As a family physician who specializes in ADHD, I see patients who are not just frustrated by their interactions with providers but devastated by the way they have been treated. They have significant impairments that provider after provider has minimized, and they have a very hard time getting help.

I have been treating ADHD for more than 15 years and what my new patients tell me about the struggles they’ve endured while seeking care is disheartening and depressing. Many of us providers haven’t been taught about ADHD in adults and are afraid to diagnose or treat it. To help you, the provider, be part of the solution, instead of part of the problem, I offer the following points to help you understand ADHD and really see the patient in front of you.

The Person in Front of You

• The person in your office is scared to death that you are going to judge them or invalidate their experiences. They have probably spent weeks or months debating whether they should say anything about their impairments.
• This person likely has been let down by the medical system that minimizes their impairments and even scoffs at their pain. As they’ve learned to expect such treatment, they may feel they have to go overboard to convince you that they really are impaired.
• At the same time, the person in front of you likely feels ashamed that they can’t “adult” — that they can’t handle the mundane details of human existence that we all have to deal with, so they may minimize their impairments. Patients, in sum, will either overstate or minimize their impairments. Both sides are normal.

[Read: Is Adult ADHD Real? Yes — and Still Heavily Stigmatized]

You, the Provider

• Please check your filters at the door and listen to your patient with curiosity and an open mind. It may help to think, “What if everything they’re saying is true?” Remember that your patient showed up because they are sure that something is wrong with them. They feel awful, tired, and overwhelmed no matter what they do. Attend to your patient’s concerns thoroughly.
• Pause if you catch yourself thinking, “That’s normal. I do that.” We all know what it is to experience forgetfulness, moments of impulsivity, and other behaviors that look like ADHD. What signals ADHD is the degree to which a patient’s symptoms cause impairment and suffering.
• Treating ADHD is incredibly rewarding. Most of us went into medicine to help people and make a positive difference in someone’s life. Helping a patient manage their condition results in truly life-changing outcomes.

On Diagnosing ADHD

• There is no one perfect way to diagnose ADHD. Most people are diagnosed with the use of rating scales like the ASRS, Barkley, or Conners, which are often sufficient to screen for ADHD alone.
• Even if you aren’t a specialist, you can diagnose ADHD.
• Neuropsychological tests are not a good way to diagnose ADHD. The psychologists who do those tests feel even less comfortable diagnosing ADHD than you do.
• ADHD is more underdiagnosed than it is overdiagnosed.

[Get This Free Download: The Clinicians’ Guide to Differential Diagnosis of ADHD]

On Treating ADHD

• Stimulants really are the best first-line treatment for ADHD.
• The Schedule II controlled substance classification for stimulants makes them sound more addictive than they actually are. After all, consider the fact that many patients who take prescribed stimulant medication for ADHD frequently miss doses and, in my experience, days of medication. How often do you think your patients who take opiates or benzodiazepines forget to take their medication? Not very often because they get physical withdrawal symptoms if they miss a dose.
• There is no way to know ahead of time what stimulant and dosage will work best for a patient. Trust what the patient says about how their medication is working. My experience shows that, if left to make the decision on their own, most patients will choose too low of a dose.
• Stimulants need to work for as long as possible during the day, not just for a few hours. A patient shouldn’t have to pick and choose the hours during which their medication should work in order for them to function and meet life’s demands. Would you want that for yourself? Would you present your most focused, productive self only to your morning patients? What about your afternoon patients and your family? Is it fair that they see your most irritable, unfocused self? These are the kinds of decisions patients have to make if their stimulant doesn’t last all day long.
• Most patients are not drug seeking. They are desperately trying to find a way to function like adults and gain control over their lives. What they seek most is your understanding and support.

Listening to Patients with ADHD: Next Steps

• Get This Free Download: The Clinicians’ Guide to Treating Complex ADHD
• Read: A Clinicians’ Guide to Better Patient Communication
• Read: Racial Disparities in ADHD Care — How Clinicians Can Better Serve Patients

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Stimulant medication may normalize certain brain regions impacted by ADHD in children, according to a cross-sectional neuroimaging study of 7,126 children aged 9 to 10 recently published in Neuropsychopharmacology.¹

Study participants were divided into three groups. The “no-med ADHD” group included 1,002 children with severe ADHD symptoms who were not taking stimulant medication. The “stim low-ADHD” group included 273 children whose ADHD symptoms were mild and well-managed with stimulant medication. The “TDC” group included 5,378 typically developing controls.

ADHD symptoms experienced by the no-med ADHD group were associated with brain structure abnormalities not seen in the TDC or stim low-ADHD group, including:

• lower cortical thickness in the insula (INS), a brain area associated with saliency detection or the ability to prioritize information
• less grey matter volume in the nuclear accumbens (NAc), a brain area associated with reward processing and motivation

Children in the stim low-ADHD group showed no significant differences in these brain areas compared to controls. This contrast in structural MRIs suggests that stimulant medication may work to normalize some (but not all) brain regions and improve symptoms in children with ADHD.

Stimulant medication was not associated with improvement in all brain regions. Among those not impacted were the following:

• the caudate (CAU), a brain area responsible for motor control
• the amygdala (AMY), a brain area responsible for emotions

“This result is consistent with previous studies,” the researchers wrote. “Reduced volume in children with ADHD in the CAU is one of the most replicated findings in sMRI studies. No effect of stimulant medications was found in the CAU in the participants with ADHD in several cross-sectional studies. Along the same lines, longitudinal studies on children pointed to the improvement of volumes in the CAU associated with age but not stimulant medications… and two previous studies also pointed out there was no effect of stimulant medications on the AMY.”

Non-stimulant medication did not significantly impact brain structure.

A separate validation analysis included 273 participants with high ADHD symptoms who were taking stimulant medication; the results were consistent with the main study and still suggested that stimulant medication had a positive and noticeable effect on the brain structure of children in this group compared to the no-med ADHD group, even though both groups had high symptom severity at the time of the study.

“These findings are important for the treatment of children with ADHD using stimulant medication,” the researchers wrote.

Stimulant Medication & the ADHD Brain

Stimulants are the first-line treatment for ADHD in children aged 6 and older, teens, and adults. However, some people with ADHD discontinue medication due to side effects. The most common side effects reported by caregivers in ADDitude’s 2023 treatment survey were appetite suppression, irritability or moodiness, and sleep problems.

“Our current medication treatments for ADHD work quite well, but unfortunately, many children stop the treatment or stop taking medication,” said Jonathan Posner, M.D., in his 2020 ADDitude webinar, “Secrets of the ADHD Brain: How Brain Imaging Helps Us Understand and Treat Attention Deficit.” “In fact, the majority of teenagers with ADHD will stop treatment within two years.”

Understanding the parts of the brain that are impacted by stimulant medication can help refine treatment and determine “which of those changes are responsible for symptom improvement versus side effects,” Posner said.

“One of the things that brain imaging has shown is that the development of the brain in children with ADHD seems to be somewhat delayed,” Posner said. “But the overall course of development in children with ADHD versus without ADHD is very similar. It’s almost as if the ADHD brain is a couple of years behind. The very optimistic part of this is that it ultimately does catch up for most children with ADHD.”

For the majority of patients, ADHD symptoms do continue into adulthood, and the prevalence of ADHD in adults is rising. ^{2, 3} However, the present study confirmed Posner’s observations and found that children with even severe ADHD caught up developmentally for the region of the brain responsible for prioritizing information.

MRI scans showed greater cortical thickness in the INS region for the stim-low ADHD group and TDC group compared to the no-med ADHD group. However, data from a two-year follow-up analysis showed these differences were no longer present. Development of the INS is complicated, the researchers noted, but they suggested that “the No-Med group has delayed INS development at baseline, which eventually catches up to the other children.” Researchers theorize that stimulant medication may speed up this process and will continue to follow up with children over the next few years.

Limitations & Future Research

Participant data was obtained from the Adolescent Brain Cognitive Development (ABCD) study, an ongoing study since 2019 that will follow children over 10 years. Data was obtained via structural MRIs and symptom questionnaires and analyzed using linear mixed-effects models (LMM). The study included measures of cortical thickness, cortical area, cortical and subcortical volumes, and total intracranial volume.

The ABCD study lacked diagnostic information for ADHD; therefore, researchers grouped participants using latent class analysis (LCA) and 18 ADHD symptoms from the K-SADS — a moderately reliable test of affective disorders and schizophrenia. Children with bipolar disorders and anxiety disorders, oppositional defiant disorder, obsessive-compulsive disorders, and conduct disorders were excluded from the study.

Results indicate that stimulant medication may enhance brain structure and alleviate ADHD symptoms; however, this study was cross-sectional and did not establish clear causation. Information on the mean dose and duration of participants’ stimulant medication use was missing from the study. Additionally, researchers warned that the study did not fully capture the association between brain structure and ADHD severity. The stim-low ADHD group was much smaller than the other two groups, which may have hindered the study’s results. The two-year follow-up (in line with ABCD study release 4.0) included fewer participants (3,992 after exclusion criteria). Results should be interpreted with caution.

Future research should further incorporate supplemental data on stimulant use, study stimulant use by patients with severe ADHD, and include more longitudinal data.

Sources

¹Wu, F., Zhang, W., Ji, W. et al. (2024). Stimulant medications in children with ADHD normalize the structure of brain regions associated with attention and reward. Neuropsychopharmacol, 49, 1330–1340. https://doi.org/10.1038/s41386-024-01831-4

²U.S. Centers for Disease Control and Prevention. (2024, October 4). ADHD in adults: an overview.
https://www.cdc.gov/adhd/articles/adhd-across-the-lifetime.html

³American Psychiatric Association. (2019, November 15). ADHD increasing among adults.
https://www.psychiatry.org/news-room/apa-blogs/adhd-increasing-among-adults

The diagnostic criteria for ADHD are largely based on studies of young white boys — and do not reflect the lived experiences of many adults with the condition. This gap between clinical guidance and real-life symptoms has contributed to a decades-long problem with misdiagnosis, missed diagnoses, and inadequate treatment for individuals who slipped under the ADHD radar in childhood.

ADHD persists into adulthood for up to 90% of children with the condition, however, only 33% of pediatricians, 30% of family practitioners, 25% of nurse practitioners, and 22% of internists said that they received adequate training on ADHD in medical school, according to data presented by the American Professional Society of ADHD and Related Disorders (APSARD) at its 2024 conference. APSARD is now working to remedy this obstacle to care with the first-ever guidelines for the diagnosis and treatment of ADHD in adults. In 2023, it established a 27-member task force that is devising clinical practice guidelines for the diagnosis and treatment of ADHD in adults. According to David Goodman, M.D., who is leading the medical subcommittee for the task force, the adult ADHD guidelines have the greatest chance at widespread adoption if they are research-based, clinically informed, and patient-focused. APSARD hopes to publish the guidelines in 2025.

Continue reading “The State of Adult ADHD Today” to learn more.

2. ADHD Medication Use Lowers the Risk of Death, Hospitalization

Treating ADHD with medication can lower the overall risk of mortality by 19% and overdose by 50%. It also reduces hospitalizations, both psychiatric and non-psychiatric, according to two large-scale Swedish studies.^{1, 2} These findings highlight the importance of ADHD medication use for long-term health and longevity, underscoring the urgent need to end the stimulant shortage that has prevented U.S. patients with ADHD from consistently accessing medication since the Fall of 2022.

Continue reading “ADHD Medication Use Lowers the Risk of Death, Hospitalization” to learn more.

3. Massive Study Ties Leaded Gasoline Exposure to 150 Million Mental Health Diagnoses in U.S.

Leaded gasoline and exposure to its exhaust may help explain an estimated 151 million U.S. cases of psychiatric disorders, including ADHD, depression, and anxiety, according to a new cross-sectional study spanning the last 75 years.

Exposure to leaded gasoline from car exhaust was tied to population-wide cases of mental health disorders from 1940 to 2015 in the study, published in December in the Journal of Child Psychology and Psychiatry.³ It estimated that more than half of the current U.S. population was exposed to harmful levels of lead in childhood, resulting in profound effects on their mental health, personality traits, and overall well-being. People born between 1966 and 1986 (referred to as Generation X) experienced the highest rate of lead exposure and are at the greatest risk for anxiety, depression, ADHD, and personality changes.

Continue reading “Massive Study Ties Leaded Gasoline Exposure to 150 Million Mental Health, ADHD Diagnoses in U.S.” to learn more.

4. High and Low Estrogen Exacerbate ADHD Symptoms in Females

The impact of rising and falling hormone levels on ADHD symptoms is compounded for females beginning in puberty, according to the multiple hormone sensitivity theory explained in a review article published in January in Hormones and Behavior.⁴ The theory offers valuable insight into how hormones — namely, high and low estrogen levels — may influence ADHD symptoms in females across the lifespan, including during the menstrual cycle, puberty, pregnancy, and menopause.

Per the theory, females may be more likely to engage in risk-taking and reward-seeking behaviors in the days leading up to ovulation. These behaviors coincide with a steady rise in estrogen levels that drops off during ovulation. In contrast, withdrawal and/or depletion of estrogen at a cycle’s end may be characterized by increased negative affect, avoidant behaviors, and reduced executive functioning.

Continue reading “High and Low Estrogen Exacerbate ADHD Symptoms in Females: New Theory.” to learn more.

5. ADHD Medication Costs Soar

ADHD medication costs have nearly doubled or tripled for doses of Ritalin, Concerta, and Focalin since the Adderall shortage began in October 2022, according to a report published in USA Today in late 2023. The newspaper analyzed the prices that retail community pharmacies pay for common ADHD prescriptions. For specific dosages of methylphenidate (i.e., Ritalin and Concerta), the average price paid by small to mid-sized independent and chain pharmacies nearly doubled from late 2022 to December 2023. The average cost of certain versions of dexmethylphenidate (Focalin) more than doubled during that period.

Continue reading “ADHD Medication Costs Soar: Price Report” to learn more.

6. ADHD Traits May Have Provided an Evolutionary Advantage

ADHD traits such as distractibility and impulsivity may have benefited our ancestors as they foraged for food, and they continue to play a crucial role in how people with ADHD adapt and survive, suggests research published in February in the journal Proceedings of the Royal Society B Biological Sciences.⁵

“We speculate that ADHD serves as an adaptive specialization for foraging, thus explaining its widespread prevalence and continued persistence in the human population,” the researchers said. “This tendency to explore while foraging might extend to other behaviors such as cycling more frequently between information sources in the classroom or sources of stimulation in the home environment.”

Continue reading “ADHD Traits May Have Provided an Evolutionary Advantage” to learn more.

7.

In June, the Justice Department charged two top officers at the telehealth company Done Global with allegedly distributing Adderall and other stimulants for ADHD to patients who officials said did not merit a proper diagnosis. While health officials warned that the “disruption” to Done could affect as many as 50,000 adult patients⁶, many of whom were already impacted by the ongoing ADHD medication shortage, this criminal action highlights another important issue: the limited access to clinical care for people with ADHD in the United States.

Continue reading “Done ADHD Investigation Sparks Worry of Inadequate Care” to learn more.

8. Boredom Triggers High Stress Response in Impulsive People

Boredom causes a heightened stress response in impulsive people, as evidenced by the elevated cortisol levels documented in research published in Physiology & Behavior in October.⁷ The research deepens the scientific community’s understanding of the interplay between impulsivity and boredom, suggesting that this relationship may be mediated by the hypothalamic-pituitary-adrenal (HPA) axis.

“This research suggests that the lived experience of boredom feels more intense and aversive for people who are highly impulsive, transforming into an overwhelming need to escape that boredom,” explained Matt Parker, Ph.D., the study’s senior author and a neuroscientist at the University of Surrey.

Continue reading “Boredom Triggers High Stress Response in Impulsive People: New Study” to learn more.

9. DEA OKs Expanded Production of the ADHD Medication Vyvanse

Vyvanse and its generic equivalents (lisdexamfetamine dimesylate) became more readily available at pharmacies following a decision in September by the Drug Enforcement Administration (DEA) to allow expanded production of the stimulant medication used to treat ADHD and moderate-to-severe binge-eating disorder (BED) in adults. The DEA approved a 24% production increase in response to the ongoing stimulant shortage.

“These adjustments are necessary to ensure that the United States has an adequate and uninterrupted supply of lisdexamfetamine to meet legitimate patient needs both domestically and globally,” the DEA said in a letter on September 5.

Continue reading “Vyvanse Shortage Update: DEA OKs Expanded Production of the ADHD Medication” to learn more.

10. ADHD Medication Prescriptions Spiked Ahead of Adderall Shortage

Prescriptions for ADHD medications increased significantly during the COVID-19 pandemic, especially for women and for adults aged 20-39, according to a study published in January in JAMA Psychiatry. The most significant increases were found among prescriptions for adults aged 20-39, up 81% for non-stimulants and 30% for stimulants; and for women, up 59% for non-stimulants and 25% for stimulants.⁸ By contrast, researchers found a decrease or no change in rates of prescriptions during the pandemic for medications used to treat other behavioral health disorders, including anxiety, depression, and opioid use disorders.

Continue reading “ADHD Medication Prescriptions Spiked Ahead of Adderall Shortage: New Report” to learn more.

Sources

¹Li, L., Zhu, N., Zhang, L., et al. (2024). ADHD Pharmacotherapy and Mortality in Individuals With ADHD. JAMA. https://doi.org/10.1001/jama.2024.0851

²Tipale, H., Bergström, J., Gèmes, K., et al. (2024). Attention-Deficit/Hyperactivity Disorder Medications and Work Disability and Mental Health Outcomes. JAMA Netw Open. 7(3):e242859. https://doi.org/10.1001/jamanetworkopen.2024.2859

³McFarland, M.J., Reuben, A. and Hauer, M. (2024). Contribution of Childhood Lead Exposure to Psychopathology in the US Population Over the Past 75 Years. J Child Psychol Psychiatr.https://doi.org/10.1111/jcpp.14072

⁴Eng, A.G., Nirjar, U., Elkins, A.R., Sizemore, Y.J., Monticello, K.N., Petersen, M.K., Miller, S.A., Barone, J., Eisenlohr-Moul, T.A., & Martel, M.M. (2024). Attention-Deficit/Hyperactivity Disorder and the Menstrual Cycle: Theory and Evidence. Hormones and Behavior. 158(105466).https://doi.org/10.1016/j.yhbeh.2023.105466

⁵Barack, D.L., Ludwig, V.U., Parodi, F., Ahmed, N., Brannon, E.M., Ramakrishnan, A.M., and Platt, M.L. (2024). Attention Deficits Linked with Proclivity to Explore While Foraging. Proceedings of the Royal Society B Biological Sciences. https://doi.org/10.1098/rspb.2022.2584

⁶CDC. Disrupted Access to Prescription Stimulant Medications Could Increase Risk of Injury and Overdose. June 13, 2024. https://emergency.cdc.gov/han/2024/han00510.asp

⁷ Clay, J.M., Badariotti, J.I., Kozhushko, N., Parker, M.O. (2024). HPA Activity Mediates the Link Between Trait Impulsivity and Boredom. Physiology & Behavior. 284, 114637. https://doi.org/10.1016/j.physbeh.2024.114637

⁸Chai, G., Xu, J., Goyal S, et al. (2024). Trends in Incident Prescriptions for Behavioral Health Medications in the US, 2018-2022. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2023.5045

Leaded gasoline and exposure to its exhaust may help explain an estimated 151 million U.S. cases of psychiatric disorders, including ADHD, depression, and anxiety, according to a new cross-sectional study spanning the last 75 years published in the Journal of Child Psychology and Psychiatry.¹

Exposure to leaded gasoline from car exhaust was tied to population-wide cases of mental health disorders from 1940 to 2015 by researchers from Duke University, Florida State University, and the Medical University of South Carolina. They estimated that more than half of the current U.S. population was exposed to harmful levels of lead in childhood, resulting in profound effects on their mental health, personality traits, and overall well-being. People born between 1966 and 1986 (referred to as Generation X) experienced the highest rate of lead exposure and are at the greatest risk for anxiety, depression, ADHD, and personality changes.

“Research on lead as a developmental neurotoxicant is robust,” says Joel Nigg, Ph.D., a clinical psychologist and a professor in the departments of psychiatry and behavioral sciences at Oregon Health & Science University. “Its correlation with ADHD is also well established. Even low levels of exposure have an effect on ADHD.”², ³

Nigg was the principal investigator on several studies suggesting that lead exposure has a causal role in ADHD. One study published in Psychological Science found that children with ADHD who had the HFE C282Y gene mutation exhibited significantly more symptoms of hyperactivity and impulsivity than did children with ADHD who lacked the mutation.⁴

“Because the C282Y gene helps to control the effects of lead in the body, and the mutation was spread randomly in the children, it is difficult to explain these findings unless lead is, in fact, part of the cause of ADHD, not just associated with it. Numerous animal studies also support a link,” he says.

Leaded Gasoline Exposure Is a Public Health Crisis

Nigg’s study and others have linked lead exposure to life-long mental, physical, and behavioral issues; lowered IQ points; and personality changes.⁵, ⁶, ⁷, ⁸ However, the findings from the Journal of Child Psychology and Psychiatry’s study highlight the historic and pervasive effects of lead exposure on the cognitive and psychological health of a staggering slice of the U.S. population.

“Lead’s potential contribution to psychiatry, medicine, and children’s health may be larger than previously assumed,” the researchers wrote.

The study analyzed lead levels in children’s blood collected for the CDC’s National Health and Nutrition Examination Surveys (NHANES) and correlated that with historic leaded-gasoline data. The researchers calculated “mental illness points” based on the fraction of changes in the mental health of Americans born in different years and the population elevations of mental health symptoms associated with lead exposure.

The researchers identified a cumulative increase of 602 million general psychopathology points across the population, corresponding to an estimated 151 million additional mental disorders. They found that lead exposure heightened the risks for anxiety, depression, and ADHD; increased neuroticism, associated with negative emotionality; and decreased conscientiousness, reflecting less self-control and goal-oriented behavior.

While the study’s results do not prove causation, the researchers say that their findings will provide doctors with insights about their patients’ symptoms and underscore the need for expanded lead testing in patients and the recognition of lead poisoning as a neurodevelopmental disorder within a psychiatric diagnostic framework.

Leaded Gasoline Exposure: Next Steps

Lead was added to gasoline in the 1920s to improve engine performance. During the early childhood years of Generation X, leaded gasoline became the predominant fuel type in the U.S. In the mid-1970s, the U.S. Environmental Protection Agency (EPA) began phasing out leaded gasoline, but a U.S. ban did not go in effect for on-road vehicles until 1996. Lead is still found in some paints, children’s toys, and deteriorating water pipes.

According to The CDC, high levels of lead exposure can lead to seizures, vomiting, memory loss, and even death. Exposure to even small amounts of lead can be harmful. Children 6 years or younger are most vulnerable to lead poisoning, which can cause development and growth delays, hearing and speech problems, difficulty learning and paying attention, and serious illness and death.

Symptoms of lead poisoning can be hard to recognize in children. The CDC recommends discussing possible lead exposure with a child’s healthcare provider and testing children ages 1 to 5 for lead if they:

• Live in a home built before 1978
• Receive Medicaid services
• Are an immigrant, refugee, or adopted from another country
• Live near a known source of lead, such as a lead smelter or mine

Sources

¹McFarland, M.J., Reuben, A. and Hauer, M. (2024). Contribution of Childhood Lead Exposure to Psychopathology in the US Population Over the Past 75 Years. J Child Psychol Psychiatr.https://doi.org/10.1111/jcpp.14072

²Sanders, T., Liu, Y., Buchner, V., Tchounwou, P.B. (2009). Neurotoxic Effects and Biomarkers of Lead Exposure: A Review. Rev Environ Health. https://doi.org/10.1515/reveh.2009.24.1.15

³Nigg, J. T., Knottnerus, G. M., Martel, M. M., Nikolas, M., Cavanagh, K., Karmaus, W., & Rappley, M. D. (2008). Low Blood Lead Levels Associated with Clinically Diagnosed Attention-Deficit/Hyperactivity Disorder and Mediated by Weak Cognitive Control. Biological Psychiatry. 63(3), 325–331. https://doi.org/10.1016/j.biopsych.2007.07.013

⁴Nigg, J. T., Elmore, A. L., Natarajan, N., Friderici, K. H., & Nikolas, M. A. (2016). Variation in an Iron Metabolism Gene Moderates the Association Between Blood Lead Levels and Attention-Deficit/Hyperactivity Disorder in Children. Psychological Science.https://doi.org/10.1177/0956797615618365

⁵Reuben, A., Schaefer, J.D., Moffitt, T.E., Broadbent, J., Harrington, H., Houts, R.M., Ramrakha, S., Poulton, R., Caspi, A. (2019). Association of Childhood Lead Exposure With Adult Personality Traits and Lifelong Mental Health. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2018.4192

⁶Heidari, S., Mostafaei, S., Razazian, N. et al. (2022). The Effect of Lead Exposure on IQ Test Scores in Children Under 12 Years: A Systematic Review and Meta-Analysis of Case-Control Studies. Syst Rev. https://doi.org/10.1186/s13643-022-01963-y

⁷Roy, A., Bellinger, D., Hu, H., Schwartz, J., Ettinger, A.S., Wright, R.O., Bouchard, M., Palaniappan, K., Balakrishnan, K. (2009). Lead Exposure and Behavior Among Young Children in Chennai, India. Environ Health Perspect. https://doi.org/10.1289/ehp.0900625

⁸Schwaba, T., Bleidorn, W., Hopwood, C.J., Gebauer, J.E., Rentfrow, P.J., Potter, J., Gosling, S.D. (2021). The Impact of Childhood Lead Exposure on Adult Personality: Evidence from the United States, Europe, and A Large-Scale Natural Experiment. Proc Natl Acad Sci USA. https://doi.org/10.1073/pnas.2020104118

Children with ADHD are more likely to be obese, despite lower-than-average birth weights, according to a new study that found a correlation between elevated ADHD symptoms and higher body mass index (BMI) scores for both females and males. ¹The study, published in the Journal of the American Academy of Child & Adolescent Psychiatry, complements additional research tying ADHD impulsivity to unhealthy food consumption and overeating.

In analyzing data from the Millennium Cohort Study (MCS) of more than 19,000 families with children born between 2000 and 2002, researchers found that children with ADHD had significantly lower birth weights than did children in the control group. Both groups maintained similar obesity rates until age 5, when the ADHD group experienced a rise in obesity that continued throughout adolescence.

“As children with ADHD are typically lighter in weight at birth than children without ADHD, the results suggest there may be a sensitive time period between the ages of 3 and 5 years during which this association reverses, and higher ADHD symptoms become associated with obesity,” the researchers wrote.

Researchers collected data when the 442 ADHD cohort members reached 9 months and 3, 5, 7, 11, 14, and 17 years. (The study excluded cohort members taking ADHD medications.) They found that weight gain began earlier for girls with ADHD (age 7) compared to boys with ADHD (age 11). “The weight changes in girls additionally seemed to be more long-lasting, whereas the observed changes in boys seemed to be transitory,” the researchers wrote. It is unclear whether these associations continue into adulthood.

Further analysis revealed that elevated ADHD symptoms in females at ages 7, 11, and 14 predicted higher body mass index (BMI) scores at ages 11, 14, and 17, respectively. The same association occurred in males at ages 11 and 14. These results suggest that ADHD symptoms are not entirely responsible for the uptick in weight children experience between the ages of 3 and 5 years.

Genetics, Prenatal Factors Impact BMI

Hormones and puberty contribute to weight gain. “Sometimes pre-teens can gain weight as the body prepares for a growth spurt in height,” says Roberto Olivardia, Ph.D., clinical psychologist at Harvard Medical School. “Therefore, BMI normalizes as they gain height.”

Prenatal factors, including the mother’s pre-pregnancy BMI, prenatal blood pressure, smoking during pregnancy, and poor nutrition, predicted a higher BMI at 5 years. Genetics may also increase the risk of obesity.

“It is possible that there is a common genetic background to both ADHD and [being] overweight or, as parents with ADHD are more likely to have children with ADHD, this may have an impact on executive function skills involved in parenting, such as planning healthy meals, which in turn may influence weight status,” the researchers wrote. “Parents with an increased genetic risk may be influencing their child’s home environment in ways that compound inherited risk.” ², ³

Impulsivity Linked to Poor Dietary Decisions

Another recent observational study found a strong link between impulsivity, a common ADHD trait, and unhealthy food consumption and overeating, specifically in the form of snacking. ⁴

The study, published in the Journal of Attention Disorders, analyzed data from the KOALA Birth Cohort Study of 810 adolescents aged 16 to 20 years. The researchers identified five dietary patterns

• Snack — high intakes of regular (non-diet) soft drinks, fruit juice/drinks, fried snacks, chips, nuts or snacks, and energy drinks
• Healthy — high intakes of lettuce, raw vegetables, fruit, eggs, and tea
• Animal-based — high intakes of animal dairy products, meat and chicken, and fish
• Sweet — high intakes of pastry, chocolate bars, candy bars, cake or biscuits, and sweets
• Beverage — high intakes of diet soft drinks, light fruit juice/drinks, sports drinks, and energy drinks

Among the five dietary patterns, adolescents with an ADHD diagnosis scored higher on the Snacking dietary pattern than did those without ADHD. Higher Snack scores were associated with difficulties with cognition, inattention, and impulsiveness. Impulsivity was inversely related to Sweet dietary patterns and positively related to Beverage dietary patterns.

Interestingly, adolescents with ADHD appeared no less likely than their neurotypical peers to engage in Healthy dietary patterns. “The lack of a reverse association between ADHD symptoms, especially impulsivity, and the healthy pattern is unexpected and raises questions,” the researchers wrote.

Though the study does not prove causality, the findings suggest that eating habits may differ based on the specific ADHD symptoms each individual experiences.

“When studying how ADHD impacts an adolescent’s diet, looking beyond a simple diagnosis and considering the specific dimensions of their ADHD symptoms, like inattention, hyperactivity, and impulsivity, provides a more nuanced understanding of their dietary behaviors, as these individual dimensions can differentially influence food choices and eating patterns, even among individuals with the same ADHD diagnosis,” the researchers wrote.

Both ADHD and high BMI are associated with poor health outcomes, including asthma, diabetes, and cardiovascular disorders, so it’s vital that children understand the potential consequences of their dietary decisions. ⁵,⁶

Adolescents have more independent access to food, which can also result in unhealthy choices when impulsivity collides with puberty. “Parents have less control over what teenagers eat since they are not always with them,” Olivardia says, “and this most likely plays a bigger role in weight gain.”

Preventing Childhood Obesity

Educating children about their food choices can help curb unhealthy food cravings. For example, instead of banishing carbs from your kitchen, Olivardia says, explain them in a way children can understand. “Say, ‘Simple carbs, like potato chips, taste good, but basically break down in the body as sugar. There is no nutritional value in simple carbs, and they get in the way of healthy weight, high energy, and other things that matter, like your complexion.’”

Caregivers can help children and adolescents make better dietary decisions by incorporating the following strategies:

• Set up a “food environment” that promotes healthy eating. Children with ADHD may not notice they’re hungry until they’re starving. To fend off unhealthy pantry raids, stock up on nutritious, easy-to-grab meals and snacks that require little preparation, such as peanut butter crackers, yogurt, or string cheese. Display healthy snacks and fruits in plain view in the refrigerator or pantry.
• Practice good sleep hygiene. In addition to regulating hormone levels, a good night’s sleep makes it less likely that children will turn to food for comfort in fragile moments.
• Set healthy eating rules. Create family eating rules that encourage children to eat attentively — for example, no eating while watching T.V. or eating straight out of the bag. Consider requiring children to eat only in the kitchen or dining area.
• Teach children mindful eating skills. Children are less likely to overeat when they practice mindful eating. Teach children to put down their fork in between bites. Or ask them to describe what they’re eating as though the person listening has never tasted that food.
• Set a good example. Children learn by watching others, especially their parents. Set a good example by making smart food choices, dishing appropriate portions, and not distractedly eating while engaging in another activity (like using your phone).
• Treat ADHD. Make sure children adhere to their ADHD treatment plan. ADHD stimulant medications help children better observe and regulate their behaviors and avoid impulsive eating. They also make it easier to follow through with healthy eating and exercise plans.

Sources

¹ Reed, C., Cortese, S., Golm, D., Brandt, V., et al. (2024). Longitudinal Associations Between Physical Health Conditions in Childhood and Attention-Deficit/Hyperactivity Disorder Symptoms at Age 17 Years. Journal of the American Academy of Child & Adolescent Psychiatry https://doi.org/10.1016/j.jaac.2024.09.009
² Barker, E.D., Ing, A., Biondo, F., Jia, T., et al. (2021). Do ADHD-Impulsivity and BMI Have Shared Polygenic and Neural Correlates? Mol Psychiatry;26(3):1019-1028. https://doi.org/10.1038/s41380-019-0444-y
³ Faraone, S.V., Larsson, H. (2019). Genetics of Attention Deficit Hyperactivity Disorder. Mol Psychiatry; 24(4):562-575. https://doi.org/10.1038/s41380-018-0070-0
⁴ Dalnoki, L., Hurks, P. P. M., Gubbels, J. S., Eussen, S. J. P. M., Mommers, M., & Thijs, C. (2024). Exploring the Relationship of Dietary Intake With Inattention, Hyperactivity, and Impulsivity, Beyond ADHD. Journal of Attention Disorders https://doi.org/10.1177/10870547241293946/a>
⁵ Arrondo, G., Solmi, M., Dragioti, E., et al. (2022).Associations Between Mental and Physical Conditions in Children and Adolescents: An Umbrella Review. Neurosci Biobehav Rev. https://doi.org/10.1016/j.neubiorev.2022.104662
⁶ Horesh, A., Tsur, A.M., Bardugo, A., et al. (2021). Adolescent and Childhood Obesity and Excess Morbidity and Mortality in Young Adulthood—a Systematic Review. Curr Obes Rep; 10, 301–310. https://doi.org/10.1007/s13679-021-00439-9

Brain volume, and the genetic variants that influence it, is tied to ADHD and Parkinson’s disease risks, suggests one of the most extensive international studies to date on DNA and brain structure.¹

The new study, published in Nature Genetics, examined how brain size and genetic differences influence key subcortical or ‘deep brain’ regions crucial for memory, emotional regulation, proprioception, sensory processing, and responses to rewards and punishments.

A team of 189 researchers from 45 countries analyzed data from genome-wide association studies (GWAS) and magnetic resonance imaging (MRI) brain scans of 74,898 participants across 19 countries. They identified 254 genetic variants that impact brain volume and the likelihood of developing ADHD and Parkinson’s disease.

“Genetic variants associated with larger brain volumes in key brain regions also increase the risk of Parkinson’s disease, while variants linked to smaller brain volumes in key regions are associated with an increased risk of ADHD,” said Miguel Rentería, Ph.D., study principal and associate professor at the Queensland Institute of Medical Research (QIMR Berghofer) in Australia, in a statement. “These findings suggest that genetic influences that underpin individual differences in brain structure may be fundamental to understanding the underlying causes of brain-related disorders.”

However, more studies are needed on the causal relationship between genes and brain-based diseases. “It’s worth noting that these are correlations, not causal relationships, and so interpretation must be approached with caution,” Rentería said.

“My theory is that the underlying mechanisms involve genes crucial to brain development, growth, and aging processes,” Rentería told Medical News Today. “We plan to further investigate to identify the exact biological pathways involved. Understanding these mechanisms could illuminate how brain structure impacts susceptibility to both neurodegenerative and psychiatric conditions, potentially guiding future therapeutic strategies.”

The researchers used data from the Enhancing Neuro Imaging Genetics through Meta-Analysis (ENIGMA) consortium, an international effort led by Keck School of Medicine of USC; the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) at Baylor College of Medicine; the UK Biobank; and the Adolescent Brain Cognitive Development (ABCD) study.

ADHD and Parkinson’s Disease

According to the World Health Organization and the Centers for Disease Control and Prevention, rates of Parkinson’s disease and ADHD continue to rise.

In 2018, researchers from the University of Utah Health found that the risk of early-onset Parkinson’s disease and similar disorders is 2.4 times greater among patients with ADHD than it is among individuals of the same gender and age without ADHD. The study, published in Neuropsychopharmacology, examined medical records from the Utah Population Database (UPDB) of 31,769 patients with ADHD and 158,790 individuals without the condition.²

Sources

¹ García-Marín, L. M., Campos, A. I., Diaz-Torres, S., Rabinowitz, J. A., Ceja, Z., Mitchell, B. L., Grasby, K. L., Thorp, J. G., Agartz, I., Alhusaini, S., Ames, D., Amouyel, P., Andreassen, O. A., Arfanakis, K., Arias-Vasquez, A., Armstrong, N. J., Athanasiu, L., Bastin, M. E., Beiser, A. S., … Rentería, M. E. (2024). Genomic Analysis of Intracranial and Subcortical Brain Volumes Yields Polygenic Scores Accounting for Variation Across Ancestries. Nature Genetics. https://doi.org/10.1038/s41588-024-01951-z

² Curtin, K., Fleckenstein, A.E., Keeshin, B.R., et al. (2018). Increased Risk of Diseases of the Basal Ganglia and Cerebellum in Patients with a History of Attention-Deficit/Hyperactivity Disorder. Neuropsychopharmacology. https://doi.org/10.1038/s41386-018-0207-5

Communication in Healthcare: Key Takeaways

• Ask open-ended questions to build trust and gather rich patient information.
• Actively listen to patients without rushing to treat. Be mindful of verbal and non-verbal communication.
• Restate patients’ concerns in your own words and acknowledge their feelings to demonstrate understanding and empathy.
• Invite patients’ feedback on treatment plans to ensure their buy-in.

Medical school teaches us many skills, like how to decipher symptoms, perform a physical exam, and document medical history. But it doesn’t always teach us the skill of patient communication. In fact, research indicates that clinicians “listen” to patients for a mere 11 seconds, on average, before interrupting.

Respectful, open communication vastly improves a patient’s outcomes. This is especially true for patients whose conditions may provoke distrust and miscommunication — depression, anxiety, trauma, and ADHD, to name a few. With stronger patient-provider communication, we are more likely to win over patients and improve treatment adherence. Take the following communication strategies to your next patient appointments.

1. Shift to Open-Ended Questions

Do close-ended questions — which only produce “Yes,” “No,” and “I don’t know” answers — dominate your interactions with patients? You’re sure to obtain rich, insightful information about a patient’s health and build trust if you shift to open-ended questions. The trick is to invite patients to tell you about a topic. Take social activities.

• Instead of: “Do you spend time with friends?”
• Try: “Tell me about your friends and the activities you do together.”

• Use empathetic responses as your patient shares.
  • Normalize (e.g., “I can understand why you would feel scared if…”)
  • Self-disclose (e.g., “We never seem to stop worrying about our kids, even as adults.”)
  • Highlight and amplify (e.g., “I’m impressed with how clearly you’ve communicated your concerns.”)

• Look for shame and stigma, which makes it difficult for patients to trust and open up. Patients with ADHD, for example, often develop shame as a result of criticism and negative feedback from peers and authority figures.
  • Say, “I sense that you’re feeling some shame. Is it something I said? Is there something going on in your life that’s causing it?”

• Avoid blaming and lecturing patients, making dismissive comments, and minimizing their complaints.

[Free Download: How Is ADHD Diagnosed? Your Free Guide]

2. Listen. Don’t Rush to the Treatment Plan.

It’s second nature for us — because it’s our job — to immediately devise treatment plans in our heads as patients communicate their concerns. But if your attention is on plans and processes, then it’s not on actively listening to your patients. Momentarily abandon all agendas and be present as your patient shares.

• Listen for needs. The basic human needs — to feel loved, to be important, to belong, and to be good at something — are particularly relevant here. When these needs are not met, depression, anxiety, and other mental health conditions are often the result. What does your patient want you to hear and understand about them and these needs?
• Look up from your screen. Eye contact lets your patient know that you are present.
• Consider all forms of communication, including body language, facial expression, and tone. Be mindful of your expressions, posture, and affect, too.
• Don’t try to get ahead of the patient. You know a lot about treating conditions in your specialty, but your patient doesn’t. Don’t fall into the “I know what’s going on” trap and risk cutting your patient short. Trying to bring your patient up to speed will only result in pushback. See problems from the patient’s perspective, not the clinical one.

3. Share Your Understanding

Clinical empathy is achieved when your patient sees that you understand what they’re saying and feeling. You don’t need to mirror the patient’s emotional state, but you do need to recognize and acknowledge it. You may not agree with the patient’s concerns, but they should feel you’re taking them seriously.

To convey understanding, restate the patient’s concerns in your own words. Consider the following openings:

• “So, you’re saying…”
• “It sounds like…”
• “You’re wondering if…”
• “I hear you saying…”

[Use This Expert Overview: Choosing the Right Professional to Treat ADHD]

4.Negotiate, Don’t Impose

After sharing your understanding of your patient’s health concerns, it’s time to share ideas for how to move forward. This is not a one-way conversation to force a treatment plan on your patient. This is a two-way exchange in which you invite the patient — who is now more inclined to open up — in shared decision-making about their health. Find areas that you both agree to focus on first.

Preface your ideas with the following scripts:

• “Would it be okay with you…”
• “What do you think about…”
• “Does it make sense to…”

Throughout the exchange, remember that the patient is the most important member of the health team. Emphasize that you can’t do this without them and their buy-in, which may mean compromising on a treatment plan.

Let the patient know that this won’t be your last meeting. Explain that you are available to troubleshoot and modify their treatment plan if needed.

Encouraging Words Patients Want to Hear

• “There is hope for your future, despite these problems.”
• “You are not alone in dealing with this problem.”
• “Your condition is not your fault.”
• “I understand what you are saying and navigating.”
• “You have many strengths.”

The Power of a Minute

You may think it impossible to implement these strategies within the short timeframe of an appointment. Yes, following these strategies may extend your patient visits, but not as much as you think. What’s more, investing in effective communication early on will save you and your patients time in the long run, as you’ve invested in truly understanding needs and collaborating first. If time remains an issue for implementing these strategies, consider splitting appointments into two or more sessions.

If you only have one minute with a patient, don’t spend that minute leaving. Your full, undivided attention — even for just 60 seconds — can go a long way in making patients feel respected and heard.

Communication in Healthcare: Next Steps

• Download: New! The Clinicians’ Guide to Treating Complex ADHD
• Read: How Collaborative Care Models Deliver Quality ADHD Care – Seamlessly
• Read: “Collaborative Care” Improves ADHD Symptoms in Children

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “For Clinicians: Common Treatment Barriers for Patients with Depression, Trauma” [Video Replay & Podcast #471] with Lawrence Amsel, M.D., which was broadcast on September 13, 2023.

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Sleep problems are highly prevalent among adults with ADHD. Individuals who have ADHD and one or more psychiatric comorbidities face an increased risk for disordered sleep, according to a study published in the Journal of Attention Disorders.¹

The study followed a large sample of adults with ADHD in the Netherlands after they were referred to an outpatient mental health clinic. Nearly two-thirds of these patients screened positive for a sleep problem. Most screened positive for delayed sleep phase syndrome (35.8%), followed by insomnia (30.6%) and restless leg syndrome (28.8%).

Women with ADHD were more likely to report more types of sleep problems compared to men with ADHD. Women more often reported insomnia, hypersomnia, and parasomnia, while men more often reported sleep-related breathing disorders (SBD).

Adults with ADHD and mental health conditions faced a higher likelihood of having any type of sleep problem and of having more than one sleep problem than did those with ADHD alone. The risk of sleep problems was highest in adults with PTSD (OR=3.21), followed by:

• Substance use disorder (OR=1.76)
• Depression (OR=1.73)
• Anxiety (OR=1.51)
• Personality disorders (OR=1.54)

Why Do Adults with ADHD Struggle with Sleep?

Sleep disorders impact around 50 million Americans or 15% of the U.S. population.² This percentage is significantly higher in ADHD populations, as shown in the current study. According to data cited by the authors, disordered sleep affects an estimated 40% to 80% of adults with ADHD.^{3, 4} The most common sleep disorders are similar for both groups and include insomnia, restless legs syndrome (RLS), narcolepsy, and sleep apnea.^{5, 6}

ADHD and sleep go hand in hand, and the impact of one disorder can worsen the symptoms of the other. For example, the American Academy of Neurology found that people with ADHD and RLS experience more severe RLS symptoms than do those without ADHD.⁷

Many sleep problems are biological, but they can also be behaviorally motivated. A study cited by the authors shows that cognitive behavioral symptoms such as bedtime procrastination can delay sleep onset and potentially disrupt melatonin production.⁸

“Symptoms of ADHD exacerbate the things that make sleep hard for all of us,” said Joel Nigg, Ph.D., in his 2018 webinar with ADDitude, “Sleep and the ADHD Brain: Why It’s Critical and How to Get More.”

“Your body reacts more strongly to stimulation,” Nigg said. “You’re more hyper-aroused by things that happen during the day. It’s harder to turn your brain off. It’s a natural side effect of what ADHD is. Sleep requires the opposite of the energy that ADHD provokes, [making sleep] naturally difficult. That’s why it takes the kind of deliberate attention, behavioral strategy, or kind of tackling of this so often for those with ADHD.”

What Are the Consequences of Untreated Sleep Problems?

The impact of misdiagnosing symptoms of disordered sleep can have long-term consequences, leading to “poor treatment, and persistence and aggravation of symptoms,” the authors wrote.

Symptoms of poor sleep can look like ADHD and vice versa, making them somewhat difficult to differentiate. Left untreated, disordered sleep can worsen with age and cause a ripple effect from caregivers to their children.⁹

“Sung did a study [in 2008], which found that moderate or severe sleep problems in children with ADHD were strongly associated with the mental health of their primary caregivers and with those caregivers’ work attendance and overall family functioning,” said Roberto Olivardia, Ph.D., during his 2019 webinar with ADDitude, “Time for Bed! Sleep Solutions for the ADHD Brain.”

The good news is that “treatments for specific sleep problems are available, relatively accessible to implement in ADHD patients, and can improve ADHD treatment results substantially,” the authors wrote. Cognitive behavioral therapy (CBT) and lifestyle changes are first-line treatments for many sleep disorders and can be more effective than sleep medicine.¹⁰

Limitations, Strengths, and Future Research

The study followed 3,691 adults diagnosed with ADHD from 2018 to 2020. Data was assessed via electronic patient files and included an even male-to-female ratio. Adults with ADHD were referred to one of 46 specialized outpatient clinics in the Netherlands by their general practitioner or mental health counselor. The Holland Sleep Disorder Questionnaire (HSDQ) was used to assess sleep disorders, though it was used as a screening tool and not to diagnose. The DIVA-5 was used to test for ADHD, and the M.I.N.I was used to screen for psychiatric comorbidities.

Limitations of the study include a lack of control group. And although some patients had been diagnosed with a sleep disorder before being referred to an outpatient clinic, the HSDQ was only able to screen for sleep problems. Some data, such as BMI and treatment status, was not accounted for as it was not systematically recorded in patient files. Given each patient received a clinical referral, the severity of symptoms experienced by patients should be considered when interpreting results.

Future studies would benefit by measuring causal factors contributing to sleep problems in adults with ADHD. These studies should also include subjective sleep parameters, such as actigraphy and polysomnography, which were not included here. Insomnia has been widely studied in sleep research; more research is needed on other sleep disorders, including periodic limb movement disorder (PLMD), RLS, DSPS, and SBD.

Sources

¹ van der Ham, M., Bijlenga, D., Böhmer, M., Beekman, A.T.F., & Kooij, S. (2024). Sleep problems in adults With ADHD: prevalences and their relationship with psychiatric comorbidity. Journal of Attention Disorders, 28(13), 1642-1652. https://doi.org/10.1177/10870547241284477

² American Psychiatric Association. (2024). What are Sleep Disorders? https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders

³Wynchank, D., Bijlenga, D., Beekman, A.T. et al. (2017). Adult attention-deficit/hyperactivity disorder (ADHD) and insomnia: an update of the literature. Curr Psychiatry Rep 19, 98. https://doi.org/10.1007/s11920-017-0860-0

⁴Batten, L. (2022, August 17). How ADHD Impacts Your Sleep And What You Can Do About It. Frida. https://www.talkwithfrida.com/learn/how-adhd-impacts-your-sleep/

⁵ U.S. Centers for Disease Control & Prevention. (2024, May 15). About Sleep. https://www.cdc.gov/sleep/about/index.html

⁶ Cleveland Clinic. (2023, June 19). Sleep Disorders. https://my.clevelandclinic.org/health/diseases/11429-sleep-disorders

⁷ American Academy Of Neurology. (2001, May 8). Adults With Restless Legs Syndrome More Likely To Have ADHD. ScienceDaily. www.sciencedaily.com/releases/2001/05/010508082849.htm

⁸ Li, X., Buxton, O. M., Kim, Y., Haneuse, S., & Kawachi, I. (2020). Do procrastinators get worse sleep? Cross-sectional study of U.S. adolescents and young adults. SSM – Population Health, 10, 100518. https://doi.org/10.1016/j.ssmph.2019.100518

⁹ Sung, V., Hiscock, H., Sciberras, E., Efron, D. (2008). Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med, 162(4):336–342. https://doi.org/10.1001/archpedi.162.4.336

¹⁰ Mitchell, M.D., Gehrman, P., Perlis, M. et al. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract, 13, 40. https://doi.org/10.1186/1471-2296-13-40

In this final installment of ADDitude magazine’s two-part series, “The Future of ADHD” (the first part appeared in the Winter 2023 issue), I’ll explain each of the developments poised to revolutionize ADHD understanding and treatment.

New Pharmacologic Interventions for ADHD

Development of pharmacologic interventions for ADHD has mushroomed over the last two decades. Though researchers have made progress in developing non-stimulant treatment options (i.e., long-acting forms of clonidine and guanfacine, as well as atomoxetine and viloxazine), most of the FDA-approved agents are simply tweaks of methylphenidate and amphetamine compounds.

There are now more choices available to prescribers and patients, offering stimulant preparations of varying durations, delivery formats (patch, liquid, tablet, capsule), and pharmacokinetic profiles. It should be noted that both older and newer preparations are exceptionally effective for most patients and, when comparing them to non-stimulants in head-to-head trials and in clinical practice, the psychostimulants generally win hands-down. However, the various forms of psychostimulants differ in their rate of onset, duration of coverage, convenience (once daily vs. multiple doses daily), and cost.

Psychostimulants, however, are not effective for everyone; about 30% of patients may not have a satisfactory response.¹ As a result, researchers are increasingly exploring the benefits of combining psychostimulant treatment with other compounds (e.g., methylphenidate paired with atomoxetine, or a dextroamphetamine compound plus guanfacine).

[Get This Free Download: 2024 Scorecard of ADHD Treatments]

The robust effectiveness of psychostimulants in treating ADHD has somewhat slowed the development of alternatives. However, researchers are exploring newer agents that target different neurotransmitter systems, including:

• Solriamfetol (used to treat excessive daytime drowsiness)
• Tipepidine (used as a cough suppressant)
• Amantadine (used to treat Parkinson’s disease)
• Dasotraline (used to treat depression and other disorders)

Not yet FDA-approved for ADHD, these compounds face two main challenges: matching the effectiveness of psychostimulants and effectively targeting symptoms not currently treated by psychostimulants.

ADHD and the Gut-Brain Axis

Emerging research suggests a significant, but underappreciated, relationship between the gut biome — a diverse community of microorganisms living in the digestive tract — and behavior and emotions. The gut and the brain communicate through the gut-brain axis, allowing gut microbiota to influence brain function and vice versa.

Multiple studies have now shown that abnormalities in the gut microbiome can affect mood, anxiety, and stress levels.² Certain gut bacteria can even produce neurotransmitters like serotonin and gamma-aminobutyric acid (GABA), which play a crucial role in regulating emotions.³ Other gut bacteria can produce toxins, inflammatory molecules, and other metabolites that can cross the blood-brain barrier to adversely impact brain health and cognitive function.⁴

[Get This Free Download: Lifestyle Changes for Adults with ADHD]

Imbalances in the gut microbiome can be caused by diet, stress, and even antibiotic use during the prenatal period or during infancy.^{5 6} Longitudinal studies have shown that these gut factors can be linked to mental health disorders, including ADHD, in later childhood.⁷ Multiple studies also suggest that restoring a healthy gut balance through probiotics, prebiotics, or dietary changes might improve emotional wellbeing.⁸ Research involving the microbiome’s impact on human behavior and emotions is still emerging.

ADHD and Gene-Environment Interactions

ADHD is highly heritable; however, environmental influences are exceptionally important in determining whether, when, and how a set of genes will manifest in ADHD symptoms. Environments determine whether a particular illness or disease manifests. This area of research — how certain genes are differentially expressed due to differences in environments — is in its infancy.

A major challenge: Because there are so many genes and possible environmental factors unfolding over time, there are literally trillions of possible gene-environment interactions that could affect the timing, severity, and persistence of ADHD. Due to the likely number and complexity of these interactions, multiple replications across independent studies will be essential.

Several studies have already shown that the severity and persistence of ADHD can be a function of parent-child interactions and supervision across different settings.⁹ This is not a “blame the parents” finding, but, instead, suggests that certain interventions from caregivers (and possibly teachers, coaches, and other adults) may mitigate a child’s symptom severity and persistence. For example, teaching parents how to remain neutral, or even express warmth in the face of difficult behaviors, is likely an important area of intervention. Related findings indicate that parental rejection¹⁰ can affect a child’s outcomes, as can the level of household disorganization¹¹, overall life stress¹², and other factors. Attention to such challenges offers an opportunity for targeted interventions.

Many different factors contribute to ADHD’s etiology, timing of onset, and severity, as well as possibilities for prevention and person-specific treatment. Our research to date, and our research programs unfolding over the next decades, will continue to lead to advances in the way we diagnose and treat ADHD in childhood and in adults.

ADHD Research: Next Steps

• Read: The Evolution of ADHD — Examining the Last 25 Years and the Future
• Read: Prenatal and Early Life Risk Factors of ADHD
• Watch: Epigenetics — Understanding Its Role in ADHD and Future Applications
• Hub: ADHD News & Research

Peter S. Jensen, M.D., is the founder of The REACH Institute, which trains providers in interventions for children’s mental health care.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Spencer, T., Biederman, J., & Wilens, T. (2004). Nonstimulant treatment of adult attention-deficit/hyperactivity disorder. The Psychiatric clinics of North America, 27(2), 373–383. https://doi.org/10.1016/j.psc.2003.12.001

² Xiong, R. G., Li, J., Cheng, J., Zhou, D. D., Wu, S. X., Huang, S. Y., Saimaiti, A., Yang, Z. J., Gan, R. Y., & Li, H. B. (2023). The Role of Gut Microbiota in Anxiety, Depression, and Other Mental Disorders as Well as the Protective Effects of Dietary Components. Nutrients, 15(14), 3258. https://doi.org/10.3390/nu15143258

³ Chen, Y., Xu, J., & Chen, Y. (2021). Regulation of Neurotransmitters by the Gut Microbiota and Effects on Cognition in Neurological Disorders. Nutrients, 13(6), 2099. https://doi.org/10.3390/nu13062099

⁴ Parker, A., Fonseca, S., & Carding, S. R. (2020). Gut microbes and metabolites as modulators of blood-brain barrier integrity and brain health. Gut microbes, 11(2), 135–157. https://doi.org/10.1080/19490976.2019.1638722

⁵ Madison, A., & Kiecolt-Glaser, J. K. (2019). Stress, depression, diet, and the gut microbiota: human-bacteria interactions at the core of psychoneuroimmunology and nutrition. Current opinion in behavioral sciences, 28, 105–110. https://doi.org/10.1016/j.cobeha.2019.01.011

⁶ Fish-Williamson, A., Hahn-Holbrook, J., Hobbs, M., Wallander, J., & Morton, S. M. B. (2022). Prenatal antibiotic exposure in pregnancy and early childhood socioemotional development. JCPP advances, 2(2), e12066. https://doi.org/10.1002/jcv2.12066

⁷ Cassidy-Bushrow, A. E., Sitarik, A. R., Johnson, C. C., Johnson-Hooper, T. M., Kassem, Z., Levin, A. M., Lynch, S. V., Ownby, D. R., Phillips, J. M., Yong, G. J. M., Wegienka, G., & Straughen, J. K. (2023). Early-life gut microbiota and attention deficit hyperactivity disorder in preadolescents. Pediatric research, 93(7), 2051–2060. https://doi.org/10.1038/s41390-022-02051-6

⁸ Bistas, K. G., & Tabet, J. P. (2023). The Benefits of Prebiotics and Probiotics on Mental Health. Cureus, 15(8), e43217. https://doi.org/10.7759/cureus.43217

⁹Haack, L. M., Villodas, M. T., McBurnett, K., Hinshaw, S., & Pfiffner, L. J. (2016). Parenting Mediates Symptoms and Impairment in Children With ADHD-Inattentive Type. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 45(2), 155–166. https://doi.org/10.1080/15374416.2014.958840

¹⁰ Brinksma, D. M., Hoekstra, P. J., de Bildt, A., Buitelaar, J. K., van den Hoofdakker, B. J., Hartman, C. A., & Dietrich, A. (2023). Parental rejection in early adolescence predicts a persistent ADHD symptom trajectory across adolescence. European child & adolescent psychiatry, 32(1), 139–153. https://doi.org/10.1007/s00787-021-01844-0

¹¹ Agnew-Blais, J. C., Wertz, J., Arseneault, L., Belsky, D. W., Danese, A., Pingault, J. B., Polanczyk, G. V., Sugden, K., Williams, B., & Moffitt, T. E. (2022). Mother’s and children’s ADHD genetic risk, household chaos and children’s ADHD symptoms: A gene-environment correlation study. Journal of child psychology and psychiatry, and allied disciplines, 63(10), 1153–1163. https://doi.org/10.1111/jcpp.13659

¹² Hartman, C. A., Rommelse, N., van der Klugt, C. L., Wanders, R. B. K., & Timmerman, M. E. (2019). Stress Exposure and the Course of ADHD from Childhood to Young Adulthood: Comorbid Severe Emotion Dysregulation or Mood and Anxiety Problems. Journal of clinical medicine, 8(11), 1824. https://doi.org/10.3390/jcm8111824

Sleep problems in children are associated with restless behavior and iron deficiency, two problems more common in patients with ADHD, according to a small study published in the journal Nutrients.¹

The study followed 199 patients referred to a Sleep/Wake Behavior Clinic between 2021 and 2023. It found that patients with ADHD were nearly twice as likely as their neurotypical counterparts to have restless leg syndrome (RLS). The most common psychiatric comorbidities among patients with sleep disorders included ADHD (46%), autism (45%), and anxiety disorder (41%).

Most patients in the study had an iron deficiency (94%), and 41% knew someone in their family who did. When comparing ADHD patients only, a family history of iron deficiency increased the patient’s risk of having RLS and insomnia.

“Recently, iron has received increasing attention due to its role in sleep disorders, as well as wake behaviors associated with mental health and/or neurodevelopmental disorders such as ADHD, autism spectrum disorder, and prenatal alcohol exposure/fetal alcohol spectrum disorder,” the research authors wrote.

RLS was the most common sleep disorder (74%) in the study, followed by:

• Chronic insomnia: 61%
• Signs of sleep-disordered breathing: 50%
• Restless sleep or PLMS: 30%
• Circadian rhythm sleep disorder (CRSD): 16%
• Probable painful RLS: 11%

Sleep and ADHD

Nearly three-quarters of children with ADHD experience a sleep problem or disorder.² For many children, sleep problems last into adolescence and can aggravate ADHD symptoms during the day.

“By the time they get into adolescence, we know that teens with ADHD are more likely than their peers without ADHD to get insufficient sleep on school nights,” said Stephen Becker, Ph.D., in his 2021 webinar with ADDitude, “Why Am I Always So Tired? The Latest Science on Improving Sleep in Children and Teens with ADHD.”

“We’ve also shown that poor sleep impacts academics, including academic performance, organization, and lower grades based on report cards that we’ve acquired from schools and college institutions,” Becker said. “In some of our work with young teens, even after we account for a teen’s initial levels of depressive symptoms or oppositional behaviors, those teens who had sleep problems went on to experience an increase in depressive symptoms and oppositional behaviors over time.”

Restlessness, defined as the “urge to move,” was a strong risk factor for sleep problems in children with and without ADHD in the present study. Hypermotor restlessness and hyper-arousal are central to ADHD and RLS but are often missed in pediatric patients, according to the authors. Symptoms of restlessness are based on adult criteria and do not account for physical differences that may be present in children.

“Characterizing hyper-motor restlessness during sleep as a new diagnostic entity supports our understanding that disorders presenting with hypermotor restlessness and/or hyper-arousability need an in-depth phenotyping approach from a pediatric sleep medicine perspective,” the authors wrote.

Limitations & Future Research

Standard diagnostic evaluations for sleep disorders typically do not assess for iron levels, according to the authors. Testing iron levels using blood tests could help improve treatment outcomes, as many patients in the present study were shown to be deficient. The authors noted that iron supplementation is often an effective treatment approach.

Evening activities, screen time, stimulant medication, homework stress, and inconsistent sleep/wake times may also make it difficult for children with ADHD to wind down at night.

Patients ages 3 months to 23 years and/or their family members answered questions upon intake about bedtime habits, excessive daytime sleepiness, nighttime awakenings, routines, sleep-disordered breathing, quality of sleep, and other non-specific concerns. The Sleep Disturbance Scale for Children (SDSC) and ADHD Rating Scale-IV were also administered.

The study has several limitations, including the absence of a control group and a small sample size. Additionally, medication use was not controlled, and there was no distinction made between anemic and non-anemic individuals with iron deficiency, nor between maternal and paternal family histories. Future research should explore the causes of iron deficiency. Inadequate nutrition, inflammation, and malabsorption were listed as potential contributors to iron deficiency.

Findings associated with other psychiatric disorders, including autism, were also shared in the study and can be found here.

Sources

¹ Ipsiroglu, O.S., Pandher, P.K., Hill, O., McWilliams, S., Braschel, M., Edwards, K., Friedlander, R., Keys, E., Kuo, C., Lewis, M.S., et al. (2024). Iron deficiency and restless sleep/wake behaviors in neurodevelopmental disorders and mental health conditions. Nutrients, 16(18):3064. https://doi.org/10.3390/nu16183064

² Sung, V., Hiscock, H., Sciberras, E., Efron, D. (2008). Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med, 162(4):336–342. https://doi.org/10.1001/archpedi.162.4.336

More than half of individuals with ADHD — and significantly more women than men — were diagnosed in adulthood, according to new data published in the U.S. Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR).¹ These findings constitute the CDC’s first update on the prevalence and age of diagnosis for ADHD in nearly 20 years.

The CDC report, which found that 6 percent of U.S. adults have a current ADHD diagnosis, identified several gender-based discrepancies regarding the age of diagnosis. Sixty-one percent of women received their ADHD diagnosis during adulthood, compared to 40 percent of men. One-quarter of women received an ADHD diagnosis before age 11, compared to 45 percent of men.

“Taken together, these data highlight the significant public health burden of ADHD and challenges experienced by adults with this diagnosis,” said Greg Mattingly, M.D., president of the American Professional Society of ADHD and Related Disorders (APSARD), and Ann Childress, M.D., past president of APSARD, in an article published in Psychiatric Times.²

The MMWR analyzed data collected from the National Center for Health Statistics Rapid Survey System (RSS) from October through November 2023 on the prevalence, treatment barriers, and telehealth usage of adults with ADHD.

Consequences of Undiagnosed Adult ADHD

Once considered a childhood condition, ADHD is now recognized as one of the most common mental health conditions in adults, affecting men and women almost equally. ³,⁴ A new national survey of 1,000 American adults by The Ohio State University Wexner Medical Center and College of Medicine revealed that as many as one in four adults suspect they may have undiagnosed ADHD, however, only 13 percent have consulted a doctor about their suspicions. The researchers say the findings raise concerns that self-diagnosis may lead to incorrect treatment.

“In recent years, the number of adults diagnosed with ADHD has risen significantly – thanks, in part, to decades of research that has advanced awareness of ADHD as a lifelong disorder,”⁵ wrote APSARD secretary Maggie Sibley, Ph.D., in the ADDitude article, “Why We Need U.S. Guidelines for Adults with ADHD.” “Though ADHD is commonly detected in childhood, later-in-life diagnoses are providing clarity and relief for many adults with once unexplained, misunderstood, or overlooked lifelong struggles.”

Untreated adult ADHD symptoms may impair individuals personally and professionally, and they may exacerbate comorbidities like depression, anxiety, bipolar disorder, insomnia, substance use disorders, and trauma-related conditions. ⁶, ⁷

“ADHD does not happen in a vacuum, and its effects are far more impairing when the condition goes undiagnosed, untreated, or improperly treated,” said Nelson M. Handal, M.D., DFAPA, in the ADDitude webinar, “New Insights Into and Treatments for Comorbid Depression” “It’s not difficult to see how untreated symptoms of ADHD — from impulsivity and emotional instability to poor planning and execution skills — compromise one’s ability to find success in school, work, relationships, and other parts of life.”

Even with an ADHD diagnosis, adults face barriers to care amid the ongoing stimulant shortage. Approximately 7 in 10 adults treating ADHD with stimulant medications reported difficulty obtaining their prescriptions, the CDC found.

The CDC’s findings suggest that telemedicine may improve access to healthcare and decrease systemic discrepancies in care. Nearly half of adults with a current ADHD diagnosis said they received some of their ADHD healthcare via telemedicine.

“These benefits must, however, be balanced with the need for thorough diagnostic evaluation and follow-up for both the in-person and virtual models of care,” said Mattingly and Childress.

“Some telehealth companies are under federal investigation for their prescribing practices, highlighting a need for clarity on appropriate practices for the prescription of stimulants – a first-line treatment for ADHD,” Sibley wrote. “APSARD’s forthcoming adult ADHD guidelines will address this urgent need for providers and patients alike — making evaluations more thorough, diagnosis more reliable, and treatment safer.”

Importance of Adult ADHD Guidelines

The Ohio State study and CDC data underscore the need for adult ADHD diagnosis and treatment guidelines, which APSARD is working to finalize by late this year or early 2025.

“These will be the first U.S. guidelines for the diagnosis and treatment of adults with ADHD, and they will provide a valuable framework of treatment for clinicians and families,” said Mattingly and Childress. “While many unanswered questions remain, these findings bring us one step closer to a deeper understanding of the needs of adults with ADHD.”

The impact of the APSARD guidelines may be felt most profoundly by adult women.

“Many women do not recognize that they have ADHD or seek evaluations until their children are diagnosed,” wrote Childress in an ADDitude article earlier this year. They are often treated for anxiety or depression that developed secondarily to ADHD. Helping clinicians recognize the difference in presentation of ADHD symptoms in women is important.”

Sources

¹taley, S.B., Robinson, L.R., Claussen, A.H., et al. Attention Deficit/Hyperactivity Disorder Diagnosis, Treatment and Telehealth Use in Adults – National Center for Health Statistics Rapid Surveys System, United States, October – November 2023. MMWR Morb Mortal Wkly Rep. 2024;73(40)

² Mattingly, G., Childress, A. (2024). Clinical Implications of Attention-Deficit/Hyperactivity Disorder in Adults: What New Data on Diagnostic Trends, Treatment Barriers, and Telehealth Utilization Tell Us. J Clin Psychiatry; 85(4): 24com15592. https://doi.org/10.4088/JCP.24com15592

³Ayano, G., Tsegay, L., Gizachew, Y, et al. (2023). Prevalence of Attention Deficit Hyperactivity Disorder in Adults: Umbrella Review of Evidence Generated Across the Globe. Psychiatry Res; 328:115449. https://doi.org/10.1016/j.psychres.2023.115449

⁴Faraone, S.V., Bellgrove, M.A., Brikell, I., et al. (2024). Attention Deficit/Hyperactivity Disorder. Nat Rev Dis Primers; 10(1):11. https://doi.org/10.1038/s41572-024-00495-0

⁵Sibley, M.H., Arnold, L.E., Swanson, J.M., Hechtman, L.T., Kennedy, T.M., Owens, E., Molina, B.S., Jensen, P.S., Hinshaw, S.P., Roy, A., Chronis-Tuscano, A. (2022). Variable Patterns of Remission from ADHD in the Multimodal Treatment Study of ADHD. American Journal of Psychiatry;179(2):142-51. https://doi.org/10.1176/appi.ajp.2021.21010032

⁶Kessler, R.C., Berglund, P., Chiu, W.T., et al. (2004). The US National Comorbidity Survey Replication (NCS-R): Design and Field Procedures. Int J Methods Psychiatr Res; 13(2):69–92. https://doi.org/10.1002/mpr.167

⁷Katzman, M.A., Bilkey, T.S., Chokka, P.R., et al. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC Psychiatry. 17(1):https://doi.org/10.1186/s12888-017-1463-3

ADHD and dyslexia share 174 genes and 49 genetic regions, according to a new study published in Molecular Psychiatry. The findings suggest that ADHD more closely resembles a learning difference than a psychiatric disorder.¹

Led by a team of researchers from the University of Edinburgh, UK, the study aimed to find common genes underlying dyslexia and 10 neurodevelopmental and psychiatric conditions, including ADHD, autism, anorexia nervosa, anxiety, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome.

The researchers identified five genetically linked clusters, known as latent genomic factors, that revealed ADHD to be more significantly associated with attention and learning issues than it is with neurodevelopmental conditions, such as autism and Tourette syndrome.

Further analysis showed that dyslexia and ADHD share 49 genetic regions, 40 of which were newly discovered, and 174 genes, including 121 previously unidentified ones.

Dyslexia and ADHD

Dyslexia is a language-based learning disorder with neurodevelopmental origins. It is characterized by reduced accuracy and speed in reading and spelling. Dyslexia and ADHD are highly comorbid. Roughly one-quarter to 40% of individuals with ADHD also have dyslexia.²

“Considerable overlap exists between dyslexia and ADHD,” said Cheryl Chase, Ph.D., in the ADDitude webinar “When Dyslexia and ADHD Overlap: Symptoms, Misconceptions, and Interventions.” “ADHD and dyslexia are both linked to problems in school and with learning, but for different reasons. Ultimately, these overlapping traits complicate evaluations for ADHD and dyslexia, especially when both conditions are present. Nevertheless, a thorough evaluation that carefully considers each symptom cluster is critical to receive appropriate support.”

Strong heritability exists for both dyslexia and ADHD. Twin studies of dyslexia estimate its heritability at 60% to 70%.³, ⁴ Heritability for ADHD ranges from 77% to 88%.⁵

Previous genome-wide association studies have struggled to identify genes common to people with dyslexia and ADHD, largely because such research would require a substantial sample size. The UK study examined large public anonymized datasets of genetic data from the Psychiatric Genomics Consortium genome-wide association study and dyslexia genetic statistics from an analysis of roughly one million people in collaboration with 23andMe, a U.S.-based consumer genetics company.

The researchers also leveraged the findings of a 2022 study that included data from more than 1.1 million individuals (51,800 dyslexia cases). The 2022 study identified 42 genes responsible for dyslexia and confirmed its genetic link to ADHD. Of the 42 genetic variants identified, 15 were in genes linked to cognitive ability/educational attainment and 27 were new, suggesting that individuals with more genetic variants were more likely to have dyslexia.⁶

The UK study used a combined sample of 453,408 cases and 2,374,026 controls.

“This is the first time that genetic links to dyslexia have been studied in the context of psychiatric traits,” says Austėja Čiulkinytė, a translational neuroscience Ph.D. student at the University of Edinburgh, who led the study. “In the future, other learning difficulties such as dyscalculia or dysgraphia should be included to allow for a more nuanced understanding of their relationships.”

Sources

¹ Čiulkinytė, A. et al. (2024). Genetic Neurodevelopmental Clustering and Dyslexia. Molecular Psychiatry. https://doi.org/10.1038/s41380-024-02649-8

² DuPaul, G.J., Gormley, M.J., & Laracy, S.D. (2013). Comorbidity of LD and ADHD: Implications of DSM-5 for assessment and treatment. Journal of Learning Disabilities; 46(1), 43–51. https://doi.org/10.1177/0022219412464351

³ Hawke, J.L., Wadsworth, S.J., DeFries, J.C. (2006). Genetic Influences on Reading Difficulties in Boys and Girls: The Colorado Twin Study. Dyslexia; 12:21–29. https://doi.org/10.1002/dys.301

⁴ Hensler, B.S., Schatschneider, C., Taylor, J., Wagner, R.K. (2010). Behavioral Genetic Approach to the Study of Dyslexia. J Dev Behav Pediatrics; 31:525–32.https://doi.org/10.1097/DBP.0b013e3181ee4b70

⁵ Faraone, S.V., & Larsson, H. (2019). Genetics of Attention Deficit Hyperactivity Disorder. Molecular Psychiatry; 24(4), 562–575. https://doi.org//10.1038/s41380-018-0070-0

⁶ Doust, C., Fontanillas, P., Eising, E. et al. (2022). Discovery of 42 Genome-Wide Significant Loci Associated with Dyslexia.Nat Genet.https://doi.org/10.1038/s41588-022-01192-y

Academic achievement is strongly predicted by the presence of certain non-cognitive skills, like persistence and motivation, which are linked to genetic factors and become increasingly important as children age, according to a study published in Nature Human Behaviour.¹

“Children who are emotionally stable, motivated, and capable of regulating their attention and impulses do better in school, independent of their level of cognitive ability,” the researchers wrote.

The study involved a U.K.-based sample of more than 10,000 children aged 7 to 16 that used surveys and multiple genetic methods, including twin models and DNA-based analyses. Data was collected at ages 7, 9, 12, and 16.

Non-Cognitive Skills

Parents, teachers, and twins were asked questions related to the child’s performance at school and non-cognitive skills, including academic interest and self-regulation. After accounting for general cognitive ability, researchers performed multiple regression analyses that revealed an association between non-cognitive skills and academic achievement at all ages studied.

Non-cognitive skills grew more predictive of academic achievement as children approached late adolescence. Self-report surveys revealed the biggest effect sizes (as compared to surveys completed by parents and teachers). The correlation between self-reported, education-specific non-cognitive skills and academic achievement grew significantly over time (from r=0.10 at age 9 to r=0.51 at age 16).

While cognitive skills refer to objective traits, such as memory, reasoning, and IQ, non-cognitive skills refer to more subjective qualities. In this study, non-cognitive skills were broadly classified as:

• Education-specific non-cognitive skills (academic interest, attitudes towards learning, academic self-efficacy)
• Domain-general self-regulation skills (behavioral and emotional regulation that exist outside of school).

“These findings highlight the important role that non-cognitive skills play during primary and secondary education and suggest that fostering such skills might provide an avenue for successful educational strategies and interventions,” the researchers wrote.

Genetic Influence

Similar findings were revealed using polygenic scores, or PGSs, which estimate the effect of multiple genes on a specific trait. Non-cognitive PGS on academic achievement doubled from ages 7 to 16, while cognitive PGS stayed the same. By the end of the study, the variance in academic achievement was equally accounted for by non-cognitive and cognitive skills.

When controlling for shared family environments, as in the case of siblings, the effects of non-cognitive PGS were slightly diminished but still significant. According to the gene-environment correlation theory, or rGe, this can be attributed to genetic control over environmental exposures.² As children grow up, they “evoke and actively select academic environments that correlate with their genetic disposition towards non-cognitive skills,” the researchers wrote. These traits are then reinforced over time. In contrast, cognitive PGS predictions remained the same through development.

Socioeconomic status did not alter the overall findings. Although children from higher socio-economic backgrounds performed better academically, the slope of association between academic achievement and non-cognitive skills did not change from one group to the next.

“Higher PGS, for both cognitive and non-cognitive skills, corresponded to higher academic achievement, and higher SES corresponded to both higher mean PGSs and higher achievement, indicating a correlation rather than an interaction between genetic and environmental influences on academic achievement,” the researchers wrote.

Mental Health & ADHD

The study confirmed strong correlations between cognitive and non-cognitive genetic factors and their links to psychiatric, personality, and socioeconomic traits. But non-cognitive skills played a bigger role in certain outcomes, like mental health. The disparity between genetic factors was more pronounced for certain psychiatric traits, such as autism and ADHD, compared to earlier studies.³

Some studies suggest mental health conditions are influenced by the same genetic factors. A study published in Nature in 2023 and covered by ADDitude found that 84% to 98% of common genetic variants tied to ADHD seemed to influence other psychiatric disorders, including autism, depression, and schizophrenia.⁴ Genetic research has also linked ADHD to emotion regulation and motivation.⁵

“One of the main areas of the brain affected by the genetics of ADHD is the reward center — in particular, the transmission of a chemical called dopamine. The neurons in the brain of a person with ADHD act differently…They need higher levels of stimulation from their environment,” said Maggie Sibley, Ph.D., in her 2022 ADDitude webinar “My Teen with ADHD Lacks All Motivation! How to Build Executive Function Skills and Drive.”

“You can see that translating into prominent motivation difficulties in kids with ADHD,” Sibley said.

Limitations and Future Research

Targeted interventions that build non-cognitive skills could benefit children with relative social and emotional weaknesses, including those with ADHD. But more research is needed to understand how non-cognitive skills develop. Future studies should focus on the association between these and academic achievement.

Sources

¹ Malanchini, M., Allegrini, A.G., Nivard, M.G. et al. (2024). Genetic associations between non-cognitive skills and academic achievement over development. Nat Hum Behav. https://doi.org/10.1038/s41562-024-01967-9

² Jaffee, S., & Price, T. (2007). Gene–environment correlations: a review of the evidence and implications for prevention of mental illness. Mol Psychiatry, 12, 432–442. https://doi.org/10.1038/sj.mp.4001950

³ Demange, P. A. et al. (2021). Investigating the genetic architecture of noncognitive skills using GWAS-by-subtraction. Nat. Genet., 53, 35–44. https://doi.org/10.1038/s41588-020-00754-2

⁴ Demontis, D., Walters, G. B., Athanasiadis, G., Walters, R., Therrien, K., Nielsen, T. T., … Børglum, A. D. (2023). Genome-wide analyses of ADHD identify 27 risk loci, refine the genetic architecture and implicate several cognitive domains. Nature Genetics, 55(2), 198–208. https://doi.org/10.1038/s41588-022-01285-8

⁵ Merwood, A., Chen, W., Rijsdijk, F., Skirrow, C., Larsson, H., Thapar, A., Kuntsi, J., & Asherson, P. (2013). Genetic association between the symptoms of attention‐deficit/hyperactivity disorder and emotional lability in child and adolescent twins. Journal of the American Academy of Child and Adolescent Psychiatry, 53(2), 209‐220. https://doi.org/10.1016/j.jaac.2013.11.006

At the same time, the medical community has its work cut out for it. We’ve barely begun to scratch the surface on ADHD and autism — conditions with strikingly similar traits and challenges that also happen to co-occur at significant rates. We primarily understand these conditions in white males, and we have a long way to go to ensure that women, people of color, and gender-diverse individuals are represented in research and published findings.

As our understanding of ADHD, autism, and neurodivergence evolves, I share my insights on where we are and where the field should be headed.

1. Most Providers Are Not Trained in ADHD or Autism

My first introduction to diagnosing and supporting ADHD and autism wasn’t until my pre-doctoral internship, after I had already spent four years in graduate school. A lot of what I have learned since then about ADHD and autism has been through clinical experience with patients and ongoing self-education.

Until 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM) did not even allow for co-diagnosis of both ADHD and autism. With the publication of DSM-5 that year came significant changes to the diagnostic criteria for both conditions.

[Get This Free eBook: The Truth About Autism in Adults]

• Autism spectrum disorder was once divided into several distinct disorders, including autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). The DSM-5 consolidated these categories into a single diagnosis: autism spectrum disorder.
• With the DSM-5, the age by which ADHD symptoms must be present to qualify for a diagnosis changed from age 7 to age 12. Additionally, the DSM-5 said adults need to show five symptoms of inattention and/or hyperactivity/impulsivity, compared to the six required by children for diagnosis. These and other changes have helped to capture more girls and women in the diagnostic process.

That ADHD and autism were kept separated for so long invariably affected clinical work and research, which we are still working to rectify. Neurodevelopmental conditions are not a standard part of medical training in the first place, and many medical providers, especially those who have not sought training in these conditions, remain unaware of how the diagnostic categories have evolved and how to diagnose and support these conditions.

2. The ADHD-Autism Overlap Is Significant — and Seriously Under-recognized

Autism and ADHD are highly comorbid and share a staggering number of traits and symptoms, many of which are not reflected in diagnostic criteria for either condition.

Autism and ADHD: Shared Symptoms, Traits, and Challenges

• inattention to non-preferred tasks; hyperfocus on interests
• hyperactivity and restlessness
• impulsivity
• executive dysfunction (manifested by issues with organization, time management, planning, etc.)
• hypo or hypersensitivity to sensory input
• social and communication issues, including fear of rejection
• inflexibility; difficulty with change and transitions
• emotional dysregulation; meltdowns
• sleep problems
• self-esteem issues
• anxiety
• masking
• perfectionistic tendencies
• dichotomous, all-or-nothing thinking

[Read: “A Living Contradiction” — the AuDHD Experience]

While distinct, multidimensional, and complex conditions, ADHD and autism overlap so much that I sometimes view them along the same spectrum. This does not mean that I think everyone who has ADHD is also autistic, or the inverse. It’s just that, when we look closely, we see that a vast number of people with ADHD frequently exhibit autistic traits, and vice versa.

As clinicians, we need to educate ourselves beyond the basic mechanics of diagnosis for either condition, seek experience and supervision when necessary, and include clinical judgment in our decision-making matrices. We cannot rely only on test or scores. We need to learn about behaviors and traits that we know clinically exist in both ADHD and autism but may not be currently reflected in diagnostic criteria.

3. ADHD and Autism Are Routinely Overlooked in Girls and Women

Boys are more likely than girls to be diagnosed with ADHD and autism. Girls and women, who often display more subtle, internalizing symptoms, tend to be overlooked because clinicians and researchers largely continue to view these conditions from a male-centric view. Female manifestations of either condition are often misdiagnosed, misinterpreted, and normalized. Gender and societal norms also mean that girls and women are more likely to overcompensate and mask their symptoms and challenges of ADHD and/or autism.

To understand female presentations and potential signs of neurodivergence (e.g., emotional dysregulation, low self-esteem, overwhelm, perfectionism, social anxiety) clinicians must take a different, nuanced approach when evaluating girls and women for ADHD and/or autism. It can be helpful to see patients across multiple sessions during the diagnostic process and ask about functioning in different settings.

4. How We Talk About Autism and Neurodiversity Matters Greatly

• Be the paradigm shift. Changes are underway in how we collectively understand autism, ADHD, learning differences, and other neurodevelopmental conditions. We see this in the growing use of the term “neurodivergence” — language that aims to normalize and de-stigmatize, not pathologize, differences in thinking and functioning. While we must pay attention to medicalized and pathologized language, we must also retain the idea that neurodivergent individuals may need specific kinds of support, especially if their symptoms and traits interfere with functioning and cause distress.
• Identity-first vs. person-first language. Individuals can label themselves however they want to. But many autistic individuals — viewing autism as a fundamental part of their identity that shapes all aspects of life — prefer identity-first language over person-first language. That is, most of the time, people want to be referred to as “autistic,” not as “having autism.” With ADHD, however, person-first language appears to dominate. Patients may feel more respected when they hear medical professionals use these terms.
• The medical community must listen to patients. Understanding — not undermining — the lived experiences of those who live with ADHD and/or autism is critical. The experiences, traits, symptoms, and challenges of our patients do not always align with textbook definitions and available research findings, and firsthand accounts can offer a more accurate and comprehensive understanding of these conditions. Listening to patients helps us appreciate the nuances and variations in symptoms and offer personalized treatment plans. When patients feel heard and respected, they are more likely to engage in their care and advocate for themselves, leading to better outcomes.

5. Those Who Don’t Diagnose Still Play a Role

Licensed and trained medical and mental health providers who specialize in neurodevelopmental conditions can properly and comprehensively evaluate, diagnose, and treat ADHD and/or autism. It also bears repeating that those outside of healthcare— a patient’s family members, friends, teachers, and so on — absolutely cannot diagnose or treat these conditions.

And yet, non-specialists and those outside of healthcare still hold tremendous influence over a patient’s outcomes. Pediatricians and primary care providers, regardless of specialization in ADHD or autism, should be able to notice signs of these conditions, perform preliminary screenings, and refer patients to specialists. At the same time, family, friends, and teachers are often first to notice if someone is exhibiting signs that would warrant speaking to a medical professional. These individuals are often part of the clinical evaluation process.

While important people in a patients’ lives can serve as catalysts for diagnosis and support, they can also derail the process, especially when they are uninformed or misinformed about ADHD and autism. Family, friends, teachers, and even medical providers may miss the signs. Even worse, they can deny them, which can cause harm by derailing the path to evaluation and diagnosis on a child, adolescent, or adult’s health journey. Without a label or diagnosis, neurodivergent individuals are at greater risk of mental health issues, lack of appropriate and needed supports, and co-occurring issues like depression, anxiety, and self-harm.

My suggestion to all non-specialists and those outside of medicine: Don’t put individuals in a position where they begin to doubt themselves and their health providers. Instead, be curious. Educate yourself and ask how you can be supportive. Listen and be respectful of peoples’ experiences.

6. We Need to Pay Close Attention to Gender-Diverse Populations

Research is beginning to uncover what many clinicians and patients have observed: That gender diversity is present more frequently in autistic individuals and in those with ADHD.^{1 2} To be clear, research is limited in this area.

Nonetheless, his is an important connection because gender-diverse populations are already vulnerable to mental health issues — from depression and anxiety to self-harm and loneliness — due to stigma, discrimination, and social rejection. Living with ADHD or autism can compound these challenges.

The association between gender diversity and neurodivergence shines a light on the importance of inclusive, affirming care among ADHD and autism specialists. This includes asking patients for their pronouns, updating intake forms to include more gender options, self-monitoring for gender bias, and committing to ongoing education, among other approaches. Clinicians must also be careful about diagnostic overshadowing, whereby a patient’s emotional and behavioral issues are attributed to their experiences related to gender identity as opposed to other co-occurring conditions. As all of available studies on ADHD and autism are based on binary gender, researchers should include gender diverse options in studies and testing.

7. Social Media Can Open the Door to Understanding

There is a lot of misinformation on social media, and we should always view what’s online through a critical lens.

That being said, there is also lots of excellent, valid, and vital discussion online around the neurodivergent experience. On social media, individuals speak openly about their lived experiences with ADHD and/or autism — conversations that create transformative communities of understanding, friendship, support, and belonging while helping the undiagnosed begin to put a name to their experiences. (It’s my view that conversations in these spaces have and will continue to inform research on ADHD, autism, and neurodivergence.) From a health equity perspective, these online spaces offer support when access to evaluations, treatments, and health insurance is difficult.

As medical providers, we should refrain from making blanket statements about the “harms” of social media when it is a tool that has helped many. At the same time, patients should remember that people online are sharing their own unique experiences that may not apply to others. All-or-nothing statements about ADHD and autism should raise an eyebrow or two, as should anything that is offered as a “cure” for neurodivergence.

The ADHD-Autism Overlap: Next Steps

• Take This Self-Test: Female Autism Test — “Am I Autistic?”
• Autism in Kids Self-Test: Early Signs of ASD
• Free Download: Autism Evaluation Checklist
• Read: Stop Fighting Your Child’s Neurodiversity

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “AuDHD Guidance: Why Autism is So Difficult to Diagnose in Women and Girls with ADHD” [Video Replay & Podcast #511] with Karen Saporito, Ph.D., which was broadcast on June 27, 2024.

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Sources

¹ Warrier, V., Greenberg, D. M., Weir, E., Buckingham, C., Smith, P., Lai, M. C., Allison, C., & Baron-Cohen, S. (2020). Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nature communications, 11(1), 3959. https://doi.org/10.1038/s41467-020-17794-1

² Kahn, N. F., Sequeira, G. M., Garrison, M. M., Orlich, F., Christakis, D. A., Aye, T., Conard, L. A. E., Dowshen, N., Kazak, A. E., Nahata, L., Nokoff, N. J., Voss, R. V., & Richardson, L. P. (2023). Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents. Pediatrics, 152(2), e2023061363. https://doi.org/10.1542/peds.2023-061363

Vyvanse and its generic equivalents (lisdexamfetamine dimesylate) may be more readily available at pharmacies following a decision by the Drug Enforcement Administration (DEA) to allow expanded production of the stimulant medication used to treat ADHD and moderate-to-severe binge-eating disorder (BED) in adults. About one-quarter of the 24% (6,236 kg) production increase in lisdexamfetamine will address domestic demand, and the remaining 75% will address foreign demand.¹

“These adjustments are necessary to ensure that the United States has an adequate and uninterrupted supply of lisdexamfetamine to meet legitimate patient needs both domestically and globally,” the DEA said in a letter on September 5.

The DEA’s decision arrives amid a stimulant shortage that has disrupted treatment for millions of patients with ADHD for nearly two years. The U.S. Food and Drug Administration (FDA) first reported a shortfall of Adderall (the brand name for the immediate-release formulation of amphetamine mixed salts used to treat ADHD) due to manufacturing delays at Teva Pharmaceutical Industries in October 2022. The nationwide Adderall shortage triggered a domino effect, with ADHD patients struggling to fill prescriptions for other stimulant medications, such as Vyvanse and Ritalin.

In August 2023, the FDA granted approval for 15 manufacturers to produce generic Vyvanse capsules and chewable tablets after Takeda Pharmaceuticals’ U.S. patent for the medication expired.² (The FDA stipulates that generic ADHD medications contain exactly the same active ingredients as their name-brand counterparts; however, compounds in generic drugs are allowed to include different binding chemicals, fillers, and colors.) However, one year later, the promise of generic Vyvanse has done little to ease the stimulant shortfall.

As of September 9, the American Society of Health-System Pharmacists (ASHP) reported lisdexamfetamine dimesylate capsule shortages among nine drug manufacturers. Eight attributed the shortage to an “issue with the active ingredient.”

Controversy Surrounding APQs

The DEA sets yearly aggregate production quotas (APQs) for stimulant medications, which are classified as Schedule II controlled substances due to their high potential for abuse. The process has drawn the ire of many drug manufacturers, clinicians, and patients with ADHD, who cite production limits as the main reason for the stimulant shortage.

“The DEA is the only governmental agency that sets production and distribution quotas for every drug company manufacturing controlled medication,” William Dodson, M.D., LF-APA, wrote in an ADDitude Op-Ed earlier this year. “The DEA decides how much of each medication can be released to pharmacies in any given month. Therefore, this problem traces its roots and long tendrils back to the DEA alone. No other agency has the authority to create and prolong it.

“This process tries to predict in March of 2024 how much medication will be needed 21 months later in December of 2025,” Dodson continued. “It is a crude and inadequate system that the DEA is too inflexible to relinquish.”

Stimulant Drug Manufacturers Speak Out

Mounting frustration over the stimulant shortage has begun influencing some positive change.

The public comment period for the DEA’s “Proposed Aggregate Production Quotas for Schedule I and II Controlled Substances” drew 4,699 comments, according to The Federal Register. (Last year, the DEA received 357 comments.)

Commentators included patients with ADHD, drug manufacturers, members of U.S. and Australian professional associations, representatives from the Royal Australian and New Zealand College of Psychiatrists, and others. They expressed concerns about the ongoing ADHD medication shortage and the DEA’s lack of transparency in setting quotas, among other issues. ³

In response, the DEA said it is “considering methods that might increase transparency in its quota-setting process,” including public notification and an opportunity for public input when prescribing rates for controlled substances substantially deviate from FDA’s estimate of medical needs. The agency is also considering regulatory changes to gain access to more real-time data, such as monthly updates in the Automated Reports and Consolidated Ordering System (ARCOS), a database where manufacturers and distributors report their controlled substances transactions to the DEA.

However, an association representing drug manufacturers asserted that the DEA’s practice of allocating procurement quotas based on a company’s historical drug sales disadvantages generic lisdexamfetamine drug manufacturers because they lack an established sales history.

The DEA disputed the claim. “DEA has always been cognizant that new manufacturers entering the market for the first time would not have any established sales history, and thus the manufacturer’s past sales history is not a factor when determining the quota needed to launch a new product,” it said in the January 3 issue of The Federal Register.³

The federal agency also denied that APQs are causing the stimulant shortage. “The DEA utilizes the available, reliable data and information received by the agency at the time APQs are proposed and proactively monitors drug production, distribution, and supply during the year,” it said. “Drug shortages may occur subsequently due to factors outside of DEA control such as manufacturing and quality problems, processing delays, supply chain disruptions, or discontinuations.”

Drug manufacturers’ hands are not necessarily tied after the DEA releases its yearly APQs. Any DEA-registered manufacturer may apply for an increase in the manufacturing quota for a basic class of controlled substance in Schedule I or II throughout the year. The DEA must review such requests within 30 days of receipt.

The decision to raise the APQs of name brand and generic Vyvanse came at the behest of the FDA and a DEA-registered manufacturer earlier this summer. In October 2023, the DEA raised the production limits of methylphenidate (brand names: Ritalin, Concerta) by 27% after receiving requests from the FDA and a DEA-registered drug manufacturer.

It is too early to tell if the expanded Vyvanse APQs will inspire more DEA-registered drug manufacturers to request quota reviews. In the meantime, the increased production of Vyvanse and its generic equivalents will promise welcome relief to the estimated one million Americans regularly taking the stimulant.

Vyvanse was the most popular prescription stimulant, according to ADDitude’s 2023 treatment survey. Nearly one-quarter of respondents said they (or their child) were taking Vyvanse to treat ADHD symptoms, outnumbering other prescription stimulants used by ADDitude readers, including Concerta (15%), Adderall (15%), Adderall XR (13%), and Ritalin (10%).

Among ADDitude survey respondents taking Vyvanse, 44% said the medication is extremely or very effective at treating their ADHD symptoms.

“Vyvanse has, without exaggeration, changed my life and made me into the kind of person I’ve always wanted to be,” one survey respondent said.

Sources

¹Adjustment to the Aggregate Production Quota for Lisdexamfetamine and dAmphetamine (for Conversion) for 2024. Drug Enforcement Administration. The Federal Register. September 5, 2024. https://public-inspection.federalregister.gov/2024-20114.pdf

²FDA Approves Multiple Generics of ADHD and BED Treatment. FDA. Published August 28, 2023. Accessed August 28, 2023. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-multiple-generics-adhd-and-bed-treatment?utm_medium=email&utm_source=govdelivery

³Established Aggregate Production Quotas for Schedule I and II Controlled Substances and Assessment of Annual Needs for the List I Chemicals Ephedrine, Pseudoephedrine, and Phenylpropanolamine for 2024. Drug Enforcement Administration. The Federal Register. January 3, 2024. https://www.federalregister.gov/documents/2024/01/03/2023-28962/established-aggregate-production-quotas-for-schedule-i-and-ii-controlled-substances-and-assessment