Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition that affects approximately 2.5% of adults worldwide. Although traditionally considered a childhood disorder, ADHD frequently persists into adulthood, with at least one-third of affected children continuing to have the disorder as adults and an even greater proportion experiencing lasting functional impairment. Adult ADHD is often underrecognized, particularly in women and in individuals presenting with coexisting psychiatric conditions. A recent clinical practice review published in the New England Journal of Medicine by Buitelaar and Newcorn examines current evidence and recommendations for the assessment, diagnosis, and management of ADHD in adults.
The clinical presentation of ADHD changes across the lifespan. In adults, inattention commonly manifests as difficulty with organization, planning, time management, and task completion, whereas hyperactivity often presents as inner restlessness or an inability to relax. Impulsivity can involve blurting out comments, interrupting others, and making impulsive decisions such as careless spending; more severe manifestations include “road rage” or antisocial behavior. Emotional dysregulation, although not part of the core diagnostic criteria, is present in most adults with ADHD and may contribute to irritability and interpersonal difficulties. ADHD frequently coexists with anxiety, mood, sleep, substance use, and personality disorders, as well as with somatic conditions such as obesity, cardiovascular disease, and diabetes. Women are more likely to be diagnosed late or missed because girls tend to be less disruptive and to compensate for or mask symptoms, and because women more often seek evaluation for anxiety or depression.
ADHD is a clinical diagnosis, and no laboratory test can establish it. Neuropsychological tests can aid in characterizing the disorder, but assessment requires a clinical interview, and the guidelines the authors review state that ADHD should not be diagnosed solely on the basis of rating scales. According to DSM-5-TR criteria, adults aged 17 years or older must have at least five symptoms of inattention and/or at least five symptoms of hyperactivity–impulsivity, present for at least six months, with several symptoms present by age 12 and in two or more settings. Symptoms must interfere with functioning and must not be better explained by another condition. Standardized rating scales can efficiently collect information on current and retrospective symptoms, and collateral information from a partner or parent is recommended, particularly because adults’ recall of childhood symptoms can be inconsistent. Differentiating ADHD from anxiety, depression, and substance use disorders is important, because inattention and restlessness overlap across these conditions.
Pharmacotherapy is a cornerstone of adult ADHD treatment, and existing guidelines converge in recommending either psychostimulant class as first-line treatment for core symptoms. Methylphenidate- and amphetamine-based medications reduce core ADHD symptoms. The latest network meta-analysis reported effect sizes for both stimulant classes together of 0.39 for patient-rated symptoms and 0.61 for clinician-rated symptoms, with no significant difference between the classes. Long-acting formulations are recommended because adults often need coverage during work and after-work hours; they are expected to last 8 to 12 hours, with one formulation labeled for up to 16 hours, and immediate-release supplementation may be helpful if coverage is insufficient. Dose optimization and frequent follow-up are important, and a clinically meaningful response typically requires a 40 to 50% change in symptoms.
Nonstimulant medications are an alternative for patients who have an inadequate response to or side effects from stimulants, and they have the advantages of uncontrolled status, longer duration of action, and lack of abuse liability. In most guidelines they are a second-choice option, and their effect sizes are moderate and somewhat lower than those of stimulants, with considerable variability in response. Approved nonstimulants include the norepinephrine-reuptake inhibitor atomoxetine and extended-release viloxazine. In a recent meta-analysis, atomoxetine had an effect size of 0.48 (15 randomized trials) and guanfacine 0.66 (2 trials), while viloxazine rests on a single trial to date; the small trial numbers for guanfacine and viloxazine limit comparison with atomoxetine. Extended-release guanfacine and clonidine are not FDA-approved for adults and are used off-label. Centanafadine, a norepinephrine–serotonin–dopamine reuptake inhibitor, was recently approved by the FDA for children and adults and showed a more modest effect size of 0.37 in a meta-analysis of five trials.
Safety considerations are essential when selecting and monitoring ADHD medications. The most common stimulant adverse effects are decreased appetite and weight, initial insomnia, and increased heart rate and blood pressure. Long-term stimulant treatment carries some increased risk of cardiovascular disease, primarily hypertension, so baseline cardiovascular screening is recommended: medical and family history, physical examination with blood pressure, pulse, and weight, and an electrocardiogram if the history or examination warrants. Concerns that stimulant treatment increases the risk of substance misuse are not supported by the data: the most recent meta-analysis and a longitudinal follow-up of the Multimodal Treatment of ADHD study showed neither increased risk nor protective effects, and large registry and insurance-claims studies associated stimulant treatment with a decreased risk of substance abuse. Nevertheless, stimulants can be misused or diverted, particularly immediate-release formulations, so clinicians should monitor for misuse and substance use during treatment.
Psychosocial interventions are another important component of ADHD management, particularly because inattention and poor organization predominate in adults and may be less adequately treated with medication. Evidence-based approaches include cognitive-behavioral therapy (CBT), metacognitive therapy, organizational-skills training, and dialectical behavior therapy. A recent meta-analysis found that CBT had moderate positive effects on functional domains, with effect sizes of 0.47 for global functioning, 1.00 for occupational functioning, 0.36 for social relationships, and 0.48 for academic functioning, but limited effects on core symptoms and quality of life (0.28). Psychoeducation is recommended at the start of treatment to help patients understand ADHD as a neurobiologically based condition. Given the range of impairments that is frequently present, a combination of medication and psychosocial treatment is often required.
Overall, this review emphasizes recognizing ADHD as a potentially lifelong condition with substantial psychiatric, somatic, and functional consequences. Effective management requires careful diagnostic assessment, identification of coexisting conditions, individualized medication selection, and tracking of both symptoms and function. Stimulants remain the preferred initial pharmacologic treatment in most guidelines, with nonstimulants and evidence-based psychosocial interventions as alternatives or adjuncts. The authors identify several areas of uncertainty: the ADHD phenotype in women and the effects of hormonal changes across life stages; the long-term outcomes of medication treatment and whether to prioritize stimulant or nonstimulant approaches; how best to treat ADHD alongside coexisting mood, anxiety, and substance use disorders; the association between ADHD and later cognitive impairment, including whether stimulants are protective or a risk factor; and the role of digital tools and exercise.