ADHD Across the Lifespan

Diagnostic and Therapeutic Guide for the Modern Clinician

Executive Summary

Adults need only 5 symptoms (vs. 6 in children) per DSM-5-TR
Amphetamines may be superior for adults >30 years
75-80% of adults with ADHD have comorbidities
CBT for Adult ADHD: Effect size 0.8+ for symptoms
Cardiovascular screening essential before stimulants in adults

Evolving Clinical Presentation

Domain	Childhood (Externalized)	Adulthood (Internalized)
Hyperactivity	Running, climbing, "driven by motor"	Inner restlessness, racing thoughts, fidgeting
Inattention	Careless mistakes, losing homework	Procrastination, poor time management, "zoning out"
Impulsivity	Blurting, interrupting, can't wait turn	Financial impulsivity, job hopping, impulsive life decisions

DSM-5-TR Diagnostic Criteria

Children (≤16): 6+ symptoms from either domain
Adults (17+): 5+ symptoms from either domain
Age of onset: Symptoms present before age 12
Impairment: Present in 2+ settings

Adult Assessment Tools

Tool	Purpose	Cutoff
ASRS v1.1 (Part A)	Screening	≥4 suggests ADHD
WURS-25	Retrospective childhood	AUC 0.956
Combined ASRS + WURS	Optimal accuracy	AUC 0.964

Pharmacotherapy Across Lifespan

Class	Child Efficacy	Adult Efficacy	Notes
Methylphenidate	High (ES 0.8-1.0)	Reduced >30y	First-line for children
Amphetamines	High	High (superior)	Vyvanse: ↓ hospitalization
Atomoxetine	Moderate	Moderate	Good for comorbid anxiety/SUD

Cardiovascular Risk: Stimulants increase HR ~5.7 bpm, BP ~1.2 mmHg. Amphetamines carry higher CV risk than methylphenidate. Screen cardiac history.

Comorbidity Management

75-80% of adults with ADHD have comorbidities:

Comorbidity	Prevalence	Treatment Approach
Anxiety Disorders	47-50%	Atomoxetine or SSRI + stimulant
Major Depression	30-40%	Treat most impairing first
Substance Use	15-25%	Long-acting stimulants or atomoxetine