ADHD Symptoms: Hyperactive and Inattentive Tests https://www.additudemag.com ADHD symptom tests, ADD medication & treatment, behavior & discipline, school & learning essentials, organization and more information for families and individuals living with attention deficit and comorbid conditions Wed, 15 Jan 2025 14:31:21 +0000 en-US hourly 1 https://wordpress.org/?v=6.6.2 https://i0.wp.com/www.additudemag.com/wp-content/uploads/2020/02/cropped-additude-favicon-512x512-1.png?w=32&crop=0%2C0px%2C100%2C32px&ssl=1 ADHD Symptoms: Hyperactive and Inattentive Tests https://www.additudemag.com 32 32 216910310 Can a Busy Schedule Help ADHD Symptoms? A New Study Says Yes. https://www.additudemag.com/whats-helps-adhd-longitudinal-study-busy-schedule/ https://www.additudemag.com/whats-helps-adhd-longitudinal-study-busy-schedule/?noamp=mobile#comments Sat, 23 Nov 2024 02:59:42 +0000 https://www.additudemag.com/?p=367349 November 22, 2024

ADHD is not a static condition with fixed symptoms, but rather a dynamic disorder with symptoms that wax and wane over the lifespan, sometimes disappearing for years at a time. This was the finding of a new study published in the Journal of Clinical Psychiatry 1 that made another unexpected discovery: periods of higher environmental demands were associated with times of remission or reduced ADHD symptoms.

Led by Margaret Sibley, Ph.D., professor of psychiatry and behavioral sciences at the University of Washington School of Medicine, the research used data from the longitudinal Multimodal Treatment of ADHD (MTA) study, which followed 483 participants, diagnosed with ADHD at 7-10 years of age, for 16 years.2 Follow-up assessments, which were administered every two years, asked participants and parents about the severity and frequency of ADHD symptoms and impairments, as well as about environmental demands, including responsibilities in education, work, and finances.

The researchers found that longitudinal patterns revealed four groups:

  • Fluctuating ADHD: 64%

Alternating periods of remission and recurrence

  • Stable Partial Remission: 16%

A significant reduction in symptoms was experienced, typically beginning in late adolescence or early adulthood, that remained stable afterward

  • Stable Persistence: 11%

High symptoms that met diagnostic thresholds with minimal or no improvement over time

  • Recovery: 9%

Sustained full remission of symptoms

Among the group that experienced fluctuating ADHD, the following trends were uncovered:

  • There were typically three to four transitions between remission and recurrence over the 16-year period.
  • The first remission period often began in early adolescence, around age 12, with symptoms returning within a few years.
  • Compared to other groups, symptom severity was moderate.

ADHD symptoms improved to a point of remission at some point over the 16 years for most study participants, Sibley explains in an article titled “ADHD’s Vanishing Act” that appears in ADDitude’s forthcoming spring 2025 issue. In most cases, faded symptoms returned three to four years later, Sibley says.

“In other words, most individuals with ADHD can expect to go through years when their symptoms do not cause meaningful problems,” Sibley writes. “The neurocognitive risks are always present, but the clinical problems may only emerge sometimes. This is comparable to a person who may struggle with weight gain biologically, but who may fluctuate in and out of the obesity range over the course of their lifetime.”

A Busy Schedule Linked to Reduced ADHD Symptoms

The MTA study gathered information about environmental demands, such as an increase in significant responsibilities at work, school, or home, in order to explore whether these demands impacted ADHD symptoms. It turns out they did — but not in the way researchers hypothesized.

“We speculated that increased stresses would be associated with higher levels of ADHD in participants,” Sibley explains. “We were surprised to find quite the opposite, [that] higher levels of demands were associated with remission of ADHD. In other words, people with ADHD were rising to the challenge when demands were high.”

Sibley notes that the nature of the relationship between higher demands and reduced symptoms remains unclear; the study revealed a link, but not how the link works.  “One explanation is that ADHD symptoms fade when consequences in the environment create an urgent need to stay on track,” she speculates. “It is also possible that, when people have lower ADHD symptom levels, they are able to take on greater responsibilities.” Likely, it’s a combination of the two, Sibley says.

Childhood Factors Predict Long-Term Outcomes

The study found that certain childhood factors served as predictors for long-term outcomes. Individuals in the stable persistent group tended to be at higher risk for mood disorders, substance use problems in adolescence, low medication utilization, and poorer response to treatment in childhood. Those in the partial remission group tended to have higher rates of comorbid anxiety. By contrast, individuals in the recovery group were less likely to have mood disorders and parents with psychopathology.

The study helps the scientific community more fully understand the complex landscape of ADHD, and Sibley sees great potential benefit if clinicians pass along this nuanced understanding to patients.

“For some people with ADHD, this may mean staying busy and keeping an active schedule,” Sibley ventures. “It may also mean working with practitioners to leverage a nuanced understanding of ADHD fluctuations when designing a treatment plan that boosts wellbeing.”

Sources

1Sibley MH, Kennedy TM, Swanson JM, Arnold LE, Jensen PS, Hechtman LT, Molina BSG, Howard A, Greenhill L, Chronis-Tuscano A, Mitchell JT, Newcorn JH, Rohde LA, Hinshaw SP. Characteristics and Predictors of Fluctuating Attention-Deficit/Hyperactivity Disorder in the Multimodal Treatment of ADHD (MTA) Study. J Clin Psychiatry. 2024 Oct 16;85(4):24m15395. doi: 10.4088/JCP.24m15395. PMID: 39431909.

2The MTA Cooperative Group: A 14-Month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder (ADHD) . Arch Gen Psychiatry 1999;56:1073-1086.

]]> https://www.additudemag.com/whats-helps-adhd-longitudinal-study-busy-schedule/feed/ 2 367349 A Clinicians’ Guide to Better Patient Communication https://www.additudemag.com/communication-in-healthcare-strategies-clinicians-patients/ https://www.additudemag.com/communication-in-healthcare-strategies-clinicians-patients/?noamp=mobile#respond Wed, 13 Nov 2024 08:28:51 +0000 https://www.additudemag.com/?p=366948

Communication in Healthcare: Key Takeaways

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

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

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

1. Shift to Open-Ended Questions

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

  • Instead of: “Do you spend time with friends?”
  • Try: “Tell me about your friends and the activities you do together.”
Close-Ended Questions Open-Ended Questions
  • “Are you taking your medications daily?”
  • “What is your experience with taking your medications?”
  • “Do you smoke?”
  • “Tell me about your smoking experience.”
  • “Do you exercise?”
  • “What is your attitude toward regular exercise?”
  • “Have you ever seen a therapist?”
  • “What are your thoughts about seeing a therapist?”
  • “Do you have side effects with the new medication?”
  • “Tell me about your experiences with any side effects that you are having.”
  • Use empathetic responses as your patient shares.
    • Normalize (e.g., “I can understand why you would feel scared if…”)
    • Self-disclose (e.g., “We never seem to stop worrying about our kids, even as adults.”)
    • Highlight and amplify (e.g., “I’m impressed with how clearly you’ve communicated your concerns.”)
  • Look for shame and stigma, which makes it difficult for patients to trust and open up. Patients with ADHD, for example, often develop shame as a result of criticism and negative feedback from peers and authority figures.
    • Say, “I sense that you’re feeling some shame. Is it something I said? Is there something going on in your life that’s causing it?”
  • Avoid blaming and lecturing patients, making dismissive comments, and minimizing their complaints.

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

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

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

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

3. Share Your Understanding

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

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

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

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

4.Negotiate, Don’t Impose

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

Preface your ideas with the following scripts:

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

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

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

Encouraging Words Patients Want to Hear

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

The Power of a Minute

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

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

Communication in Healthcare: Next Steps

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

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.

]]> https://www.additudemag.com/communication-in-healthcare-strategies-clinicians-patients/feed/ 0 366948 “Mastering the Head Game:” 6 Life-Changing Insights from ADHD Gurus https://www.additudemag.com/how-to-deal-with-adhd-expert-strategies/ https://www.additudemag.com/how-to-deal-with-adhd-expert-strategies/?noamp=mobile#respond Wed, 12 Jun 2024 19:03:09 +0000 https://www.additudemag.com/?p=356329 “Living with ADHD is a breeze,” said no one ever with the condition. Between distractibility and forgetfulness, and the daily flood of emotions and insecurities, coping with ADHD takes patience, resilience, and a generous dash of humor.

To help our readers better manage symptoms and manifestations, ADDitude turned to the pros in the field of ADHD and asked: What do you want your patients/clients/caregivers to know to make life better?

1. There’s nothing simple about living as good a life as you can.

Ned Hallowell, M.D., author of many books, including Driven to Distraction (#CommissionsEarned)

Every day poses hurdles. Use your innate creativity to turn the challenges into opportunities. And when you mess up, as we all do, forgive yourself — immediately. The world loves punctuality and rewards it lavishly, while punishing tardiness with a vengeance. No one ever changed the world by virtue of their punctuality.

Next Steps:

2. You must care for yourself in addition to caring for others.

Lisa Woodruff, author and founder of Organize 365

When someone needs physical care, they often also need support in their life administration. Household cleaning, laundry, and meal planning are obvious tasks to consider. However, the invisible work of managing mail, bills, insurance claims, doctors’ appointments, tax payments, and other correspondence is often overlooked. Designate a basket for these items as they come in and make a weekly schedule for handling these administrative tasks.

Next Steps:

3. Setting strong boundaries supports acceptance of differences and healthy relationships.

Melissa Orlov, marriage consultant and author of The Couple’s Guide to Thriving with ADHD (#CommissionsEarned)

It can be a gift to help a partner in need, but non-ADHD partners should avoid the temptation to do too much and take over. ADHD partners often need to learn better coping strategies so they can step up more reliably.

For parents of kids with ADHD, having good boundaries is about balancing caretaking with knowing when not to engage. When teens and kids with ADHD struggle with tasks, don’t take over. Instead, help them put coping strategies in place to foster independence. Too many young adults with ADHD go to college without enough practice in keeping themselves on task without a parent’s help.

Next Steps:

4. Change your perspective and you may find it easier to navigate ADHD.

Brendan Mahan, M.Ed., M.S., host of the ADHD Essentials podcast

Managing ADHD isn’t necessarily about learning tricks and hacks; it’s often mastering the head game that makes the most difference.

  • ADHD is a roller coaster. Just because someone was on top of everything yesterday doesn’t mean they won’t struggle today. Meeting an individual where they are, and patiently supporting them as they get to where they need to be, leads to greater success overall.
  • Accept ADHD manifestations. People with ADHD are going to lose items, forget to do things, and overbook themselves. We judge a person with ADHD for having a disability in a way that we don’t judge a person with asthma, for example. Let’s give the person with ADHD permission to have the struggles they have.

Next Steps:

5. You can be inconsistent in all your behaviors and still get great results.

Alan Brown, ADHD coach and creator of the ADD Crusher video series

Here’s a common scenario: We start a new behavior, and a week later, we fall off and beat ourselves up. “See? I’m not consistent with anything. So why bother?” I have countless systems and hacks to make my life easier and get more done. And I’m far from 100% consistent with any of them. And I’m okay with that. When I mess up, I just get back at it and try to diagnose why I fell off. No matter how inconsistent you are, stop berating yourself, give yourself some grace, and get back on the pony again.

The way we talk to ourselves impacts our well-being and success. For instance, we’ve likely adopted what we heard growing up: “Why can’t you try harder?” This brings thoughts like, “I must be lazy.” Try these two actions to improve your self-talk:

  • Identify disempowering scripts from the past. When you notice them, pause and rewrite them.
  • Shift from first-person to second-person scripts. “You are trying, Buddy. And you’re going to keep trying to figure it out.”

Next Steps:

6. There are laws that protect individuals with ADHD.

Susan Yellin, Esq., director of Advocacy and Transition Services at The Yellin Center for Mind, Brain, and Education

It’s important to know that several federal laws protect students and workers with ADHD and other differences in school and in the workplace. Understanding differences and similarities between the Individuals with Disabilities Education Act, Section 504, and the Americans with Disabilities Act is the first step toward securing the necessary accommodations and supports. Take time to research these laws, and how they are applied in your state or city.

All services, accommodations, and supports should start with documentation of a good evaluation. Students can receive an evaluation at no cost from their school district as a starting point, and adults under treatment for ADHD can obtain documentation from their treating physician.

How to Deal with ADHD: Next Steps

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.

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

]]> https://www.additudemag.com/how-to-deal-with-adhd-expert-strategies/feed/ 0 356329 How to Dodge Social Isolation in Retirement https://www.additudemag.com/how-to-deal-with-loneliness-older-adult-adhd/ https://www.additudemag.com/how-to-deal-with-loneliness-older-adult-adhd/?noamp=mobile#respond Thu, 16 May 2024 08:11:10 +0000 https://www.additudemag.com/?p=354670 Loneliness is a real and painful risk as we get older. We lose a spouse, miss our far-away children and grandchildren, and lose touch with friends who have moved away or slipped into poor health.

Being an older adult with ADHD is a double whammy. In addition to older-age loneliness, we struggle with maintaining old friendships and making new friends in our later years. Building and maintaining relationships requires skills that are often impaired by ADHD — initiating contact, making and noting plans on a calendar, and showing up on time. Many older people with ADHD have told me, “I talk too much,” or “I annoy everyone by interrupting, but if I don’t interrupt, I’ll forget what I wanted to say.”

What can we, as older adults with ADHD, do to fight the looming loneliness of our 60s, 70s, 80s, and beyond? Think structure, strategies, and support.

[Self-Test: How Severe Is Your Loneliness? Take This Quiz]

Prevent Loneliness with Structure, Strategies, and Support

  • Find an environment with structure. Adults with ADHD function best within structure. Consider moving to a community that plans activities designed for older adults. You won’t need to organize anything, and no one will be upset if you run a few minutes late. Some senior centers also provide many of the same kinds of planned activities.
  • Develop strategies to keep in touch with people. I often encourage older adults with ADHD to make it a daily habit to reach out to a friend or relative. Send a text, message friends on social media, or make a phone call. Set up a daily walk with a neighbor. It will keep you socially connected and provide exercise and exposure to nature and sunshine.
  • Interact with other neurodivergent people your age. Socializing with a group of people who get and accept you can be emotionally supportive and validating. It may also improve your mood and decrease your social anxiety.
  • Need help making changes and decisions that will help you re-establish ties with friends and family? Working briefly with an ADHD coach or therapist may be the catalyst you need to reconnect with your social world.

How to Deal with Loneliness: Next Steps

Kathleen Nadeau, Ph.D., is the author of Still Distracted After All These Years. (#CommissionsEarned)

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.

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

]]> https://www.additudemag.com/how-to-deal-with-loneliness-older-adult-adhd/feed/ 0 354670 ADHD Symptoms in Women Aren’t ‘Hidden.’ They Are Misinterpreted. https://www.additudemag.com/adhd-symptoms-in-women-female-signs/ https://www.additudemag.com/adhd-symptoms-in-women-female-signs/?noamp=mobile#respond Fri, 12 Apr 2024 09:03:06 +0000 https://www.additudemag.com/?p=352431

ADHD Symptoms in Women: Key Takeaways

  • ADHD continues to be overlooked in girls and women because of male-centric views of the condition.
  • Emotional dysregulation, overwhelm, and social challenges are major clues of female ADHD, which often leads to other health concerns when left unaddressed.
  • Clinicians must recalibrate approaches to diagnosing and treating female patients with ADHD to consider emotional dysregulation, hormonal fluctuations, and other specific factors.

ADHD symptoms in women and girls aren’t “hidden” or “easy to miss.” They are obvious, persistent, and often quite serious. Why, then, do we continue to disregard or misdiagnose ADHD in girls and women? And why do we more accurately diagnose boys, who get a head start of about four years on treatment?1

The reason: ADHD is still viewed from a largely male-centric point of view. This bias toward recognizing externalizing symptoms and disruptive behaviors means that female manifestations of ADHD — including the critical role of hormonal fluctuations on symptoms and functioning — are all but disregarded. Clinicians readily misattribute the downstream consequences of undiagnosed ADHD in women, and this is why, in a bizarre twist, girls and women often show up everywhere in the health care system before they’re identified with ADHD.1

ADHD in Girls and Women: Under Our Noses, Off Our Radars

Emotional Dysregulation: A Major Clue for Female ADHD

Emotional dysregulation — a core feature of ADHD — and distressing social-emotional outcomes impact girls and women with ADHD in the following ways:

  • Masking and overcompensating. Girls realize earlier than boys what’s expected of them in social settings, so they try their best to hide their symptoms and challenges — an exhausting feat.2
  • Social difficulties and bullying. Girls with ADHD are more likely than girls without ADHD to experience peer rejection and victimization, and to face challenges with social skills, among other social difficulties.3
  • Tantrums and meltdowns. While girls and women keep it together in the world, they lower their guards at home and other safe places. Emotional dysregulation shows through here as big emotions damage interpersonal relationships and further harm self-concept.
  • Low self-esteem and negative self-talk. Without answers or explanations for their challenges, girls and women with ADHD assume that something is terribly wrong with them.

Over time, teen girls and young women with undiagnosed and untreated ADHD become increasingly impaired by emotional dysregulation, and they begin to show up in the healthcare system seeking help for depression, anxiety, eating disorders, self-harm, and other related conditions.1 They also seek social services for trauma or victimization.1 Over and over again, we miss identifying ADHD in these girls and women, despite the signs. We get the causality backwards; we blame their struggles on trauma, depression, or social failure instead of considering that ADHD is at the core.

[Read: ADHD in Women and Girls — Why Female Symptoms Slip Through Diagnostic Cracks]

Hormonal Fluctuations Matter

Complicating the picture are hormonal fluctuations during the menstrual cycle (and across the entire lifespan). Given that sex hormones influence neurotransmitters like serotonin and dopamine — which is heavily implicated in ADHD — it’s plausible that fluctuating hormonal levels through the monthly cycle impact symptom severity, mood, functioning, and even medication efficacy. That the medical community at large overlooks this relationship is astonishing, especially when we consider that hormone-related mood disorders like premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS), disproportionately impacts women with ADHD.4

Most of our approaches, unfortunately, are based on studies done on males with ADHD, who do not experience monthly fluctuations of estrogen and progesterone once they hit puberty.

Girls and Women with ADHD Deserve Better: Steps for Clinicians

Girls and women with ADHD continue to fly under the radar because our tracking systems are calibrated to signs of male ADHD only. The result is that girls and women with ADHD feel abandoned by healthcare and left to ‘fix’ life with an incomplete toolbox of strategies and treatments.

Consider the following insights, approaches, and steps to recalibrate how you evaluate, diagnose, and treat female patients.

[Read: Protecting the Emotional Health of Girls with ADHD]

1. Understand that female ADHD isn’t male ADHD-lite. (If anything, research indicates that ADHD may be even more impairing for women than it is for men.) Lead with the understanding that you will need to adopt a differentiated view when looking at your female patients with ADHD and their challenges.

2. Look for signs of emotional distress and educate yourself on how ADHD may appear in girls and women, from perfectionism to low self-esteem. Understand that masking and mimicking are coping mechanisms that may, alongside shame, impair your patient’s ability to fully report their symptoms and symptom severity. Overwhelm, in my experience, is a major theme of discussion among undiagnosed girls and women with ADHD. Be curious, clever, and receptive when you evaluate your patients.

3. Disentangle emotional dysregulation. Consider the full picture to separate ADHD emotional dysregulation from distinct and overlapping comorbidities like bipolar disorder, borderline personality disorder, anxiety, and depression. The presence of these conditions, of course, will require different treatment approaches. Given that 85% of adult patients with ADHD also have at least one comorbid condition, it’s your duty to screen your female patients thoroughly.

4. Consider hormones and how a naturally cycling patient’s symptoms, ADHD medication efficacy, and overall functioning may change with monthly fluctuations in estrogen and progesterone. High-estrogen states may improve mood, symptoms, and functioning in some patients, while low-estrogen states may exacerbate symptoms and render ADHD medications ineffective. For patients who struggle with impulsivity, high-estrogen states may trigger greater levels of dopamine and increase the likelihood of engaging in risky behaviors due to a surge in positive emotions.5 6

  • Encourage menstruating patients to track their cycles. They should log objective data on changes to their mood, ADHD symptoms, and functioning through their cycles to improve shared medical decision-making and treatment.
  • Consider cyclic dosing by fine-tuning a patient’s ADHD medication dosages based on hormonal status and functioning. A 2023 study found that increasing premenstrual psychostimulant dosage in women with ADHD resulted in improvements in ADHD symptoms, mood stabilization, emotional control, and productivity, with minimal side-effects.7

5. Bolster your patient’s care toolbox. Some patients abandon medication because of inconsistent results (perhaps due to hormonal fluctuations that weren’t factored into care), and feel that self-care, emotional regulation, and skills training are their only options. Help patients understand that the most effective treatment takes a multimodal approach including pharmacological treatment and coping/life skill strategies.

ADHD Symptoms in Women: Next Steps

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “The Emotional Lives of Girls with ADHD” [Video Replay & Podcast #488] with Lotta Borg Skoglund, M.D., Ph.D., which was broadcast on January 23, 2024.

ADDitude readers: Sign up to access LetterLife, an app co-founded by Dr. Lotta Borg Skoglund that provides users with personalized insights — on hormonal cycles, ADHD symptoms, and lifestyle factors — to better manage ADHD.

Use the discount code ADDWEB20 to get 20% off Dr. Skoglund’s book, ADHD Girls to Women, when purchased via uk.jkp.com.

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

Sources

1 Skoglund, C., Sundström Poromaa, I., Leksell, D., Ekholm Selling, K., Cars, T., Giacobini, M., Young, S., & Kopp Kallner, H. (2023). Time after time: failure to identify and support females with ADHD – a Swedish population register study. Journal of child psychology and psychiatry, and allied disciplines, 10.1111/jcpp.13920. Advance online publication. https://doi.org/10.1111/jcpp.13920

2 Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16(3), PCC.13r01596. https://doi.org/10.4088/PCC.13r01596

3 Kok, F. M., Groen, Y., Fuermaier, A. B., & Tucha, O. (2016). Problematic Peer Functioning in Girls with ADHD: A Systematic Literature Review. PloS one, 11(11), e0165119. https://doi.org/10.1371/journal.pone.0165119

4 Dorani, F., Bijlenga, D., Beekman, A. T. F., van Someren, E. J. W., & Kooij, J. J. S. (2021). Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of psychiatric research, 133, 10–15. https://doi.org/10.1016/j.jpsychires.2020.12.005

5 Roberts, B., Eisenlohr-Moul, T., & Martel, M. M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015

6 Eng, A. G., Nirjar, U., Elkins, A. R., Sizemore, Y. J., Monticello, K. N., Petersen, M. K., Miller, S. A., Barone, J., Eisenlohr-Moul, T. A., & Martel, M. M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and behavior, 158, 105466. https://doi.org/10.1016/j.yhbeh.2023.105466

7 de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., & Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Frontiers in psychiatry, 14, 1306194. https://doi.org/10.3389/fpsyt.2023.1306194

]]> https://www.additudemag.com/adhd-symptoms-in-women-female-signs/feed/ 0 352431 The Menstrual Cycle Impacts ADHD Symptoms in Disparate Ways https://www.additudemag.com/adhd-and-periods-menstrual-cycle-hormones/ https://www.additudemag.com/adhd-and-periods-menstrual-cycle-hormones/?noamp=mobile#respond Mon, 08 Apr 2024 09:39:48 +0000 https://www.additudemag.com/?p=352284 What do fluctuating hormones across the menstrual cycle mean for my ADHD symptoms and treatment? What do I need to know, and what should I expect?

For individuals with ADHD who menstruate, fluctuating estrogen and progesterone across the menstrual cycle invariably impact ADHD symptoms, emotions, and functioning. We know this to be true, but there is almost no research validating this relationship. So, we arrive at this conclusion using available research on how hormonal changes affect the body, along with anecdotal information and clinical observations of patients with ADHD.

But how hormonal fluctuations affect your ADHD symptoms  — and even medication efficacy — is for you to learn and discuss with your doctor.

[Get This Free Guide: Women, Hormones, and ADHD]

ADHD Symptoms Through the Menstrual Cycle

Estrogen and progesterone are produced in the ovaries, among other places in the body. These hormones easily pass through the blood-brain barrier to access the brain, which is filled with receptors that are involved in emotional regulation and cognitive functioning. Note that dopamine, which is heavily implicated in ADHD, is modulated by estrogen.

Through the menstrual cycle, which lasts 28 days on average, estrogen and progesterone levels rise and fall as the body prepares for possible pregnancy. Day 1 through Day 14 marks the follicular phase, where estrogen levels rise and rise, peaking at ovulation. After this point comes the luteal phase, where progesterone levels rise, and estrogen levels fall quite steeply before stabilizing at a low level. In this hormonal environment leading up to menstruation, women generally report more symptoms of depression, anxiety, stress, sleeping problems, binge eating, cognitive difficulties, memory problems, and other symptoms of premenstrual syndrome (PMS).1

If your ADHD profile comprises traits like low energy levels, inattention, and anxiety, then the follicular phase, when estrogen is highest, might offer a welcome boost of energy, good mood, and clarity. In the luteal phase, you may suffer tremendously with PMS or its more severe form, PMDD, which disproportionately impacts women with ADHD.2 3 4

If your ADHD profile comprises impulsivity and hyperactivity, high-estrogen states may be the most challenging part of each month for you. This is because high estrogen levels could cause a surge in positive emotions that may increase the likelihood of engaging in risky, sensation-seeking behaviors.2

[Read: PMS and ADHD — How the Menstrual Cycle Intensifies Symptoms]

Medication Efficacy Through the Menstrual Cycle

Many individuals with ADHD who menstruate report differences in symptom severity and, thus, stimulant efficacy across the menstrual cycle.2 5 Research on this front is limited, but it’s a valid hypothesis that fluctuating hormonal status can influence the effectiveness of ADHD medication. In the low-estrogen luteal phase, for example, some individuals may find that their ADHD medication doesn’t work at all, which only worsens functioning. For those who face increased risk for risky behaviors in the high-estrogen follicular phase, it’s possible that a medication dose can suddenly be too high (as estrogen and dopamine potentiate each other) further increasing the risk for these behaviors and other side effects.

Tailoring medication dosages to hormonal status — known as cycle dosing — could be key for optimizing treatment.2 5 Tracking your cycle will give you powerful insights into how hormonal fluctuations influence your ADHD symptoms, medication effectiveness, and overall functioning. With this data, you’ll be in a better position to talk to your doctor about enhancements to your treatment plan to improve your health and wellbeing.

ADHD and Periods: Next Steps

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “The Emotional Lives of Girls with ADHD” [Video Replay & Podcast #488] with Lotta Borg Skoglund, M.D., Ph.D., which was broadcast on January 23, 2024.

ADDitude readers: Sign up to access LetterLife, an app co-founded by Dr. Lotta Borg Skoglund that provides users with personalized insights — on hormonal cycles, ADHD symptoms, and lifestyle factors — to better manage ADHD.

Use the discount code ADDWEB20 to get 20% off Dr. Skoglund’s book, ADHD Girls to Women, when purchased via uk.jkp.com.

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

Sources

1 Handy, A. B., Greenfield, S. F., Yonkers, K. A., & Payne, L. A. (2022). Psychiatric Symptoms Across the Menstrual Cycle in Adult Women: A Comprehensive Review. Harvard review of psychiatry, 30(2), 100–117. https://doi.org/10.1097/HRP.0000000000000329

2 Roberts, B., Eisenlohr-Moul, T., & Martel, M. M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015

3 Dorani, F., Bijlenga, D., Beekman, A. T. F., van Someren, E. J. W., & Kooij, J. J. S. (2021). Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of Psychiatric Research, 133, 10–15. https://doi.org/10.1016/j.jpsychires.2020.12.005

4 Eng, A. G., Nirjar, U., Elkins, A. R., Sizemore, Y. J., Monticello, K. N., Petersen, M. K., Miller, S. A., Barone, J., Eisenlohr-Moul, T. A., & Martel, M. M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and behavior, 158, 105466. https://doi.org/10.1016/j.yhbeh.2023.105466

5 de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., & Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Frontiers in psychiatry, 14, 1306194. https://doi.org/10.3389/fpsyt.2023.1306194

]]> https://www.additudemag.com/adhd-and-periods-menstrual-cycle-hormones/feed/ 0 352284 “What Years of Debilitating Migraines Taught Me About ADHD in Women” https://www.additudemag.com/migraines-in-women-adhd-estrogen/ https://www.additudemag.com/migraines-in-women-adhd-estrogen/?noamp=mobile#comments Tue, 12 Mar 2024 09:30:29 +0000 https://www.additudemag.com/?p=350039 Before I was diagnosed with ADHD at age 33, my body felt like a mystery, an experience I assume is nearly universal for women with a late diagnosis. Yes, there was forgetfulness, distractibility, “careless” errors, internal restlessness, and emotional dysregulation. Yes, there were incredibly painful menstrual cycles with mood changes so drastic they should have their own amusement park rides named after them. But there were also migraine headaches so severe that they’d often lead me to hide in the bathroom and vomit while working a retail job at age 20.

Despite the unbearable pain and nausea associated with migraines, I attended regular work and school hours. With then-undiagnosed ADHD, untreated migraines, severe mood swings, and an unpredictable body, I completed all of my responsibilities with a smile on my face, masking the feeling of being a walking zombie. Experiencing – or rather, trying to act like I wasn’t experiencing any of it – was likely a big reason why I was diagnosed with depression before I was diagnosed with ADHD.

All Roads Lead Back to Estrogen

After my ADHD diagnosis, I poured myself into research, as I quickly learned I would need to educate myself about ADHD’s unique presentation in women. One finding that struck me was just how much hormonal fluctuations influence ADHD symptoms in women, which complicates an already-complicated picture. The villain causing all of my challenges, it seemed, was low estrogen levels.

[Get This Free Download: Hormones & ADHD in Women]

It turns out that there’s a strong relationship between estrogen and dopamine, which is one of the main neurotransmitters involved in ADHD. Low estrogen levels mean low dopamine levels. The inverse is true. When we consider that there are predictable drops in estrogen throughout the female lifespan, like right before getting a period or during perimenopause, to name a few, it means there’s a predictable worsening of ADHD symptoms, too. Low estrogen levels seem to hit us hard, which may be why premenstrual mood disorder (PMDD), a severe form of premenstrual syndrome (PMS), disproportionately affects women with ADHD.1

But that’s not all. Low estrogen levels are also known to trigger migraines.2 Could this connection explain why migraines, which are more prevalent in women, co-occur with ADHD about 35% of the time?3 As I tried to put the pieces together, I felt like a detective uncovering the mystery of my life. I finally understood why I felt so out of my body and mind in the midst of a migraine attack. I understood why, on migraine days with yet undiagnosed ADHD, it felt like there was an ineffective replacement version of me steering the ship, and the vessel that was me was constantly on the verge of collapse.

Silent Conditions

As I tried to learn more about the migraines-ADHD connection in women, I learned that, as with ADHD, research on migraines and the scientific attention given to migraines are biased with respect to gender. In Migraine: Inside a World of Invisible Pain (#CommissionsEarned), Maria Konnikova writes that, despite the disease’s prevalence, migraines receive little to no attention in medical schools. Further, Konnikova explains that Sigmund Freud can be thanked for the gender divide in migraine diagnosis. If women are suffering, it must be, quite literally, an unobservable, unexplainable phenomenon in their heads. Like ADHD, migraines are a silent and overlooked condition in women. As with my own ADHD diagnosis journey, I suffered from migraine headaches for years before going to a neurologist to finally get them treated.

[Read: Hormonal Changes & ADHD — a Lifelong Tug-of-War]

Invisible No More

In her 1968 essay “In Bed,” Joan Didion writes that the public often views migraines as “imaginary.” I argue that ADHD is often viewed similarly in women. And why wouldn’t this be the case? As long as we mask our pain and our symptoms — a habit I’m still unlearning — ADHD in women will continue to be difficult to detect. As long as the medical community dismisses the relationship between hormonal fluctuations and ADHD, women will go misdiagnosed and improperly treated.

Here’s the truth: Women with ADHD, like women with migraines and other conditions heavily tied to hormonal and dopamine imbalances, are boiling pots with ill-fitting lids that we and the people around us use to avoid being misperceived as untamed shrews. And I’d venture to guess you’re just as tired of acting as I am. Regardless of the condition, we deserve to have all of our symptoms taken seriously.

ADHD in Women: Next Steps

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.

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

Sources

1Dorani, F., Bijlenga, D., Beekman, A. T. F., van Someren, E. J. W., & Kooij, J. J. S. (2021). Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of psychiatric research, 133, 10–15. https://doi.org/10.1016/j.jpsychires.2020.12.005

2Reddy, N., Desai, M. N., Schoenbrunner, A., Schneeberger, S., & Janis, J. E. (2021). The complex relationship between estrogen and migraines: a scoping review. Systematic reviews, 10(1), 72. https://doi.org/10.1186/s13643-021-01618-4

3Hansen, T. F., Hoeffding, L. K., Kogelman, L., Haspang, T. M., Ullum, H., Sørensen, E., Erikstrup, C., Pedersen, O. B., Nielsen, K. R., Hjalgrim, H., Paarup, H. M., Werge, T., & Burgdorf, K. (2018). Comorbidity of migraine with ADHD in adults. BMC neurology, 18(1), 147. https://doi.org/10.1186/s12883-018-1149-6

]]> https://www.additudemag.com/migraines-in-women-adhd-estrogen/feed/ 1 350039 ADHD Symptoms You Won’t Find in the DSM https://www.additudemag.com/adhd-symptoms-not-in-dsm-5/ https://www.additudemag.com/adhd-symptoms-not-in-dsm-5/?noamp=mobile#comments Fri, 03 Nov 2023 09:24:05 +0000 https://www.additudemag.com/?p=342654 The American Psychiatric Association’s Diagnostic and Statistical Manual is the enduring authority for healthcare providers who diagnose and treat mental health conditions. Its origins date back to the 1800s1 and, though it continues to serve an important role for patients and clinicians, the DSM is not without significant problems. In the context of ADHD, “the DSM simply does not describe ADHD as the rest of us experience it,” said William Dodson, M.D., in an article outlining the diagnostic symptoms that are missing.

Emotion dysregulation, which research has shown to be a fundamental component of ADHD,2, 3 is one such symptom. Another is gender differences, particularly in females who tend to mask or internalize their symptoms.4 “There’s some research on whether there might be a completely different presentation [of ADHD], at least in females, with a different time of onset and a different level of severity,” said Dave Anderson, Ph.D., in a recent ADDitude webinar on understanding the evolution of ADHD.

If you could add any symptom to the DSM diagnostic criteria for ADHD, what would it be? The answers we received from ADDitude readers included many familiar ADHD behaviors like rumination, daydreaming, time blindness, insomnia, sensory sensitivity, anger, and anxiety. Some readers even suggested changing the name entirely.

“‘Attention deficit’ seems to be the exact opposite of my experience,” said Amanda, an ADDitude reader in Utah. “I cannot pull myself away from the things I am interested in! And hyperactivity represents such a small portion of diagnosed individuals (primarily boys younger than 12). It is only one of dozens of significant symptoms that affect the greater population.”

Below, ADDitude readers share the symptoms that they feel are central dimensions of ADHD. What would you choose to add? Tell us in the Comments section, above.

[Download: 3 Defining Features of ADHD That Everyone Overlooks]

ADHD Symptoms Not in the DSM

“I would love to see separate sets of diagnostic criteria for boys, girls, adult men, and adult women, because (generally speaking) ADHD can look quite different in each of those four groups. Yes, there is some overlap, but I don’t think it serves girls or adult men and women to compare them to a single ADHD picture, that of the stereotypical hyperactive young boy. The rest of us know that isn’t the only face of ADHD.” — Jen, Missouri

“I think the biggest thing I would like to see is more of a focus on emotional dysregulation and the intense emotions that you can feel as a symptom of ADHD. This is one of the main ADHD symptoms that I personally struggle with, and it was never recognized. I was misdiagnosed with bipolar as a teenager because my intense emotions were more associated with BD than with ADHD.” — Kate, Florida

“I’d make sure that comorbidities are noted more directly with the DSM diagnosis of ADHD.” — An ADDitude reader

“I believe today’s criteria don’t adequately address adult patients. The word ‘adult’ obliquely refers to patients age 17 and older, but ADHD may manifest differently in older adults. Our prefrontal cortex continues to develop into our mid-20s, does it not? Typically, career advances are met with increased responsibility and visibility, and ADHD traits can become more of an encumbrance further up the corporate ladder (as I learned in my 40s and 50s). Clinicians would likely benefit from a subset of criteria for adults 25 and older.” — Greg, Ohio

[Read: A Critical Need Ignored: Inadequate Diagnosis and Treatment of ADHD After Age 60]

“Feeling like you have multiple thoughts at once; thinking spherically as opposed to linearly.” — Sunshine, Colorado

“Apparently, sleep issues are a telltale sign [of ADHD] for young children, yet I read every sleep training book I could get my hands on when [my daughter] was a baby, and not one of them mentioned [ADHD]. I didn’t learn this until she was in high school, which I feel is not just criminal negligence by so-called sleep experts but a huge disservice to parents and to kids with ADHD who could be assessed earlier.” — Kelly, California

“The emotional regulation symptoms of ADHD are sorely lacking.” — An ADDitude reader

“The social impacts of ADHD and how it impacts the ability to maintain friendships is a big hallmark for me. In general, I wish the DSM had a great deal more nuance, especially when it comes to identifying ADHD in girls and adults.” — LeAnn, Wisconsin

“I would differentiate between symptoms that boys have versus symptoms that girls have.” — Tracy, New York

“Anything about sensory challenges. To me, this is actually what ADHD is all about: difficulty blocking out sensory input. ADHD encompasses the challenges and ways people deal with sensory overwhelm. The fact that the DSM — and as a result, many practitioners — don’t understand this is so frustrating. Without this understanding, they are missing so many people who are probably unable to get support.” — Katie, Maryland

“Communication lapses: The tendency [for my son] to think that he communicated something verbally because he already thought it in his mind. We’ve had many incidents where family dynamics were impacted by communication lapses. From his point of view, the communication happened even though nothing verbal was spoken, so the other person wasn’t in the know. This also happens with my spouse (who was diagnosed at 52 after our son).” — Julieann, Ohio

“Clumsiness — anecdotally, this is very common among ADHDers, even being accident-prone. I see this a lot in the chat rooms I frequent for ADHDers.” — Diane, New Hampshire

“If it is not already in there, I believe the aspect of emotional dysregulation and/or rejection sensitivity dysphoria is such a huge component of ADHD that gets so very little attention – especially when it comes to treatment for younger children. But even for me as an adult, when I learned about the term RSD and what it meant, it stopped me in my tracks and totally changed the way I looked at my ADHD.” — Geoff, Rhode Island

“I would add criteria under affective disorders relating to anxiety and personality disorders like BPD/OCD to ensure it isn’t ADHD before making one of those other diagnoses.” — Greg, Canada

“Include not recalling content in a conversation literally right after or immediately after the information is shared. I think my kids are ready to kill me; they have told me that they purposefully don’t talk with me that much because I never remember. It’s awful.” — Shannon, Ohio

“I would make sure that something like survivalist, problem-solver, or despiser of mundane tasks were all in there!” — Blythe, Oklahoma

“A ‘constant state of overwhelm’ would be one. Or ‘takes tons of effort just to exist.’” — Natalie, Pennsylvania

ADHD Symptoms Not in the DSM: Next Steps

Sources

1 PsychDB. (n.d.) History of the DSM. https://www.psychdb.com/teaching/1-history-of-dsm

2 Hirsch, O., Chavanon, M., Riechmann, E., & Christiansen, H.. (2018). Emotional dysregulation is a primary symptom in adult attention-deficit/hyperactivity disorder (ADHD). Journal of Affective Disorders, 232, 41-47. https://doi.org/10.1016/j.jad.2018.02.007

3 Soler-Gutiérrez, A.M., Pérez-González, J.C., & Mayas, J. (2023). Evidence of emotion dysregulation as a core symptom of adult ADHD: a systematic review. PLoS One, 18(1), e0280131. https://doi.org/10.1371/journal.pone.0280131.

4 Young, S., Adamo, N., Ásgeirsdóttir, B.B., et al. (2020). Females with ADHD: an expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry, 20, 404. https://doi.org/10.1186/s12888-020-02707-9

]]> https://www.additudemag.com/adhd-symptoms-not-in-dsm-5/feed/ 1 342654 How the Science of ADHD Is Advancing: fMRI and Beyond https://www.additudemag.com/adhd-research-updates-fmri-open-science/ https://www.additudemag.com/adhd-research-updates-fmri-open-science/?noamp=mobile#respond Wed, 11 Oct 2023 13:56:23 +0000 https://www.additudemag.com/?p=340612 The science of ADHD is evolving and, with it, so is our understanding of the condition. Over the past 25 years, research has blossomed as institutions share data sets to combine and test earlier findings, says Dave Anderson, Ph.D., of the Child Mind Institute.

The use of fMRI brain scans in ADHD research has helped scientists spot abnormalities in underlying neural networks and circuitries. Differences in the default mode network (overactivity) and frontostriatal circuits (underactivity) of the ADHD brain remain key findings.

“The default mode network (DMN) is one of the most fascinating and significant discoveries to come out of neuroscience in the past 20 years,” writes Edward Hallowell, M.D., in his ADDitude article, “ADHD’s Secret Demon — and How to Tame It.” “The DMN seems to be more active in those of us who have ADHD, and it may explain our tendency to make ‘careless’ mistakes. In fact, when using a functional MRI, you can predict a mistake 20 seconds before it is made by watching for activity in the DMN.”

The emergence of multiple large-scale, multi-site studies has called into question other previous conclusions from neuroscience research. In short, complex answers are replacing some of our more simple ones, and care is improving as a result.

“Large-scale, multi-site, open-science data sharing brings us closer and closer to the idea that we might discover either objective task-based markers or objective biological markers that would allow us to index risk for ADHD and make this not so much dependent on therapists’ subjectivity and the quality of a diagnostic interview,” Anderson said during his 2023 ADDitude webinar on the evolution of ADHD.

For more information about the evolution of ADHD research and diagnostic tools, watch Dr. Anderson’s free ADDitude webinar, “ADHD Then and Now: How Our Understanding Has Evolved.” Dr. Anderson is Vice President of School and Community Programs and former Senior Director of the ADHD & Behavior Disorders Center at the Child Mind Institute.

ADHD Research: Next Steps

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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.

]]> https://www.additudemag.com/adhd-research-updates-fmri-open-science/feed/ 0 340612 How the DSM-5 Fails People with ADHD — and a Better Way to Diagnose https://www.additudemag.com/dsm-5-adhd-diagnosis-criteria-problems/ https://www.additudemag.com/dsm-5-adhd-diagnosis-criteria-problems/?noamp=mobile#comments Tue, 03 Oct 2023 07:13:38 +0000 https://www.additudemag.com/?p=340316 October 3, 2023

Approximately 25 years ago, when ADDitude published its first newsletter, the diagnosis of ADHD was based on criteria published in the Diagnostic and Statistical Manual of Mental Disorders, Version III-C. The DSM-IV diagnostic criteria adopted two years later were the most scientifically validated to date.

Its 18 symptoms were evenly divided into two lists: problems with inattention vs. problems with hyperactivity-impulsivity. To warrant a diagnosis, a patient had to exhibit at least six symptoms on either list, suffer impairment in one or more major life activities (home, school, community, peers), and begin experiencing symptoms by age seven. Furthermore, the symptoms could not be better explained as those of another condition.

Yet, problems remained. The committee handling ADHD criteria for the DSM-5 hoped to improve the DSM’s rigor and diagnostic accuracy. It proposed recommendations that reflected independent research findings. Sadly, many of those recommendations were rejected by higher-ranking committees, perhaps partly out of fear they would significantly increase the prevalence of ADHD diagnoses. Thus, the ADHD criteria in the DSM-5, released in 2013, represented only modest improvements.

The Problems with the DSM-5

The DSM-5 does not capture ADHD accurately because its criteria do not conceptualize ADHD as a disorder of executive functioning (EF) and self-regulation (SR). This limitation greatly narrows the concept of ADHD, trivializes its nature as just an attention deficit, and discourages diagnosing clinicians from focusing on the wider range of impairments inherent in ADHD. These impairments impact executive inhibition, self-awareness, working memory, emotional self-regulation, self-motivation, planning/problem-solving, and other functions not typically associated with ADHD. Ignoring them restricts diagnosis and, ultimately, treatment for many patients.

Why Qualifier Symptoms Should Go Unheeded

In the DSM-5, qualifier symptoms were added after each listing of a symptom to help clinicians understand the expression of that symptom beyond childhood. However, problems with these clarifiers include:

[Read: ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.]

  • None of these clarifications arose out of prior research that tested them for their affiliation with ADHD, for their relationship to the root symptom they are supposed to clarify, for their accuracy in detecting ADHD, or for their relationship to impairment in major life activities. They were simply invented by committee members in a meeting.
  • Adding such new and untested symptoms may have broadened eligibility for the disorder by up to 6 percent in older teens and adults.
  • Some clarifications seemed to correlate with anxiety, which could lead to cross-contamination of the ADHD criteria.

These clarifications also were not informed by any theory of ADHD, such as EF-SR theory.

So, until the status of these parenthetical clarifiers is better researched, clinicians would do best to ignore them in making a diagnosis of ADHD in a teen or an adult.

A Better Way to Diagnose ADHD

Clinicians can ensure more accurate diagnoses and more appropriate care by following these five recommendations:

#1. Avoid placing undue emphasis on hyperactive symptoms.

Six of the nine hyperactive-impulsive symptoms on the DSM list reflect excessive activity, even though impulsivity has been viewed as a more prevalent ADHD symptom for the last 40 years. At best, hyperactivity is reflective of early childhood disinhibition of motor movement and, later, the inability to regulate such movement to the demands of the situation (e.g., teacher’s instructions to complete desk work). Those symptoms decline steeply over development and are of little diagnostic value by late adolescence. This is one reason why clinicians before the 1980s thought the disorder was outgrown before adulthood, which we now know is false for most people.

[Research: Only 1 in 10 Children with ADHD Will Outgrow Symptoms]

#2. Look for additional symptoms of impulsivity.

Poor inhibition may manifest not just in speech (currently, the DSM criteria include only three verbal symptoms) but in motor behavior, cognition, motivation, and emotion. Clinicians should screen for any of the following manifestations:

  • often fails to consider the consequences of their actions
  • has trouble motivating to persist toward goals
  • has trouble deferring gratification or waiting for rewards
  • lacks willpower, self-discipline, drive, and determination
  • seems unusually impatient, easily emotionally aroused and frustrated, and quick to anger

Abundant research shows that these aspects of poor self-regulation are as common in people with ADHD as are the traditional DSM symptoms and, with age, more so than the symptoms of hyperactivity.

#3. Think of inattention as affecting a range of executive function deficits in daily life…

…particularly those involving impaired self-awareness, working memory, self-organization, emotional self-regulation, self-motivation, and time management. This will encourage clinicians to broaden their focus beyond the DSM symptoms when conducting open-ended interviews and selecting rating scales.

After the evaluation is completed, clinicians should explain to clients why their condition is so serious, impairing, and pervasive across major domains of life. This will also help clinicians and parents appreciate why teens (and young adults) may seem to be outgrowing ADHD, based on DSM criteria, when they are far less likely to outgrow their EF-SR deficits (and that these impairments may increase with age).

#4. Use rating scales broken down by sex and not just age.

Research suggests that females in the general population, at least in childhood and adolescence, do not show the same symptom severity as their male peers.1 This makes it harder for a female to meet the DSM criteria. Another complicating factor: because males were overrepresented in field trials for earlier versions of the DSM, the symptom threshold was male-biased.

#5. Don’t adhere too rigidly to diagnostic thresholds when there are clear signs of impairment.

Empirical research demonstrates that ADHD falls along a continuum in the general population. So, clinicians will see clients who don’t meet all of the DSM criteria, yet who are experiencing enough impairment that they sought a diagnosis. This means clinicians should diagnose ADHD if:

  • Clients or their caregivers state that a child or teen has a high number of ADHD (and EF) symptoms (place above the 20th–16th percentile in severity) and there is evidence of impairment in major life activities, even if the client fails to meet all DSM-5
  • Symptoms became evident sometime during development, usually before age 21–24, and the patient meets all other criteria. DSM-5 raised the age of onset for ADHD from age 7 to age 12, but research repeatedly shows that few people are reliable or accurate in recalling the age of onset of their symptoms. It is a mistake, therefore, to consider age of onset in diagnosing ADHD, where all other criteria are met.

DSM-5 ADHD Criteria Challenged: Next Steps

Russell A. Barkley, Ph.D., is a retired clinical scientist, educator, and practitioner.

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

Sources

1 Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., Tierney, K., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry, 20(1), 404. https://doi.org/10.1186/s12888-020-02707-9

]]> https://www.additudemag.com/dsm-5-adhd-diagnosis-criteria-problems/feed/ 3 340316 ADHD Is a Whole-Life Experience. The DSM Needs to Reflect That. https://www.additudemag.com/emotional-dysregulation-dsm-5-adhd-women/ https://www.additudemag.com/emotional-dysregulation-dsm-5-adhd-women/?noamp=mobile#respond Thu, 21 Sep 2023 09:09:36 +0000 https://www.additudemag.com/?p=339295 The days of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are probably numbered.

For one, the rest of the world already defines the criteria for conditions using the International Classification of Diseases (ICD-10-CM), which became the official health classification of the U.S. government in 2014. But, more significantly, the DSM simply does not describe ADHD as the rest of us experience it.

The DSM was written solely by and for the use of researchers, not for consumers or for practicing clinicians, and it describes only childhood behaviors. Everything else has been intentionally ignored since the very beginning of ADHD, for the sake of publishing research validating ADHD as a real thing with extremely significant impairments in children ages 6 to 12.

Our diagnostic definition is incomplete and grossly inadequate by virtue of ignoring emotional dysregulation, cognition, gender, hormones, ADHD in old age, ADHD at menopause, and the effects of ADHD on a developing personality.

[Free Resource: Rein In Intense ADHD Emotions]

Here are the dimensions missing from the DSM‘s criteria for ADHD:

Emotions: The most impairing feature of ADHD at all ages, emotional dysregulation, was not mentioned in the DSM as a fundamental component because emotions are hard to research. Why?

  • They are not always present.
  • They are very difficult to measure. (For example, how bad is a temper tantrum? Exactly how would anyone measure and compare one tantrum to another, even in the same child? It can’t be done.)
  • People are embarrassed when they cannot control their own emotions and, thus, hide the very impairments that need to be studied.

The problems of controlling emotions are more disruptive and painful than are all the other core features of ADHD (inattention, impulsivity, and hyperactivity/hyperarousal) combined. The subject of emotional regulation in ADHD has begun to appear in research literature only within the last few years and, even now, mostly in European journals.

Age: The ADHD criteria have never been validated in a study of participants over the age of 16. All the research on adults has been done using twisted versions of the childhood criteria. For an adult to meet the child-based criteria, they would have to be functioning on the level of an elementary school-age child with untreated ADHD. Though it was officially acknowledged in 1980 that ADHD usually persists into adult life, work has only just begun on writing official adult ADHD criteria 43 years later.

[Read: Why We Need U.S. Guidelines for Adults with ADHD]

Development: ADHD remains the same throughout life. We are the ones who change as the challenges of life grow, shift, and demand more of us. We are very different at age 28 from what we were at eight or 18. This makes ADHD look as if it is changing when it’s not. The sources of the impairments from ADHD are the same, the medications and doses of medications used for ADHD are the same, and the problems with controlling emotional expression remain the same.

Gender: Simply put, it was once thought that females did not get ADHD because they are not as hyperaroused and disruptive as are males. This is still a significant problem. No existing research studies involve only females in adulthood.

It’s Time for a Shift in Thinking

ADHD was once a vague, controversial idea. Today, no rational person doubts that ADHD exists and that, if left untreated, it can have devastating consequences through adulthood. The time has come to see the full picture of ADHD. It is more than a disorder of behavior; it impairs emotions and affects the lives of millions of people.

While we are at it, we should give the same attention, thinking, and research to additional components of ADHD that impair people every day: the sleep disturbances caused by the hyperarousal of ADHD, rejection sensitivity, and the effects of an ADHD nervous system on the development of personality.

William Dodson, M.D., is a psychiatrist and consultant on adult ADHD medicine.

Emotional Dysregulation & Adult ADHD: Next Steps