logan J, et al. Decreased dopamine brain reactivity in marijuana abusers is associated with negative emotionality and addiction severity. Proc Natl Acad Sci U S A. 2014 Jul 29;111(30):E3149-3156.

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