COMMENTARY CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 90 • NUMBER 7 JULY 2023 413 doi:10.3949/ccjm.90a.22080 A new paradigm for adult ADHD: A focused strategy to monitor treatment M edical professionals face a significant chal- lenge when treating adults with attention defi- cit hyperactivity disorder (ADHD). Although adult ADHD bears similarities to its childhood expression, the distinct features are associated with ADHD across the life span, with particular attention focused on the ADHD symptom-generated task incompletion as the single, primary dysfunction in adults with ADHD. Shifting the paradigm of treatment from reducing symptoms to one of effectively increasing task comple- tions allows for the physician and patient to quickly determine treatment effectiveness that accrues from pharmacotherapy. Rather than review changes in their patients’ symptoms checked off on an ADHD behavior scale, the physician can review the patient’s report on the status of incompletions (no change, increase, or decrease) and thereby play a prominent role in management of adult ADHD. This shift in the paradigm of treatment effectiveness allows the physi- cian to reinterpret task incompletions, encourage the patient to form collaborative partnerships to enlist assistance of others to improve work completion (an effective strategy called “social scaffolding”), and objectify and name problematic effortful attention to tasks. Further, this transforms the ADHD problem from a perspective of mental health disorder existing inside the skin to a single, functional condition occurring outside the skin, ie, in the world of manageable action and behavior. Adopting this new paradigm in the context of medical management allows a necessary step in effective treatment plans for adults diagnosed with ADHD. We suggest herein that the medical model paradigm of reducing multiple dysfunctional symptoms be changed to the evaluation of the single behavior of task completions to address this shift in thinking. ■ DIAGNOSING ADHD The estimated prevalence of current adult ADHD in the United States is 1% to 6%, 1 lower than the 11% childhood prevalence identified by the US Centers for Disease Control and Prevention. 2 ADHD dysfunction changes over time, 3 with numerous factors impacting the age of diagnosis, including intelligence, symptom severity, environmental support, and changes in task demands. Because of increased awareness of ADHD in the adult population, physicians are likely to see more adults seeking treatment. ADHD diagnosis requires the presence of dysfunc- tional symptoms of inattention, hyperactive/impul- sive behavior, or both, as noted in Table 1, 4,5 with clinicians examining the presence of reported symp- toms in context. A person’s highly reactive, impulsive behavior may be effective on the college football field but dysfunctional in a classroom lecture. Thus, ADHD behavior must meet the following criteria: • Problematic in 2 or more settings • Interfere with daily life functioning • Not be due to another mental health disorder • Be present (but not necessarily impairing) in childhood prior to age 12. 5 The clinician must confirm the presence and intrusiveness of at least 5 behaviors for inattention, hyperactivity/impulsivity, or both, as outlined in Table 1. 4,5 It is not enough that the patient engages in the behaviors associated with ADHD sometimes, as everyone exhibits them from time to time. It is criti- cal to determine that the behaviors present a problem in daily functioning. As noted above, adult ADHD Michael J. Manos, PhD 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 Elizabeth J. Short, PhD Professor of Psychology, Director of the Developmental Masters and Early Intervention Program, Department of Psychological Sciences, Case Western Reserve University, Cleveland, OH on May 8, 2024. For personal use only. All other uses require permission. www.ccjm.org Downloaded from