Approaching Adult ADHD Diagnosis and Management

David Goodman, MD, shared clinical insights from his APA presentation on adult attention-deficit hyperactivity disorder (ADHD) alongside colleague Jim McGough, MD, of UCLA.

Goodman framed the session’s central purpose as addressing a significant gap in formal psychiatric training, noting that many clinicians have never received structured instruction in adult ADHD and have instead acquired knowledge through on-the-job situational learning. He underscored the clinical stakes, describing ADHD as the second most prevalent psychiatric disorder in adults, with a general population prevalence of approximately 3% that rises dramatically in clinical settings.¹

A key diagnostic teaching point Goodman emphasized was that adult patients with ADHD rarely self-identify their core symptoms. Instead, they typically present with anxiety, depression, and general distress—requiring the clinician to actively probe for ADHD features beyond the presenting complaint. He stressed that the diagnosis must be anchored in a childhood onset: "if the patient complains about cognitive difficulties and they do not have a history of such symptoms in childhood or early adolescence, then it is unlikely to be ADHD." He also highlighted the disorder's high heritability (approximately 80% genetic in origin) as a diagnostically useful feature, such that a first-degree family history of ADHD meaningfully raises the prior probability in the patient being evaluated.²

Goodman pushed back against the notion that late diagnosis is clinically unhelpful or that stimulants are contraindicated in this adult population. He also addressed pressure to curtail stimulant prescribing more broadly, stating that "40 years of international research and international consensus reports and clinical practice guidelines" support the efficacy and legitimacy of stimulant pharmacotherapy, and cautioning that withholding such treatment constitutes a failure of care for patients who need it.

Dr Goodman is an assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine and a clinical associate professor in the Department of Psychiatry at Norton College of Medicine at SUNY Upstate Medical University. He is also the founder of the nonprofit charity, My ADHD Foundation.

References

1. Song P, Zha M, Yang Q, et al. The prevalence of adult attention-deficit hyperactivity disorder: a global systematic review and meta-analysis. J Glob Health. 2021;11:04009.

2. Faraone SV, Larsson H. Genetics of attention deficit hyperactivity disorder. Mol Psychiatry. 2019;24(4):562-575.