Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
ADHD in adults
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Acute activation is not routine ADHD
New severe agitation, sleeplessness, grandiosity, psychosis, chest pain, syncope, marked hypertension, suicidal intent or suspected stimulant toxicity demands urgent assessment for mania, psychosis, cardiovascular disease, overdose or substance-related harm.
Action: Assess ABCDE, observations, glucose, ECG and toxicology context as indicated, stop the next ADHD dose when a serious medicine-related event or acute psychotic or manic episode is suspected, and obtain emergency medical and mental-health advice.
Overview
Identify developmentally persistent attention, activity and impulse-regulation difficulties across settings, obtain specialist diagnosis, and deliver multimodal adult treatment with safe cardiovascular, psychiatric and diversion monitoring.
ADHD affects regulation of attention, activity and impulses across development. Adult inattention may appear as losing essential items, unfinished tasks, time blindness, distractibility, errors, missed appointments and inability to sustain routine work. Hyperactivity may become internal restlessness, constant activity or difficulty remaining seated, while impulsivity can affect speech, driving, spending, substances and relationships. Diagnosis requires impairment rather than personality style or occasional procrastination, and symptoms must be understood against the person's opportunities, responsibilities and coping systems.
Establish childhood onset through the adult's account, school reports, prior records and informants where available. Explore examples before age twelve, persistence and effects across home, education, employment, relationships and daily living. Lack of paperwork or a living parent does not rule out diagnosis, but vague retrospective symptoms need careful corroboration and differential assessment. Some adults were protected by intelligence, rigid family structure or high interest until university, parenthood, shift work or independent living increased executive demands.
Aetiology
01
Polygenic liability
Many common genetic variants contribute to ADHD susceptibility, with substantial heritability but no single diagnostic gene in most adults.
02
Early neurodevelopmental factors
Prematurity, brain injury and some prenatal exposures are associated with risk, while association does not establish blame or one preventable cause.
03
Environmental expression
Sleep, stress, structure, task interest and social demand strongly modify visible impairment without creating the underlying developmental syndrome by themselves.
Pathophysiology
1
Executive control variation
Working memory, inhibition, planning and sustained effort are inconsistently recruited, especially during delayed reward or low-interest tasks.
2
Reward timing
Immediate feedback and novelty can capture performance more effectively than distant consequences, producing marked context-dependent ability rather than simple unwillingness.
3
Arousal regulation
Activity and stimulation may be used to maintain alertness, contributing to restlessness, task switching and variable concentration across the day.
4
Network maturation
Development of frontostriatal and distributed attention networks differs over time, so childhood hyperactivity may evolve into adult internal restlessness and disorganisation.
Clinical features and red flags
Persistent inattention
Organisation, sustained effort, working memory, task completion and resistance to distraction are impaired across more than one important context.
Adult hyperactivity
Visible overactivity may become inner restlessness, excessive talking, constant occupation, impatience or difficulty tolerating quiet sedentary situations.
Impulsive action
Interrupting, rapid decisions, spending, driving, substance use or relationship behaviour occurs before consequences are adequately considered.
Developmental continuity
Examples from childhood and adolescence connect to current difficulties, although presentation and protective structure may have changed with age.
Cross-setting impairment
Symptoms materially affect at least two domains such as work, home, study, relationships, finances, health routines or driving.
Red flags requiring action
Symptoms that began only after head injury, substance use, mood episode, sleep disorder or another adult illness do not establish developmental ADHD and require an alternative-cause assessment.
Exertional syncope, cardiac-origin chest pain, sudden death in a first-degree relative under forty, congenital heart disease or a murmur prompts cardiovascular opinion before ADHD medication.
Investigations
01Specialist developmental interviewFirst step
Why
Confirm childhood onset, persistence, cross-setting symptoms, impairment and alternative explanations.
Interpretation and limitations
Diagnosis rests on the complete clinical assessment and observer evidence where available, not a symptom checklist or current performance in one setting.
02Psychiatric and substance assessment
Why
Identify mood, anxiety, psychosis, trauma, autism, personality, sleep and substance conditions that mimic or modify ADHD.
Interpretation and limitations
Establish chronology and episodicity; comorbidity may coexist, while symptoms confined to an acute episode suggest another primary cause.
03Baseline physical and cardiovascular review
Why
Identify contraindications and establish safe parameters before medication.
Interpretation and limitations
Record medical and family cardiac history, pulse, blood pressure, height and weight; arrange ECG or cardiology only when specified clinical features create an indication.
04Medication and diversion-risk review
Why
Select a formulation safely and identify interactions, adherence barriers, misuse or sharing risk.
Interpretation and limitations
Discuss storage, controlled-drug rules and formulation duration without using substance history alone to deny clinically indicated treatment.
Differential diagnosis
01
Bipolar disorder
Distinct episodes of elevated or irritable mood, decreased sleep need and grandiosity contrast with lifelong trait-like ADHD, though both can coexist.
02
Sleep disorder
Insomnia, circadian disruption or sleep apnoea causes inattention and irritability that follow the sleep problem rather than childhood developmental continuity.
03
Anxiety or trauma
Threat monitoring, rumination, avoidance and hyperarousal can impair concentration, with chronology and content distinguishing them from persistent ADHD.
04
Substance or brain disorder
Intoxication, withdrawal, medication, epilepsy, thyroid disease or acquired brain injury may produce adult-onset cognitive and behavioural change.
Management
01ReferralConfirm developmental suspicionFirst stepAdult attention, restlessness or impulsivity suggests persistent childhood-onset ADHD with significant impairment.+
1Document current examples, childhood evidence, affected settings, functional impact, strengths, sleep, substances, mental health and possible neurodevelopmental overlap.
2Refer for assessment by a professional trained in adult ADHD diagnosis rather than diagnosing solely from a screening score or medicine response.
3Address immediate suicide, psychosis, mania, intoxication, driving and safeguarding risks while useful organisational adjustments begin.
02Treatment choiceCombine access and targeted therapySpecialist assessment confirms ADHD and identifies treatment goals.+
1Provide developmentally appropriate information, environmental modifications and support for work, study, sleep, routines and coexisting conditions.
Complications
01
Functional instability
Missed tasks, time errors and impulsive choices can disrupt education, employment, finances, relationships and consistent management of physical health.
02
Accident and driving risk
Distractibility and impulsivity may increase collisions and injury, particularly when symptoms, sleep or substance use are poorly controlled.
03
Mental-health comorbidity
Depression, anxiety, substance problems and suicidal behaviour require direct assessment rather than being explained solely by frustration from ADHD.
04
Medicine-related harm
Cardiovascular effects, appetite or weight change, insomnia, psychiatric activation and diversion can occur without structured titration and review.
Monitoring and follow-up
During titration, record ADHD symptoms, functional targets and adverse effects at each dose change using the adult's account and relevant observer reports with consent.
Measure pulse and blood pressure before and after every dose change and at least every six months. If resting heart rate is sustained above 120 beats/minute, arrhythmia occurs, or systolic blood pressure is above the 95th percentile or rises clinically significantly on two occasions, reduce the dose and refer to an adult physician.
Measure adult weight every six months, review appetite and nutrition, and consider BMI monitoring when treatment-related weight change persists.
Review sleep, anxiety, depression, irritability, psychosis, mania, tics, seizures, sexual effects, substance use, adherence, safe storage and diversion at clinically appropriate intervals.
Complete an annual comprehensive review of benefit, adverse effects, optimisation, work or study needs, coexisting conditions and the person's preference about continuation or a planned trial off; do not order routine ECGs or blood tests, including liver tests, without a clinical indication.
Special situations
Structure can hide impairment
Strong external routines, a highly engaging role or family organisation may compensate until adult independence or competing demands increase.
ECG is selective
NICE does not require a routine pretreatment ECG when cardiovascular history and examination are normal and no interacting medicine creates added risk.
Response does not diagnose
Improved concentration after a stimulant cannot establish childhood onset, cross-setting impairment or exclude sleep, mood and substance explanations.
Formulations are not equivalent
Methylphenidate release profiles, food instructions and licensing differ, so switching requires product-specific calculation and counselling rather than name-only substitution.
Common pitfalls
01
Diagnosing adult ADHD from an online scale or stimulant response without developmental onset, impairment and specialist differential assessment.
02
Mistaking episodic decreased need for sleep, grandiosity or psychosis for ordinary hyperactivity and continuing stimulant treatment through an acute episode.
03
Ordering an ECG for every patient while omitting the required cardiac history, pulse, blood pressure, height and weight.
04
Changing between modified-release methylphenidate brands as though release profile, food effect and dose conversion were identical.
05
Judging success only by a symptom score while work, driving, relationships, sleep or daily self-management remain unchanged.
06
Ignoring storage and diversion planning or using a history of substance use as an automatic reason to withhold all evidence-based care.
Practice
Two practice questions
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Question 1 of 2
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PsychiatryOriginal SBA
Adult medication sequence
An adult with specialist-confirmed ADHD has persistent impairment and no contraindication to medication. Which initial pharmacological choice matches NICE guidance?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Specialist assessment covers the full neurodevelopmental and psychiatric history, mental state, physical health, medicines and substance use. Examine mood episodes, anxiety, trauma, sleep deprivation or apnoea, autism, learning disability, personality difficulties, epilepsy, thyroid disease and acquired brain injury. Rating scales can structure symptoms and observer input but cannot make the diagnosis alone. Formulate strengths, compensatory strategies, severity and functional targets, and ask about driving, employment, finances and parenting without assuming inevitable risk.
Management combines understanding, environmental modification and, when indicated, medication or structured psychological support. Agree written instructions, reminders, task breakdown, reduced distraction, movement breaks, coaching and workplace or education adjustments. For adults who decline medication, cannot tolerate it or retain impairment despite benefit, consider a structured ADHD-focused psychological intervention that may include CBT elements. Address sleep, substance use and coexisting disorders, but do not require every comorbidity to disappear before treating well-formulated ADHD.
NICE recommends lisdexamfetamine or methylphenidate as adult first-choice pharmacological treatment, selected through duration, adverse effects, misuse risk, preference and licensing. Switch between them after an adequate six-week trial if benefit is insufficient; consider off-label dexamfetamine when symptoms respond to lisdexamfetamine but its longer effect profile is not tolerated; and offer atomoxetine when both first-choice medicines are not tolerated or separate adequate trials fail. Obtain a second opinion or tertiary-service input when symptoms remain unresponsive to at least one stimulant and one non-stimulant, and do not use adult guanfacine without tertiary ADHD advice. Titrate against symptoms, function and adverse effects using preparation-specific instructions. Baseline cardiovascular assessment is essential, but an ECG is not routine unless history, examination, coexisting condition or another medicine creates a clinical indication.
Key points
Adult ADHD is a neurodevelopmental disorder: impairing inattention and/or hyperactivity-impulsivity began in childhood, persist, occur in at least two important settings and are not better explained elsewhere.
Refer adults without a childhood diagnosis to a trained ADHD specialist when typical manifestations began during childhood, persisted and cause at least moderate impairment.
Diagnosis requires full clinical, developmental, psychiatric, physical and functional assessment with observer information when useful; rating scales cannot be the sole basis.
Assess sleep, mood, anxiety, autism, learning disability, trauma, substance use, epilepsy, brain injury and environmental demands because overlap and comorbidity are common.
Before medicine, record pulse, blood pressure, height and weight, cardiovascular history, current medicines, mental health and diversion risk; routine ECG is unnecessary without a clinical indication.
NICE offers lisdexamfetamine or methylphenidate as adult first-choice pharmacological options, with atomoxetine after intolerance or inadequate separate trials, alongside environmental modifications and information.
Monitor symptoms and function as well as adverse effects, pulse and blood pressure around dose changes and at least six-monthly, adult weight every six months, and treatment need at least yearly.
Current psychosis, mania, severe depression, suicide risk, uncontrolled substance use or safeguarding crisis changes treatment priority and may require same-day specialist care.
Rapid dose escalation, repeated lost prescriptions, early refill requests, intoxication or third-party demand raises diversion or misuse risk without automatically proving it.
05
Functional baseline measures
Why
Define individual goals and track whether treatment improves ordinary life beyond a symptom score.
Interpretation and limitations
Use examples such as task completion, punctuality, driving events and relationship conflict while considering changing demands and accommodations.
2
AlternativeOffer lisdexamfetamine or methylphenidate when medication is indicated; titrate one preparation carefully and consider the alternative after an adequate trial with insufficient benefit.
3Consider off-label dexamfetamine when symptoms respond to lisdexamfetamine but its longer effect profile is not tolerated; offer atomoxetine when both first-choice medicines are not tolerated or separate adequate six-week trials fail, and consider structured ADHD-focused psychological treatment according to need and preference.
03Titration and reviewMeasure benefit against burdenADHD medicine is starting, changing or continuing long term.+
1Record baseline targets and adverse effects, increase according to the specific product and specialist plan, and obtain input from the adult and relevant observers.
2Check pulse and blood pressure before and after each dose change, monitor weight, sleep, appetite, mental state, tics, seizures and diversion risk.
3Review at least yearly whether treatment remains needed, effective and acceptable, considering planned dose reduction or supervised trial off when appropriate.
Key medicines and prescribing safety3 treatments · regimens, roles and cautions+
NICE offers lisdexamfetamine as one of two initial adult pharmacological options and recommends switching to methylphenidate after an adequate trial with insufficient benefit.
Lisdexamfetamine for adult ADHD
Using the current Elvanse SmPC, start 30 mg orally each morning; a 20 mg start may be used when appropriate. Increase by 10 mg or 20 mg at about weekly intervals to the lowest effective dose; maximum 70 mg once daily, reduced to no more than 50 mg daily in severe renal insufficiency with further reduction considered during dialysis. Do not divide a capsule dose, and avoid afternoon dosing because of insomnia. Stop if symptoms do not improve after appropriate dose adjustment over one month.
Specialist initiation and titration are required. It is contraindicated with an MAOI or within 14 days, hyperthyroidism or thyrotoxicosis, an agitated state, symptomatic cardiovascular disease, advanced arteriosclerosis, moderate-to-severe hypertension, glaucoma or phaeochromocytoma. Monitor appetite, weight, sleep, mood, psychosis or mania, substances and diversion and check the current SmPC for interactions.
Methylphenidate is the other NICE initial adult option; formulation choice considers duration, adherence, food requirements, adverse effects and misuse or diversion risk.
Concerta XL methylphenidate example
For adults new to this prolonged-release preparation, the current SmPC starts 18 mg orally once each morning and permits 18 mg increments at approximately weekly intervals according to response and tolerability, to a maximum 72 mg daily. Modified-release products are not automatically interchangeable; use the chosen product's instructions. Stop if symptoms do not improve after appropriate dose adjustment over one month.
Specialist titration and controlled-drug governance apply. Concerta XL is contraindicated with an irreversible non-selective MAOI or within 14 days, glaucoma, phaeochromocytoma, hyperthyroidism or thyrotoxicosis; diagnosis or history of severe depression, anorexia nervosa or anorexic disorder, suicidal tendency, psychotic symptoms, severe mood disorder, mania, schizophrenia, psychopathic or borderline personality disorder; uncontrolled severe episodic type-I bipolar disorder; serious cardiovascular disease including severe hypertension, heart failure, arterial occlusive disease, angina, haemodynamically significant congenital heart disease, cardiomyopathy, myocardial infarction, potentially life-threatening arrhythmia or channelopathy; or cerebrovascular disease including aneurysm, vascular abnormality, vasculitis or stroke. Monitor pulse, blood pressure, weight, appetite, sleep, psychiatric change and misuse; swallow it whole and verify licensing and conversion before switching.
NICE offers atomoxetine when adults cannot tolerate lisdexamfetamine or methylphenidate, or symptoms have not responded to separate adequate six-week trials of both.
Atomoxetine for adult ADHD
Using the cited adult SmPC, start 40 mg orally daily and maintain for at least 7 days before titration; usual maintenance is 80 mg to 100 mg daily and maximum 100 mg daily. It may be taken once in the morning or divided if tolerability or efficacy supports this. Reduce initial and target doses to 50% in Child–Pugh B hepatic impairment and 25% in Child–Pugh C.
It is contraindicated with an MAOI or within two weeks, narrow-angle glaucoma, phaeochromocytoma or its history, and severe cardiovascular or cerebrovascular disease. Monitor blood pressure, pulse, suicidal thinking, aggression, urinary or sexual effects and CYP2D6 interactions. Discontinue and do not restart after jaundice or laboratory evidence of liver injury, and review continued need beyond one year.