Why Adolescents With ADHD Need Better Transitions to Adult Care

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental condition that does not end in childhood. Symptoms often persist into adulthood and, while they may become less overt, can remain significantly impairing.

This evolution in symptoms, along with the possibility of a missed diagnosis in childhood, can make early adulthood especially challenging. Estimates suggest that about 15% of individuals diagnosed in childhood continue to meet full diagnostic criteria in their mid-20s. Many others are not diagnosed until adulthood.

Jasdeep Sohi, MD, a child and adolescent psychiatrist at Cleveland Clinic, is drawing attention to the particular vulnerability of early adulthood for patients with ADHD.

“There is a misconception that ADHD is a childhood disorder that kids will simply outgrow,” says Dr. Sohi. “ADHD doesn’t just disappear at 18. There is a huge need for providers to understand, recognize and respond to an adult ADHD age group.”

Transitioning to young adulthood often means becoming untethered from support systems of childhood, like an individualized education program (IEP), established medication routines, or even a consistent pediatric healthcare provider. Young adults with ADHD may not have developed the coping skills needed to manage new demands, Dr. Sohi explains.

“They might appear more depressed and anxious, even lazy and not adhering to the recommendations. Meanwhile, their providers may have missed the core symptoms of what is leading up to this,” she says.

How ADHD symptoms change over time

In childhood, ADHD may present with hyperactivity, inattention, impulsivity and difficulty with emotional regulation. In adulthood, symptoms are often less obvious but no less disruptive, and may include impulsivity, impatience, oversharing, risk-taking and emotional reactivity.

Many adults with ADHD compensate for inattention by working harder and longer, yet still struggle with chronic lateness, disorganization or difficulty completing tasks. Keeping up with societal expectations and responsibilities can contribute to anxiety, depression, lack of sleep and burnout. 

Considerations for a highly treatable disorder

Medications can be highly effective, according to Dr. Sohi. Approximately 75% of patients will respond favorably to a first-line stimulant in the methylphenidate or amphetamine class. If one stimulant is ineffective despite dose optimization and adherence, she recommends trying the other class.

Treatment decisions should take into account potential side effects, substance use history, cardiovascular risk and other coexisting conditions.

Nonstimulant therapies such as atomoxetine may be appropriate for select patients, particularly those with anxiety, tics or misuse concerns. Guanfacine and clonidine are additional options, especially for patients with impulsivity, hyperactivity or sleep problems. Bupropion may be considered as an adjunctive therapy or off-label option, particularly when depression is present.

Overall, she emphasizes that multimodal care involving medication, therapy, psychoeducation, accommodations, and sleep and routine support is the most effective approach for managing ADHD.

Helping patients navigate ADHD care in early adulthood

Despite the advances in treatment, the transition to adult ADHD care remains a major challenge. A national shortage of specialists who treat adult ADHD, rising demand for evaluation and treatment, and concerns about prescribing controlled substances have all complicated access to care. Executive dysfunction may further interfere with scheduling, follow-up and medication adherence.

Dr. Sohi makes the following recommendations to providers to help their patients maintain consistency:

• Start transition planning early.
• Involve families when appropriate.
• Identify adult providers before pediatric care ends.
• Connect students with campus resources.
• Help prevent interruptions in medication access.

The takeaway message

Dr. Sohi says the priority in transitioning from pediatric to adult care is ensuring that patients have ongoing support, a reliable pathway for medication access, and resources to help with executive functioning.

“We know ADHD is highly treatable, so early identification and intervention are key,” she says. “When facilitating these transitions, we must identify adult providers who understand that ADHD does not have an expiration date.”