Methylphenidate and atomoxetine use do not increase a pregnant woman’s risk for miscarriage or congenital anomalies in the fetus, finds a new systematic review and meta-analysis published in JAMA Network Open.¹

The review included 10 studies involving 16.5 million pregnant women from 6 countries. It is the first study to compare pregnant women with ADHD who took methylphenidate or atomoxetine with pregnant women with ADHD who did not take these medications, as well as with pregnant women who did not have ADHD or take these medications.

The study, which helps to fill in the gaps of a still-evolving research landscape, has critical implications for millions of women of reproductive age. Medications for ADHD including atomoxetine and methylphenidate are classified by the FDA as “pregnancy category C,” indicating a lack of controlled studies. As a result, no definitive guidelines yet exist for prescribers, though recent research has demonstrated that many ADHD medications are safe for use in pregnancy. In 2020, a qualitative review of eight studies found “no convincing evidence to indicate that prenatal exposure to ADHD medication results in clinically significant adverse effects.”² In 2023, a large population-based register study concluded that taking ADHD medication, including stimulants, while pregnant does not impact the neurodevelopment or growth of the fetus.³

Historically, some research has suggested that using certain ADHD medications during pregnancy may pose risks to the fetus. One such study from 2018 found a slight association between the use of methylphenidate (though not amphetamine) and some cardiac malformations in infants.⁴

More recent research focused on maternal health has revealed that continued use of ADHD medication during pregnancy may have protective effects for mothers. A 2022 study published in Frontiers in Reproductive Health found that women with ADHD who were unmedicated during pregnancy were significantly more likely than their non-ADHD counterparts to experience adverse health outcomes including depressive episodes, postpartum depression, gestational hypertension, and cardiac disease. Pregnant women with ADHD who took medication, stimulants or non-stimulants, demonstrated lower risks of these conditions.⁵

ADHD and Pregnancy: Further Research Needed

According to a recent ADDitude survey, just 2% of readers who have been pregnant reported taking ADHD medication during their pregnancies. For some, this was true because their pregnancy pre-dated their ADHD diagnosis; others said they were concerned about the impact of ADHD medications on fetal health. While some readers found the hormonal changes of pregnancy led to an improvement in ADHD symptoms, many encountered the opposite.

“I went through both pregnancies and breastfeeding without my ADHD medication and it was very difficult, especially when I was working while continuing college classes,” says Chrissy, an ADDitude reader in Pennsylvania. “Brain fog and tiredness loomed over me the entire time, which became frustrating and depressing at times, despite staying on my depression medication.”

“I was diagnosed after the birth of my second child,” recounts Daniela, an ADDitude reader in Italy who now takes medication. “So, I was a mess during my first pregnancy with more forgetfulness, more mood swings, and raging paranoia.”

While the new JAMA Network study contributes an important piece to the puzzle of ADHD medication use during pregnancy, the full picture remains incomplete. The investigators explain the study’s limitations include the nonspecific definition of “congenital anomaly” and potential confounding variables related to ADHD severity. “Further studies are needed to support pregnant women with ADHD in facing a comfortable pregnancy,” the authors write.

Sources

¹di Giacomo E, Confalonieri V, Tofani F, Clerici M. Methylphenidate and Atomoxetine in Pregnancy and Possible Adverse Fetal Outcomes: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024;7(11):e2443648. doi:10.1001/jamanetworkopen.2024.43648

²Li  L, Sujan  AC, Butwicka  A,  et al.  Associations of prescribed ADHD medication in pregnancy with pregnancy-related and offspring outcomes: a systematic review.  CNS Drugs. 2020;34(7):731-747. doi:10.1007/s40263-020-00728-2

³Madsen, K. B., Robakis, T. K., Liu, X., Momen, N., Larsson, H., Dreier, J. W., … Bergink, V. (2023). In utero exposure to ADHD medication and long-term offspring outcomes. Molecular Psychiatry, 1–8. doi: 10.1038/s41380-023-01992-6

⁴Huybrechts KF, Bröms G, Christensen LB, et al. Association Between Methylphenidate and Amphetamine Use in Pregnancy and Risk of Congenital Malformations: A Cohort Study From the International Pregnancy Safety Study Consortium. JAMA Psychiatry. 2018;75(2):167–175. doi:10.1001/jamapsychiatry.2017.3644

⁵Walsh, C. J., Rosenberg, S. L., & Hale, E. W. (2022). Obstetric complications in mothers with ADHD. Frontiers in reproductive health, 4, 1040824. https://doi.org/10.3389/frph.2022.1040824

The upshot? Most of the survey respondents said they wish they’d started medication sooner.

Here, ADHD families share their stories of starting stimulants and non-stimulants.

“We were reluctant to use medication but decided to give it a go as our son reached an age when he could tell us if he felt it made a difference. He asked for the tablet the second day because he felt a change in his ability to concentrate.”

“I was reluctant to try medication at first, given the frightening reputation of amphetamines, but my psych provider encouraged me to look past the headlines and investigate the decades of research on stimulants and their effect on ADHD. I was reassured, took the meds, and never looked back.”

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

“For anyone out there who thinks, ‘I don’t want medication. I can treat ADHD without it,’ you’re probably wrong. I have more self-control than I’ve ever had. Maybe medication isn’t for everyone, but you’ll never know what it can do if you don’t try. Start with a very low dose if you’re nervous. Also, a balanced diet, sleep, and proper supplements have a huge impact on symptoms.”

“I had fears about how meds would affect my teenage son, so after he lost weight on the first couple of stimulants he tried, we were ready to try a non-stimulant. He’s been on it for about two months, and so far, so good.”

“By the time our son was in first grade, he was struggling every single day and was being corrected and fussed at by pretty much every adult in his life. We got him diagnosed, but my husband was adamantly against ADHD medication. The fact is, if our child had cancer or diabetes, we wouldn’t be withholding medication. My son started medication and it was absolutely the best thing we could have done for him. I only wish we’d started it earlier.”

“I wish doctors approached stimulant medications with less fear, particularly around cardiovascular risk. The willingness of at least some doctors to sacrifice treatment for ADHD, a lifelong and potentially harmful condition, in favor of a slightly lower perceived cardiac risk is a real impediment to effective treatment.”

Should I Take ADHD Medication? Next Steps

• Free Download: What to Ask Before Starting ADHD Medication
• Watch: Medication Strategies for Hard-to-Treat Complex ADHD
• Read: How Does ADHD Medication Work?
• Read: Your Top 10 Questions About ADHD Medications for Children

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Women with ADHD can continue using the stimulant medication dexamphetamine and the painkiller acetaminophen (brand name: Tylenol) during pregnancy, according to two recent studies that refute a long-standing medical consensus.

An observational study published in the Archives of Women’s Health found that use of dexamphetamine (DEX), the main ingredient in brand-name ADHD medications such as Adderall, Dexedrine, Zenzedi, and ProCentra, does not put women or their babies at increased health risks. However, women who ceased using DEX during pregnancy were more than twice as likely to have a threatened abortion (mild to moderate bleeding during the first trimester) compared to those who continued DEX or who did not use the stimulant during pregnancy.¹

“This could indicate a possible association with DEX withdrawal,” the study’s authors wrote. “However, this is something that requires further investigation due to the small sample size, difficulties examining timing, and the inability to examine spontaneous abortion.”

The researchers analyzed a cohort of 1,688 women diagnosed with ADHD who gave birth in Western Australia between 2003 and 2018. Of the participants, 65% (547) ‘continuers’ took dexamphetamine throughout their pregnancy; 35% (297) ‘ceasers’ stopped using DEX before the end of the second trimester. A matched ‘unexposed’ group of 844 women had prescriptions for dexamphetamine before but not during pregnancy.

The three groups shared similar maternal health and labor and delivery characteristics, such as the onset of labor and delivery method. Complications during pregnancy, such as threatened pre-term labor, premature rupture of membranes, and bleeding in the second trimester, did not differ between the ‘ceasers’ and the ‘unexposed.’

Compared to the ‘continuers’ and ‘ceasers,’ the ‘unexposed’ group had a lower risk of:

• preeclampsia
• hypertension
• postpartum hemorrhage
• neonatal special care unit admittance
• fetal distress

While the findings illustrate the possible benefits of ceasing DEX before conception, the study’s authors noted that discontinuing ADHD medication puts pregnant people with ADHD at a higher risk for depression, anxiety, feelings of isolation, and family conflict. ²

“The results indicated that continuing to take dexamphetamine did not put women or their babies at increased health risks,” said Dani Russell, the study’s lead author, and a Ph.D. student from the University of Western Australia School of Population and Global Health. “Pregnancy can be a really stressful period for women with ADHD, so it is good to know that stopping their medication during pregnancy may not always be necessary.”

This research is part of a larger body of work investigating different ADHD treatments during pregnancy. The study’s authors said that more investigations are needed on the topic.

Acetaminophen Use in Pregnancy Not Linked With ADHD

A new study published in JAMA found that acetaminophen exposure during pregnancy does not increase the risk of autism, ADHD, or intellectual disability in children; however, factors such as genetics and the environment do. ³ This is the largest nationwide cohort study to date on acetaminophen usage during pregnancy. The study challenges prior research claiming that acetaminophen exposure during pregnancy may increase the risk of neurodevelopmental disorders in children. ⁴, ⁵

Scientists from the Karolinska Institute of Sweden and Drexel University’s Dornsife School of Public Health analyzed the prenatal and medical records of nearly 2.5 million children born in Sweden from 1995 to 2019, with follow-up through 2021. Of the 185,909 children exposed to acetaminophen in pregnancy, nearly 9% were diagnosed with autism, ADHD, or an intellectual disability, compared to about 7.5% of children whose mothers did not use the medication while pregnant. Children exposed to acetaminophen had marginally higher rates of diagnoses compared to those not exposed (1.53% vs. 1.33% for autism, 2.87% vs. 2.46% for ADHD, and 0.82% vs. 0.70% for intellectual disability).

The research team used the same database to conduct a second study focused on pairs of siblings whose mothers used acetaminophen during one pregnancy but not the other. This sibling control analysis found no evidence of increased risk of autism, ADHD, or intellectual disability associated with acetaminophen use during pregnancy.

“Associations observed in models without sibling control may have been attributable to confounding,” they wrote. “Results suggested that there was not one single ‘smoking gun’ confounder, but rather that multiple birthing parents’ health and sociodemographic characteristics each explained at least part of the apparent association.”

The study found acetaminophen had similar risks for neurodevelopmental disorders as non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and anti-migraine medicines. (The FDA recommends against using NSAIDs, such as Aspirin and Ibuprofen, in the third trimester of pregnancy because they may cause a blood vessel in the fetus to close prematurely.)

The researchers said that, despite the study’s large sample size and long duration, their reliance on self-reported and prescription dispensing data introduced several limitations. Still, these findings coincide with the American College of Obstetricians and Gynecologists, which maintains that acetaminophen is safe for pregnant women to use.

The Archives of Women’s Health and JAMA studies highlight the importance of pre-conception or early pregnancy counseling, individualized treatment plans, and medication management and recommend that patients discuss all medication decisions with their doctor.

Sources

¹ Russell, D.J., Wyrwoll, C.S., Preen, D.B. et al. (2024). Investigating Maternal and Neonatal Health Outcomes Associated with Continuing or Ceasing Dexamphetamine Treatment for Women with Attention-Deficit Hyperactivity Disorder During Pregnancy: A Retrospective Cohort Study. Arch Womens Ment Health. https://doi.org/10.1007/s00737-024-01450-4

²Damer, E.A., Edens, M.A., van der Loos, M.L.M., van Esenkbrink, J., Bunkers, I., van Roon, E.N., Ter Horst, P.G.J. (2021). Fifteen Years’ Experience with Methylphenidate for Attention-Deficit Disorder During Pregnancy: Effects on Birth Weight, Apgar Score and Congenital Malformation Rates. Gen Hosp Psychiatry. https://doi.org/10.1016/j.genhosppsych.2021.09.003

³Lee, B.K., et al. (2024). Acetaminophen Use During Pregnancy and Children’s Risk of Autism, ADHD, and Intellectual Disability. JAMA. https://doi.org/10.1001/jama.2024.3172

⁴Ji, Y., et al. (2019). Association of Cord Plasma Biomarkers of In Utero Acetaminophen Exposure with Risk of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in Childhood. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2019.3259

⁵Bauer, A.Z., Swan, S.H., Kriebel, D. et al. (2021) Paracetamol Use During Pregnancy — A Call for Precautionary Action. Nat Rev Endocrinol. https://doi.org/10.1038/s41574-021-00553-7

Treating ADHD with medication can lower overall risk of mortality and of hospitalizations, both psychiatric and non-psychiatric, according to two new 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.

Lower Risk of Death from All Causes

An observational study from Sweden, published in JAMA, followed nearly 150,000 adults and adolescents with a diagnosis of ADHD, tracking participants for two years following diagnosis.

The researchers found that use of ADHD medication:

• Reduced overall risk of death by 19%: Among people with ADHD who did not receive medication, there were 48 deaths for every 10,000 people, contrasted with 39 deaths per 10,000 people within the medicated cohort.

• Reduced risk of overdose by 50%: Medication use also reduced the risk of death from other unnatural causes, including accidental injuries, accidental poisoning such as drug overdoses, and suicide. This trend was particularly pronounced among men and significant in the category of accidental poisoning, where risk of death was lowered by almost 50%.

• Reduced risk of death from natural causes for women: ADHD medication use reduced the risk of death from natural causes, such as medical conditions, for women. Though it did not reduce this risk for men, medication use did not increase risk either. This is an important finding that may alleviate long-standing worries about the impact of stimulant use on cardiovascular health, among other concerns.

While the authors of the study caution that these findings show correlation, not causation, the results are encouraging for patients and clinicians with reservations about ADHD medication use, especially later in life.

Fewer Hospitalizations

A second Swedish study sought to investigate the effect of a variety of ADHD medications on rates of hospitalizations. Published in JAMA Network Open, the cohort study used nationwide medical and administrative databases to identify 221,000 people with ADHD, 56% of whom had a psychiatric comorbidity including anxiety or stress-related disorder (24%), and depression or bipolar disorder (20%). These individuals were then followed for up to 15 years.

The study found that a patient’s use of amphetamine, lisdexamphetamine, dexamphetamine, and/or methylphenidate significantly lowered the risk of:

• Suicidal behavior
• Psychiatric hospitalization
• Non-psychiatric hospitalization

Untreated ADHD in Adults Leads to “Dire Consequences”

The authors of the study featured in JAMA Network Open believe that the decrease in hospitalizations reflects the fact that ADHD medication use is associated with decreased risk for suicide attempts,³ substance use disorder,⁴ depression,⁵ car accidents,⁶ and unintentional injuries.⁷

“Impulsivity in adults can lead to dire consequences. The idea is that by improving impulsiveness and executive functioning, people are able to make better decisions,” explains Frances Levin, M.D., author of the JAMA editorial “Treating Attention-Deficit/Hyperactivity Disorder Matters,” ⁸ in a recent interview. “If you’re dealing with a substance use disorder (SUD) population, treating the ADHD allows them to better utilize clinical treatment for their SUD, and therefore reduce their risk of substance use and reduce accidental poisoning or overdose.”

“A Significant Public Health Problem”

The mortality risk study emphasizes the importance of treating ADHD, Levin explains: “Unlike other conditions, there’s often a sense that ADHD is over-hyped or it’s not a big deal, but this article demonstrates that this group is at higher risk of having both substantial morbidity as well as mortality.”

ADHD expert Russell A. Barkley, Ph.D., echoes this sentiment, stressing that ADHD is the number one factor affecting mortality for people with the condition. In other words, ADHD is not just a mental health issue; it’s a significant public health problem.

Barkley published a study in the Journal of Attention Disorders that found adults with ADHD could expect an 11- to 13-year reduction in life expectancy compared to neurotypical peers of a similar age and health profile.⁹

However, most of the ADHD-related factors impacting life expectancy — impulsivity, risky behavior, and inattention, to name a few — can be improved with interventions. Behavioral programs designed to improve overall health will also improve life expectancy, but only if ADHD symptoms are under control first, Barkley says. That requires more accurate diagnosis and more thoughtful treatment.

“When adults ask me questions about why they should try medication to manage their ADHD, my answer always comes down to two words: Medication works,” Barkley says in the ADDitude article, “Adult ADHD Treatment Options.” “When you find the right medicine, you can experience substantial improvements in your ADHD symptoms.”

Sources

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

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

³ Chang  Z, Quinn  PD, O’Reilly  L,  et al.  Medication for attention-deficit/hyperactivity disorder and risk for suicide attempts. Biol Psychiatry. 2020;88(6):452-458. doi:10.1016/j.biopsych.2019.12.003PubMedGoogle ScholarCrossref

⁴ Chang  Z, Lichtenstein  P, Halldner  L,  et al.  Stimulant ADHD medication and risk for substance abuse.  J Child Psychol Psychiatry. 2014;55(8):878-885. doi:10.1111/jcpp.12164PubMedGoogle ScholarCrossref

⁵ Chang  Z, D’Onofrio  BM, Quinn  PD, Lichtenstein  P, Larsson  H.  Medication for attention-deficit/hyperactivity disorder and risk for depression: a nationwide longitudinal cohort study. Biol Psychiatry. 2016;80(12):916-922. doi:10.1016/j.biopsych.2016.02.018PubMedGoogle ScholarCrossref

⁶ Chang  Z, Quinn  PD, Hur  K,  et al.  Association between medication use for attention-deficit/hyperactivity disorder and risk of motor vehicle crashes.  JAMA Psychiatry. 2017;74(6):597-603. doi:10.1001/jamapsychiatry.2017.0659ArticlePubMedGoogle ScholarCrossref

⁷ Ghirardi  L, Chen  Q, Chang  Z,  et al.  Use of medication for attention-deficit/hyperactivity disorder and risk of unintentional injuries in children and adolescents with co-occurring neurodevelopmental disorders. J Child Psychol Psychiatry. 2020;61(2):140-147. doi:10.1111/jcpp.13136PubMedGoogle ScholarCrossref

⁸ Levin FR, Hernandez M, Mariani JJ. Treating Attention-Deficit/Hyperactivity Disorder Matters. JAMA. 2024;331(10):831–833. doi:10.1001/jama.2024.1755

⁹Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of Attention Disorders, 23(9), 907-923. https://doi.org/10.1177/1087054718816164

If your son is adamant about stopping ADHD medication to attempt to join the military right out of high school, then he (and you) needs to talk to his medical provider(s) and teachers to understand how to come off medication, monitor any adverse effects, and replace the treatment, if possible, with other supports and strategies. His doctor may recommend a plan for gradually titrating off medication, though that depends on your child’s circumstances.

In general, it’s not a good idea to abruptly stop medication, especially if it’s helping your child. He needs a plan in place well before he stops medication so he can learn how to manage ADHD while continuing to meet academic requirements and function outside of school, too. Working with a therapist who specializes in ADHD could really help him. An ADHD coach might be a good addition, too. Your son should also focus on building coping strategies to manage stress and emotional dysregulation. Executive functioning is another area to target, as is building healthy habits around nutrition, exercise, and sleep.

[Read: I Have ADHD. Is the Military Right for Me?]

The goal here is for your child to understand what it looks like to go for an extended time without medication. If he does go off medication, perhaps he can start in the summer when he’s not in school. That way, he’ll have time to adjust without it potentially affecting academic performance. (Then again, you’ll want to closely monitor what happens when school resumes.)

To be sure, medication use within 24 months of attempting to enlist is considered a disqualifying factor, according to Department of Defense military accession guidelines. (Some branches may be more flexible in this regard.) But it’s not the only disqualifying factor. Documentation of adverse academic performance is another one. The last thing your child wants, I’m sure, is to struggle academically — possibly compromising his chances of joining the military — as a result of coming off medication.

Another option is for your child to finish high school while on medication, and then take the next few years to learn how to manage ADHD at work without medication. This approach could eliminate concerns around reaching an important educational and life milestone. Besides, while in high school, he can still work on enhancing his coping skills, executive functioning, and establishing healthy habits all around as he enters adult life. After high school, he can find work and/or take college classes or technical training as he continues to learn how to cope without medication and truly test himself. Your child’s chances of enlisting in the military will improve if he’s able to demonstrate stability off medication.

Stopping ADHD Medication for Military Service: Next Steps

• Read: Can You Join the Military with ADHD?
• Read: Uncle Sam Wants You! (Maybe)
• Read: Can You Make It Without ADHD Medication?

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “Can You Join the Military with ADHD? What Hopeful Service Members Need to Know” [Video Replay & Podcast #457] with Brandi Walker, Ph.D., which was broadcast on June 1, 2023. The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.

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.

Long-term use of ADHD medications may increase the risk of cardiovascular disease (CVD) in children and adults, according to a new study published in JAMA Psychiatry.¹ However, ADHD experts caution against changing ADHD treatment based on these findings.

“The substantial improvement in ADHD impairments significantly outweighs the study’s risk, which is easily monitored and addressed by the prescribing clinician,” David W. Goodman, M.D., LFAPA, assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine, told ADDitude. “I hope that patients and prescribers don’t overemphasize the study’s findings by stopping effective medication or not prescribing when clinically indicated.”

The case-control study suggests that the potential for cardiovascular disease increases by an average of 4% each year a patient takes ADHD medication (stimulants and non-stimulants). The percentage rose to 23% for some people who used ADHD medication for more than five years compared with those who did not.¹

Patients who used methylphenidate (brand names: Ritalin, Concerta, Focalin, etc.) and lisdexamfetamine (brand name: Vyvanse) had a higher risk of hypertension and arterial disease compared with people who did not take ADHD medication. The non-stimulant medication atomoxetine (brand name: Strattera) was statistically significant only for the first year of use.

The study’s cohort comprised more than 278,000 individuals with ADHD, aged 6 to 64, identified from the Swedish National Inpatient Register and the Swedish Prescribed Drug Register. Researchers monitored the patients for hypertension, heart failure, arrhythmias, and ischemic, cerebrovascular, and thromboembolic diseases for an average of four and up to 14 years between 2007 and 2020. During the follow-up period, slightly less than 5% of the study’s cohort had received a CVD diagnosis.

“The conclusion of this study sounds really scary, but it’s not,” ADHD expert Russell A. Barkley, Ph.D., said on his YouTube channel, Weekly Research Update. “The vast majority [95%] had no risk for CVD. These small increases in CVD risk are well outweighed by the benefits of treatment compared to no treatment at all.”

Barkley considered an alternative explanation for the findings: “The study did not control in any way the severity of ADHD,” he said. “This is important because we know that the more severe your ADHD, the more likely you’re going to be prone to various cardiovascular problems, specifically hypertension, arterial disease, and so on. It is possible that people with more severe ADHD take medications for longer periods than people with less severe ADHD. So, it may not be the duration of medication use that’s the issue. Duration could be a marker for the severity of your disorder.”

Further, the observational nature of the study means that the researchers “could not prove causality” between ADHD medication and cardiovascular disease.

Peter Jensen, M.D., Founder of the REACH Institute, which trains clinicians in the diagnosis and treatment of mental health disorders in children, told ADDitude that patients in the JAMA Psychiatry study could have had co-occurring conditions like diabetes or obesity that raised their risk of cardiovascular disease.

“If a child diagnosed with ADHD has a family history of unusual heart rhythms, then it could make sense for that child to have an EKG before being prescribed a stimulant to manage symptoms. Otherwise, an EKG would not be necessary for children because the risk for a cardiac event is trivial,” he said, likening it to the odds of getting hit by lightning.

“This is what I’d say to parents of my patients: The impact of ADHD causes all kinds of problems if it’s untreated,” Jensen said. “School failure, substance use, and as an adult, not doing well in a job or getting fired, breakups in marriages — these are known risks when ADHD is not well managed.”

He said the JAMA Psychiatry study is relevant in older populations because the risk for cardiovascular disease generally increases with age. “But even then, I would say to my patients, ‘How’s your diet, exercise, sleep, other health habits?’ These are the risks (for heart problems) as best as we know. The study didn’t look at these things,” Jensen said. “The risk from stimulant use is basically less than the risk of being obese, of having sleep problems, and less than the risk of not getting regular exercise. So, if you’re thinking, what is the risk of cardiovascular disease? By far, obesity is worse than years of exposure to stimulants.”

Jensen headed up the National Institute of Mental Health study, the Multimodal Treatment of Children with ADHD (MTA), which followed nearly 600 children taking stimulants to manage symptoms for 16 years — from elementary school to young adulthood — beginning in 1992. He said those study findings detected no meaningful change in cardiovascular risk.²

In addition, a November 2022 meta-analysis of 19 observational studies from the last 15 years, including 3.9 million participants, found no statistically significant association between ADHD medications and cardiovascular disease, even among middle-aged and older adults. ³

That study, published in JAMA Network Open, was the most comprehensive systematic review and meta-analysis of longitudinal observational studies to date on the association between ADHD medication use and the risk of CVD and included patients from the United States, South Korea, Canada, Denmark, Spain, and Hong Kong.

The American Academy of Pediatrics (AAP) recommends treating ADHD in children and adolescents aged 6 to 18 with FDA-approved medications, plus parent training in behavior modification and behavioral classroom interventions. Research studies like this one conducted by scientists at McGill University have found that “stimulant medications are most effective, and combined medication and psychosocial treatment is the most beneficial treatment option for most adult patients with ADHD.” Patients should make all ADHD treatment decisions in consultation and coordination with a licensed medical provider.

The findings of the JAMA Psychiatry study underscore the importance of carefully weighing potential benefits and risks when making ADHD treatment decisions. “Clinicians should be vigilant in monitoring patients, particularly among those receiving higher doses, and consistently assess signs and symptoms of CVD throughout the course of treatment,” the researchers wrote.

Sources

¹Zhang, L., Li, L., Andell, P., et al. (2023) Attention-Deficit/Hyperactivity Disorder Medications and Long-Term Risk of Cardiovascular Diseases. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2023.4294

²Jensen, P.S., Hinshaw, S.P., Swanson, J.M., Greenhill, L.L., et al. (2001) Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): Implications and Applications for Primary Care Providers. J Dev Behav Pediatr. doi: 10.1097/00004703-200102000-00008

³Zhang, L., Yao, H., Li, L., et al. (2022). Risk of Cardiovascular Diseases Associated with Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2022.43597

by David W. Goodman, M.D., LFAPA

“ADHD is widely studied and recognized — except when it occurs in older adults. For a variety of reasons, research on ADHD in older age has historically lagged, resulting in a dearth of relevant diagnostic and treatment tools. Regardless of research deficits, it is abundantly clear that older adults with ADHD have unique needs and characteristics – including age-related cognitive changes, co-existing psychiatric and medical conditions, and more – that influence evaluation and treatment for the disorder.”

• Continue reading ADHD in Older Adults: Distinct Diagnostic and Treatment Considerations

2. What Is Inattentive ADHD? Symptoms, Characteristics, Diagnostic Considerations

by Mary V. Solanto, Ph.D.

“Individuals with inattentive type ADHD do not exhibit the stereotypical symptoms of ADHD — namely physical hyperactivity and impulsivity. Their executive dysfunction is easily blamed on carelessness or laziness, and their social struggles may be attributed to growing pains or character idiosyncrasies. All of this contributes to a chronic problem of underdiagnosis and inadequate treatment for inattentive type ADHD, particularly in girls and women.”

• Continue reading What Is Inattentive ADHD?

3. Why We Must Achieve Equitable ADHD Care for African American and Latinx Children

by Tumaini Rucker Coker, M.D., MBA

“As rates for ADHD diagnosis increase across the population, a growing body of literature highlights barriers to ADHD diagnosis and treatment – from the clinical level to systemic factors – that disproportionately impact children and adolescents of color. These inequities have created and deepened societal divides that put Black and Latinx children at greater risk of poor educational outcomes. Sufficiently addressing disparities in care starts with an understanding of why racial and ethnic imbalances matter, the roots of these inequities, and their consequences for overall health and well-being.”

• Continue reading Why We Must Achieve Equitable ADHD Care for African American and Latinx Children

4. Traumatic Stress Alongside ADHD: 5 Reasons Clinicians Need to Consider Trauma

by Michelle Frank, Psy.D.

“Traumatic stress and ADHD share significant associations, according to a growing body of research. Studies show that people with ADHD score higher than their neurotypical peers on the Adverse Childhood Experiences (ACEs) questionnaire, which measures the impact of negative, stressful, or traumatic events on well-being. This means that they are likely to report troubling events like domestic violence, caregiver substance abuse, physical or sexual abuse, neglect, mental illness, poverty, and community violence. Experiences of racism, discrimination, and oppression can also lead to trauma. So, what is the connection between trauma and ADHD? How do we tease apart the diagnoses? What do their similarities mean for symptoms, diagnosis, and treatment?”

• Continue reading Traumatic Stress Alongside ADHD

5. ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks

by Stephen Hinshaw, Ph.D.; Ellen Littman, Ph.D.; and Andrea Chronis-Tuscano, Ph.D.

“Empirical evidence on female manifestations of ADHD – including findings on self-harm, peer relationships, trauma, and more – reveal crucial aspects of the condition that are as devastating as they are under-appreciated. Along with a recognition of general sex and gender differences, these factors must inform future research practices and clinical approaches for this group. The bottom line: Our approach to ADHD in women and girls has been broken for too long. To fix it, we must challenge everything we know about the assessment, diagnosis, and treatment of ADHD today.”

• Continue reading ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks

6. ADHD in Teens: How Symptoms Manifest as Unique Challenges for Adolescents and Young Adults

by Timothy Wilens, M.D.

“The delayed frontal lobe development associated with ADHD in the teenage years makes regulating the limbic system – the circuitry associated with emotion, anxiety, reward, and risky behavior – more difficult. This differential brain development may explain some observable dysregulation and instability in adolescents with ADHD, and it builds a case for why families still need to remain involved and vigilant through the teen’s development in this period.”

• Continue reading ADHD in Teens: How Symptoms Manifest as Unique Challenges for Adolescents and Young Adults

7. Menopause, Hormones & ADHD: What We Know, What Research is Needed

by Jeanette Wasserstein, Ph.D.

“How do the hormonal changes of menopause uniquely affect women who have ADHD? Unfortunately, despite increased and hugely warranted interest, there are no studies that specifically examine menopause in females with ADHD, and that is a serious medical problem. But what we do know – about menopause in general, the role of estrogen, and the effects of hormonal fluctuations on ‘ADHD-like’ symptoms – may help us understand the menopausal transition for women with ADHD, and how clinicians can approach treatment and care for this group.”

• Continue reading Menopause, Hormones & ADHD

8. Treatment for Depression and ADHD: Treating Comorbid Mood Disorders Safely

by Roberto Olivardia, Ph.D.

“Comorbid depression and ADHD present a unique set of risks and challenges. For people with mood disorders, having comorbid ADHD is associated with an earlier onset of depression, more frequent hospitalizations due to depression, more recurrent episodes, and higher risk of suicide, among other markers. Proper management and treatment of both ADHD and depression is, therefore, crucial.”

• Continue reading Treatment for Depression and ADHD

9. The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations

by Joel Nigg, Ph.D.

“Even when controlling for related comorbid conditions, individuals with ADHD experience disproportionate problems with anger, irritability, and managing other emotions. These problems walk in lock step with the general difficulties in self-regulation that characterize ADHD. Recent findings, however, suggest that problems with emotional regulation, including anger and negative emotions, are genetically linked to ADHD, too. Ultimately, emotional dysregulation is one major reason that ADHD is subjectively difficult to manage, and why it also poses such a high risk for other problems like depression, anxiety, or negative self-medication.”

• Continue reading The ADHD-Anger Connection

10. A Clinician’s Guide to Tic Disorders in Children: Symptoms, Comorbidities & Treatments

by John Piacentini, Ph.D., ABPP

“Persistent tic disorders, including Tourette’s disorder, affect about one in fifty children in the U.S. according to the latest research. What’s more, tic disorders are highly comorbid. More than 80% of children with Tourette’s disorder have a co-occurring mental, behavioral, or developmental disorder, with ADHD and anxiety topping the list of commonly diagnosed conditions. These facts and figures suggest that clinicians are more likely than not to encounter tic disorders when caring for pediatric patients.”

• Continue reading A Clinician’s Guide to Tic Disorders in Children

11. The Choice to Medicate for ADHD: A Clinician’s Guide to Navigating Parental Concerns

by Roberto Olivardia, Ph.D.

“The issue of medication for children with ADHD — more than with any other condition that I treat — is controversial and murky. For parents, the question of adding medication to their child’s treatment plan is one that weighs heavily. They research the pros and cons of ADHD medication, but their findings are colored by feelings of guilt and fear of judgment from others. While it’s important to educate parents on how medications work and why they might be used, it’s equally critical for clinicians to support parents by being mindful of the concerns that are often present, though not always overtly stated, as they navigate the decision-making process.”

• Continue reading The Choice to Medicate for ADHD: A Clinician’s Guide to Navigating Parental Concerns

12. We Need to Talk About ADHD Stigma in BIPOC Communities

by Evelyn Polk Green, M.S.Ed.

“Stigma in Black and other marginalized communities spurs resistance to ADHD diagnoses and treatment. Parents believe an ADHD diagnosis implies their child has an intellectual disability. They also fear an ADHD diagnosis will relegate their child to special education. Black and Latinx children are assigned disproportionately to these programs, often with poor outcomes. Historical and institutional medical maltreatment also informs decisions about treatment. These fears are not without justification, but they bring devastating results. They often lead to parents refusing medication in an ADHD treatment plan.”

• Continue reading We Need to Talk About ADHD Stigma in BIPOC Communities

13. A Critical Need Ignored: Inadequate Diagnosis and Treatment of ADHD After Age 60

by Kathleen Nadeau, Ph.D.

“ADHD doesn’t diminish — like your hairline or stamina — with age. In fact, symptoms of ADHD may flare and grow after midlife — especially when mixed with normal age-related cognitive decline, worsening physical health, and the lack of structure that often comes with retirement. Why then, do the unique needs of this large (and growing) population of adults with ADHD remain largely ignored in diagnostic tests, accepted treatment practices, and peer-reviewed research?”

• Continue reading A Critical Need Ignored: Inadequate Diagnosis and Treatment of ADHD After Age 60

14. Sleep and ADHD Medication Use: A Clinician’s Guide to Mitigating Side Effects in Children

by Mark A. Stein, Ph.D.

“Research confirms the increased prevalence of sleep problems among children with ADHD, and clinical experience shows us that ADHD symptoms and characteristics – difficulty ‘shutting down’ the mind, for instance – plus comorbid psychiatric disorders like anxiety and oppositional defiant disorder can cause or aggravate sleep problems as well. In addition, sleep problems, such as insomnia, are a common side effect associated with ADHD medications. In other words, ADHD symptoms and the first-line interventions to treat those symptoms both elevate an individual’s risk for poor sleep.”

• Continue reading Sleep and ADHD Medication Use: A Clinician’s Guide to Mitigating Side Effects in Children

15. The Science of Fear: Probing the Brain Circuits That Link ADHD and PTSD

by Joseph Biederman, M.D.; Mohammed R. Milad, Ph.D.; and Andrea Spencer, M.D.

“Our systematic review and meta-analysis of several studies examining the relationship between ADHD and PTSD reveals a bidirectional association between the two disorders. The relative risk for PTSD in individuals with ADHD is four times greater compared to normal controls; it is close to 2 against psychiatric controls, and 1.6 against traumatized controls. The risk for ADHD in individuals with PTSD is twice that observed in normal controls.”

• Continue reading The Science of Fear: Probing the Brain Circuits That Link ADHD and PTSD

16. Professional Guidelines for Diagnosing Autism Spectrum Disorder

by Theresa Regan, Ph.D.

“While ‘autism awareness’ is growing, what we’re really lacking is holistic ‘autism recognition.’ Few medical professionals and mental health care professionals can confidently say: ‘I know what autism looks like in the classroom, in the medical clinic, in families, and in neighborhoods.’ Since ASD presents with multiple behavioral characteristics, professionals often miss the big picture of autism and, instead, diagnose small pieces of the picture separately — for example, obsessive compulsive disorder (OCD), social anxiety, eating disorder, bipolar disorder, or ADHD.”

• Continue reading Professional Guidelines for Diagnosing Autism Spectrum Disorder

17. How a Physician Treats ADHD with Combination Therapy

by Oren Mason, M.D.

“I discovered ‘combination therapy’ by accident. The term refers to using a stimulant and a non-stimulant to reduce ADHD symptoms. There were no lectures in medical school on this therapy and no studies of it yet, in 2000, when I started my ADHD practice. I learned about it from my patients, who noticed that it did a very effective job of helping them manage symptoms.”

• Continue reading How a Physician Treats ADHD with Combination Therapy

18. When a Mood Disorder Looks Like ADHD — and Vice Versa: Differentiating Signs of Emotional Dysregulation

by Thomas E. Brown, Ph.D., and Ryan J. Kennedy

“Emotional dysregulation and moodiness are not included in the diagnostic criteria for ADHD – a detrimental omission, according to many researchers and clinicians. The reality is that children and adults with ADHD commonly experience irritability, low frustration tolerance, and mood lability. However, emotional dysregulation is not exclusive to ADHD. Chronic moodiness is also a central component of mood disorders like bipolar disorder, which may complicate the evaluation, diagnosis, and treatment process. Differentiating moodiness as it appears in ADHD, bipolar disorder, and similar disorders is critically important — and not always straightforward.”

• Continue reading When a Mood Disorder Looks Like ADHD — and Vice Versa

19. ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.

by Russell Barkley, Ph.D.

“The ADHD symptoms listed in the DSM were developed for children. We can see this in the phrasing of certain symptoms, such as ‘can’t play quietly’ or ‘driven by a motor’ in the hyperactive/impulsive items. These phrasings don’t translate well to the adult experience. Few adults with ADHD would use these terms to describe their daily experience with the condition, leaving clinicians to extrapolate these items into clinical practice with adults.”

• Continue reading ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.

20. The Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth

by Elena Man, M.D.; Amy Dryer, M.D.; and Rachel Sayer, LCPC, PCIT-C

“LGBTQIA+ youth face an elevated risk for experiencing serious mental health issues.¹ Depression and anxiety impact more than half of all youth who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, or asexual, according to a 2022 survey by the Trevor Project. In addition, 45% of LGBTQIA+ adolescents and young adults say they have seriously considered attempting suicide in the past year, according to the same survey. To end this devastating trend and save lives, LGBTQIA+ youth need many things — primary among them is support.”

• Continue reading The Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth

21. 11 Steps to Prescribing and Using ADHD Medication Effectively

by William Dodson, M.D., LF-APA

“The most recent Practice Parameters update on ADHD from the American Academy of Child and Adolescent Psychiatry recommends medication as a primary therapy for ADHD because it shows detectable, lasting benefit over multi-modal treatment. In other words, ADHD medication works. Yet, 93% of psychiatry residencies don’t mention ADHD in four years of training, and a full 50% of pediatric residencies don’t mention ADHD. So how is a physician supposed to understand and adjust treatment plans without a rich background in ADHD?”

• Continue reading 11 Steps to Prescribing and Using ADHD Medication Effectively

22. The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD

by Roberto Olivardia, Ph.D.; Jannice Rodden, and ADDitude Editors

“Bipolar disorder (BD) often co-occurs with ADHD, with comorbidity figures as high as 20% Recent research also suggests that about 1 in 13 patients with ADHD has comorbid BD, and up to 1 in 6 patients with BD has comorbid ADHD. This comorbidity rate is significant enough to justify dual evaluations for virtually every patient, yet bipolar disorder is often missed or misdiagnosed, in part because several depressive and manic symptoms of bipolar disorder and ADHD symptoms closely resemble each other.”

• Continue reading The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD

23. Beyond the Core Symptoms of ADHD in Children: Comorbid Screening and Treatment Guidance

by Adelaide S. Robb, M.D.

“ADHD rarely exists in isolation. As treating clinicians, we must properly screen for and address ADHD and its comorbidities at the same time. ADHD and its common comorbid conditions are best diagnosed through a comprehensive psychological evaluation. These fuller evaluations — in contrast to the lone rating scales many pediatricians use — extract a wealth of information about a patient’s ADHD symptoms and any present comorbidities, like learning and language disabilities, early in the evaluation process.”

• Continue reading Beyond the Core Symptoms of ADHD in Children: Comorbid Screening and Treatment Guidance

24. Migraines and ADHD: The Overlooked Connection to Headaches

by Sarah Cheyette, M.D.

“Children with ADHD may be twice as likely to experience headaches as are children without ADHD. Children with ADHD are also at greater risk for migraines than are children without ADHD, and frequency of migraine headaches may be directly linked to risk of ADHD. The issue extends into adulthood as well. One study estimates that migraines occur with ADHD about 35% of the time in adult patients. Headaches, including migraine headaches, do seem to be triggered by ADHD.”

• Continue reading Migraines and ADHD: The Overlooked Connection to Headaches

25. 4 Reasons Adults Give Up on ADHD Medication: Solving Nonadherence and Treatment Inconsistency

by William Dodson, M.D., LF-APA

“ADHD medications work dramatically well. Still, medication nonadherence is a serious – and often unnoticed – problem among adult patients, regardless of age or prescription. According to a recent study, fewer than half of adult patients could be considered ‘consistently medicated’ for ADHD, based on prescription renewal records. Prescribers must understand and address the barriers to ADHD medication adherence to provide the best care possible for patients and improve long-term outcomes.”

• Continue reading 4 Reasons Adults Give Up on ADHD Medication

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TITRATION: How long will it take to get the ADHD medication and dosage right?

A: Titration is a big word that means working with your doctor to get your child’s medication just right. The goal is to find the dose (or amount) of medicine that controls… | Keep reading on ADDitude »

MED SAFETY: What are the short- and long-term effects of using ADHD medication?

A: Side effects and risks associated with the long-term use of ADHD medication include heart disease, high blood pressure… | Keep reading on ADDitude »

MEDS & PERSONALITY: Will ADHD medication turn my child into a “zombie?”

A: Sometimes, parents say their child appears dazed when they start taking a stimulant ADHD med. This “zombie effect” is a kind of hyperfocus that could mean their dose is too high… | Keep reading on ADDitude »

EXPLAINING TREATMENT: How should I talk with my child about taking ADHD medication?

A: For a young child, choose simple, familiar language. For example, to describe being unable to sit still, “You have the wiggles”… | Keep reading on ADDitude »

UNTREATED ADHD: What are the risks of not using ADHD medication?

A: Untreated ADHD can cause problems throughout life. People with ADHD tend to be impulsive and have short attention spans, which can make it harder to succeed in school… | Keep reading on ADDitude »

SUBSTANCE USE: Could stimulant use lead to substance abuse in my child?

A: One of the longest-term studies, which followed 100 boys with ADHD for 10 years, showed no greater risk for substance abuse in boys who took stimulant drugs compared to those who didn’t take… | Keep reading on ADDitude »

FIRST-PERSON: “What I Want to Say to My Mom, Who ‘Drugged’ Me”

“Thank you, Mom. Thank you for listening when I told you I was struggling. Because of your decision, I did better in school, I felt more confident, and was able to reach my potential.” | Keep reading on ADDitude »

RELATED RESOURCES

FREE DOWNLOAD: Understanding ADHD Medications

In this infographic, learn about differences between stimulants and non-stimulants, signs your child’s dosage needs to be adjusted, and more. | Download now on ADDitude »

FREE DOWNLOAD: ADHD Medication Tracking Log

Learn about indicators that your child’s medication is working plus signs that point to side effects, then track their symptoms in the daily log. | Download now on ADDitude »

8-Part Guide to ADHD Treatment in Children:

Q 1: How should I approach my child’s ADHD treatment plan?
> Q 2: Is ADHD medication right for my child?
Q 3: How can I address side effects associated with my child’s ADHD medication?
Q 4: How can I integrate nutrition & supplements into my child’s ADHD treatment?
Q 5: How can I integrate exercise & mindfulness into my child’s ADHD treatment?
Q 6: What therapies should I integrate into my child’s ADHD treatment plan?
Q 7: How should I adjust and optimize my child’s ADHD treatment plan over time?
Q 8: How can my child’s treatment plan safely address comorbid conditions?

ADHD treatment rates are staggeringly low for children, according to a study recently published by JAMA Network that found only 12.9% of 9- and 10-year-olds with parent-reported symptoms had taken ADHD medication during the preceding two weeks. ¹ Children who received treatment for their ADHD were more commonly boys, white children, and from families with a lower socioeconomic status. These findings expose treatment gaps that span the boundaries of a clinical ADHD diagnosis.

This study comprised a self-administered, semi-structured computerized parent interview used to identify 1,206 children aged 9 to 10 with ADHD using the Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (KSADS). Treatment groups included ADHD medication; outpatient mental health care; and both (“any treatment”).

“…A focus on the increasing numbers of children treated for ADHD does not give a sense of what fraction of children in the population with ADHD receive treatment,” the researchers wrote. “To estimate the unmet need for ADHD treatment, it is necessary to ascertain children from outside of clinical settings, evaluate them for ADHD, and assess their treatment use.”

Gaps in Treatment

ADHD Medication

According to the survey findings, twice as many boys (15.7%) as girls (7%) took medication for their ADHD after adjustment for ADHD subtype, comorbid disruptive behavior disorders, and other common psychiatric comorbid conditions. Stimulant use was significantly higher among boys than it was among girls.

Additionally, among children with parent-reported ADHD who were currently receiving ADHD medication:

• a significantly higher percentage were children of parents without a high school education compared to children of parents with at least a bachelor’s degree (32.2% v. 11.5%)
• a significantly higher percentage had combined type ADHD compared to inattentive ADHD (17% v. 9.5%)
• a significantly higher percentage were White children compared to Black children (14.8% v. 9.4%)

More than half of all children receiving ADHD medication did not have parent-reported ADHD at the time of the study (57%).

Outpatient Mental Health Care

Outpatient mental health care was more commonly used to treat parent-reported ADHD in adolescents than was ADHD medication. Slightly over one quarter (26.2%) of children in the ADHD group had ever received this course of treatment.

The difference between girls and boys was insignificant, however, among children with parent-reported ADHD and a history of outpatient mental health care:

• a significantly higher percentage were children of parents with a high school education or some college compared to children of parents with at least a bachelor’s degree (36.2% or 31% v. 21.3%)
• a significantly higher percentage were children with family incomes of less than $25,000 or $25,000 to $49,999 compared to $75,000 or more (36.5% or 27.7% v. 20.1%)
• a significantly higher percentage had combined type ADHD vs. inattentive ADHD or hyperactive/impulsive ADHD (33.6% v. 20% or 22.4%)

Children who received either treatment (medication or mental health care) accounted for 34.8% of the parent-reported ADHD group.

Treatment Disparities

The study’s findings conflict with data reported by the CDC in 2016. It found that 77% of children in the U.S. with parent-reported ADHD received treatment, and 69% aged 6 to 11 received medication. ² A survey conducted by ADDitude in 2017 similarly found that 67% of children with ADHD were currently taking ADHD prescription medication.

But unlike the current study, where ADHD was based on results from parent interviews, the CDC relied on clinical diagnoses, and in turn, access to mental health care professionals.

“Low treatment rates among children with parent-reported ADHD suggest a need to increase mental health service availability; enhance knowledge of ADHD symptoms among parents, teachers, and primary care clinicians; and develop accessible care pathways,” the researchers wrote. “Local shortages of child mental health clinicians also hinder care access in many communities.”

Accessible care pathways must address diagnostic biases and under-referral for treatment related to ADHD symptom presentation in girls, who often go misdiagnosed or underdiagnosed. Pathways should also address disparities in care received by minority racial and ethnic groups that can be attributed to structural racism-related issues, including implicit bias by prescribers, mistrust of clinicians, and stimulant medication safety.

“Physician efforts to recognize and manage their own implicit biases, together with patient-centered clinical approaches that promote shared decision-making, including open explorations of Black parents’ knowledge, attitudes, and beliefs concerning ADHD and its management, might help reduce these treatment disparities.”

According to researchers, lower treatment rates among higher socioeconomic groups could be related to a reliance on non-conventional methods or greater concern about side effects of treatment. In the ADDitude treatment survey, 20% of caregivers tried other treatment options before turning to medication and 14.5% called it a “last resort.” When it came to other treatment options, insurance, cost, and availability were most often cited as concerns.

“The side effects were not worth it,” wrote one survey respondent. “We preferred to adjust diet, household routine, treat sibling and parental relationships and involvement, add more exercise, and did genetic testing.”

Another respondent wrote about the “terrifying experience” of medicating a child, stating: “It would be helpful if doctors provided more information about the emotional expectations. They were pretty good at listing the possible physical side effects. It’s a very hard decision for a parent to stick with medication in the beginning when you’re constantly questioning yourself: ‘Am I doing the right thing for this child, when he feels awful?’”

Additional Considerations

A total of 11,723 children were recruited between 2016 and 2018 via the Adolescent Brain Cognitive Development (ABCD) Study. Parents were asked to complete a self-administered, computerized parent version of the KSADS. Teacher ratings were collected using the Brief Problem Monitor teacher-version attention scale and shared in a secondary analysis. Recruiters surveyed 21 public and private schools across the U.S.

Participation was voluntary and response rates were not available; therefore, researchers state that the full sample used in the study is not representative of the selected school systems or the nation. Parents were asked to report on medication use in the previous two weeks, which may have impacted medication rates. For the full summary of study limitations, click here.

Sources

¹Olfson M, Wall MM, Wang S, Laje G, Blanco C. (2023). Treatment of US children with attention-deficit/hyperactivity disorder in the adolescent brain cognitive development study. JAMA Netw Open, 6(4):e2310999. doi:10.1001/jamanetworkopen.2023.10999

²Centers for Disease Control and Prevention. (2022, August 9). Data and statistics about ADHD.  https://www.cdc.gov/ncbddd/adhd/data.html

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

The Clinicians’ Guide to Treating Complex ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when treating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: What should I consider when developing a comprehensive treatment plan for ADHD?
• DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
• DECISION 3: How can I decide which ADHD medication to prescribe first?
• DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
• DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

NOTE: This resource is for personal use only.

Low-income Black families are more likely to seek medication treatment for their children with ADHD following positive experiences and collaborative involvement with healthcare providers and schools, according to a new study published in the Journal of Attention Disorders. ¹

Researchers analyzed datasets from the National Survey of Children’s Health (NSCH) that comprised 450 uninsured or publicly insured Black children with ADHD, ages 6 to 17, who were taking ADHD medication. Researchers analyzed the data to test the validity of seven themes that emerged in their initial-stage interviews with low-income Black caregivers of children with ADHD recruited from an outpatient pediatric behavioral health clinic in New Jersey. The caregivers were interviewed about their views, concerns, and accounts of treatment decisions and treatment experiences for their children; their input helped form the study’s hypotheses.

7 Hypotheses Related to ADHD Medication Decision-Making for Black Children

Researchers identified seven themes from the interviewed caregivers regarding their treatment decisions.

• Child safety and volatility related to the child’s behavior influenced treatment decisions, as did caregiver aggravation tied to the frustrations and burdens of caring for a child with ADHD. Caregivers believed that medication would decrease their children’s ADHD symptoms, such as impulsivity and inattention, and would keep their children and others safe.
• Family-centered care (FCC) and shared decision-making (SDM) were commonly reported among caregivers who felt included in their children’s treatment decisions. Some caregivers felt clinicians involved them in decision-making about their child’s treatment; others felt dismissed and believed clinicians perceived them as uneducated. Caregivers also described positive (appreciation to schools for identifying the need for treatment, administering medications, etc.) and negative (frequently disrupted by school calls, the perception that children had lower intelligence, etc.) experiences with schools.
• Caregiver mental health — caregivers and other family members commonly took medication for a psychiatric diagnosis.
• Sole parent status were associated with self-reported “feelings of being alone in dealing with the challenges of parenting a child with ADHD with a right to independence in making decisions regarding treatment,” researchers wrote.

Analysis of the NSCH data confirmed that SDM and FCC did impact caregivers’ decisions to medicate their children. Researchers reported that children whose caregivers engaged actively in the treatment decision-making process were twice as likely to take ADHD medication as were those who did not. Conversely, feeling dismissed or excluded from decision-making made caregivers apprehensive and unsure regarding medication choices for their children.

Black children who do not receive appropriate treatment can suffer severe consequences for behaviors associated with their ADHD symptoms. “Ample data shows Black students are more likely to be placed in the school-to-prison pipeline than white students,” said Tumaini Rucker Coker, M.D., MBA, Associate Professor of Pediatrics and Chief of General Pediatrics at the University of Washington School of Medicine. “Black students are suspended and expelled three times more often than white students.² And when students are suspended or expelled for behavior, they’re almost three times more likely to be in contact with the juvenile justice system in the following year.” ³

The study also found that Black children who previously received special education services were more than twice as likely to be treated with medication than were those who never received services. However, researchers could not determine “the exact nature of the relationship between receiving special education services and taking medication for ADHD.”

Findings did not confirm a direct causal relationship between taking ADHD medication and caregiver mental health, child safety and volatility, or sole caregiver status. However, the authors wrote that “these topics warrant further discussion.”

Why Shared Decision-Making Matters

Current guidelines for treating ADHD in children focus on behavioral therapy and medication management; however, “Black children are significantly less likely to receive medication than white children due to racially based structural and attitudinal barriers,” researchers wrote. ⁴, ⁵, ⁶

“Sufficiently addressing disparities in care starts with understanding why racial and ethnic imbalances matter, the roots of these inequities, and their consequences for overall health and well-being,” said Coker, who discussed how barriers to ADHD diagnosis and treatment – from the clinical level to systemic factors – disproportionately impact children and adolescents of color in the presentation titled “Equity, Diversity, and ADHD: Achieving Equitable ADHD Care for African American and Latinx Children” at the 2021 APSARD Annual Virtual Meeting.

Next Steps for Clinicians

Sarah Vinson, M.D., Associate Clinical Professor of Psychiatry and Pediatrics at Morehouse School of Medicine, offered several tips for clinicians in the ADDitude article “Evaluating and Treating ADHD in African American Children: Guidance for Clinicians.”

• Clinicians should strive for cultural humility — and embrace the idea that the patient’s family is the expert on the child and their situation. “The patient’s expertise is needed, and cultivating this relationship is a two-way process,” Vinson said. “The clinician educates the patient and family about ADHD, and the caregiver informs the clinician about the child’s realities, challenges, and ideas about ADHD and other neurological and mental health issues.”
• Clinicians should learn how patients and families feel about the child’s ADHD diagnosis, the possibility of medication, and what resources the family can access. “Some families, for example, may bring up the difficulties surrounding being a Black person in a racist society, and having that compounded by mental illness and medication — both of which are still commonly stigmatized,” she said.
• Clinicians must explain what medications do and don’t do to allow patients and families to make informed choices and set realistic expectations.
• Clinicians should understand issues surrounding insurance and family dynamics. “Black children are more likely to be publicly insured, meaning that the medication formulations available are limited,” Vinson said.
• Clinicians should avoid aiming for competency alone. Vinson explained, “Being aware of and continuously learning about historical and current factors (at the local level and beyond) can help clinicians contextualize experiences and issues related to Black communities.
• White clinicians must contend with their ingrained biases and examine any defensiveness and fragility that comes with it to address larger, structural issues.
• Clinicians should know what resources local schools have available and what inequities exist regarding access to school counselors, therapists, and psychoeducational testing to inform treatment planning.
• Clinicians should be guided by an understanding that any intervention which helps the primary caregiver and family unit feel heard and informed is important.

Researchers from the Journal of Attention Disorders study reiterated Vinson’s recommendation in their report. “Clinicians must recognize that applying their expertise in concert with FCC and SDM can ensure that the most vulnerable children receive evidence-based treatment for ADHD,” they wrote. “Interventions should focus on supporting teachers to partner with low-income Black caregivers of children with ADHD and developing partnerships between school districts and medical providers to ensure appropriate referrals for ADHD care and improve access to care for vulnerable populations.”

The study had several limitations, including the lack of specificity regarding medication decision-making over time for low-income Black children with ADHD. Researchers recommended that future research focus on communication between teachers and caregivers from this demographic and the relationship between medication treatment and exit from special education services.

Sources

¹Glasofer, A., Dingley, C., Kim, J., Colosimo, R., & Gordon, H. R. D. (2023). Medication Decision Making in Low-Income Families of Black Children With ADHD: A Mixed Methods Study. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547231158382

²U.S. Department of Education Office for Civil Rights (USDEOCR). (2014). Civil rights data collection, data snapshot: School discipline. Retrieved from https://www2.ed.gov/about/of-fices/list/ocr/docs/crdc-discipline-snapshot.pdf

³Fabelo, T., Thompson, M. D., Plotkin, M., Carmichael, D., Marchbanks, M. P. III, and Booth E. A. (2011). Breaking Schools’ Rules: A Statewide Study of How School Discipline Relates to Students’ Success and Juvenile Justice Involvement. New York , NY; College Station, TX: Council of State Governments Justice Center; Public Policy Research Institute of Texas A&M University. Retrieved from https://www2.ed.gov/about/of-fices/list/ocr/docs/crdc-discipline-snapshot.pdf

⁴Bax, A. C., Bard, D. E., Cuffe, S. P., McKeown, R. E., Wolraich, M. L. (2019). The Association Between Race/Ethnicity and Socioeconomic Factors and the Diagnosis and Treatment of Children with Attention-Deficit Hyperactivity Disorder. Journal of Developmental & Behavioral Pediatrics, 40(2), 81–91. DOI: 10.1097/DBP.0000000000000626

⁵Danielson, M. L., Bitsko R. H., Ghandour R. M., Holbrook J. R., Kogan M. D., Blumberg S. J. (2018a). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents. Journal of Clinical Child & Adolescent Psychology, 47, 199–212. https://doi.org/10.1080/15374416.2017.1417860

⁶Rostain, A. L., Ramsay J. R., Waite R. (2015). Cultural background and barriers to mental health care for African American adults. Journal of Clinical Psychiatry, 76, 279–283. https:0.4088/JCP.13008co5c

Just 19% of American youth diagnosed with ADHD are receiving medication treatment, according to a review and meta-analysis published in The Journal of Attention Disorders.¹ Findings from the study suggest that, for every overtreated or improperly treated American youth, there are three more undertreated youths with ADHD.

The study rose from a debate over whether pharmacological treatment for youths with ADHD is overused or underused in the U.S. Researchers screened more than 25,000 potentially relevant studies, and retained 36 studies of 104,305 individuals. Using the 18 studies that met the main analysis criteria (that diagnosis was established using DSM criteria or validated rating scales, and not parental report), researchers identified three groups:

1. Youth with ADHD who were receiving medication treatment
2. Youth with ADHD who were not receiving medication treatment
3. Youth without ADHD who were receiving medication treatment

Across the studies, pharmacological treatment rates were 19.1 % and 0.9 % in school-age children/adolescents with and without ADHD, respectively. Essentially, more than 80% of youth diagnosed with ADHD were not being treated with medication.

In an A.D.D. Resource Center blog post on the study, David Rabiner, Ph.D. reflects that “only a minority of children and teens with ADHD receive medication treatment for the condition,” and it is,“reasonable to conclude that undertreatment is substantially more common than overtreatment. Given concerns that ADHD medication is frequently prescribed to youth without ADHD, finding that this is relatively uncommon (under 1%) is reassuring.”²

Sources

¹ Massuti et al. Assessing under-treatment and over-treatment of ADHD medications in children and adolescents across continents: A systematic review and meta-analysis. Neuroscience and Behavioral Reviews, 128, 64-73. (2021). https://www.sciencedirect.com/science/article/abs/pii/S0149763421002396

² Rabiner, David. The Over and Under Use of ADHD Medication Treatment. The A.D.D. Resource Center. (Jan. 2022). https://www.addrc.org/the-over-and-under-use-of-adhd-medication-treatment/

Integrative ADHD treatment — combining stimulant medication with directive cognitive behavioral therapy — has been accepted as the gold standard of ADHD treatment for decades. Despite this, the popular press still questions the inclusion of medication as equal with therapy, leaving many parents somewhere between bewildered and opposed to using it with their kids.

Every week, we receive intake requests from young (and not so young) adults who note something like, “My parents knew I had problems in school, but they didn’t believe in diagnosis or medication” or “I was tested in fourth grade and they said I had ADHD, but my parents thought I was just immature.” Others admit, “We knew I had ADHD and I took medication for it until I was 14, but I didn’t like taking it so I stopped.” Each request comes from someone having a really hard time in work, school, or relationships.

Should I Medicate My Child for ADHD?

One of the biggest critiques of medication management for ADHD is reserved for the treatment of minors. Skeptics ask, “Aren’t we just treating kids for being kids?” or worry that children are too young to make the choice, or will suffer long-term consequences. Some people are just plain upset by the idea that prescribers give kids “speed” and claim that it calms them down. Others fear the Zombie Effect — that stimulants turn playful children and teens into robotic, Stepford Children, overriding their natural personalities.

The problem with this perspective is simple: Your child either has ADHD or he does not. If he does have it, he is either impaired, or not. And if he is impaired, talk therapy or supplements or nutrition or exercise or discipline isn’t going to resolve that.

It’s OK to try those things for a reasonable time, and if the symptoms are more manageable, you can declare your child ADHD-free. But if the symptoms persist, and you don’t treat your child’s neurological condition, he will grow up having missed critical learning, both academic and social, that other kids have. And that is the definition of “being behind” in school and in life.

[Free Download: A Parent’s Guide to ADHD Medications]

ADHD Medication: Addressing Stimulant Tolerance

The longitudinal Multimodal Treatment of ADHD study found that some children who use stimulants for years end up no better off than their peers who didn’t take medication. Nobody seems to understand how this makes sense. People who need to be on stimulants nearly always have a love-hate relationship with them, so nobody is going to stay on them if they aren’t benefitting. We think that the problem identified in the MTA study is that of stimulant tolerance, a rarely discussed topic that seems oddly controversial among prescribers.

Simply put, the more you take stimulant medication, the less effective it is. The less effective it is, the more you want a dosage increase. The more you increase the dosage, the more tolerant your body becomes, and (you guessed it) the less effective the medication becomes. Eventually, you hit a ceiling, where you can go no higher, and often that ceiling is well past the maximum recommended dose. To anyone who has taken stimulants for more than six months, this idea isn’t controversial. It’s obvious. We believe this is why, after taking thousands of doses of stimulant, the MTA kids ended up in the same spot as their non-medicated peers.

Fortunately, there’s a good workaround for tolerance — taking regular stimulant breaks, as our prescribers recommend at our clinic. These breaks last not for a day or a weekend, but for about two weeks every four months. We suggest this be done under supervision, but we’ve found many prescribers who don’t know about, recognize, or believe in tolerance. Parents may have to be persistent to get them on board. Adhering to this strategic approach changes every aspect of a teen or young adult’s relationship to medication, their satisfaction using it, and the efficacy it has in their lives.

ADHD Medication Side Effects

ADHD medication is not all sunlight and roses, just take the pill and you’ll be fine. There are three problems that maximize side effects and minimize benefit. The first is starting your child’s ADHD treatment journey at the primary care physician’s office. We love our PCPs, but they aren’t optimal prescribers. They aren’t paid to sit down for an hour or two or three and get to know you, your history, and your experiences. Specialized mental health providers are.

[ADHD in Teens: How Symptoms Manifest as Unique Challenges for Adolescents and Young Adults]

The second problem is that even some mental health providers don’t use standardized assessments, like the Conners, Barkley, or Brown scales to make their initial evaluation. These scales aren’t simply checklists of symptoms. They’re “norm-referenced,” meaning they’re given to subjects known to have ADHD and to those known not to have it. The results are used to pick out the diagnosable kids from the non-diagnosable ones. There are test forms for teens, parents, and teachers to complete. You should not consider treating your child’s ADHD without completing them, along with having a good one- to three-hour interview.

The final obstacle is the common disconnect between the therapist/evaluator and the medication provider. When we say, “integrative treatment,” we mean that the prescriber and therapist either work in the same office or staff cases regularly, so they can give each other feedback. If you’ve struggled to find a practice that operates this way, we offer some tips in our book to help you along.

When things go wrong with ADHD medication management in teens and young adults, the problem is usually in the system of deployment, not in the medication itself.

How to Help Teens Ease into Medication

Problematize. To accept treatment, teens need to feel ADHD as problematic, as a pain in their life that limits and controls them. This requires matching a formula that considers what they value, how much energy they exert to enact those values, and whether they attribute achievement to their own striving or to a sense of entitlement. Too many parents normalize their children’s struggles to make them feel better, when they should, in a kind but direct way, problematize and propose solutions.

Build a prescribing relationship. There must be a meaningful relationship between the client and the prescriber/therapist team. Teens and young adults need to feel like they aren’t just a member of that team, but its leader. They need to trust providers to take them seriously, speak to them like peers, and to be genuinely interested in solving the problem.

Emphasize consent. Teens will only respond to treatments to which they have given full and informed consent. We won’t see anyone from middle school or up if she does not agree to be seen. This increases compliance dramatically.

Parents also have consent. Your child may decline medication, but if that affects his performance in school or leaves him dependent on you and living in the basement, you are free to support good decisions and extinguish bad ones through behavioral modification. Make deals with your child to incentivize success in life, and link that to taking medication. This seems harsh to many parents, but it works.

Wes Crenshaw, Ph.D., is co-author of the new book, ADD and Zombies: Fearless Medication Management for ADD and ADHD.

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The New England Journal of Medicine dedicated significant and noteworthy space to a research review of the pharmacologic treatment for attention deficit hyperactivity disorder (ADHD)¹from Samuele Cortese, M.D., Ph.D. In the NEJM‘s September 2020 issue, Dr. Cortese summarized the most notable findings of the last decade related to use of medications for ADHD, their efficacy, side effects, and safety.

Medication Use in ADHD

Reported in the article was a study of prescription databases that revealed that the prevalence of ADHD medication use increased from 2001 to 2015.² The average relative percentage increase in the United States was 2.83% per year. Follow-up periods of a systematic review revealed the average length of treatment with stimulants was 136 days in children and 230 days in adults.³ Rate of medication discontinuation were highest among 15- to 21-year-olds. Among the reasons for discontinuation were side effects, perceived lack of effectiveness, dislike of taking medications, and stigma.⁴

ADHD Medication Efficacy and Effectiveness

According to the article, a meta-analysis of randomized controlled trials (RCTs) demonstrated that medications approved for ADHD more effectively decreased the severity of inattention, hyperactivity, and impulsivity than did placebos. The largest effect sizes were found for amphetamines, followed by methylphenidate.⁵ At the group level, amphetamines were more efficacious than methylphenidate, atomoxetine, and guanfacine. However, at the patient level, approximately 41% of participants had equally good responses to both amphetamines and methylphenidate.⁶

Some studies that used a within-person design found that, in periods during which patients were receiving medication, there was a significant decrease in negative outcomes such as “unintentional physical injuries, motor vehicle accidents (among male patients), substance use disorder, and criminal acts, as well as an improvement in academic functioning.”⁷

A double-blind RCT of medication discontinuation found that participants who had been treated with methylphenidate for an average of 4.5 years and continued taking methylphenidate experienced ongoing benefits related to ADHD symptoms, compared to participants who stopped or switched to a placebo.⁸

Side Effects and Safety of Medications for ADHD

A meta-analysis of RCTs found that several ADHD medications were linked to higher discontinuation rates due to adverse events, as compared with placebo. Short-term trials have shown significant increases in heart rate or blood pressure in patients with ADHD treated with stimulants or atomoxetine, as compared with placebo.⁹ Small but persistent increases in blood pressure or heart rate are concerning if sustained over a long period, but a meta-analysis found no significant link between ADHD medication and sudden death, stroke, or myocardial infarction.¹⁰

Some within-person studies demonstrated that patients being treated with ADHD medications had a decreased risk for seizures, depression, mania, and suicidality.¹¹

Neurological Effects of ADHD Medication

Across randomized trials, the most consistent benefit of a dose of stimulant medication was enhanced attention control and inhibition.¹² Longer-term neurobiologic effects (in patients who received stimulants for more than six months) included “activation in the right caudate nucleus that is generally close to normal levels during tasks requiring attention.”¹³

Nonmedical Use of ADHD Medication

There is little evidence that use of ADHD medications without a prescription improves academic or work performance in those without ADHD. Nonetheless, 58.7% of college students in the United States reported nonmedical use of stimulants on at least one occasion, and 2.1% of adults in the United States reported at least one episode of nonmedical stimulant use.¹⁴ Motivation for nonmedical stimulant use included enhancement of academic or work performance, as well as recreational use. Self-medication for undiagnosed ADHD could be another explanation “since persons who engaged in nonmedical use of stimulants reported more symptoms of ADHD than those who did not engage in nonmedical stimulant use.”

Sources

¹Cortese, Samuele. Pharmacologic Treatment of Attention Deficit-Hyperactivity Disorder. The New England Journal of Medicine (Sept. 2020).

²Raman SR, Man KKC, Bahmanyar S, et al. Trends in attention-deficit hyperactivity disorder medication use: a retrospective observational study using population-based databases. Lancet Psychiatry 2018;5:824-35.

³Gajria K, Lu M, Sikirica V, et al. Adherence, persistence, and medication discontinuation in patients with attentiondeficit/hyperactivity disorder — a systematic literature review. Neuropsychiatr Dis Treat 2014;10:1543-69.

⁴Zetterqvist J, Asherson P, Halldner L, Långström N, Larsson H. Stimulant and non-stimulant attention deficit/hyperactivity disorder drug use: total population study of trends and discontinuation patterns 2006-2009. Acta Psychiatr Scand 2013;128:70-7

⁵Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry 2018;5:727-38

⁶Arnold LE. Methylphenidate vs. amphetamine: comparative review. J Atten Disord 2000;3:200-11.

⁷Chang Z, Ghirardi L, Quinn PD, Asherson P, D’Onofrio BM, Larsson H. Risks and benefits of attention-deficit/hyperactivity disorder medication on behavioral and neuropsychiatric outcomes: a qualitative review of pharmacoepidemiology studies using linked prescription databases. Biol Psychiatry 2019;86:335-43.

⁸Matthijssen A-FM, Dietrich A, Bierens M, et al. Continued benefits of methylphenidate in ADHD after 2 years in clinical practice: a randomized placebo-controlled discontinuation study. Am J Psychiatry 2019;176:754-62.

⁹Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry 2018;5:727-38

¹⁰Liu H, Feng W, Zhang D. Association of ADHD medications with the risk of cardiovascular diseases: a meta-analysis. Eur Child Adolesc Psychiatry 2019;28: 1283-93.

¹¹Chang Z, Ghirardi L, Quinn PD, Asherson P, D’Onofrio BM, Larsson H. Risks and benefits of attention-deficit/hyperactivity disorder medication on behavioral and neuropsychiatric outcomes: a qualitative review of pharmacoepidemiology studies using linked prescription data

¹²Rubia K, Alegria AA, Cubillo AI, Smith AB, Brammer MJ, Radua J. Effects of stimulants on brain function in attentiondeficit/hyperactivity disorder: a systematic review and meta-analysis. Biol Psychiatry 2014;76:616-28.

¹³Hart H, Radua J, Nakao T, Mataix-Cols D, Rubia K. Meta-analysis of functional magnetic resonance imaging studies of inhibition and attention in attention-deficit/hyperactivity disorder: exploring taskspecific, stimulant medication, and age effects. JAMA Psychiatry 2013;70:185-98.

¹⁴Faraone SV, Rostain AL, Montano CB, Mason O, Antshel KM, Newcorn JH. Systematic review: nonmedical use of prescription stimulants: risk factors, outcomes, and risk reduction strategies. J Am Acad Child Adolesc Psychiatry 2020;59:100-12.

Nearly 79% of White children with attention deficit hyperactivity disorder (ADHD) take medication to manage their symptoms, following a thorough diagnosis and prescription by a medical provider. Among African American children with ADHD, this number is only 27.3% — and the rate of medication discontinuation is comparatively higher as well. What causes this racial disparity in ADHD treatment? Many factors ranging from institutional racism to healthcare access to clinician education to cultural norms and beyond. In a synthesis of 14 existing studies centered around one such factor — namely, caregiver medication decision making (MDM) — researchers have recently proposed three main influences:

• Fundamental caregiver perspectives on ADHD, which are influenced by exposure to ADHD research and information, personal experience with individuals who have diagnosed ADHD, as well as cultural norms and explanations for behaviors
• Caregiver concerns about the safety and effectiveness of stimulant medications
• Caregiver mistrust in physicians and the pharmaceutical industry, fueled in part by the belief that ADHD diagnosis and treatment is a form social control that is exacerbated by culturally biased ADHD screening tools

These findings, recently published in the Journal of Attention Disorders¹ , appeared in a study titled “Medication Decision Making Among African American Caregivers of Children With ADHD: A Review of the Literature.” In it, researchers found that historical, structural, cultural, and political factors all coalesce to create health disparities that disproportionately affect African American families and strongly influence MDM.

To arrive at their conclusions, researchers analyzed seven observational studies, four qualitative studies, and three mixed method studies using the following databases: the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychINFO, PubMed, and Education Resources Information Center (ERIC). In synthesizing these 14 studies, they identified three themes that help to explain the factors influencing MDM for African American caregivers of children with ADHD, specifically.

Factor 1: Fundamental Perspectives of ADHD and Cultural Norms for Child Behavior

In reviewing various existing studies, the researchers found that “African American parents had lower ADHD knowledge, less exposure to ADHD information, and less frequent interactions with individuals with ADHD than their White counterparts.” They also found that “African American parents, some of whom were caregivers to children with ADHD and some who were not, attributed ADHD-like behaviors to origins other than medical or biological causes. Explanations of ADHD-like behaviors included poor parenting, lack of attention, insufficient discipline, or a normal stage of development that would be outgrown.” One of the studies used in the analysis found that African American caregivers “were significantly less likely to attribute ADHD to genetic origins, or apply a medical label,” and another found them almost half as likely as White caregivers to consider ADHD a real disorder.

As a result, research has shown that “White children had twice the odds of African American children to receive an evaluation, diagnosis, or treatment for ADHD, despite the fact that there were no differences in rates of recognition of ADHD symptoms.”

Factor 2: Fundamental Perspectives on ADHD Medication Among Caregivers

Studies considered in this research revealed that “significantly fewer African American parents believed medications can be effective in treating ADHD than White parents.  The odds of an African American endorsing medication as a treatment were 0.7 compared to White parents.”² In addition, caregiver concerns about sedating side effects, extreme weight changes, and obsessive use resulted in ADHD medication being viewed a last resort or refused entirely by African American caregivers. What’s more, “parents who expressed concerns about medications were 2.5 times less likely to use treatment at follow-up,” which means a higher rate of medication discontinuation.

Studies also revealed that African American caregivers perceived ADHD symptoms as typical childhood behaviors and were less likely to recognize ADHD behavioral symptoms as problematic or impairing compared to White counterparts.³ This could mean medications might not be offered to minority children based on differences in caregiver report of symptoms.

Factor 3: The View of ADHD As A Form of Social Control

One study⁴ of African American caregiver perspectives of ADHD found that participants felt the diagnosis of ADHD represented a form of social control, and was described as “something the medical people came up with to handle kids” so they “just sit like zombies.” The researchers suggested that a lack of trust in healthcare professionals contributes to this outlook and to pharmacological disparities for ADHD.

The findings of this review have many implications for clinical practice and research moving forward. Culturally based ADHD treatment disparities should be can be addressed with a patient-centered approach to ADHD management, the researchers say. Exploring beliefs, knowledge, and misgivings regarding both the diagnosis and treatment of ADHD can help to provide better patient education, pursue acceptable forms of treatment, and promote shared decision-making. Additional research is necessary to understand how assessment and diagnostic tools for ADHD are culturally sensitive and how current ADHD diagnostic rating scales are used and administered in culturally diverse communities, the research concludes.

Sources

¹Glasofer, A., Dingley, C., & Reyes, A. T. (2020). Medication Decision Making Among African American Caregivers of Children With ADHD: A Review of the Literature. Journal of Attention Disorders. https://doi.org/10.1177/1087054720930783

²Bussing, R., Schoenberg, N. E., Perwein, A. R. (1998). Knowledge and information about ADHD: Evidence of cultural differences among African-American and White parents. Social Sciences Medicine, 46(7), 919–928. https://doi.org/10.1016/s0277-9536(97)00219-0

³Mychailyszyn, M. P., dosReis, S., Myers, M. (2008). African American caretakers’ views of ADHD and use of outpatient mental health care services for children. Families, Systems, & Health, 26(4), 447–458. https://doi.org/10.1037/1091-7527.26.4.447

⁴Olaniyan, O., dosReis, S., Garriett, V., Mychailyszyn, M. P., Anixt, J., Rowe, P. C., Cheng, T. L. (2007). Community perspectives of childhood behavioral problems and ADHD among African American parents. Ambulatory Pediatrics, 7(3), 226–231. https://doi.org/10.1016/j.ambp.2007.02.002