I read these words shortly after I was diagnosed with ADHD at age 44. Those 15 words, which appeared in a book meant for ADHD families, left me stunned for weeks. They helped me understand my entire life experience far more than any other sentence – or any person, for that matter – ever had.

Growing up with undiagnosed ADHD, I was repeatedly labeled…

Lazy. Unmotivated. Smart but slacks off. Careless. Indifferent. Clumsy. Forgetful. Distracted. Sloppy. Listens but doesn’t follow directions. Doesn’t listen. Won’t listen. Stubborn.

Despite all evidence to the contrary and much work on my part to see myself differently, I still identify to some degree with the above labels. And I know that I’m not the only one. I think of the many women today who learn that they grew up with undiagnosed ADHD, and that girls today still struggle to get properly diagnosed with ADHD.

A diagnosis as a child would have been incredible. But beyond that, I wish I had grown up hearing the following words of encouragement – the things all girls with ADHD need to hear to build their self-esteem and avoid viewing their symptoms as character flaws.

1. “You’ll need to stand up for yourself over and over. And that’s OK.” Though things are getting better, ADHD is still stigmatized and misunderstood. What’s more, girls are still socialized and expected to be obedient and compliant. When we push back, it is viewed a lot differently than when boys do it. Assertiveness and self-advocacy, especially for girls with ADHD, are essential life skills that build confidence and self-reliance.

[Read: How to Raise a Self-Confident Daughter]

2. “We will stand up for you.” Self-advocacy only works if girls with ADHD know that trusted adults have their backs, too. Girls need to know they’re not alone when they stand up for themselves.

3. “Accommodations are a legal entitlement, not a favor.” Growing up, I had family members who genuinely believed that any accommodations, such as extra time on tests, were a way for lazy students to get out of doing schoolwork. Anything that was different “wasn’t fair” to the other students. What critics don’t understand is that a neurotypical environment is already inherently unfair to individuals with ADHD, and the reason we are chronically dismissed and overlooked is because our disability can be largely invisible. No matter how hard we try, most of us will never succeed without external support.

The reason the Americans with Disabilities Act (ADA) became law is to equalize the playing field for individuals with disabilities. My customized accommodations aren’t a special favor; they’re what I need.

4. “Other girls with ADHD need you as a friend.” Shame and isolation have a lot to do with why experts miss ADHD in women and girls. Throughout my entire childhood, every adult in my life blamed me for my symptoms, and my father told me that one of the reasons I struggled to make friends was because other kids knew about my poor grades.

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

But what girls like me need most of all are friendships with other girls with ADHD. Bonding over common problems, social challenges, and struggles at home and at school all reduce shame and stigma while building strong connections. Greater awareness leads to feeling confident in asking for help and support. Most importantly, I wouldn’t have felt so alone for so long.

5. “Other people don’t decide your value.” Throughout my entire life, I let my parents, siblings, teachers, doctors, and bosses decide my value based on their inaccurate and sexist views of me. Now that I know better — that I’m not fundamentally deficient — I want every woman and girl to hear this: No one else decides our value.

Don’t give your power away to someone who doesn’t have any idea about what living with ADHD is like, especially when they don’t care. We all have our strengths, and there are so many different ways for our talents to shine. But we’ll never realize that if we listen to our uninformed critics.

Girls with ADD: Next Steps

• Read: The ADHD Soul Shine Kit — Build Your Child’s Self Esteem
• Read: How to Protect the Emotional Health of Girls with ADHD
• Read: You Are Enough — How to Counteract Imposter Syndrome, Perfectionism, and RSD
• Read: You Are Not the Sum of Your ADHD Challenges

Maria Reppas lives with her family on the East Coast.  Her writing has been in the Washington Post, USA Today, Newsweek, New York Daily News, Ms. Magazine, and Business Insider.  Visit her on Twitter and at mariareppas.com.  

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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.

Dialectical behavior therapy (DBT) combines elements of mindfulness and cognitive behavioral therapy (CBT) to treat conditions marked by emotional dysregulation, including ADHD, mood disorders, and anxiety disorders.

Initially developed by Marsha Linehan, Ph.D., in the 1980s to treat borderline personality disorder (BPD), DBT helps people learn to tolerate internal experiences (i.e., emotions), physical sensations (i.e., agitation and restlessness), and the urge to fidget or interrupt. It has become a go-to treatment for ADHD.

A central tenet of DBT is validation — accepting uncomfortable emotions and situations before trying to change them. By coming to terms with troubling thoughts and emotions, change appears possible, and patients can work with their therapists to create a recovery plan.

In this download, you will learn:

• The four modules that comprise DBT skills training
• Types of coping strategies presented in DBT
• How DBT improves emotional regulation skills
• How DBT improves ADHD symptoms
  The difference between cognitive behavioral therapy (CBT) and DBT
• And much more!

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

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

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

Non-Cognitive Skills

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

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

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

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

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

Genetic Influence

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

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

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

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

Mental Health & ADHD

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

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

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

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

Limitations and Future Research

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

Sources

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

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

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

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

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

ADHD and obsessive-compulsive disorder (OCD) are brain-based disorders that co-exist at elevated rates. Studies have found that approximately 21% of children with OCD have ADHD as well, though some clinicians estimate an even higher co-occurrence rate. For caregivers, navigating a dual diagnosis of pediatric OCD and ADHD can be confusing and counterintuitive because these conditions may seem contradictory.

Contrary to commonly held beliefs, many pediatric OCD presentations have little or nothing to do with the fear of germs. In fact, the number one compulsion for both adults and children with OCD is avoidance. For example, a child may see school as a trigger for social phobia, causing panic and anxiety.

In this one-hour webinar, caregivers and educators will deepen their understanding of OCD and learn how to identify and support this dual diagnosis in children with ADHD.

In this webinar, you will learn:

• About common misconceptions pediatric presentations of OCD, which have led to chronic underdiagnosing
• How to identify the less common presentations of OCD, using examples of common OCD presentations in neurodivergent children
• How OCD and ADHD can interfere with learning. For example, OCD can lead to and intensify school avoidance
• About the treatment of concurrent OCD and ADHD, which usually involves medication, parent training, school-based accommodations, and Exposure Response Prevention therapy
• About typical outcomes and common roadblocks to recovery

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Audacy; Spotify; Amazon Music; iHeartRADIO

OCD in Children with ADHD: More Resources

• Download: How Are Symptoms of OCD Different from ADHD?
  
• Read: Does OCD Always Come with Anxiety?
  
• Read: “I’ve Called My OCD Compulsions ‘Screaming Mimis’ Since I Was 7”
• eBook: 9 Conditions Often Diagnosed with ADHD

Obtain a Certificate of Attendance

If you attended the live webinar on October 22, 2024, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker

Natalia Aíza, LPC, is a seasoned therapist, parent trainer, writer, and entrepreneur. Her core missions are to facilitate awareness and healing for those with OCD, and to amplify OCD competency among mental health practitioners. She is the co-founder of Kairos Wellness Collective, an innovative therapy center that specializes in OCD and anxiety disorders. In the last three years, Kairos has expanded to four locations in Colorado and has served over 2.000 families and individual clients. Natalia also advocates for OCD awareness and provides free psychoeducation on her popular instagram account @letstalk.ocd. Natalia received her BA in Literature at Harvard University, and MA in Clinical Mental Health Counseling from Palo Alto University.

Listener Testimonials

“Thank you for presenting a complex diagnosis in plain and understandable language!”

“Natalia did an excellent job introducing us to this intersectionality of ADHD and OCD.”

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“In talking with Maria, it is clear that her family and instructors have historically viewed her as being intellectually quite bright and an underachiever.”

These are not a passive-aggressive bully’s words, a sibling’s backhanded compliment, or careless remarks delivered at a parent-teacher conference. These are the very deliberate words of a neurologist, neuropsychologist, and medical-education specialist following my ADHD evaluation in childhood. The intended audience: my parents, my family physician, and my teachers.

The clinic’s problematic “assessment” and cruel words still haunt me years later. I didn’t read their words until I was in my 40s, and I finally understood why I had a decades-long habit of telling people I have no special talents. The specialists stated in scientific terms that I, a child, was a talentless loser. My parents and my family physician believed them without question. What could my parents have done differently?

[Take This Self-Test: ADHD Symptoms in Women and Girls]

Set in Their Ways

Despite education and experience, we know that experts make mistakes all the time. It’s why we frequently seek second medical opinions. My parents certainly needed one when the politely insulting report described my problems as “common” with ADHD, but the tone of the recommendations was “do better.” A second opinion would have offered my parents another analysis of my behaviors. Most importantly, I could have had a chance at a better life.

But my parents – education experts – were inclined to go along with what the evaluators said, as they shared similar vocational backgrounds. Though my mother still harbored some suspicions that I had ADHD, she and my father ultimately assumed that I was failing my classes on purpose. They made sure to share their theories about my behaviors with my teachers, who were more inclined to default to their opinions rather than their own judgment about my classroom behavior they saw every day.

What I Cannot Forgive

I can forgive science not catching up in time. (After all, it’s been more than 30 years since that evaluation and we’re still working to better understand ADHD in girls.) What I cannot forgive is my parents and the clinic for the cruelty, sexism, and failure to recognize the fact that I didn’t want to do poorly. In any setting, telling someone they do not have any special talents or that they’re an underachiever is an appalling insult.

[Read: “11 Things I’d Tell My Younger Self”]

The rest of the report would eventually prove hilariously inaccurate. “During the evaluation Maria did not demonstrate many of the learning deficits often observed in adolescents with a primary attention deficit hyperactivity disorder,” reads part of the report. Thirty-one years later, I received my ADHD diagnosis at age 44.

Ironically, the experts who wrote the report that detailed my carelessness and sloppiness also committed typographical, punctuation, and grammatical errors along with listing my incorrect home address on every page and misspelling my last name. Perhaps they were gifted in other areas? Unfortunately, those doctors didn’t provide their full names in the “scientific” report they authored, so I was never able to track them down to find out. What a relief for them.

Undiagnosed ADD: Next Steps

• Free eBook! We Demand Greater Research on Women with ADHD
• Read: “I Could Have Been Myself for So Much Longer.”
• Read: Stop the Cycle of Shame for Girls with ADHD

Maria Reppas lives with her family on the East Coast. Visit her on X and at mariareppas.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.

Children with ADHD or autism are twice as likely to experience chronic disabling fatigue by the age of 18, even when controlling for comorbid depression, according to a new study published in the journal BMJ Open. Researchers point to the high levels of inflammation (often resulting from elevated stress levels) found among research subjects as a possible explanation for this association.¹

While previous research has demonstrated a high prevalence of chronic fatigue in patients with ADHD,² this is the first study to investigate potential mechanisms underlying the association.

Data from The Avon Longitudinal Study of Parents and Children (ALSPAC) was analyzed to assess whether children who scored above the threshold for ADHD or autism at ages 7 and 9 had an increased risk of chronic disabling fatigue at age 18. Mediation analyses were performed to investigate whether an inflammatory marker (IL-6) at age 9 was linked to fatigue and neurodivergence.

In fact, it did. IL-6 levels at age 9 were associated with a higher likelihood of chronic disabling fatigue at age 18. Though the causes of inflammation are myriad, it is often exacerbated by elevated stress levels, common among neurodivergent children.

“Research shows that neurodivergent children experience higher levels of loneliness, and are more likely to experience bullying,” the authors of the study explain. “Neurodivergent children are also more vulnerable to experience pain.”

In addition to chronic fatigue, adults with ADHD suffer in higher numbers with many different physical conditions. In fact, a recent study found that adults with ADHD are at elevated risk for 34 of 35 conditions studied, including nervous system, respiratory, musculoskeletal, metabolic, circulatory, gastrointestinal, genitourinary, and skin conditions. ³ These include:

• ulcer or chronic gastritis
• pulmonary disease
• Type 2 diabetes
• epilepsy
• heart failure
• kidney infections
• spinal conditions
• eczema

The mechanisms of action underlying the association between ADHD and its comorbid physical conditions are not yet known, but this study brings us one step closer to understanding a complex and critically important picture, the authors of the study explain.

“Children who are suspected to be or diagnosed as neurodivergent should routinely be screened for physical and mental health concerns,” they urge. “Earlier integration of brain-body concerns in a holistic framework can facilitate tailored support and improve quality of life of neurodivergent individuals.”

Putting a Spotlight on Chronic Fatigue

“When you think of hyperactivity, you think of talking non-stop, fidgeting, interrupting, distractible,” says Walt Karniski, M.D., a developmental pediatrician. “Lethargy is the last thing you would think about.” Yet, Karniski says he has seen an increase in pediatric patients who present with lethargy as one of the most problematic symptoms. A slightly different approach is needed to treat ADHD patients dealing with chronic fatigue, he adds.

The authors of the study assessed the presence of “chronic disabling fatigue” (defined broadly as lacking energy and getting tired during the last month) rather than the presence of myalgic encephalomyelitis/chronic fatigue syndrome because up to 91% of ME/ CFS cases go undiagnosed. “Despite its evident detrimental impact on quality of life, prolonged or chronic fatigue as a medical symptom is frequently described as an ‘unexplained’ symptom, and patients regularly report being dismissed about their experience,” the study’s authors write.

The symptoms of ME/ CFS include chronic widespread pain, unrefreshing sleep and rest, and dysfunction in the areas of memory, attention, and cognition — many of the same symptoms as ADHD.

“Neurodivergence and chronic fatigue are conditions with complex individual neurodevelopmental pathways,” the researchers explain. “It is therefore likely that inflammation is not the only mediating or moderating factor […] Additional mechanistic insights are needed to disentangle the intricacies of this relationship.”

As is the case with all ADHD comorbidities, optimized treatment is a byproduct of comprehensive diagnostic care and a holistic picture of each individual’s conditions. When diagnoses are missed, patients suffer.

“For years I have struggled with chronic fatigue syndrome, going in cycles of boom and bust. I would work successfully for years, energetic and committed to what I was doing. Eventually, I could no longer sustain the pace and would crash, taking months to recover, unable to work,” explains Cathy, an ADDitude reader in the United Kingdom. “Only recently have I realized that I also have ADHD and begun my journey to a formal diagnosis.”

Polly, an ADDitude reader with chronic fatigue syndrome, depression, anxiety, and chronic pain, shares this: “I have taken various medications over the years for these issues, which have had benefits and drawbacks but never resolved anything. It is so clear to me now where the root of it all lies. I’ve only recently realized, at the age of 60, that I am neurodivergent and probably have ADHD.”

Sources

¹ Quadt, L., Csecs, J., Bond, R., et al. (2024). Childhood Neurodivergent Traits, Inflammation and Chronic Disabling Fatigue in Adolescence: A Longitudinal Case Control Study. BMJ Open. 14:e084203. doi.org//10.1136/bmjopen-2024-084203
² Sáez-Francàs, N., Alegre, J., Calvo, N., et al. (2012). Attention-Deficit Hyperactivity Disorder in Chronic Fatigue Syndrome Patients. Psychiatry Res. 200: 748, 53 doi:10.1016/j.psychres.2012.04.041

³ Du Rietz, E., Brikell, I., Butwicka, A., Leone, M., Chang, Z., Cortese, S., D’Onofrio, B.M., Hartman, C.A., Lichtenstein, P., Faraone, S.V., Kuja-Halkola, R., Larsson, H. (2021). Mapping Phenotypic and Aetiological Associations Between ADHD and Physical Conditions in Adulthood in Sweden: A Genetically Informed Register Study. Lancet Psychiatry. 8(9):774-783. doi.org/10.1016/S2215-0366(21)00171-1

First, ADHD is a complex condition comprising genetic, environmental, and neurobiological factors. This intricate relationship makes it challenging to pinpoint specific brain patterns or abnormalities that definitively indicate ADHD. Unlike some neurological conditions in which a distinct physical anomaly (e.g., tumor, stroke, etc.) or clear activity pattern (e.g., seizure) can be observed, ADHD presents a more nuanced picture.

Second, the symptoms of ADHD can vary widely among individuals. While difficulties with attention, motivation, and impulsivity are hallmark features, these symptoms present differently from person to person. Some may primarily struggle with attention and focus, while others exhibit more impulsive behaviors. This variability makes it difficult to identify a universal brain signature for ADHD across all affected individuals. In addition, claims of certain types of ADHD based on particular brain patterns go way beyond what the research supports. This is why using brain scans to diagnose ADHD is not supported by any of the professional organizations, including the American Medical Association.

Brain scans, such as functional MRI (fMRI) or PET scans, measure brain activity by detecting changes in blood flow or metabolic activity. These techniques provide valuable insights into brain function and can help detect certain kinds of neurological problems. Unfortunately, they don’t sufficiently capture the more subtle underlying neurochemical processes associated with ADHD. The brain’s intricate network of neurotransmitters, like dopamine, norepinephrine, and serotonin, are involved in ADHD. But their levels and interactions cannot be assessed through conventional brain imaging alone.

Clinical Assessments Are the Gold Standard for ADHD Diagnosis

ADHD is best diagnosed through comprehensive clinical assessments that consider a range of factors. These assessments typically include interviews with the individual, observation of behavior, reports from family members, and standardized rating scales. These methods provide a holistic view of a person’s symptoms, functioning, and history under real-life conditions and across time and circumstances. By contrast, brain scans capture a snapshot in time, sitting still in a scanning device. To put it bluntly, ADHD should be diagnosed based on an evaluation of real-life functioning, not test results.

[Get This Expert Resource: Unraveling the Mysteries of the ADHD Brain]

It’s essential to recognize that brain scans do contribute to our understanding of ADHD in meaningful ways. Research using neuroimaging techniques has identified differences in ADHD brain structure and connectivity, specifically in the regions involved in attention, executive function, and impulse control. While such findings are valuable for scientific knowledge, they are not yet precise or consistent enough to serve as diagnostic markers for individuals in clinical settings.

The interpretation of brain scan results requires expertise and context. It’s not possible to equate a particular brain pattern or system observed in an MRI or PET scan to ADHD. Many other factors can influence brain activity, function, and structure, including mood, medication effects, substance abuse, sleep deprivation, and co-occurring conditions such as anxiety or depression. Failing to consider all these variables and relying solely on brain scans for ADHD diagnosis can lead to misinterpretation or misdiagnosis.

ADHD Assessment Requires a Holistic View

Advances in technology and methodology may eventually lead to more refined ways of using brain imaging for ADHD diagnosis, such as incorporating machine learning algorithms to analyze complex brain patterns. In the meantime, a comprehensive and individualized approach remains the gold standard for ADHD assessment. This approach considers not only brain function, but also the psychological, behavioral, and environmental factors that contribute to an individual’s experience of ADHD. It emphasizes the importance of tailored interventions, including behavioral therapies, educational support, and medication management.

While brain scans offer valuable insights into the complexities of brain function, they currently don’t add much as diagnostic tools for ADHD. The disorder’s multifaceted nature, variability in symptoms, and the need for comprehensive assessment underscore the limitations of relying on neuroimaging. Understanding ADHD requires a holistic perspective, including clinical expertise, thorough evaluation, and ongoing research into its biological underpinnings.

Functional MRI (fMRI) for ADHD? Next Steps for Parents of ADHD Teens

• Self-Test: Do I Have ADHD? Symptom Test for Adults
• Download:What Every Thorough ADHD Diagnosis Should Include
• Read:Mapping the ADHD Brain: MRI Scans May Unlock Better Treatment and Even Symptom Prevention
• Watch: How Brain Imaging Helps Us Understand and Treat Attention Deficit

This personal essay reflects the opinions of the authors.

Stephanie Sarkis, Ph.D., is an author, mediator, and therapist.

Ari Tuckman, Psy.D., is a psychologist and the author of More Attention, Less Deficit: Success strategies for Adults with ADHD (#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.

From age 8 to 12, children with ADHD experience significant functional changes in the brain regions that control motor and executive function, as well as visual processing and spatial cognition, suggests new research published in the journal Scientific Reports. ¹

For the study, a research team from Seoul National University Hospital (SNUH) in South Korea analyzed the brain scans of 157 children diagnosed with ADHD and 109 children without the condition using a noninvasive imaging technique that uses magnets to label and measure cerebral blood flow (CBF). The researchers found that brain scans of children with ADHD, ages 8 to 9, revealed lower blood flow in the brain regions associated with motor and executive functions. The researchers also detected significantly lower CBF in children with ADHD, ages 10 to 12, in brain areas related to visual processing and spatial cognition. They did not find any significant differences in CBF between children with ADHD, ages 6 to 7, and their matched control group.

The scans also suggest that children with ADHD experience higher blood flow in specific brain regions, indicating slower brain maturation. This finding supports previous studies suggesting that children with ADHD mature more slowly than their neurotypical peers, especially in terms of executive function.

“It is estimated that children and adolescents with ADHD trail behind their neurotypical peers by a few years,” says Ellen Littman, Ph.D. ²

Ryan Wexelbatt, LCSW, explains that “a child with ADHD has a two- to three-year delay in their executive function (EF) skills, which means a 7-year-old has the executive function skills of a 4- or 5-year-old. A 13-year-old’s EF age is between 10 and 11, and a 19-year-old’s EF age is about 16.”

ASL-MRI’s Potential to Diagnosis ADHD

According to the researchers, the study’s results demonstrate the potential of arterial spin labeling magnetic resonance imaging (ASL-MRI) to diagnose and evaluate ADHD across different age groups.

“Understanding associated changes in brain development may be critically important in treating and mitigating ADHD,” they say. “ASL has the potential to be a good diagnostic and evaluation test for ADHD.” ASL-MRIs may be particularly advantageous for children because the procedure takes approximately five minutes and does not require injections or radiation exposure.

ASL-MRI joins a growing list of Neuroimaging tools (i.e., Brain SPECT, PET and CAT scans, and fMRI) that show promise for identifying the underlying brain systems associated with ADHD.

“Advances in brain-imaging techniques may lead to a better understanding of the neural mechanisms underlying ADHD. However, there are caveats,” said Peter Jensen, M.D., the president and CEO of The REACH Institute, in the ADDitude article “The Future of ADHD Research Looks Like This.” “It appears that single neuroimaging receptor or cellular studies have provided clues about differences in brain structure and functioning in individuals with ADHD, but the brain comprises billions of interacting cells, circuits, and networks that do or do not work together during specific tasks.”

“Neuroimaging tools cannot yet make an accurate diagnosis of ADHD, but we’ll look for important breakthroughs in this area,” Jensen said in discussing how scientific discoveries could lead to the recognition of more than a dozen ADHD subtypes, and the implications of such findings in the ADDitude webinar “Unlocking the Future of ADHD: Advances in Research, Diagnosis, & Treatment.”

The South Korean research team says that more studies involving larger sample sizes and covariates are needed to “delineate the developmental trajectory of ADHD more precisely and to enhance the diagnostic capabilities of ASL-MRI in the understanding and management of ADHD.”

Sources

¹Lim, Y.B., Song, H., Lee, H., et al. (2024). Comparison of Arterial Spin Labeled MRI (ASL MRI) Between ADHD and Control Group (Ages of 6–12). 14, 14950. Sci Rep .doi.org/10.1038/s41598-024-63658-9

²Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J. P., Greenstein, D., Clasen, L., Evans, A., Giedd, J., & Rapoport, J. L. (2007). Attention-Deficit/Hyperactivity Disorder Is Characterized by a Delay in Cortical Maturation. Proceedings of the National Academy of Sciences of the United States of America, 104(49), 19649–19654.doi.org/10.1073/pnas.0707741104

A few years ago, Michael, a nine-year-old boy, was brought to my office by his parents. Mom and Dad seemed comfortable when I greeted them in the waiting room, and they easily conversed as they followed me back to my office. They joked with Michael, and he appeared at ease.

After talking for a few minutes, I asked them, “So, why did you bring Michael to see me?

“The teachers say that he has a lot of trouble staying focused in the classroom,” his mom responded. “They say that he is very bright but doesn’t do well on tests because he rushes, doesn’t check his answers, and seems to stare off. Often, he only completes half of his tests. While he answers questions correctly, he fails the test because he does not complete it.”

At this point, Dad spoke up. “Wait a minute, Gayle. You know my mother told you I had the same trouble in school, but I turned out fine.”

I would have missed it had I not been sitting directly across from her, but it was at this moment that Michael’s mom rolled her eyes.

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After some testing and discussions with the teacher, Michael was diagnosed with ADHD. However, over the next five years, his father resisted the idea of treating Michael with ADHD medication, even though he responded extremely well to it, with minimal, non-serious side effects.

Dad also frequently “forgot” to give Michael his ADHD medication. If I had missed this earlier warning, I am sure I would have eventually picked up on Dad’s resistance. But the point of this story is not that Michael’s medical care would have been compromised had I missed the eye-rolling. It is that every person emits hundreds of these small, non-verbal communications every hour. And all of us, including physicians, unconsciously interpret these communications, usually accurately. Telehealth interferes with those subtle cues, which may result in a patient’s misdiagnosis or inappropriate treatment decisions.

Pros & Cons of Telehealth Evaluations for ADHD

There are certainly advantages to telehealth medical evaluations for ADHD. For one, they are relatively easy to set up. They eliminate the need to travel from home to a clinic or office, which can be problematic for some. For patients who do not have a steady income source, these evaluations also may be less expensive than in-person evaluations.

Regardless, there are serious concerns about the accuracy of telehealth evaluations. Since there are no blood tests, specific laboratory findings, X-ray findings, or diagnostic findings on a patient’s physical or neurological evaluations, the diagnosis of ADHD usually depends on a patient’s (or their parent’s) self-reporting.

[Free Directory: ADHD Specialists Serving Patients Near You]

This has proven problematic — and, in some cases, fraudulent. In June, the Justice Department charged two executives at the telehealth company Done Global with allegedly distributing Adderall and other stimulants for ADHD to patients without a proper diagnosis. Done reportedly made ADHD diagnoses based on a patient’s minute-long self-assessment and a 30-minute or less virtual evaluation with a provider.

A Better Way to Evaluate ADHD

Most pediatricians will evaluate their young patients with one parent in the room. I strongly encourage both parents to come to the initial evaluations and follow-up visits.

During the 40 years that I have evaluated patients for ADHD, I have noticed that subtle non-verbal facial expressions and messages reveal much more about how each parent feels about their child’s diagnosis or treatment than what they say. These cues could be easily missed during a telehealth evaluation.

For example, I met Danny several years ago. His mother sat in front of my desk, with Danny to her right. He appeared uninterested in our conversation but was in a good mood and smiled occasionally. While his mother spoke, Danny fidgeted, looked out the window, moved around in his seat, and interrupted occasionally.

When I asked Danny’s mom what her biggest concern was, she said, “Well, he is highly intelligent, but he has a tough time staying focused and quiet in school. As a result, he has a difficult time learning. He is very scattered.”

So, I asked my usual questions: When did this start? How was he doing in school? How were his grades? How did he get along with other kids?

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She tried to answer each question but became visibly frustrated. Her voice quivered, and she seemed on the brink of crying. Then, she stopped talking and reached into her bag. She pulled out a brightly colored, ragged spiral notebook and handed it to me.

“Danny’s teacher uses this calendar notebook to communicate with her students’ parents,” she explained. “The teacher will write a short note about how Danny did that day. I can write a response or ask a question. The notebook goes from home to school and back again daily.”

Later that day, I started reading the notebook. But by the time I got to the third page, I felt tears in my eyes.

I didn’t need to continue reading to know what was in the rest of the notebook. I was so used to treating children with behavior and learning problems like a detective, objectively analyzing the facts, that I had forgotten what it felt like to a child and their parents. Suddenly, reading this notebook, I could tell exactly how Danny and his mother felt.

If I had used telehealth, I might have received the notebook eventually, but I would have missed how Danny’s behavior affected their lives. I might also have seen Danny’s mother’s tears on the computer monitor. However, my bigger concern was what I may have missed and how that could have affected Danny’s diagnosis and treatment.

Telehealth ADHD Evaluations: Next Steps

• Special Report: ADHD Telehealth Patients Report Rushed Diagnoses, Medication Prescriptions
• Read: Your Complete ADHD Diagnosis and Testing Guide
• Watch: Virtual Mental Health Providers – How to Get Quality ADHD Care Online
• Download: Free Guide: Does My Child Have ADHD? 

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What are the signs of ADHD in a preschooler? Can preschoolers be diagnosed with ADHD? Research suggests that symptoms of ADHD can emerge in young children. In fact, to qualify for an ADHD diagnosis under the Diagnostic and Statistical Manual (DSM-5), the symptoms must be present before the age of 12. But because preschool children are typically active and easily distractable, identifying early signs of ADHD can be a challenge.

In general, today’s parents have more research-based information available to them than did previous generations of caregivers. But so-called “expert” opinions often conflict about what constitutes typical toddler behavior. Some experts minimize extreme behavior and suggest that most children will simply “outgrow” hyperactive or impulsive tendencies. Others over-pathologize common variations in typical child development, such as when preschoolers struggle to stay engaged in adult-oriented activities that are challenging for most young children. The contradictory information can leave parents perplexed about how to address their child’s behavior and whether that behavior indicates early signs of ADHD.

As such, conversations between parents and providers on the early identification and treatment of ADHD are critical. Indeed, some children will exhibit emergence of ADHD in early development, and the accurate diagnosis of children with ADHD can, in turn, help parents learn strategies to mitigate challenging behavior and teach skills that lead to long-term success.

This webinar will provide an overview of the behavioral onset patterns of ADHD as well as the early signs, symptoms, and treatment for preschool children with suspected ADHD.

In this webinar, participants will also learn:

• How to differentiate between typical development and behaviors among preschoolers that may indicate ADHD
• About the different types of ADHD and their early signs and symptoms
• How a diagnosis of ADHD is made during the preschool years
• Evidenced-based treatment guidelines for managing ADHD in young children at home and in preschool
• How to advocate for your child’s needs

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ADHD in Preschool: More Resources

• Self-Test: ADHD Symptoms in Children
• Read: Isn’t My 4-Year-Old Too Young to Be Diagnosed With ADHD?
• Read: “The Day My Hyperactive Toddler Aced His ADHD Test”
• eBook: A Parent’s Guide to Effective Routines

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Meet the Expert Speakers

Alexis Bancroft, Ph.D., is a psychologist in the Autism Center at the Child Mind Institute. She is a nationally certified school psychologist and a leader in the field of early childhood development. Dr. Bancroft specializes in the psychological and neuropsychological evaluation of individuals with autism and co-occurring neurodevelopmental disorders. She received her Ph.D. in school psychology from Columbia University and completed an APA-accredited internship at Mount Sinai Hospital in New York City, NY. Dr. Bancroft also completed a two-year postdoctoral fellowship program in pediatric psychology, with an emphasis in neurodevelopmental disorders, at Boston Children’s Hospital/Harvard Medical School. Read more here.

Cynthia Martin, Psy.D., is the Senior Director and a senior psychologist in the Autism Center at the Child Mind Institute. She is a nationally recognized expert in autism, neurodevelopmental disorders and rare genetic conditions that affect development and behavior. Dr. Martin is an international trainer on gold standard assessments used in autism evaluations and she specializes in the comprehensive evaluation, early detection and evidenced-based treatment of autism and related disorders. Read more here.

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About 1 in 9 U.S. children received an ADHD diagnosis in 2022, contributing to an increase of 1 million new pediatric diagnoses since 2016, according to a new report from the Centers for Disease Control and Prevention (CDC). The total number of children aged 3 to 17 diagnosed with ADHD increased from 6.1 million in 2016 to 7.1 million in 2022. ¹

Nearly 60% of newly diagnosed children experienced moderate or severe ADHD, the CDC says. Further, 78% reported having at least one co-occurring condition (behavioral problems, anxiety, depression, or learning disorders), corroborating previous research on the prevalence of ADHD comorbidities. ^{2 3}

“Co-occurring conditions with ADHD are so common that “we might say this is the rule rather than the exception,” said Theresa Cerulli, M.D., during the June 2021 ADDitude webinar “Complex ADHD: The New Approach to Understanding, Diagnosing, and Treating Comorbidities in Concert.” “ADHD’s heterogeneous presentation, as well as the parts of the brain implicated in ADHD, may explain why comorbidities are not only frequent but also wide-ranging.”

Gender Differences in ADHD Diagnoses

Boys are likelier to receive an ADHD diagnosis than are girls, but that gap is narrowing. In prior years, the CDC reported a 2:1 ratio of boys to girls diagnosed with ADHD; that ratio was 1.8:1 in 2022.

Lotta Borg Skoglund, M.D., Ph.D., author and associate professor at Uppsala University, Department for Women’s and Children’s Health in Sweden, thinks more work is needed to identify and diagnose girls with ADHD.

“ADHD is still viewed from a largely male-centric point of view,” she said during the January 2024 ADDitude webinar “The Emotional Lives of Girls with ADHD.” “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 healthcare system before they’re identified with ADHD. ⁴

The CDC study also found that children living in rural or suburban areas in the Northeast, Midwest, or South were more likely to be diagnosed with ADHD than were children living in urban areas or the West. Children from lower-income households and those with public insurance also reported higher incidences of ADHD, the CDC reported.

Education Contributes to Rise in ADHD Diagnoses

Diagnoses rose, in part, due to greater public awareness and understanding of ADHD, particularly among girls and adolescents, and less stigma surrounding diagnosis and treatment, according to the study authors. In addition, the COVID-19 pandemic may have exacerbated ADHD symptoms. “Virtual learning, changes in daily routines, and increased stress levels during the pandemic might have affected the recognition and management of ADHD symptoms,” the study’s authors wrote.

“The last quarter century has been pivotal, yielding myriad advances in our understanding of ADHD,” Dave Anderson, Ph.D., said during the March 2023 ADDitude webinar “ADHD Then and Now: How Our Understanding Has Evolved.” “Thanks to ongoing research on diagnosis and treatment, we know more about the causes of ADHD, its trajectory, how it presents across different groups, and the treatments that work — plus those that don’t.”

ADHD Diagnoses Up; ADHD Treatment Down

Despite the rise in ADHD diagnoses, fewer children received treatment in 2022 than in previous years. Slightly more than half of children with ADHD used medication in 2022 (down from 62% in 2016); 44.4% received behavioral therapy in 2022 (down from 46.7% in 2016).

Access to treatment professionals with experience in ADHD, side effects of ADHD medication, long wait times for care, and the downstream effects of the Adderall shortage were the biggest impediments to effective treatment, according to a 2023 ADDitude treatment survey of more than 11,000 adults with ADHD and caregivers of children with the condition. Other barriers include:

• Side effects.
• Long wait times.
• Poor access to diagnosing clinicians.
• Comorbid conditions that complicate evaluation and treatment (82% of children with ADHD report comorbid diagnoses).

Findings of the CDC report show that close to one-third of children received no ADHD-specific treatment in 2022 compared to 23% in 2016. Notably, older children aged 12 to 17 and children living in non-English-speaking households were more likely than younger children aged 6 and 11 to go untreated.

Disruptions to healthcare services during the COVID-19 pandemic and the stimulant shortage, which began in 2022, may have contributed to restricted access to ADHD medication in 2022 compared to 2016, the CDC suggests.

Stimulant Shortage Disrupts ADHD Treatment

In a recent ADDitude poll about how the stimulant shortage has impacted their ability to manage their ADHD and co-existing conditions, 16% said delayed access to medications has been a real problem, and 15% said there’s an increased reliance on non-medication strategies.

Roughly 38% of caregivers and adults with ADHD who participated in the September 2023 ADDitude treatment survey reported having trouble finding and filling their prescription medication over the last year, and 21% continue to suffer treatment disruptions.

“Finding stimulants is a nightmare,” an ADDitude reader says. “I am a PMHNP and prescribe them for patients who cannot find them and also have to find the medications for my three kids with ADHD.”

Says another, “We started rationing medications for our two sons by only giving them medicine five days a week instead of seven. “Because of the need to ration, we skip Sunday School and weekend sports, as our children’s behavior without medication is too much for coaches to handle.”

The CDC study examined data from more than 45,000 parent responses to the 2022 National Survey of Children’s Health (NSCH)

“Pediatric ADHD remains an ongoing and expanding public health concern,” the study’s authors wrote. “Estimates from the 2022 NSCH provide information on pediatric ADHD during the last full year of the COVID-19 pandemic and can be used by policymakers, government agencies, healthcare systems, public health practitioners, and other partners to plan for the needs of children with ADHD.”

Untreated ADHD affects multiple domains of life. “Individuals with ADHD are more likely to be in traffic accidents, experience peer difficulties and tumultuous interpersonal relationships, and drop out of school, be expelled from school, and experience academic failure earlier,” said Anderson, vice president of school and community programs and former senior director of the ADHD & Behavior Disorders Center at the Child Mind Institute. ⁵ “The latter is particularly troubling when we consider that ADHD has historically been underrecognized and undertreated in marginalized and disadvantaged communities; academic difficulties and expulsions can start the school-to-prison pipeline, which disproportionately impacts Black youth. Individuals may end up incarcerated before ever learning that they have ADHD and that it was the root cause of their difficulties in school and early life. ⁶

Sources

¹ Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., Ghandour, R. (2024). ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment. Journal of Clinical Child & Adolescent Psychology, 1–18. https://doi.org/10.1080/15374416.2024.2335625

² Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC Psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

³ Melissa L. Danielson, Rebecca H. Bitsko, Reem M. Ghandour, Joseph R. Holbrook, Michael D. Kogan & Stephen J. Blumberg. (2018). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47:2, 199-212, https://doi.org/10.1080/15374416.2017.1417860

⁴ 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, https://doi.org/https://doi.org/10.1111/jcpp.13920

⁵ Franke, B., Michelini, G., Asherson, P., Banaschewski, T., Bilbow, A., Buitelaar, J. K., Cormand, B., Faraone, S. V., Ginsberg, Y., Haavik, J., Kuntsi, J., Larsson, H., Lesch, K. P., Ramos-Quiroga, J. A., Réthelyi, J. M., Ribases, M., & Reif, A. (2018). Live Fast, Die Young? A Review on the Developmental Trajectories of ADHD Across the Lifespan. European Neuropsychopharmacology: The Journal of the European College of Neuropsychopharmacology, 28(10), 1059–1088. https://doi.org/10.1016/j.euroneuro.2018.08.001

⁶ Behnken, M. P., et. al. (2014). Linking Early ADHD to Adolescent and Early Adult Outcomes Among African Americans. Journal of Criminal Justice,42(2), 95–103.https://doi.org//10.1016/j.jcrimjus.2013.12.005