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Commentary

A new paradigm for adult ADHD: A focused strategy to monitor treatment

Michael J. Manos, PhD and Elizabeth J. Short, PhD
Cleveland Clinic Journal of Medicine July 2023, 90 (7) 413-421; DOI: https://doi.org/10.3949/ccjm.90a.22080
Michael J. Manos
Clinical Director, ADHD Center for Evaluation and Treatment (ACET), Cleveland Clinic, Cleveland, OH; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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  • For correspondence: [email protected]
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Elizabeth J. Short
Professor of Psychology, Director of the Developmental Masters and Early Intervention Program, Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH
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    TABLE 1

    Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for attention deficit hyperactivity disorder in adults4,5

    Symptom criteria (minimum 5/9) for inattention
    • Makes careless mistakes when working on boring or difficult tasks

    • Difficulty sustaining attention while working on boring or repetitive tasks

    • Difficulty concentrating on what people say even when spoken to directly

    • Difficulty wrapping-up final details; fails to complete tasks

    • Difficulty with organization and getting tasks in order

    • Avoids or delays tasks requiring sustained mental effort

    • Loses or misplaces personal possessions; difficulty finding things

    • Easily distracted by surrounding activity or noise

    • Forgetful; difficulty remembering appointments or obligations

    Symptom criteria (minimum 5/9) for hyperactivity/impulsivity
    • Fidgets or squirms with hands or feet

    • Leaves the seat in meetings or situations where sitting is expected

    • Feels restless or needs to be chronically active

    • Difficulty unwinding, relaxing, or engaging in leisure activities quietly

    • Feels compelled to stay active ("on the go" or "driven by a motor")

    • Talks excessively in social situations

    • Blurts out or finishes sentences of others who are talking

    • Difficulty awaiting turn; has to have demands met immediately

    • Interrupts or intrudes on others when they are busy

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    TABLE 2

    Stimulants to treat attention deficit hyperactivity disorder

    Immediate-releaseaExtended-releasea
    Methylphenidate
    Methylphenidate HCl chewable, 3–4 hrs
    Methylin liquid, 3–4 hrs
    Ritalin, 3–4 hrs
    Adhansia XR, > 12 hrs (discontinued)
    Aptensio XR, 12 hrs
    Concerta, 12 hrs
    Cotempla XRODT, 12–13 hrsb
    Daytrana (patch), 9 hrs wear-time
    Jornay PM (night before), 12–14 hrs
    Metadate CD, 8–10 hrs
    Methylphenidate HCl, 6–8 hrs
    Quillichew ER, 8 hrs
    Quillivant XR (suspension), 12 hrs
    Ritalin LA, 8–12 hrs
    Ritalin SR, 8 hrs
    Serdexmethylphenidate and dexmethylphenidate
    Azstarys, 13 hrs
    Dexmethylphenidate
    Focalin, 4–6 hrsFocalin XR, 8–12 hrs
    Amphetamine
    Adzenys ER, 10–12 hrs
    Adzenys XR-ODT, 10–12 hrs
    Dyanavel XR (suspension), 13 hrs
    Dextroamphetamine
    Dexedrine, 3–4 hrs
    Procentra (suspension), 3–6 hrs
    Zenzedi, 4–6 hrs
    Dexedrine ER, 5–10 hrs
    Xelstrym (patch), 9 hrs
    Methamphetamine
    Dexosyn, 4–6 hrs
    Mixed amphetamine salts
    Adderall, 4–6 hrsAdderall XR, 10–12 hrs
    Mydayis, 14–16 hrs
    Amphetamine sulfate
    Evekeo, 4–6 hrs
    Lisdexamfetamine
    Vyvanse, 10–13 hrs
    Vyvanse (chewable), 10–13 hrs
    • ↵a Numbers following drug name represent approximate upper limit of duration of action in hours.

    • ↵b Extended-release orally disintegrating tablet.

    • CD = controlled delivery; ER = extended release; HCl =hydrochloride; LA = long-acting; ODT = orally disintegrating; SR = sustained release; XR = extended release

    • Adapted from references 10 and 12

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    TABLE 3

    Questions to support patients with attention deficit hyperactivity disorder regarding agreements and task completions

    Physician/patient queryAgreement with home/office/family/friends/self
    What did you say you would do in the past week that you did do? (label frequency of occurrence)Agreements made and kept; monitor frequency
    Whom did you say that to? (eg, spouse, family member, colleague)Agreements made and kept
    What is your experience of actually doing what you said you would do? (especially the effect on relationships, eg, spouse, family member, colleague)Agreements made and kept
    What did you say you would do in the past week that you did not do? (label frequency of occurrence)Broken agreement; monitor frequency
    Whom did you say that to?Broken agreements with whom—spouse, family member, colleague
    What is your experience of actually not doing what you said you would do? (especially the effect on relationships, eg, spouse, family member, colleague)Empowering/disempowering
    How might you clean up the things you said you would do that you didn’t do?
    • • Complete the thing you said you would do

    • • Change the thing you said you would do (eg, make a new agreement)

    • • Cancel the thing you said you would do

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    TABLE 4

    Resources for patients with attention deficit hyperactivity disorder (ADHD)

    ADHD Coaches Organization (ACO): https://www.adhdcoaches.org/
    Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD): https://chadd.org/
    The American Professional Society of ADHD and Related Disorder (APSARD): https://apsard.org/
    ADHD World Federation: From Child to Adult Disorder: https://www.adhd-federation.org/
    ADHD Success Network Coaching: https://www.adhd-coach-asn.com/
    ADDITUDE ADHD Experts Podcast: https://www.additudemag.com/adhd-expert-webinars-index/
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Cleveland Clinic Journal of Medicine: 90 (7)
Cleveland Clinic Journal of Medicine
Vol. 90, Issue 7
1 Jul 2023
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A new paradigm for adult ADHD: A focused strategy to monitor treatment
Michael J. Manos, Elizabeth J. Short
Cleveland Clinic Journal of Medicine Jul 2023, 90 (7) 413-421; DOI: 10.3949/ccjm.90a.22080

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A new paradigm for adult ADHD: A focused strategy to monitor treatment
Michael J. Manos, Elizabeth J. Short
Cleveland Clinic Journal of Medicine Jul 2023, 90 (7) 413-421; DOI: 10.3949/ccjm.90a.22080
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  • Article
    • DIAGNOSING ADHD
    • UNIQUE CONSIDERATIONS IN DIAGNOSING AND TREATING ADHD IN ADULTS
    • CHANGE IN EXPRESSION OF ADHD FROM CHILDHOOD TO ADULTHOOD
    • THE CORE DYSFUNCTION IN ADULT ADHD
    • RECOMMENDATIONS TO MANAGE ADHD IN ADULTHOOD
    • AGREEMENT-KEEPING MAY RELY ON ENVIRONMENTAL SUPPORT TO ENSURE COMPLETION
    • UNDERSTANDING TASK COMPLETION AND THE NECESSITY OF CLEANUP STRATEGIES
    • IMPEDIMENTS TO SOCIAL SCAFFOLDING
    • GUIDANCE FOR THE PHYSICIAN
    • DISCLOSURES
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