Adult diagnostic framework #
An adult DSM-based assessment requires at least five symptoms in an applicable symptom domain, persistence for at least 6 months, evidence of symptoms before age 12, and impairment across at least two settings. Establish that another disorder does not better account for the difficulties. A retrospective positive checklist alone is insufficient.
History and baseline function #
Reconstruct schooling, organization, relationships and work performance, using available reports and collateral with consent. Ask how symptoms were compensated for and when demands exceeded those strategies. Document concrete treatment goals such as completing essential tasks or reducing recurrent errors; assess sleep, substance use and mood history.
Persistent symptoms versus new change #
| Alternative or comorbidity | Assessment discriminator |
|---|---|
| Mood/anxiety disorder | Determine whether attention problems track an episode or predate it. |
| Sleep disruption | Clarify timing, sleep opportunity and daytime sleepiness. |
| Learning difficulty | Identify specific academic deficits alongside broader organization problems. |
| Substance or medicine effects | Reconstruct exposure and symptom timing. |
| Autism or other developmental differences | Assess developmental social, sensory and functional needs separately. |
Before starting medication #
Record weight, pulse, blood pressure, cardiovascular history and concurrent medicines. Seek cardiac assessment where history or examination suggests disease. NICE does not require routine ECGs or blood tests without a clinical indication; investigate specific symptoms rather than ordering an automatic laboratory panel.
Treatment sequence #
Combine environmental adjustments with ADHD-focused support. NICE positions methylphenidate or lisdexamfetamine as first-line adult medicines and atomoxetine after intolerance or inadequate response to appropriate stimulant trials. Availability and controlled-drug requirements must be checked locally.
Psychological work should teach organization, task breakdown and strategies for impulsive responses; residual functional difficulty warrants intervention even when symptom ratings improve.
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Methylphenidate
Adult ADHD; new to methylphenidate
Adults up to 65 years under the cited US label · CONCERTA extended-release tablet; not interchangeable instructions for all methylphenidate products · Oral · US FDA CONCERTA label, 2026; no Indian product equivalence assumed
- Starting dose
- 18 mg or 36 mg once each morning.
- Titration
- Increase by 18 mg at weekly intervals according to response and tolerability.
- Treatment range / target
- 18–72 mg once daily.
- Maximum / limits
- 72 mg/day under this adult product label.
- Trial & duration
- Periodically reassess continuing benefit; dose optimization is guided by symptoms and functioning.
- Monitoring
- Blood pressure, pulse, weight/appetite, sleep, psychiatric effects and misuse/diversion.
- Population & organ-function adjustments
- Existing immediate-release treatment requires the product conversion table; do not substitute mg-for-mg automatically.
- Important cautions
- Swallow whole. Avoid in serious cardiac disease; contraindicated with MAO inhibitors or within 14 days of stopping them.
Atomoxetine
Adult ADHD
Adults · Capsule · Oral · US STRATTERA label, June 2026
- Starting dose
- 40 mg/day.
- Titration
- Increase to 80 mg/day after at least 3 days; consider 100 mg/day after another 2–4 weeks if response remains suboptimal.
- Treatment range / target
- Target 80 mg/day; maximum 100 mg/day, once daily or evenly divided morning/late afternoon.
- Maximum / limits
- 100 mg/day.
- Trial & duration
- Reassess long-term usefulness. Label permits discontinuation without tapering.
- Monitoring
- Pulse/BP, activation, urinary symptoms and possible hepatic injury.
- Population & organ-function adjustments
- Strong CYP2D6 inhibitor or poor metabolizer: wait 4 weeks before increasing. Child-Pugh B: use 50% of usual initial/target doses; C: 25%.
- Important cautions
- Screen for bipolar disorder. Contraindicated with MAOIs, narrow-angle glaucoma, pheochromocytoma and severe cardiovascular disorders. Swallow capsules whole.
Before switching or increasing #
Check adherence, duration of daily coverage, release formulation, adverse effects and the original diagnosis. Distinguish inadequate coverage from persistent impairment that needs skills-based treatment. Do not exceed a product ceiling to compensate for an unaddressed comorbidity.
Continuing treatment #
Review medication at least annually, including benefit, adverse effects and the impact of missed doses or planned reductions. Continuing treatment needs a documented functional rationale rather than automatic repeat prescribing.
Comorbidity and dose adaptation #
Use slower titration and more frequent review with neurodevelopmental, psychiatric or significant physical comorbidity. Atomoxetine exposure rises with strong CYP2D6 inhibition and hepatic impairment; apply the label-specific changes below rather than using the ordinary titration schedule.
Monitoring schedule #
Check pulse and blood pressure before/after dose changes and every 6 months; measure adult weight every 6 months. Track sleep, appetite, target symptoms and functioning. Review misuse/diversion concerns and newly emerging psychiatric symptoms.
Prescribing pitfalls #
CONCERTA tablets must be swallowed whole; crushing changes delivery. An immediate-release methylphenidate total is not a self-evident extended-release conversion. Assess cardiac disease and misuse risk before stimulant treatment, and investigate new manic or psychotic symptoms rather than simply increasing the stimulant.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
Assessment looks at a long-term pattern, not a single difficult week or test result, and identifies practical supports as well as treatment options.
References · 5
- NICE NG87: ADHD recommendations · United Kingdom · Checked 2026-10-26 · Supports: Before starting medication; Treatment sequence; Continuing treatment; Comorbidity and dose adaptation; Monitoring schedule
- NIMH: ADHD diagnostic framework · United States · Checked 2026-10-26 · Supports: Adult diagnostic framework; Persistent symptoms versus new change
- NIMH: ADHD in adults · United States · Checked 2026-10-26 · Supports: History and baseline function; Persistent symptoms versus new change; Treatment sequence; Before switching or increasing
- FDA: CONCERTA prescribing information, 2026 · United States label · Checked 2026-10-26 · Supports: Before switching or increasing; Prescribing pitfalls; Methylphenidate — Adult ADHD; new to methylphenidate (CONCERTA extended-release tablet; not interchangeable instructions for all methylphenidate products)
- DailyMed: STRATTERA prescribing information, June 2026 · United States label · Checked 2026-10-26 · Supports: Comorbidity and dose adaptation; Atomoxetine — Adult ADHD (Capsule)