Optimizing fitness for duty and post-combat clinical services for military personnel and combat veterans with ADHD—a systematic review of the current literature

Figures & data

Fig. 1 Model for the effects of trauma on cortical–subcortical functions and possible relapse of ADHD in adults with PTSD.

Abbreviations: C=cortical; SC=subcortical.

The figure shows hyperactive SC brain regions in childhood (i.e., ADHD onset) with subsequent compensation of C brain regions during adolescence that may be associated with remission of ADHD symptoms. In the event of military-/combat-related trauma and possible PTSD in adulthood, the compensatory effects of C brain regions might be reversed/compromised and ADHD symptoms may relapse.

Table 1 Criteria for enlisting in the military (as per Memorandum, Policy Guidance for Deployment-Limiting Psychiatric Conditions and Medications. Washington, DC, US Department of Defense, Assistant Secretary of Defense for Health Affairs, Nov 7, 2006)

Applicants with history of ADHD may not enlist unless the following criteria are met:

Item #	Criteria
1	The applicant has not required an Individualized Education Program or work accommodations since the age of 14
2	There is no history of comorbid mental disorders
3	The applicant has never taken more than a single daily dosage of medication or has not been prescribed medication for this condition for more than 24 cumulative months after the age of 14
4	During periods off of medication after the age of 14, the applicant has been able to maintain at least a 2.0 grade point average without accommodations
5	Documentation from the applicant's prescribing provider that continued medication is not required for acceptable occupational or work performance
6	Applicant is required to enter service

Table 2 Algorithm for the clinical evaluation for adult ADHD

Item #	Procedure
1	Establish the presence and severity of current ADHD symptoms
2	Establish age appropriate presentations—adults may report problems with time management, procrastination, planning, and completing tasks, and less overt hyperactivity
3	Establish the presence of these symptoms in multiple settings (e.g., work, school, family)
4	Establish the presence of negative impact of such symptoms on daily functioning (i.e., job performance is unsatisfactory, failing classes at school, bills unpaid, mismanagement of finances)
5	Inquire about prior treatments for similar problems (school/work accommodations, special mentorship, pharmacological treatments)
6	Establish the chronology of symptoms onset—childhood vs. adulthood
7	Establish triggers of adult symptom onset (i.e., symptoms started/ exacerbated after focal trauma)
8	Consider using self-report questionnaires (e.g., CAARS/ASRS for ADHD vs. CAPS/PCL for PTSD)
9	Establish possible comorbidities that may explain current symptoms (i.e., PTSD, mild TBI)
10	Inquire/establish past/current substance use problems
11	Consider consultations—neuropsychological testing to rule out learning disabilities, neurology for possible mild TBI