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

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

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

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

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

ADHD and Pregnancy: Further Research Needed

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

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

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

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

Sources

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

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

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

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

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

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

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

The Person in Front of You

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

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

You, the Provider

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

On Diagnosing ADHD

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

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

On Treating ADHD

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

Listening to Patients with ADHD: Next Steps

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

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.

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

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

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

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

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

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

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

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

Non-stimulant medication did not significantly impact brain structure.

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

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

Stimulant Medication & the ADHD Brain

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

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

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

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

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

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

Limitations & Future Research

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

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

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

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

Sources

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

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

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

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Sleep problems are among the most frequent co-occurring disorders in people with ADHD. Research has shown that many people with ADHD even suffer from more than one sleep disorder, often of different etiology. Science has not yet solved the questions arising from these findings, but we do know that sleep loss impairs concentration, memory, mood stability, and the immune system’s functioning, increasing risk for infections and allergies. Not surprisingly, ADHD is associated with many allergies and infections. The importance of good sleep and its association with overall health cannot be overstated.

The good news is that most sleep disorders can be treated effectively, and doing so can reduce ADHD symptoms and lead to improved health and wellness.

In this webinar, you will learn:

• Why people with ADHD commonly suffer with sleep problems and disorders
• About the different kinds of sleep disorders, including the circadian sleep-wake disorder, delayed sleep phase type, insomnia, restless legs, periodic limb movement disorder and sleep apnea
• How researchers are working to better understand the close relationship between ADHD and sleep disorders
• About treatment study findings that show low-dose melatonin, bright light therapy and other interventions may help reduce ADHD symptoms and lead to better overall health.

Have a question for our expert? There will be an opportunity to post questions for the presenter during the live webinar.

Meet the Expert Speaker

J.J. Sandra Kooij is a psychiatrist at PsyQ, psycho-medical programs, and Head of the Expertise Center Adult ADHD, in the Netherlands. She is a professor of adult ADHD studies at the Department of Psychiatry, VU University Medical Center, Amsterdam. She has published more than 100 peer-reviewed international papers and more than 20 books or book chapters on ADHD in adults.

Since 2002, Dr. Kooij has been the head of the Dutch Expertise Center Adult ADHD, leading research, treating patients, educating professionals, informing the public, and publishing books, scientific papers, websites, webinars and podcasts. She recently launched a new ADHD app, Super Brains. Read more about Dr. Kooij here.

Join an ADHD and Women’s Health Survey!  PsyQ Expertise Center Adult ADHD, in collaboration with ADHD Europe, developed an international survey on the experiences and health of women with ADHD. Are you a woman and do you have ADHD symptoms? You are invited to participate in this survey!

ADHD and Sleep: More Resources

• Download: Sleep Disorders Linked to ADHD
• Self-Test: Could You Have Delayed Sleep Phase Disorder?
• Read: What Comes First: ADHD or Sleep Problems?
• Read: How to Fall Asleep with a Rowdy, Racing ADHD Brain
• Free eBook: How to Sleep Better with ADHD

Webinar Sponsor

The sponsor of this ADDitude webinar is…

ADHD and disordered sleep can disrupt daily life, but you can take back control. Play Attention, inspired by NASA technology and backed by Tufts University research, helps you strengthen executive function and gain cognitive control. By combining mindfulness training with cognitive exercises, our program empowers you to manage focus, emotions, and routines—building the foundation for better sleep and overall well-being.

Start our online ADHD assessment now or schedule your 1:1 consultation. www.playattention.com 828-243-9291

ADDitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

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Exercise is hugely beneficial to ADHD brains. It can also be pretty boring. And tiring. And inconvenient. And expensive.

All of which makes exercise a game-changing and seldom-used tool for ADHD management. In a recent ADDitude survey, 55% of respondents said they were dissatisfied with their exercise regimen and physical health. The most common obstacles cited by the 1,885 respondents include:

• Sticking to an exercise routine: 59%
• Just getting started: 43%
• Overcoming boredom with exercise: 21%
• Managing a disability that impacts physical activity: 17%
• Pushing myself to try something new: 9%
• Finding an affordable, accessible workout options: 7%

“The motivation to continue with exercise is a major challenge. Boredom is a total killer of any good intentions in this, as in other, life realms.” — Liv, Texas

“I struggle with fatigue and lack of motivation due to over-exertion of executive function demands.” — Tracey, California

[Read: The ADHD Exercise Solution]

Exercise Apps for ADHD Brains

Convenient, low-cost, and rated 2.82 (out of 5) on our helpfulness scale, exercise apps can kickstart and fuel an exercise routine. Whether you prefer yoga, running, or pumping iron, there’s an app that can support your workout goals. Here are our readers’ 10 top recommendations:

• Couch to 5K: a 9-week running program
• Yoga with Adriene: an inclusive yoga program for every body
• Silver Sneakers: Free for adults 65+ with some Medicare plans
• Nike Training Club: A network of at-home workouts from world-class trainers
• MapMyFitness: Find a place to exercise anywhere
• Nerd Fitness: Nutrition, fitness, and motivation
• My Fitness Pal: Convenient tracking of calories, movement, and goals
• Seven: A library of seven-minute workouts
• Strava: The social network for runners
• Bodi: On-demand fitness classes ranging from yoga to power lifting
• Curves: A women’s fitness club
• Classpass: A gateway to independent fitness and exercise classes
• Peloton: Thousands of exercise classes, many of which don’t require a bike

“Fitness Blender is super ADHD-friendly. It has a huge variety of free workout videos of varying length and style. You can search with lots of different filters to find exactly what you want or purchase multi-week courses. There are ‘fitness dice’ with different no-equipment exercises on each side. You roll the dice to discover your mini-workout for the day.” — Alice, Alaska

[Read: Exercise and the ADHD Brain – The Neuroscience of Movement]

“Ladder is an exercise app that offer short workouts with equipment I have at home. It creates a weekly workout plan that has kept me from getting bored and has a coach talking you through and motivating you during your workout.” — Alison, Colorado

How to Start Working Out: Helpful Supports

What motivates people with ADHD to start exercising, and to stick with it, despite boredom, fatigue and other hurdles? ADDitude readers chimed in by rating the supports they find most helpful (out of 5):

• Personal trainer: 3.66
• Accountability partner(s): 3.33
• Gym or fitness class membership: 3.06
• Race or event registration to apply deadline pressure: 3.02
• Spouse, family member, friend: 2.94
• Exercise app: 2.82
• ADHD coach: 2.79
• In-home exercise equipment: 2.72
• Online exercise class subscription: 2.51

“Exercise trainers were incredibly helpful to make me stick to an exercise routine, not to mention learning about proper exercise form, nutrition etc.” — Liv, Texas

“Taking up competitive sport for the thrill factor, accountability, training routine and social interaction was the most helpful.” — Tony, Australia

How to Start Working Out: Reader-Tested Techniques

Anyone with ADHD knows that the slogan “Just do it” doesn’t motivate neurodivergent people to lace up their Nikes. What does work? Here is the most popular advice from our readers:

Exercise Before Coffee

“By exercising first thing, I get it over with right away, and I can move on with my day without exercise looming over my head. It also helps me to eat healthier and have more energy during the day.” — Rachel, Minnesota

“Daily exercise is probably the thing that helps me most with ADHD management, physical and mental health. The first thing I do in the morning is a 30-minute, very low-intensity routine. The key here is to lower the bar, by keeping it simple and easy, and turning it into a daily habit.” — Joanna, France

Invest

“Giving myself permission to spend money on a personal trainer has been the single best thing I’ve done as an adult. It hits all my triggers: I’ve spent money on it, have a scheduled appointment, someone else has to come up with what we are doing, and I have an accountability partner — all in one.” — LN, Wisconsin

Prioritize Fun

“I do dancing because I love it, yoga for relaxation, white water rafting for the adrenaline and fun, and swimming in natural waters because I feel really joyful to mingle with Mother Nature!” — An ADDitude Reader

“I download books and podcasts to listen to while walking the dog. If I only allow myself to listen to the series or book while exercising, I look forward to the next exercise.” — Ellie, Virginia

Do It at Home

“I got an under-the-desk elliptical that I love, as it alleviates the anxious energy I have while I have to sit at my desk, and I can do something productive with my feet instead of having non-stop leg shaking going on.” — Laura, Arizona

Do It Anywhere But Home

“I have to do exercise outside the home because there are too many excuses (laundry, email, cleaning) at home.” — Valeria, Colorado

Incorporate It Into Your Daily Routine

“I take bathroom breaks at work at least one floor away so I use the stairs multiple times a day.” — An ADDitude reader in Washington

“Park 15 minutes away from work, or get off the bus five stops early. The quiet walking time is a very nice way to gear up for the work day.” — Francine, Canada

“Have a dog that demands walks.” — MC, Canada

Identify a Goal

“Start something that has short-term goals that progress to long-term goals as part of the program, like martial arts. That’s how I ended up earning black belts in two different arts.” — An ADDitude Reader

“When I was running, signing up to participate in 5k and 10k races helped.” — Keena, Wisconsin

“Have a Plan A (big workout or run) and a Plan B (small workout or run) if you have no energy for Plan A. That way, I still feel like I’ve achieved my goal, even if it’s just five minutes of exercise.” — Alex, New Zealand

Recruit an Accountability Partner

“I walk with a friend who has limited availability; knowing that encourages me to join her on the two afternoons a week she is available.” — Dianne, Massachusetts

“I enjoy Apple Watch sharing with friends. We can compete and that keeps me from skipping workouts.” — Cassie, South Carolina

“I started horseback riding in spring, and for the health of the horse I have to exercise. Doing it for the horse is extremely helpful.” — Veronika, Germany

How to Start Working Out: Next Steps

• Read: I Can’t Muster Workout Motivation!
• Read: The Best Workout Apps for Your ADHD Brain & Body
• Read: Sports for ADHD – The Activities That Activate Neurodivergent Brains

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.

We make time for everything and everyone but ourselves. We consistently prioritize the needs of others. We feel guilty erecting boundaries. And this struggle to carve out space for our own wellbeing is the biggest barrier to mental and emotional health for more than half of adults with ADHD, according to a new survey of 1,898 ADDitude readers.

“I have a hard time putting myself first. I worry about others to my own detriment.”

“I really want to journal but, when I remember to, I spend an hour writing and then find myself thinking, ‘I don’t have time for this!’”

On a 10-point scale, where 10 is extremely satisfied, ADDitude readers rated their mental and emotional health a 5.2. Additional barriers to mental health care cited by readers include the following:

• Defining effective self-care strategies: 45%
• Sticking with a routine: 45%
• Practicing mindful meditation and/or gratitude: 38%
• Affording a mental-health practitioner: 23%

“Insurance makes things impossible sometimes. Also, I’ve had to switch mental healthcare doctors many times due to clashes of ideals and personality. One actually said ADHD wasn’t real and that I just needed discipline to work through my ‘laziness’.”

“I have not found a single counselor who is highly familiar with adult ADHD and its nasty companions.”

[Get This Free Download: Make Mindfulness Work for You]

Top Mental Health Apps and Tools

Following are the top apps, websites, podcasts, books, and other resources recommended by ADDitude readers for improving mental and emotional health.

Self-Care Apps

• Insight Timer: Guided meditation sessions, music, and courses for mindfulness and relaxation
• Balance: Personalized meditation that adapts sessions to your goals and progress
• Gratitude: Foster daily gratitude and positivity via journaling
• Happify: Activities and games to boost happiness and reduce stress
• Headspace: Mindfulness and meditation tools, sleep sounds, mindful movement, and exercise.
• Calm: Sleep stories and music, meditation and inspirational stories, mood tracking, and relaxation tools
• Healthy Minds: Unlock wellbeing my practicing four skills — awareness, connection, insight, and purpose
• Finch: Nurture a virtual pet by completing daily wellness and self-care tasks

Self-Care YouTube Channels, Podcasts, and Websites

• How to ADHD: A YouTube channel created by Jessica McCabe that offers practical tools and insights for living with ADHD.
• The Happiness Lab: A podcast by Laurie Santos, Ph.D., that explores science-backed strategies for a happier life.
• The Teen Anxiety Maze : A podcast by Cynthia Coufal, a teen anxiety coach.
• Therapy in a Nutshell : A mental health and strategies podcast, YouTube channel, and website by Emma McAdam, LMFT.
• Something Shiny: A podcast by therapists David Kessler and Isabelle Richards that tackles ADHD and relationships with humor and authenticity.
• ADDitude ADHD Experts: Leading experts in ADHD and mental health share the latest research and proven strategies.

Self-Care Books

• ADHD 2.0 (#CommissionsEarned)by Edward M. Hallowell, M.D., and John Ratey, M.D.
• Your Brain Is Not Broken (#CommissionsEarned) by Tamara Rosier, Ph.D.
• The Gift of Imperfection (#CommissionsEarned) by Brené Brown
• Get Out of Your Mind and Into Your Life (#CommissionsEarned) by Steven C. Hayes and Spencer Smith

Daily Self-Care Approaches

To prioritize self-care, many ADDitude readers incorporate small practices and routines into daily life. Here is their advice.

“Take three deep breaths a few times a day. Connect it to something you are doing anyway; do it after going to the bathroom first thing in the morning or when you get into your car.”

“I have a ‘blow off steam’ playlist that I listen to when I feel wired or hostile. (I also have calming playlists!)”

“As weird as it sounds, I find ChatGPT great for journaling. It asks me questions about what I’ve written and helps me develop a deeper understanding of my thoughts.”

“Exercise is the magic medicine for my mental health. I notice a difference in my energy, focus, attitude, and motivation to get things done when I exercise. I try to walk three days a week and attend a class at my local YMCA three days a week.”

“I write about three good things every morning. It gives me a sense of achievement and agency and calms my anxiety.”

“I have set aside Fridays after work as ‘nothing needs to get done’ time.”

“I try to have 30 minutes of ‘me’ time every day. I take a bath, listen to an audiobook, or watch a show.”

[Read: 31 Ways to Work Out the Kinks in Your Workout Plan]

The Power of Therapy and Medication for Mental Health

Readers report that taking prescribed medications and working with mental health professionals do wonders for their health, and assigned the following “helpfulness” ratings to each tool (on a 5-point scale where 5 is extremely helpful):

• Therapist (in-person or online): 4.11
• Medication for ADHD: 3.91
• Medication for another condition: 3.88
• Psychiatrist: 3.67

“ADHD meds have helped so much with emotional regulation that I’m quite upset I didn’t have access to them earlier!”

“Medication for anxiety has largely cleared up my ADHD mess, so much that I’m able to handle other sides that come up (time blindness, forgetfulness, etc.)”

“Accessing a therapist is paramount to understanding your emotions, triggers, and boundaries.”

“Medication can be so helpful, but it can take a while to figure out what works for you. Try some stuff and don’t be afraid to try something else if it is not working or if side effects make life unfun. Also, know that medication is a helpful tool, but it doesn’t do the work for you. It helps you do the work of setting up systems, finding coping skills and accommodations, and looking honestly at how your current patterns are helping or hurting you as you seek to be the best you.”

More Recommended Mental Health Supports

What other supports are helpful for improving mental and emotional health? ADDitude readers contributed the following “helpfulness” ratings:

• ADHD coach: 3.67
• Yoga or meditation class: 3.50
• Spouse, family member, friend: 3.38
• Anger-management training: 2.75
• Journaling: 3.08

“Get a good yoga teacher who focuses on the emotional benefits of yoga as well as the physical benefits. It is so much more than exercise and is really beneficial for all sorts of ADHD symptoms, too.”

“Find safe spaces to talk about your feelings, even if it is just an online community of strangers. Communities of people with ADHD are great to engage with because they have empathy for what you are experiencing and often really great advice for ways to better your daily life.”

“There is something therapeutic about writing on paper while curled up in a chair. It clears my mind and gets the chaos out of my head.”

“My most helpful experiences come from seeing others with similar struggles and finding that I am normal.”

How to Improve Mental Health: Next Steps

• Celebrate Every Step: Join the Small Wins Appreciation Network!
• Read: 11 Self Care Strategies for ADHD Brains
• Read: “Your ADHD Self-Improvement Plan — 6 Steps to a Better You”
• Join Us! ADHD Support Group for Adults

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

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

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

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

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

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

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

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

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

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

4. High and Low Estrogen Exacerbate ADHD Symptoms in Females

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

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

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

5. ADHD Medication Costs Soar

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

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

6. ADHD Traits May Have Provided an Evolutionary Advantage

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

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

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

7.

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

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

8. Boredom Triggers High Stress Response in Impulsive People

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

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

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

9. DEA OKs Expanded Production of the ADHD Medication Vyvanse

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

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

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

10. ADHD Medication Prescriptions Spiked Ahead of Adderall Shortage

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

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

Sources

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

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

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

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

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

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

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

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

Q: Do people with ADHD experience winter depression more often and more severely than do neurotypical individuals? Also, why is my quality of sleep affected in winter?

Winter depression is marked by two or more weeks of low mood, usually starting in the Northern Hemisphere’s fall or winter when there is less daylight, that resolves in the spring or summer when there is more light. There is an association between winter depression, also known as seasonal affective disorder, or SAD, and ADHD.

In the Netherlands, where I live, researchers asked 259 patients with ADHD about seasonal mood swings; 27% reported winter depression compared with 3% in neurotypical people.¹ Other researchers have confirmed this increased rate among people with ADHD.² What’s more, females are four times more likely than males to have winter depression.¹

Sleep problems are also common among people with ADHD: About 80% are late sleepers³ , which means they have a short sleep duration — they fall asleep at a later time and sleep less because they must wake up for work or school.

Q : How does winter depression relate to screen addiction in children with ADHD?

Children with ADHD who are late sleepers and who experience winter depression may turn to video games and the Internet. Screens emit blue light, and they’re often held close to the eye, so the effects are similar to light therapy if you’re staring at them for a while.

[Get This Free Download: How to Sleep Better with ADHD]

Screen use at night can induce delayed circadian rhythms, disrupting your sleep-wake cycle.⁴ Many children with ADHD are already late sleepers, so using screens after 9:30 pm will delay their rhythm even more; this is not recommended. Keep in mind that when sleep gets delayed, mood is affected.

The good news is that winter depression and sleep problems can be easily and quickly treated with artificial light therapy. A 10,000-lux light therapy lamp can be used for 30 minutes a day for 5 to 20 consecutive days. The lamp, or light box, should be used at a close distance to your eyes; the distance is very important for the intensity of the treatment. It’s best to do this every day at the same time, preferably between 7 and 8 am, to reset your biological clock and alter the sleep-wake cycle.

You may also consider using light therapy glasses, which work in the same way as lamps. You can wear these for 30 minutes a day while you’re dressing or eating breakfast; in other words, without disrupting your routine.

Light therapy is a serious antidepressant that often unlocks better mood, improved sleep, and more energy.

[Read: How to Fall Asleep with a Rowdy, Racing ADHD Brain]

Q:  Is vitamin D recommended for people with winter depression?

If your vitamin D is too low, then taking vitamin D is recommended. Vitamin D is generally low in people with ADHD, though we don’t know why.⁵ You get vitamin D from sunlight; in winter, when there is less light, you may need to take a supplement. Another way we can get vitamin D is by eating fatty fish, though many people don’t eat enough to affect levels.

Winter Depression: Next Steps

• Self-Test: Could You Have Delayed Sleep Phase Disorder?
• Read: 9 Sleep Deprivation Solutions for Adults with ADHD
• Read: 6 Tips to Overcoming Winter Depression
  

J.J. Sandra Kooij, M.D., Ph.D., is a psychiatrist and head of the Expertise Center Adult ADHD at PsyQ in the Netherlands.

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

¹Amons, P. J., Kooij, J. J., Haffmans, P. M., Hoffman, T. O., & Hoencamp, E. (2006). Seasonality of mood disorders in adults with lifetime attention-deficit/hyperactivity disorder (ADHD). Journal of affective disorders, 91(2-3), 251–255. https://doi.org/10.1016/j.jad.2005.11.017

²Wynchank, D. S., Bijlenga, D., Lamers, F., Bron, T. I., Winthorst, W. H., Vogel, S. W., Penninx, B. W., Beekman, A. T., & Kooij, J. S. (2016). ADHD, circadian rhythms and seasonality. Journal of psychiatric research, 81, 87–94. https://doi.org/10.1016/j.jpsychires.2016.06.018

³Van Veen, M. M., Kooij, J. J., Boonstra, A. M., Gordijn, M. C., & Van Someren, E. J. (2010). Delayed circadian rhythm in adults with attention-deficit/hyperactivity disorder and chronic sleep-onset insomnia. Biological psychiatry, 67(11), 1091–1096. https://doi.org/10.1016/j.biopsych.2009.12.032

⁴Hartstein, L. E., Mathew, G. M., Reichenberger, D. A., Rodriguez, I., Allen, N., Chang, A. M., Chaput, J. P., Christakis, D. A., Garrison, M., Gooley, J. J., Koos, J. A., Van Den Bulck, J., Woods, H., Zeitzer, J. M., Dzierzewski, J. M., & Hale, L. (2024). The impact of screen use on sleep health across the lifespan: A National Sleep Foundation consensus statement. Sleep health, 10(4), 373–384. https://doi.org/10.1016/j.sleh.2024.05.001

⁵Khoshbakht, Y., Bidaki, R., & Salehi-abargouei, A. (2018). Vitamin D Status and Attention Deficit Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Observational Studies.. Advances in nutrition, 9 1, 9-20 . https://doi.org/10.1093/advances/nmx002.

Can someone have both ADHD and schizophrenia? At first glance, the two conditions might seem distinct and unrelated. But they do share some similarities and risk factors, and symptoms of each can dramatically affect a person’s life.

Many adults diagnosed with schizophrenia were previously diagnosed with ADHD or another behavioral disorder in childhood. Some researchers have suggested that, in rare cases, treating childhood ADHD with stimulants — especially amphetamines — may increase the risk of developing schizophrenia later in life.¹

In this discussion, we’ll explore how early cognitive issues in children with ADHD might sometimes lead to misdiagnosis, as these issues can look similar to symptoms of other conditions. We’ll also discuss how the effects of ADHD — along with environmental factors, developmental challenges, and trauma — can sometimes lead a treatable childhood condition to give way to a severe mental illness later in life.

In this webinar, you will learn:

• About the similarities and differences between ADHD and schizophrenia
• How developmental issues can begin with ADHD and lead to schizophrenia
• About the environmental factors that could lead a child to develop schizophrenia
• About the interventions to treat the diagnosis of ADHD and schizophrenia

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.

ADHD & Mental Health Conditions: More Resources

• Sign Up: How ADHD and Schizophrenia Overlap
• Read: “They All Feed Off Each Other:” Stories of Life with ADHD and Comorbidities
• Research: Disparate Psychiatric Disorders Share Widespread Genetic Overlap
• eBook: 9 Conditions Often Diagnosed with ADHD

Obtain a Certificate of Attendance

If you attended the live webinar on December 11, 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

Napoleon Higgins, M.D., is a child, adolescent, and adult psychiatrist in Houston, Texas. He is the owner of Bay Pointe Behavioral Health Services and Kaleidoscope Clinical Research.

Dr. Higgins is the Executive Director of the Black Psychiatrists of America, CEO of Global Health Psychiatry, President of the Black Psychiatrists of Greater Houston, Psychiatry Section Chair of the National Medical Association, and Past President of the Caucus of Black Psychiatrists of the American Psychiatric Association.

Dr. Higgins is co-author of Bree’s Journey to Joy: A Story about Childhood Grief and Depression, How Amari Learned to Love School Again: A Story about ADHD, Mind Matters: A Resource Guide to Psychiatry for Black Communities and author of Transition 2 Practice: 21 Things Every Doctor Must Know In Contract Negotiations and the Job Search. (#CommissionsEarned)

Dr. Higgins has worked with and founded programs that help to direct inner-city young men and women to aspire to go to college and finish their educational goals. He has worked with countless community mentoring programs and has special interest in trauma, racism, and inner-city issues and how they affect minority and disadvantaged children and communities.

#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.

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

New Pharmacologic Interventions for ADHD

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

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

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

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

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

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

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

ADHD and the Gut-Brain Axis

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

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

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

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

ADHD and Gene-Environment Interactions

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

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

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

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

ADHD Research: Next Steps

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

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

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

Sources

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

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

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

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

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

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

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

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

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

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

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

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

Nonverbal learning disability (NVLD or NLD) is a little-understood condition characterized by deficits in visual-spatial reasoning.

Due to its confusing name and frequent co-occurrence and symptom overlap with ADHD and other conditions, NVLD is widely misunderstood, overlooked, and misdiagnosed. The name “nonverbal learning disorder” falsely suggests that those with NVLD  do not speak. Many children and adults with NVLD have strong verbal skills, vocabularies, and memory and auditory retention; their struggles are, instead, with interpreting nonverbal cues and communication.

Children with NVLD often hide or compensate for their challenges by charming adults with precocious conversation skills. Once puberty hits, NVLD can cause teenagers to develop anxiety over their inability to connect with their peers. Trouble setting priorities or picking up on social cues may jeopardize relationships or jobs in adults with the condition.

In this download, you will learn:

• Differences between NVLD and ADHD
• Signs of NVLD in Children
• Signs of NVLD in Adults
• How to treat NVLD
• Who can diagnose NVLD
• And more!

Onyda XR (clonidine hydrochloride), the first and only liquid non-stimulant ADHD medication approved in the U.S., and the only such medication with nighttime dosing, became available nationwide for the treatment of attention deficit hyperactivity disorder (ADHD) on October 1. ¹

The U.S. Food and Drug Administration (FDA) approved Onyda XR on May 24 as a monotherapy ADHD treatment or as an adjunctive therapy to approved central nervous system (CNS) stimulant medications in pediatric patients six years and older.

Tris Pharma developed Onyda XR with its proprietary LiquiXR® technology, which converts immediate-release drugs into extended-release formulations for once-daily dosing. Onyda XR is considered a centrally acting alpha2-adrenergic agonist medication that belongs to the same class of drugs as Guanfacine (Intuniv) and clonidine (Kapvay).

Patients with ADHD who experience adverse side effects from stimulants or who respond poorly to stimulant medications may find symptom relief in a non-stimulant medication. A systematic review and meta-analysis published in May by Neuroscience & Biobehavioral Reviews reported that non-stimulant medication is nearly as effective as stimulant medication at improving executive function in children, adolescents, and adults with ADHD. ²

Combination Therapy for ADHD

In addition, clinicians may prescribe Onyda XR along with a stimulant to treat ADHD symptoms. Combination therapy is becoming an increasingly popular option for patients who need longer durations of drug coverage than a stimulant dose can provide on its own or who hope to avoid common stimulant side effects.

“Most of the medicines we use for ADHD are safe in combination with other medications,” said Timothy E. Wilens, M.D., chief of child and adolescent psychiatry and co-director of the Center for Addiction Medicine at Massachusetts General Hospital, during the ADDitude webinar “Combination Therapy: Medication Strategies for Hard-to-Treat Complex ADHD.” “Certain combinations, such as stimulants plus clonidine or guanfacine, are FDA approved, and they wouldn’t be unless they were deemed effective and safe.”

Guanfacine ER (Intuniv) and clonidine ER (Kapvay), received FDA approval for the treatment of ADHD in patients 6 to 17 years old as monotherapy and as adjunctive therapy to stimulant medications in 2009 and 2010, respectively.

If a stimulant does not address symptoms at standard dosages, “it usually makes more sense to treat remaining symptoms with a second medication,” said Oren Mason, M.D., a physician at Attention MD in Grand Rapids, Michigan.

“Most adult patients in my practice who take extended-release stimulants need average to high dosages to achieve optimal symptom reduction,” Mason said. “They typically report 8 to 10 hours of medication benefit, and most require short-acting supplements to treat their evening symptoms. In contrast, most patients on combination therapy take low- to moderate stimulant dosages and report a duration of benefits of more than 12 hours.”

Mason said he finds that many adult patients using combination therapy decrease their stimulant dosages and experience fewer side effects than do patients taking only stimulants. “Waking up was less torturous, and getting ready for school was smoother,” he said. “Family life was better, without the meltdowns that many families accept as ‘normal’ as stimulants wear off.”

Anthony Rostain, M.D., M.A., professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania, recommends that clinicians consider several factors before prescribing combination therapy.

“The important thing to keep in mind if you’re combining agents,” he said, “is to be sure that the patient understands how to use each one and how to dose each one. They need to understand the inherent challenges they’re going to face, and make sure you’re paying attention to the side effects that might emerge from the combination of stimulant and non-stimulant.”

The FDA based its approval for Onyda XR on studies of clonidine hydrochloride extended-release tablets, including two 8-week, placebo-controlled trials evaluating 256 patients, as well as a 40-week, placebo-controlled, randomized-withdrawal study evaluating the drug in 135 pediatric patients aged 6 to 17 years. ³, ⁴

According to Onyda XR prescribing information, the most common adverse reactions with the medication’s use as monotherapy include somnolence, fatigue, irritability, nightmares, insomnia, constipation, and dry mouth. The most common adverse reactions with its use as an adjunct therapy include somnolence, fatigue, decreased appetite, and dizziness. ⁵

Sources

¹Tris Pharma’s Once-Daily ADHD Medication, ONYDA XR (clonidine hydrochloride) Extended-Release Oral Suspension, Now Available in the United States. News Release. Tris Pharma. October 1, 2024. Accessed October 2, 2024. https://www.businesswire.com/news/home/20241001522635/en/Tris-Pharma–Once-Daily-ADHD-Medication-ONYDA-XR-clonidine-hydrochloride-Extended-Release-Oral-Suspension-Now-Available-in-the-United-States

²Isfandnia, F., Masri, S.E., Radua, J., & Rubia, K. (2024) The Effects of Chronic Administration of Stimulant and Non-Stimulant Medications on Executive Functions in ADHD: A Systematic Review and Meta-Analysis. Neuroscience & Biobehavioral Reviews; 162. https://doi.org/10.1016/j.neubiorev.2024.105703

³Jain, R., Segal, S., Kollins, S.H., Khayrallah, M. (2011). Clonidine Extended-Release Tablets for Pediatric Patients with Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. https://doi.org/10.1016/j.jaac.2010.11.005

⁴Kollins, S.H., Jain, R., Brams, M., Segal, S., Findling, R.L., Wigal, S.B., Khayrallah, M. (2011). Clonidine Extended-Release Tablets as Add-On Therapy to Psychostimulants in Children and Adolescents with ADHD. Pediatrics. https://doi.org/10.1542/peds.2010-1260

⁵ Highlights of Prescribing Information. Onyda XR. FDA. Accessed May 29, 2024. https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/217645s000lbl.pdf

Dialectical behavior therapy (DBT) is an evidence-based treatment designed to help individuals who struggle with emotional dysregulation, aggression, self-harm, and other problem behaviors. DBT is an intensive, highly structured program that was originally created for adults in the 1970s and has since been adapted for children and adolescents. It can be an effective treatment for ADHD because it aids in the development of skills that support emotional regulation, problem-solving, and self-acceptance.

DBT works by helping children develop skills that decrease unwanted feelings and unhelpful behaviors, as well as skills that help them to accept difficult feelings about themselves and others without judgment. DBT patients participate in one-on-one therapy, group skills training, and/or phone coaching from their therapist. Parents learn the same skills as their children so that they can reinforce those skills outside of therapy.

In this webinar, you will learn:

• About the conditions that DBT treats in children and adolescents, and who would be a good fit for this therapy
• About DBT as a treatment model and how it works
• How DBT can support children and adolescents in managing mood, impulsivity, and anxiety
• About DBT strategies to support children in distress

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DBT for ADHD: More Resources

• Download: What Is Dialectical Behavior Therapy (DBT)?
• Read: Overview of ADHD Therapies
• Q&A: Why Deficient Emotional Self-Regulation is Central to ADHD
• eBook: The Parents’ Guide to Raising a Teen with ADHD

Obtain a Certificate of Attendance

If you attended the live webinar on November 19, 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

Lauren Allerhand, Psy.D., is Co-Director of the Dialectical Behavior Therapy Programs and a psychologist for the Mood Disorders Center at the Child Mind Institute in the San Francisco Bay Area. She specializes in the evidence-based assessment and treatment of youth struggling with depression, anxiety, trauma, eating disorders, ADHD, and oppositional defiant disorder. She has extensive training in cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Dr. Allerhand is particularly passionate about providing DBT to improve the lives of high-risk, diagnostically complex youth who struggle with emotion dysregulation, suicidality, and self-injury.

Dr. Allerhand’s clinical practice also emphasizes supporting parents of children and teens with emotion dysregulation, oppositional behavior, or ADHD through evidence-based intervention. She has specialized trained in a DBT parenting intervention and Parent Management Training for parents of older children and teenagers. Dr. Allerhand is also certified in Parent Child Interaction Therapy (PCIT), an evidence-based intervention for families with preschool-aged children.

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Webinar Sponsor

The sponsor of this ADDitude webinar is…

Play Attention: Play Attention, inspired by NASA technology and backed by Tufts University research, offers customized plans to improve executive function, emotional regulation, and behavior through behavior therapy principles and mindfulness. Each family is assigned a personal focus coach, and our family plan provides tailored programs for both kids and parents, so everyone can thrive together. Schedule a consultation or take our ADHD test to discover how Play Attention can support your family’s cognitive, emotional, and behavioral development. Call 828-676-2240. www.playattention.com

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