Amid this dearth of research, men* are becoming increasingly interested in testosterone’s suspected benefits on strength, energy, and mood. Testosterone replacement therapy, approved to treat hypogonadism (testosterone deficiency), has become more common among men with typical hormone levels. In the last five years, testosterone replacement prescriptions have risen dramatically, from 7.3 million to more than 11 million, and a third of these recipients have not been diagnosed with testosterone deficiency, according to the American Urological Association.

Besides being potentially ineffective at achieving desired outcomes, testosterone supplementation without a medical indication can be harmful for men, and may lead to side effects such as fertility problems, acne, sleep apnea, breast swelling, benign prostatic hyperplasia, and high red blood cell counts, which could increase the risk of blood clots

As these very real risks emerge from a murky landscape, here is a summary of what’s known — and not yet known — about the impact of testosterone on the bodies and brains of men, both with and without ADHD.

Testosterone and ADHD: Is There a Connection?

Is there an association between an individual’s testosterone level and their likelihood of developing ADHD. Is symptom severity impacted by hormones? The answer is: we don’t know. There’s no conclusive evidence to suggest an association, however research is extremely scarce.

[Read: For Men With ADHD — and Those Who Love Them]

Estrogen’s impact on mood and cognition is well-established. It plays a key role in modulating neurotransmitters, increasing dopamine and serotonin, which leads to elevated mood and focus. Recently, researchers have begun to explore the influence of estrogen on ADHD, which is thought to be significant. Women with ADHD experience premenstrual dysphoric disorder, postpartum depression, and perimenopausal challenges at far higher rates than do women without ADHD. Additionally, ADHD symptoms are often more severe and ADHD medication less effective during the luteal phase of the menstrual cycle, when estrogen is low.

Testosterone’s implications on ADHD are far less clear.

In the past, ADHD was thought to be a disorder affecting mostly boys, leading some to speculate that testosterone played a role in the development of ADHD symptoms. Some studies have explored whether prenatal exposure to high testosterone is associated with an elevated risk of ADHD. The results were mixed, with some studies finding a link between high prenatal exposure to testosterone and development of ADHD, and some finding no association.^1,2

[Read: When ADHD and Puberty Collide]

No research has been conducted investigating whether testosterone levels are related to ADHD symptom severity.

Research has investigated the influence of testosterone on mood and behavior more generally, including several studies that have tested a potential association between testosterone and depression, with conflicting results. Some studies have found an association between low levels of testosterone and depressive symptoms ^3,4 while others have found that both low and high levels of testosterone are linked to risk of depression.^5,6 Because of confounding factors, these studies have failed to show a causal relationship between hormone levels and depression. Studies regarding testosterone’s impact on cognition have been similarly inconclusive. ^7,8

Even research on testosterone’s most famous behavioral trait — aggression — fails to find a direct cause-and-effect relationship. Experts believe testosterone plays a role in the regulation of aggression, however the exact function it serves remains unclear. Testosterone fluctuates in response to cues of challenge in the environment, and it interacts with other fluctuating hormones such as cortisol, making the tangle of factors very difficult to unknot.^9,10

Testosterone research is inconclusive, in part, because testosterone is difficult to measure. Variability in testing and analysis methods, fluctuations in the hormone over the course of the day, and inconsistencies among labs regarding the parameters of “normal” levels all add to the challenge of studying testosterone.¹¹

Testosterone Over the Lifespan

Hormone levels in women rise and fall dramatically on a constant basis for the whole of their reproductive years. This regular menstrual cycle exists in stark contrast to the hormonal experience of men, for whom testosterone levels change significantly during two periods: puberty and in mid-life. While testosterone levels fluctuate slightly throughout the course of the day, their levels remain stable from the end of adolescence until roughly age 40.

Challenging Conventional Wisdom About “Hormonal” Teens

During puberty, testosterone levels in males increase exponentially. Research has found that the average total testosterone level of a male rises from 3 ng/dl to 355 ng/dl over the course of adolescence ¹² Testosterone levels reach their peak in late adolescence or early adulthood and remain stable until ages 35 to 40, when they begin to decrease very gradually.
The explosion of hormone production in puberty causes:¹³

• development of the male sex organs
• deepening of the voice
• appearance of facial and pubic hair
• muscle size and strength
• sex drive
• sperm production

Puberty is also a time of significant emotional, social, and behavioral changes — changes that are generally attributed to the dramatic hormonal escalation. But drawing a direct line between pubertal hormones and mood, behavior, and cognitive changes is an over-simplification of a complex developmental period, says Ben Balzer, M.D., pediatrician in Sydney, Australia, and Conjoint Lecturer at the University of New South Wales.

Balzer and colleagues conducted a systematic review of 27 studies in order to assess what evidence exists on the effects of testosterone on mood and behavior in teen boys. The review concluded that there was insufficient data to confirm a significant association.¹⁴

“Hormones are an easy culprit to go after,” says Balzer. “But their role may potentially be small because of the overall cognitive changes and neurological maturation that occurs in that period of life.”

Similar results were found in a 2024 systematic review of 55 studies investigating the role of pubertal hormones on mental health conditions. The review concluded that most of the studies that exist on hormones and mental health outcomes were at high risk for bias and involved many confounding factors. They determined that there wasn’t solid evidence that pubertal hormones cause mental health problems.¹⁵

The challenge of conducting this kind of research, Balzer says, is that hormones don’t act in isolation.

“When we study hormones in mice, we can control every aspect of their life,” he explains. “But when you’re looking at adolescents in the community, you’ve got to factor in their genetics, family environment, living environment, school situation, their social media use. It’s a really complicated thing to tease out.”

When Testosterone Tapers Later in Life

Testosterone levels remain more or less steady until midlife, when they begin to decline very gradually, approximately 1% a year. ¹⁶

While this decrease in testosterone is sometimes compared to menopause in women, the decline for men is far more gradual and happens over a much longer period of time. While men on average, lose 30% of the testosterone by age 75,¹⁷ women on average lose 65% of their estrogen by age 51.

No evidence exists to demonstrate that declines in testosterone due to normal aging cause mood or cognitive issues, as declines in estrogen often do for women in menopause.

Normal declines of testosterone due to aging are distinct from hypogonadism, a condition in which problems with the pituitary gland or the testicles result in the body failing to produce normal amounts of testosterone. Men with hypogonadism may suffer from chronic fatigue, low libido, erectile dysfunction, muscle loss, and weight gain, as well as mood symptoms including irritability and depression. Several studies have found a higher incidence of depression in men with hypogonadism, however research has not shown a causal link between the lack of testosterone and depression.

“The association between depression, testosterone levels, and sexual symptoms in males is difficult to assess, due to numerous confounding factors, such as medical conditions, obesity, smoking, alcohol use, diet, and stress,” according to the authors of a recent study in Frontiers in Endocrinology.¹⁸

Testosterone and ADHD in Men: Next Steps

• Read: ADHD Symptoms in Men Manifest Differently
• Watch: “ADHD and Puberty – How Hormones Shape Behavior and Mental Health in Adolescents”
• Read: Men with ADHD Are Asking: “Why Am I So Angry?”

*ADDitude is dedicated to honoring gender diversity and fluidity. For the purposes of this reporting, the terms “men” and “boys” refer to individuals assigned male at birth.

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Sources

¹Wang LJ, Chou MC, Chou WJ, Lee MJ, Lee SY, Lin PY, Lee YH, Yang YH, Yen CF. Potential role of pre- and postnatal testosterone levels in attention-deficit/hyperactivity disorder: is there a sex difference? Neuropsychiatr Dis Treat. 2017 May 16;13:1331-1339. doi: 10.2147/NDT.S136717. PMID: 28553119; PMCID: PMC5439987.

²Kocaman O, Aydoğan Avşar P, Kara T, Kuru T. The 2D:4D ratios in the mothers of children with attention deficit hyperactivity disorder. Early Hum Dev. 2025 Feb;201:106203. doi: 10.1016/j.earlhumdev.2025.106203. Epub 2025 Jan 20. PMID: 39855032.

³Joshi D, van Schoor NM, de Ronde W, Schaap LA, Comijs HC, Beekman AT, Lips P. Low free testosterone levels are associated with prevalence and incidence of depressive symptoms in older men. Clin Endocrinol (Oxf). 2010 Feb;72(2):232-40. doi: 10.1111/j.1365-2265.2009.03641.x. Epub 2009 May 25. PMID: 19486021.

⁴McIntyre RS, Mancini D, Eisfeld BS, Soczynska JK, Grupp L, Konarski JZ, Kennedy SH. Calculated bioavailable testosterone levels and depression in middle-aged men. Psychoneuroendocrinology. 2006 Oct;31(9):1029-35. doi: 10.1016/j.psyneuen.2006.06.005. Epub 2006 Sep 5. PMID: 16908107.

⁵Booth A, Johnson DR, Granger DA. Testosterone and men’s depression: the role of social behavior. J Health Soc Behav. 1999 Jun;40(2):130-40. PMID: 10467760.

⁶Määttänen I, Gluschkoff K, Komulainen K, Airaksinen J, Savelieva K, García-Velázquez R, Jokela M. Testosterone and specific symptoms of depression: Evidence from NHANES 2011-2016. Compr Psychoneuroendocrinol. 2021 Mar 10;6:100044. doi: 10.1016/j.cpnec.2021.100044. PMID: 35757365; PMCID: PMC9216439.

⁷Emmelot-Vonk MH, Verhaar HJ, Nakhai Pour HR, et al. Effect of testosterone supplementation on functional mobility, cognition, and other parameters in older men: a randomized controlled trial. JAMA. 2008;299:39–52. doi: 10.1001/jama.2007.51.

⁸Cherrier MM, Asthana S, Plymate S, et al. Testosterone supplementation improves spatial and verbal memory in healthy older men. Neurology. 2001;57:80–88. doi: 10.1212/wnl.57.1.80.

⁹Geniole SN, Bird BM, McVittie JS, Purcell RB, Archer J, Carré JM. Is testosterone linked to human aggression? A meta-analytic examination of the relationship between baseline, dynamic, and manipulated testosterone on human aggression. Horm Behav. 2020 Jul;123:104644. doi: 10.1016/j.yhbeh.2019.104644. Epub 2019 Dec 28. PMID: 31785281.

¹⁰Armstrong, T., Wells, J., Boisvert, D. L., Lewis, R. H., Cooke, E. M., Woeckener, M., & Kavish, N. (2021). An exploratory analysis of testosterone, cortisol, and aggressive behavior type in men and women. Biological Psychology, 161, Article 108073. https://doi.org/10.1016/j.biopsycho.2021.108073
[11] Tyagi V, Scordo M, Yoon RS, Liporace FA, Greene LW. Revisiting the role of testosterone: Are we missing something? Rev Urol. 2017;19(1):16-24. doi: 10.3909/riu0716. PMID: 28522926; PMCID: PMC5434832.

¹¹Yao Q, Zhou G, Xu M, Dai J, Qian Z, Cai Z, Zhang L, Tan Y, Hu R. Blood metal levels and serum testosterone concentrations in male and female children and adolescents: NHANES 2011-2012. PLoS One. 2019 Nov 7;14(11):e0224892. doi: 10.1371/journal.pone.0224892. PMID: 31697766; PMCID: PMC6837506.

¹²Duke SA, Balzer BW, Steinbeck KS. Testosterone and its effects on human male adolescent mood and behavior: a systematic review. J Adolesc Health. 2014 Sep;55(3):315-22. doi: 10.1016/j.jadohealth.2014.05.007. PMID: 25151053.

¹³Luo D, Dashti SG, Sawyer SM, Vijayakumar N. Pubertal hormones and mental health problems in children and adolescents: a systematic review of population-based studies.
EClinicalMedicine. 2024 Oct 1;76:102828. doi: 10.1016/j.eclinm.2024.102828. PMID: 39403116; PMCID: PMC11472636.

¹⁴Cheng H, Zhang X, Li Y, Cao D, Luo C, Zhang Q, Zhang S, Jiao Y. Age-related testosterone decline: mechanisms and intervention strategies. Reprod Biol Endocrinol. 2024 Nov 14;22(1):144. doi: 10.1186/s12958-024-01316-5. PMID: 39543598; PMCID: PMC11562514.

¹⁵Decaroli MC, Rochira V. Aging and sex hormones in males. Virulence. 2017 Jul 4;8(5):545-570. doi: 10.1080/21505594.2016.1259053. Epub 2016 Nov 10. PMID: 27831823; PMCID: PMC5538340.

¹⁶Indirli R, Lanzi V, Arosio M, Mantovani G, Ferrante E. The association of hypogonadism with depression and its treatments. Front Endocrinol (Lausanne). 2023 Aug 10;14:1198437. doi: 10.3389/fendo.2023.1198437. PMID: 37635965; PMCID: PMC10449581.

A growing body of research points to an association between neurodivergence, joint hypermobility, chronic pain, and anxiety, though this link is not well understood. Health care providers have recognized for years that people with ADHD and autism experience physical symptoms, such as migraines, gut disorders, and pain sensitivity, at a rate higher than the general population. But researchers are now gaining a deeper understanding of how and why hypermobility, which is much more prevalent among people with ADHD and autism, may be a mediating factor in linking neurodivergence, pain, and chronic conditions.

In one study led by Dr. Jessica Eccles, and published in The British Journal of Psychiatry, key brain mechanisms were thought to explain these connections. The study found that differences in the amygdala in people with hypermobility made them more sensitive to pain and anxiety, and it noted that their autonomic functions (symptoms include fatigue, fainting, and gut problems) were disrupted.

In this webinar, Dr. Eccles will explain:

• The link between ADHD, autism, joint hypermobility, and chronic pain, and why these are more common in neurodivergent populations
• The mechanisms of chronic pain, joint hypermobility, inflammatory disorders, and fatigue in autistic children and adults with ADHD
• Findings from the latest research on chronic pain, joint hypermobility, and other inflammatory disorders and processes that are more common in ADHD and autism.
• Treatment options and strategies for managing these conditions.

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.

Joint Hypermobility, Pain, & Neurodivergence: Resources

• Read: ADHD at the Center: A Whole-Life, Whole-Person Condition
• Read: How ADHD Can Intensify Physical Health Conditions
• Read: ADHD, Autism, and Neurodivergence Are Coming Into Focus
• Read: Comorbid Conditions with ADHD: What Is Your Primary Diagnosis?
• Read: The Gut-Brain Axis Could Accelerate Autism Understanding
• Study: Chronic Fatigue Twice as Likely Among Children with ADHD
• Watch: The Surprising Association Between ADHD & Inflammation
• Slideshow: 6 Types of Anxiety

Obtain a Certificate of Attendance

If you attended the live webinar on May 29, 2025, 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

Dr. Jessica Eccles is a researcher at the department of Neuroscience at Brighton and Sussex Medical School in the United Kingdom. Her areas of expertise include brain-body interactions, joint hypermobility, liaison psychiatry, and neurodevelopmental conditions.

Dr. Eccles trained in medicine at the University of Cambridge and the University of Oxford, which sparked a keen interest in philosophy and brain-body interactions. She completed her PhD in the relationship between joint hypermobility, autonomic dysfunction, and psychiatric symptoms. She is a recognized expert in brain-body medicine and a researcher and educator, and is chair of the Neurodevelopmental Psychiatry Special Interest Group at The Royal College of Psychiatrists.

Dr. Eccles and her team have published papers on the brain-body interactions between neurodivergence, emotion regulation and proprioception (the body’s ability to sense its own position and movements without having to rely on visual input alone), and the role of neurodivergence and inflammation on chronic fatigue in adolescents.

Dr Eccles also led a study which found that neurodivergent people are more than twice as likely as the general population to have hypermobile joints and are far more likely to experience pain on a regular basis.

In 2024, Dr. Eccles was the winner of the Research Pioneer Award conferred by The Ehlers Danlos Society for her hypermobility research.

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Either possibility is plausible, according to research from the Multimodal Treatment of Attention Deficit Hyperactivity Disorder Study (MTA). It found that individuals without a childhood history of ADHD can sometimes develop symptoms later. When this happens, their ADHD symptoms tend to emerge in adolescence, rather than in adulthood. They also tend to be temporary.

Therefore, most adults today with new diagnoses of ADHD probably did not develop their symptoms in adulthood. Instead, they were likely missed or they had mild, non-clinical symptoms in childhood that became more impairing as life’s demands multiplied. The study suggested that ADHD is more likely to be missed in childhood in females and minorities. People with intellectual gifts or supportive environments are more likely to compensate for their ADHD in childhood, so symptoms appear milder.

[Watch: ADHD Across the Lifespan – How Symptoms Evolve and Fluctuate]

However, even individuals with mild, non-clinical symptoms can experience fluctuations that temporarily send their symptoms or impairment severity into the clinical range. ADHD is, therefore, a dynamic condition like hypertension, obesity, or social anxiety. In the case of ADHD, the neurocognitive risks are always present, but the clinical problems may only emerge sometimes. This is comparable to a person who struggles with weight gain but fluctuates in and out of the obesity range over the course of their lifetime.

The Role of Environmental Stressors on ADHD Fluctuations

Over the 16 years of the MTA study, most individuals with childhood ADHD experienced fluctuations in their ADHD, and about 90% said their symptoms improved to a point of clinical remission at some point. Yet, in most cases, their ADHD returned three to four years later. In other words, most individuals with ADHD can expect to go through years when their symptoms do not cause meaningful problems.

Do certain factors trigger these ADHD fluctuations? To find out, the MTA investigators researched whether environmental demands correlated with ADHD exacerbations. We speculated that increased stresses – like the number of hours worked and/or enrolled in school, the extent of childcare responsibilities, the presence of family and/or financial support – would be associated with higher levels of ADHD in participants.

We were surprised to find the opposite, as we explained in our paper published in the Journal of Clinical Psychiatry in October 2024. Yes, environmental demands were significantly associated with ADHD fluctuations. However, higher levels of demands were associated with remission of ADHD. In other words, people with ADHD may have been rising to the challenge when demands were high – when working or going to school more often, when living with fewer supports, and when becoming financially accountable for themselves or others.

[Read: Adult ADHD – A Guide to Symptoms, Signs, and Treatments]

The MTA investigators are still processing this finding. One explanation is that ADHD symptoms fade when situations create an urgent need to stay on track. It is also possible that, when people have lower ADHD symptom levels, they are able to take on greater responsibilities. Both interpretations may be true at the same time. It is difficult to fully disentangle these types of nuanced explanations using data.

The Triggers of Symptom Severity

The MTA data show that, while environmental demands and ADHD severity seem to be linked, they change in concert over time. Symptom fluctuations are possible and could conceivably influence ADHD prevalence rates. These fluctuations might also partially explain the increased help-seeking for ADHD during the COVID-19 pandemic. Additional research is imperative, especially in collaboration with people who have lived experience with ADHD.

Despite some uncertainties about the relationship between ADHD remission and the environment, the MTA findings are still important. They suggest that individuals with ADHD should track the environmental factors that turn the volume up or down on their symptoms. They can intentionally design their lives to fit with their environment by seeking out jobs, educational paths, people, activities, and lifestyles that accentuate their strengths.

For some people with ADHD, this may mean staying busy and keeping an active schedule to help modulate the impact of ADHD. This may also include working with practitioners to leverage a nuanced understanding of ADHD fluctuations when designing a treatment plan.

What Makes ADHD Worse, or Better? Next Steps

• Read: The 15 Most Corrosive ADHD Myths
• Watch: Do Kids Outgrow ADHD?
• Read:Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately

Margaret Sibley, Ph.D. is a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine.

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.

January 24, 2025

Life expectancy for people with ADHD is 7.5 years shorter than it is for those without the condition, according to a new U.K. study published in The British Journal of Psychiatry¹.

This study is the first of its kind to examine the life expectancy of adults with ADHD using mortality data from a large population. It examined the health records of more than 9.5 million people from the IQVIA Medical Research Database and used the life-table method to compare the mortality rates of 30,039 people diagnosed with ADHD to 300,390 people without ADHD.

“Adults with diagnosed ADHD are living shorter lives than they should,” the researchers wrote. “We believe that is likely caused by modifiable risk factors and unmet support and treatment needs in terms of both ADHD and co-occurring mental and physical health conditions.”

Study participants with ADHD were more likely than members of the general population to have co-occurring conditions like autism spectrum disorder, anxiety, depression, and personality disorder — a finding that supports existing research on ADHD’s high comorbidity rate. The U.K. study did not examine the causes of death associated with ADHD or the level of treatment that patients received for ADHD or comorbid conditions.

Gender Disparities in Life Expectancy

Women with ADHD die 8.6 years younger than women without ADHD, while the life expectancy of men with ADHD is 6.8 years shorter than that of their peers, the study found.

“[This] is sort of the inverse of what we would’ve expected given that males engage in more risk-taking, especially males with ADHD, than females, and we know that accidental injuries are one of the biggest causes of early mortality in individuals with ADHD,” said Russell Barkley, Ph.D., a clinical scientist, educator, and practitioner who has published research on ADHD’s impact on life expectancy, in a video on his YouTube channel.

Research shows that women with ADHD experience more psychological distress, anxiety, depression, insomnia, and eating disorders than their male counterparts. They are also more likely than men with ADHD to suffer with low self-esteem, self-harming behaviors, poor social relationships, and emotional dysregulation.

Barkley suggested that the elevated risk for postpartum depression and intimate partner violence among women with ADHD may contribute to the gender disparity seen in mortality rates. Research findings presented by J.J. Sandra Kooij, Ph.D., at last week’s annual meeting of the American Professional Society of ADHD and Related Disorders (APSARD) suggest that elevated rates of heart disease among women with ADHD may also be a factor.

Research cited by Kooij² found that 35% of women at a Dutch cardiovascular clinic had ADHD symptoms throughout their lifetime. Studies on ADHD, heart health, and gender are scarce, and Kooij argued that the high comorbidity of cardiovascular disease with ADHD requires attention.

“Untreated ADHD means stress for several reasons,” Kooij said in the presentation. “Stress of having ADHD and being forgetful, stress of having anxiety and depression, stress of maybe inflammation and immune disorders that are accompanying ADHD.”

Why Does ADHD Reduce Life Expectancy?

A 2019 study published in the Journal of Attention Disorders³ examined factors impacting the life expectancy of people with ADHD. This longitudinal study predicted participants’ life expectancy when they reached 27 years using preexisting data on different behaviors and their relation to life expectancy.

“We found that, overall, people who had ADHD in childhood and were followed up to adulthood had reduced life expectancy of about 8.5 years,” said Barkley, a lead researcher in the 2019 study. “Very similar to what the study in the U.K. found.”

According to Barkley’s study, “behavioral disinhibition,” or impulsivity, was at the root of many variables found to reduce life expectancy among adults with ADHD, including:

• years of education
• income
• alcohol use
• smoking
• exercise
• nutrition
• sleep
• risky driving
• and more.

“What’s important here is you’ve got to treat the behavioral inhibition problems before you tackle these other first-order risk factors,” Barkley said. “ADHD treatments, particularly with medications, could be used to reduce this background risk factor, and then we can get on with helping people change these lifestyle and other factors.”

Existing research has also documented the positive impact of ADHD treatment on life expectancy. One Swedish study⁴ found that taking medication for ADHD can lower the risk of mortality by 19%.

“Life expectancy is malleable,” Barkley said. “These factors, virtually all of them, can be changed. Change the factor, change the life expectancy.”

Sources

¹ O’Nions, E., El Baou, C., John, A., Lewer, D., Mandy, W., McKechnie, D. G. J., … Stott, J. (2025). Life expectancy and years of life lost for adults with diagnosed ADHD in the UK: matched cohort study. The British Journal of Psychiatry, 1–8. https://doi.org/10.1192/bjp.2024.199

² Ter Beek LS, Böhmer MN, Wittekoek ME, Kooij JJS. Lifetime ADHD symptoms highly prevalent in women with cardiovascular complaints. A cross-sectional study. Arch Womens Ment Health. 2023 Dec;26(6):851-855. https://doi.org/10.1007/s00737-023-01356-7

³ Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of Attention Disorders, 23(9), 907-923. https://doi.org/10.1177/1087054718816164

⁴ Li L, Zhu N, Zhang L, et al. (2024). ADHD Pharmacotherapy and Mortality in Individuals With ADHD. https://doi.org/10.1001/jama.2024.0851

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

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

The researchers found that longitudinal patterns revealed four groups:

• Fluctuating ADHD: 64%

Alternating periods of remission and recurrence

• Stable Partial Remission: 16%

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

• Stable Persistence: 11%

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

• Recovery: 9%

Sustained full remission of symptoms

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

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

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

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

A Busy Schedule Linked to Reduced ADHD Symptoms

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

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

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

Childhood Factors Predict Long-Term Outcomes

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

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

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

Sources

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

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

Episode Description

For decades, ADHD was thought to begin in childhood with many people outgrowing symptoms by adulthood. However, new scientific insights reveal findings that have reshaped the ADHD community’s understanding of how ADHD symptoms evolve, fluctuate, wax, and wane over the lifespan. 

We now know that ADHD may emerge later in life in some individuals, and we have insight into factors that impact earlier versus later onset presentations. We also understand that very few people experience a form of ADHD that is always severe and debilitating. Instead, most people appear to experience a fluctuating course through adulthood in which certain situations may be associated with the flare up or down of ADHD symptoms. 

In this webinar, you will learn:

• About the latest science behind our modern conceptualization of ADHD across the lifespan
• About the difference between late-onset and late-identified ADHD, and whether people can develop ADHD for the first time as adults 
• Whether people can be considered “recovered” from ADHD if symptoms have been at bay for a long time
• About the situations that can trigger flare-ups or lead to an abatement of ADHD symptoms 
• How to decide if a person with mild ADHD-like traits qualifies for a clinical diagnosis, and what happens if they do not meet ADHD criteria but still want help 
• About the implications for diagnosis and treatment, as well as how loved ones can best support individuals with ADHD through ups and downs — and what individuals with ADHD can do to live happy and healthy lives

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ADHD in Adults: More Resources

• Download: How Common Is ADHD in Adults?
  
• Read: Is Adult ADHD Real? Yes — and Still Heavily Stigmatized
  
• Read: Why We Need U.S. Guidelines for Adults with ADHD
  
• eBook: ADHD After 40: A Guide to Symptoms, Diagnosis & Treatment Later in Life
  

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Meet the Expert Speaker

Dr. Margaret Sibley is a Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital. She has authored over 120 scholarly publications on ADHD in adolescence and adulthood with research funded by the National Institute of Mental Health and the Institute of Education Sciences. She is Secretary of the American Professional Society for ADHD and Related Disorders (APSARD), a Professional Advisory Board Member for Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD), and an Associate Editor of the Journal of Attention Disorders. She is the author of Parent-Teen Therapy for Executive Function Deficits and ADHD: Building Skills and Motivation published by Guilford Press in 2017. (#CommissionsEarned) 

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Still, I ride a motorbike every day, knowing that the only laws that I cannot defy are physics and fate. One mistake and I’m injured — or worse. It may be a dark and uneasy truth, but it’s also quite liberating.

So why is a machine that I know may maim or kill me one day such a vital part of my life?

I think it has something to do with my ADHD. Riding gives me pure peace of mind, total focus, and a rush of adrenaline. There’s a single task and purpose: To get from Point A to Point B alive. It’s urgent for the sake of everything and nothing, making every journey and movement matter with an energy that defies fatigue. There simply is no room for error and no safety net beyond my reactions and skills as a rider.

I can feel the danger in the air pushing back on me as I choose to accelerate, a quiet demonstration of the immense power beyond my daring. Nothing else matters. No distractions, just me, a little music in my ears, and the ribbon of asphalt and the obstacles on it before me as I grip an explosive rocket nestled snugly against me. It puts me right there, right on the edge of oblivion. Every. Single. Time. (It makes grocery shopping rather dramatic, too.)

[Get This Free Resource: Secrets of Your ADHD Brain]

Love at First Bike

Something about me changed after I got on my first bike at age 14. I truly loved that feeling, the rollercoaster with no end. I needed it. I obsessed about bikes for seven years until I finally persuaded my parents to let me get one. They were beautiful and dangerous, like diving eagles. I’ve since ridden bikes through tropical storms and down hellish, tattered roads — never once wishing I’d bought a car.

When my last bike was stolen and destroyed, my heart shattered. I mourned her like a lost love. I felt naked somehow like the thieves had taken more than just a vehicle, but a part of me — a part that gives me license to feel really and truly free.

Risky Behaviors Help ADHD Brains Thrive

We live in a sensible society that can feel very restrictive for people with ADHD. Our society relies on rules and a degree of moderation to function. Everything is controlled, predictable, economically prosperous, safe, and in good order. I don’t have a big problem with rules; most make a lot of sense. However, this isn’t how our ADHD brains thrive. Rules discourage the risky behaviors that are like catnip for our dopamine-starved brains.

Every Sunday, I teach one-on-one swim lessons for children with autism and ADHD. In the two years I’ve been doing it, I’ve noticed that most of my neurodivergent students quickly outstrip their neurotypical peers once they’re allowed to skip ahead and face deep water directly. I’ve been tutoring a five-year-old girl with autism who now swims 25-meter lengths. She thrives because nothing I was trained to do in standard lessons worked, so I jumped in the water with her to keep her safe. With her mother’s consent, we bypassed the centre’s depth limit (The pool manager names his headaches after me!), and I gave her tasks to do while I followed her around the deep end. She instinctively adapts to mitigate the danger. She’s perfectly capable and happy, but if I teach her at the shallow end, it’s a completely different experience, and she won’t engage.

[Get This eBook: Emotions of ADHD]

Another time, I needed to teach a student with ADHD how to tread water to ensure he could survive out of his depth. After a few lessons together, I jumped into the deep end of the pool with a float and told him to fetch the rubber duck beside me. At first, he was a bit freaked out over the depth. Then he looked into the deep and said, “Give me a minute. I’ve not got Lord Duckington yet!” He got the duck, and he trod water for a full minute. Challenging him like that forced him to innovate, which he did successfully. He’s only eight years old, but what a man.

When the only real restrictions are the irrefutable, unforgiving, and yet totally fair and logical laws of nature, it puts everything else into perspective. The laws of nature are a beautiful thing for neurotypical minds. It’s literally sink or swim. Death, or the threat thereof, provides the ultimate boundary. In doing so, it simplifies things, making the often confusing (and sometimes trivial) reality of our broad social and economic structures so much easier to rationalize and understand.

Learn to ride a motorbike or swim (safely, with witnesses, please!) a little out of your depth (safely, or at least with witnesses, please!), and you’ll see what I mean.

Risky Behaviors and ADHD: Next Steps

• Free Download: Is It Adult ADHD?
• Read: Never Enough? Why ADHD Brains Crave Stimulation
• Read: ADHD Impulsivity in Real Life

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By Russell Barkley, Ph.D.

DSM-5 ADHD criteria are flawed for several reasons. “The DSM-5 does not capture ADHD accurately because its criteria do not conceptualize ADHD as a disorder of executive functioning and self-regulation,” says Russell Barkley, Ph.D. “This limitation greatly narrows the concept of ADHD, trivializes its nature as just an attention deficit, and discourages diagnosing clinicians from focusing on the wider range of impairments inherent in ADHD.”

Despite these flaws, Barkley explains, clinicians can ensure more accurate diagnoses by focusing more on the patient’s symptoms of disinhibition and executive dysfunction and less on the age of onset for ADHD symptoms.

Continue reading “How the DSM-5 Fails People with ADHD — and a Better Way to Diagnose”

DSM-5 ADHD Criteria Challenged: Related Resources

• Read: ADHD Is a Whole-Life Experience. The DSM Needs to Reflect That.
• Read: Why We Need U.S. Guidelines for Adults with ADHD
• Read: What do I need to understand about ADHD that is not fully represented in the DSM?
• Download: How Is ADHD Diagnosed?

2. Deciphering Irritability in Children: Causes and Links to Comorbidities

By William French, M.D., DFAACAP

“Irritability is to mental health providers what fevers are to pediatricians,” says William French, M.D., DFAACAP. “Just as a fever is a core symptom of numerous illnesses and infections, irritability is a core symptom of many mental conditions.” In this guide, French outlines possible causes of irritability and provides a detailed overview of conditions such as DMDD, ODD, ADHD, and bipolar disorder. He analyzes emerging research on treatment approaches and interventions.

Continue reading “Deciphering Irritability in Children: Causes and Links to Comorbidities”

Irritability in Children: Related Resources

• Read: The ADHD-Anger Connection
• Read: Top Emotion Regulation Difficulties for Youth with ADHD
• Self-Test: Could Your Child Have DMDD?
• Read: The Parents’ Guide to Dismantling Oppositional, Defiant Behavior

3. Treatments for Depression and ADHD: New and Forthcoming Approaches

By Nelson M. Handal, M.D., DFAPA

Rising rates of depression — a condition that often accompanies ADHD — have attracted well-deserved concern and attention. Here, Nelson M. Handal, M.D., DFAPA, reviews what we know about major depressive disorder (MDD) and ADHD, combs through the latest treatment options for depression, and touches on alternative approaches for managing depression. “The field of depression treatment is making huge advances,” Handal says, referencing psychedelics, Spravato nasal spray, Zurzuvae (zuranolone), a rapid-acting oral treatment that was approved to treat postpartum depression, and others promising treatments for MDD.

Continue reading “Treatments for Depression and ADHD: New and Forthcoming Approaches”

Treatments for Depression: Related Resources

• Read: The ADHD – Depression Link
• Read: What to Expect When You Start Depression Medication
• Download: The Facts About Major Depressive Disorder in Women
• Read: How Undiagnosed ADHD Triggers Depression and Anxiety

4. Differential Diagnosis of Bipolar and ADHD: Taking a Phenomenological Approach

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

A thorough and accurate diagnosis is critical before treating bipolar disorder, ADHD, or the two together. However, high rates of comorbidity and a constellation of overlapping symptoms make the task of distinguishing between bipolar disorder and ADHD especially challenging. David W. Goodman, M.D., LFAPA, explains how clinicians can differentiate between the two conditions.

“To arrive at an accurate differential diagnosis, a clinician must carefully consider family psychiatric history and dial into the patient’s phenomenological experience. The latter focuses on specific symptoms and qualitative nature,” he says. “For example, there is a qualitative difference between a tension headache and a migraine headache, even though both are headaches. The same difference can be seen in sadness vs depression — a qualitative difference in the psychological experience.”

Continue reading “Differential Diagnosis of Bipolar and ADHD: Taking a Phenomenological Approach”

Bipolar Disorder and ADHD: Related Resources

• Download: Solving the Bipolar and ADHD Puzzle
• Read: How to Distinguish ADHD’s Rejection Sensitive Dysphoria (RSD) from Bipolar Disorder
• Read: The Physicians’ Guide for Distinguishing Bipolar Disorder and ADHD
• Self-Test: Bipolar Disorder in Adults

5. Prenatal and Early Life Risk Factors of ADHD: What Research Says — and What Parents Can Do

By Joel Nigg, Ph.D.

Is ADHD caused by birth trauma? Do prenatal complications like maternal obesity or hypertension increase a child’s risk for ADHD? What role do prenatal and postnatal exposures to substances, such as alcohol and smoking, play in the development of ADHD? Joel Nigg, Ph.D., explores the answers to these difficult-to-answer questions and provides an overview of the latest research and steps parents can take to protect their child’s health. “Exposure to risk factors does not guarantee ADHD, and early and effective treatment approaches can often mitigate the effects of previous complications and improve outcomes,” he says.

Continue reading “Prenatal and Early Life Risk Factors of ADHD: What Research Says — and What Parents Can Do”

What Causes ADHD? Related Resources

• Read: Epigenetics and ADHD: The Impacts of Environment, Lifestyle, and Stress
• Download: Free Guide to Hormones & ADHD in Women
• Read: Treating for Two: ADHD Meds in Pregnancy
• Watch: The Unspoken Truths of Postpartum Depression: Help for Women with and Without ADHD

6. The Future of ADHD Research Looks Like This

By Peter Jensen, M.D.

While no one can predict the scientific discoveries that lie ahead, three research areas are especially promising for improving our understanding of ADHD: neuroimaging, genetic research, and non-pharmacologic interventions, like transcranial magnetic stimulation and attention training. Here, Peter Jensen, M.D., describes these key three areas of ADHD research.

“As we discover more specific gene and brain developmental pathways, we should expect to find that different and precise interventions work for different ADHD subtypes, depending on the individual’s particular gene-environment mix and how factors unfold over time,” he says.

Continue reading “The Future of ADHD Research Looks Like This”

ADHD Research Updates: Related Resources

• Download:  Health & Fitness Lifestyle Changes for Adults with ADHD
• Read: The Evolution of ADHD: Examining the Last 25 Years — and the Future
• Watch: ADHD Then and Now: How Our Understanding Has Evolved
• Read: Beyond Genes: Leveraging Sleep, Exercise, and Nutrition to Improve ADHD

7. Sobering Advice: How to Treat ADHD Alongside SUD

By Timothy Wilens, M.D.

ADHD medications — both stimulants and non-stimulants — may be used to treat patients with comorbid substance use disorder and typically improve outcomes for patients with both conditions. “Unfortunately, many patients who have an active SUD (or even a past history of substance use issues) are either not diagnosed with ADHD or, even with a diagnosis, they are denied medication and appropriate treatment for their co-occurring ADHD due to overstated and misplaced fears, bias, and misinformation,” says Timothy Wilens, M.D. “In other words, far too many clinicians discriminate against patients with comorbid ADHD and SUDs.” Here, Wilens examines the role ADHD medications play in SUD treatment and suggests steps to curtail prescription misuse.

Continue reading “Sobering Advice: How to Treat ADHD Alongside SUD”

Substance Use Treatment with ADHD: Related Resources

• Read:  The ADHD & Addiction Link — Addictive Behaviors in Adults Explained
• Read: Does Stimulant Medication Cause Drug Dependence?
• Self-Test: Could You Have a Substance Use Disorder?
• Read: 5 Key Facts About Substance Use Disorders

8. First-Ever Adult ADHD Guidelines Forthcoming

By Carole Fleck

ADHD diagnoses among adults are growing faster than ever in the U.S. despite the absence of formal clinical guidelines for the accurate evaluation and treatment of the condition after childhood. That’s about to change. A task force commissioned by the American Professional Society of ADHD and Related Disorders (APSARD) is developing ADHD diagnosis and treatment guidelines for adults in the U.S., to be published in 2024. In an interview with ADDitude, APSARD President Ann Childress, M.D., discussed the implications of the forthcoming guidelines. “ADHD in adults is not just a minor inconvenience — it is a major public health problem,” Childress says. “Guidelines will help practitioners who previously may have felt uncomfortable evaluating and treating adults with ADHD, and these will improve access to high-quality care.”

Continue reading “First-Ever Adult ADHD Guidelines Forthcoming”

ADHD Treatment & Diagnosis Guidelines: Related Resources

• Read: Adult ADHD Is Real — and Still Heavily Stigmatized
• Read: ADHD in Older Adults: Distinct Diagnostic and Treatment Considerations
• Download: How Common Is ADHD in Adults?
• Read: ADHD in Women and Girls — Why Female Symptoms Slip Through Diagnostic Cracks

9. How Undiagnosed ADHD Triggers Depression and Anxiety

By Nelson M. Handal, M.D., DFAPA

Depression and anxiety disorders occur with ADHD at significant rates. What explains these high comorbidity rates? “Many factors may explain the overlap, and one of them I can’t stress enough: ADHD does not happen in a vacuum, and its effects are far more impairing when the condition goes undiagnosed, untreated, or improperly treated,” Nelson M. Handal, M.D., DFAPA, says. Here, Handal shares why depression appears to take a more significant toll on women with ADHD and how undiagnosed and/or untreated ADHD manifests in patients with depression.

Continue reading “How Undiagnosed ADHD Triggers Depression and Anxiety”

Untreated ADHD in Adults: Related Resources

• Download: Signs of Depression That May Surprise You
• Self-Test: Depression in Adults
• Read: The Depression Treatment Gap for Teens — And How to Close It
• Read: What’s Behind the “Depression Gap” Impacting Women?

10. “A Daily Nightmare:” One Year into the ADHD Stimulant Shortage

By ADDitude Editors

More than one year into the ADHD stimulant shortage, patients still struggle to fill their prescriptions for Adderall XR and other stimulants like Vyvanse, Concerta, and Focalin.

According to an ADDitude survey of 11,013 caregivers and adults with ADHD, roughly 38% of all patients have had trouble finding and filling their prescription medication over the last year, and 21% continue to suffer treatment disruptions today. Here, ADDitude readers share how they have been forced to forgo medications, make do with substitutes that aren’t as effective or cause bothersome side effects, and ration out a dwindling supply, often dividing it between multiple family members with ADHD.

Continue reading “‘A Daily Nightmare:’ One Year into the ADHD Stimulant Shortage”

ADHD Medication Shortage: Related Resources

• Read: How the Adderall Shortage Is Casting a Long Shadow on ADHD Treatment
• Read: The Real Reason ADHD Medication Supply Is Lagging Demand
• Read:  Generic Adderall Shortage Extends to Vyvanse, Ritalin

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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.

Depression and anxiety disorders occur with attention deficit hyperactivity disorder (ADHD) at significant rates. While figures vary across studies, it’s estimated that 18% of adults with ADHD also have major depressive disorder, and about half of adults with ADHD have anxiety.¹ What explains these high comorbidity rates?

Many factors may explain the overlap, and one of them I can’t stress enough: ADHD does not happen in a vacuum, and its effects are far more impairing when the condition goes undiagnosed, untreated, or improperly treated.

Untreated ADHD Causes Feelings of Inadequacy

Undiagnosed and/or untreated ADHD makes children, teens, and adults who are otherwise bright and competent feel severely inadequate. It’s not difficult to see how; untreated symptoms of ADHD, from impulsivity and emotional instability to poor planning and execution skills compromise one’s ability to find success in school, work, relationships, and other parts of life. Ongoing challenges and failures, especially when the root cause is neither identified nor treated, makes these individuals feel like failures — like they aren’t trying hard enough. Self-esteem, as a result, plummets.

Other emotions — like anger, resentment, and feelings of worthlessness — often come up as a result of experiencing challenges related to undiagnosed and/or untreated ADHD. Emotional sensitivity and reactivity are not uncommon, especially strong emotional responses to failure. These emotions cause depression and anxiety to develop. Irritability and feelings of worthlessness, after all, are symptoms of depression.

Living with ADHD and depression, of course, creates its own set of challenges. Children with ADHD and depression, for example, experience more impairment in social and academic functioning than do children with just ADHD or children without ADHD.²

[Self-Test: Could You Be Showing Signs of Depression?]

In adolescents with ADHD, feelings of worthlessness are particularly important to recognize, as one study found that these feelings are directly related to suicidal thoughts and planning.³

Women with ADHD Are at Greater Risk for Depression

ADHD does not disappear with age for most people⁴, and the longer ADHD goes undiagnosed, the more problems it potentially creates as life’s demands and responsibilities evolve in complexity. This may explain why females with ADHD — who tend to be diagnosed later than males — are more than twice as likely to develop depression compared to females without ADHD.⁵ Hyperactivity and impulsivity — obvious signs of ADHD — are not so common in girls and women, which may explain why clinicians miss or misdiagnose their ADHD. What we often see now is women getting diagnosed while in college.

Depression also appears to take a greater toll on women with ADHD, as depression has an earlier age of onset, lasts longer, comes with more severe symptoms, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization in this group compared to women without ADHD.⁵

The Importance of Recognizing ADHD, Depression, and Anxiety

Yes, there is significant comorbidity between ADHD, depression, and anxiety. But even together, these conditions are treatable. Complete, thorough evaluations are a must to identify and properly manage these conditions in patients as early as possible. Measurement-based tools can help clinicians in this respect. Clinicom® is a psychiatric assessment tool I have been developing and refining for many years to help clinicians identify more conditions that may be comorbid with a patient’s presenting complaint. The assessment tool, completed by patients, can identify 80 psychiatric conditions, and it also takes a patient’s environmental stressors into account. (As epigenetics research tells us, we cannot ignore our environment, and adverse life events do appear to be linked to a whole host of conditions, including ADHD.^{6 7})

[Get This Free Download: Signs of Depression That May Surprise You]

As an example, I recently saw an 18-year-old female patient — a college student — with depression as her chief complaint. She completed the Clinicom assessment before her visit, and after a thorough evaluation that accounted for personal and family history and stressors, we realized she exhibited symptoms of ADHD — undiagnosed until then — and generalized anxiety disorder, among other conditions.

I can tell you story after story of seeing patients who did not know they had ADHD, and who had succumbed to the belief that they were failures and would never accomplish anything. I remember another patient I first saw as she was finishing high school. After an extensive evaluation, we diagnosed her with ADHD and started her on treatment. Many years later, she came back to my clinic — when she was finishing her medical school residency — to thank us for treating her. And that meant the world to me.

Untreated ADHD in Adults: Next Steps

• Read: Depression — When It’s More Than a Symptom Of ADHD
• Read: What’s Behind the “Depression Gap” Impacting Women?
• Read: Late Diagnosis — Was ADHD to Blame All Along?

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “New Insights Into and Treatments for Comorbid Depression” [Video Replay & Podcast #456]  with Nelson M. Handal, M.D., DFAPA, which was broadcast on May 24, 2023.

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

Sources

¹ Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Faraone, S. V., Greenhill, L. L., Howes, M. J., Secnik, K., Spencer, T., Ustun, T. B., Walters, E. E., & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. The American journal of psychiatry, 163(4), 716–723. https://doi.org/10.1176/ajp.2006.163.4.716

² Blackman, G. L., Ostrander, R., & Herman, K. C. (2005). Children with ADHD and depression: a multisource, multimethod assessment of clinical, social, and academic functioning. Journal of attention disorders, 8(4), 195–207. https://doi.org/10.1177/1087054705278777

³ Katzenmajer-Pump, L., Komáromy, D., & Balázs, J. (2022). The importance of recognizing worthlessness for suicide prevention in adolescents with Attention-deficit/hyperactivity disorder. Frontiers in psychiatry, 13, 969164. https://doi.org/10.3389/fpsyt.2022.969164

⁴ Michielsen, M., Semeijn, E., Comijs, H. C., van de Ven, P., Beekman, A. T., Deeg, D. J., & Kooij, J. J. (2012). Prevalence of attention-deficit hyperactivity disorder in older adults in The Netherlands. The British journal of psychiatry : the journal of mental science, 201(4), 298–305. https://doi.org/10.1192/bjp.bp.111.101196

⁵ Biederman, J., Ball, S. W., Monuteaux, M. C., Mick, E., Spencer, T. J., McCREARY, M., Cote, M., & Faraone, S. V. (2008). New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. Journal of the American Academy of Child and Adolescent Psychiatry, 47(4), 426–434. https://doi.org/10.1097/CHI.0b013e31816429d3

In an interview with ADDitude, APSARD President Ann Childress, M.D., discussed the importance and implications of the first-ever U.S. guidelines for ADHD in men and women. Here are excerpts from that interview.

Why are clinical guidelines to diagnose and treat ADHD in adults necessary?

Recent data published by the Centers for Disease Control and Prevention found an increase in stimulant prescriptions for adults with ADHD between 2016 and 2021. Greater recognition of ADHD symptoms and improved access to care through telemedicine have contributed to this increase in the recognition and treatment of adult ADHD.

Guidelines give evidence-based recommendations for the assessment and treatment of medical disorders. We have U.S. guidelines for the treatment of ADHD in children and adolescents, but none for adults. Guidelines will help practitioners who previously may have felt uncomfortable evaluating and treating adults with ADHD, and these will improve access to high-quality care.

ADHD in adults is not just a minor inconvenience — it is a major public health problem. Consequences of adult ADHD can include lower educational achievement, increased risk of unemployment, financial instability, higher rates of divorce, and increased risky behaviors resulting in higher rates of traffic infractions and unplanned pregnancies compared to peers without ADHD.

[Self-Test: Do I Have ADHD? Symptom Test for Adults]

How do ADHD symptoms in adults generally differ from those in children?

Symptoms generally become more subtle as people age. For example, running and climbing at inappropriate times as a child may present as restlessness in an adult. ADHD symptoms may also be more difficult to recognize in adults because of coexisting conditions, such as depression and anxiety.

Many people believe that ADHD medication is no longer necessary once a student with ADHD has graduated from high school or college. With the development of these guidelines for adults, is this belief being debunked?

Although some adult patients manage well using behavioral techniques to control symptoms, many still need medication to reduce symptom severity and improve their quality of life. The guidelines will review the existing evidence for treating adult ADHD and make recommendations based on those findings.

What are the risks for older adults taking ADHD medication? Do the benefits of medication outweigh the risks?

Many older adults with ADHD have comorbid medical conditions, including cardiovascular disease. It is important for practitioners to work with their colleagues in primary care, cardiology, and internal medicine to treat patients collaboratively. For many, the benefits often outweigh the risks, but it is important for all specialists to work together to ensure that patient risks are appropriately managed.

[Free Series: The Adult’s Guide to ADHD Diagnosis]

Just as many adults are discovering they have ADHD that went undiagnosed for years, many girls and women continue to be misdiagnosed or undiagnosed by clinicians. Might APSARD consider new or expanded guidelines for girls and women?

Many women do not recognize that they have ADHD or seek evaluations until their children are diagnosed. They are often treated for anxiety or depression that developed secondarily to ADHD. Helping clinicians recognize the difference in presentation of ADHD symptoms in women is important.

How can we educate clinicians and researchers to mitigate this?

An expert consensus statement providing guidance for the recognition and treatment of ADHD in girls and women was published in BMC Psychiatry in 2020. ¹  Since then, interest in understanding the nuances associated with ADHD in girls and women has continued to increase.

When will the APSARD guidelines for adults be completed and what will happen following their release?

The APSARD Task Force is working diligently on the guidelines, and I expect that we will have a draft in 2024. After the APSARD guidelines are published, we will work with CHADD to expand them for specific populations and specialties. There is much interest from colleagues in other agencies, and we plan to partner with them to educate providers.

ADHD Diagnosis & Treatment Guidelines: Next Steps

• Read: ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.
• Download: How Is ADHD Diagnosed?
• Read: Your Complete ADHD Diagnosis and Testing Guide

Ann Childress, M.D., is a board-certified child, adolescent, and adult psychiatrist specializing in research and treatment of ADHD.  

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.

Source

¹ Young, S., Adamo, N., Ásgeirsdóttir, B.B. et al. (2020). Females with ADHD: An Expert Consensus Statement Taking a Lifespan Approach Providing Guidance for the Identification and Treatment of Attention-Deficit/Hyperactivity Disorder in Girls and Women. BMC Psychiatry. https://doi.org/10.1186/s12888-020-02707-9

Adults who suffer from migraine headaches have a higher prevalence of ADHD symptoms, a new study published in the Journal of Attention Disorders found.¹ While studies have previously demonstrated the higher incidence of migraines in ADHD patients,²  this study is the first to show that the association works the other way, establishing a bidirectional relationship between the two conditions. In addition, most previous studies were conducted in children or adolescents and were based on patients with ADHD who were assessed for migraines. This study focused on adults suffering from migraines whose ADHD symptoms may be undiagnosed. The finding could have implications for the assessment of migraine patients and could help to uncover undiagnosed ADHD in this group.

The observational cohort study involved 250 adult participants: 150 controls, who did not have migraines, and 100 patients who were treated in a headache clinic for episodic migraines. To assess hyperactivity, impulsivity, and attention deficit, researchers used the ADHD Rating Scale (ADHD-RS), the Adult ADHD Self-Report Scale (ASRS), and Plutchik’s Impulsivity Scale.

The researchers identified a much higher incidence of ADHD symptoms, specifically impulsivity, in the group of migraine patients compared to the control group. They found no difference in ADHD and ASRS scores between patients with or without aura.

The average ratings, according to ASRS:

• Inattention: 5 in migraine cases vs 2.7 in controls
• Hyperactivity: 4 in migraine cases vs 2.5 in controls
• Impulsivity: 2 in migraine cases vs 1.1 in controls

Migraine Headaches and ADHD: Understanding the Connection

This study brings the scientific community one step closer to fully understanding the link between migraines and ADHD, which is critical to ensuring the best care for patients.

“Medical providers often have not been trained to consider the connection when treating patients. The result is incomplete, inadequate patient care,” explains pediatric neurologist Sarah Cheyette, M.D., in the ADDitude webinar “The Unexpected Link Between Migraine and ADHD.” “A patient with undiagnosed ADHD and debilitating headaches, for example, likely will be referred to a neurologist – many of whom do not specialize in ADHD and may not consider its connection to headaches. Similarly, a provider treating ADHD may not be comfortable treating headaches, or even identifying co-occurring conditions.”

The new study helps fill in the gaps to build an in-depth understanding of the mechanisms underlying both ADHD and migraines, which researchers believe may have much in common.

“The pathophysiology of migraine is complex and not fully understood, although different structures and neurotransmitters involved in the genesis of migraine, such as serotonin and glutamate, have been described,”³ wrote the study’s authors. “These disorders may share pathophysiological mechanisms that explain their association.”

Not only do ADHD and migraines potentially share underlying neurological mechanisms, but each condition may also work to exacerbate the other. According to Cheyette, migraine can create additional, stressful obstacles for patients with ADHD, including missed work, increased drowsiness, poor sleep quality, and heightened anxiety, which often worsens ADHD symptoms and challenges. Conversely, symptoms of ADHD can lead to behaviors that worsen migraines; for example, disorganization can cause irregular habits (poor eating, hydration, sleep patterns), and impulsivity can increase the incidence of concussions, all of which exacerbate migraines.

“When healthcare providers recognize that these conditions are connected — and approach treatment holistically — the quality of care improves,” Cheyette says, “and patients function better.”

Sources

¹ Gonzalez-Hernandez, A., Cano-Yepes, A., Sainz de Aja-Curbelo, V., Santana-Farré, R., Rodríguez-Sosa, T., & Cabrera-Naranjo, F. (2023). Attention Deficit Hyperactivity Disorder in Adults With Migraine. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547231199256
² Hansen, T.F., Hoeffding, L.K., Kogelman, L. et al. Comorbidity of migraine with ADHD in adults. BMC Neurol 18, 147 (2018). https://doi.org/10.1186/s12883-018-1149-6
³ Dodick, D.W. (2018). A Phase-by-Phase Review of Migraine Pathophysiology. Headache: The Journal of Head and Face Pain, 4-16. https://doi.org/10.1111/head.13300

Is Adult ADHD Real? Yes, ADHD Persists

The essay’s authors, psychiatrist Nassir Ghaemi, M.D. (Tufts University School of Medicine), and Mark L. Ruffalo, MSW, DPsa (University of Central Florida College of Medicine), cite slim evidence, specifically two prospective follow-up studies of children with ADHD tracked to adulthood. These studies, they claim, show that only 20% of subjects with childhood ADHD still have it by adulthood.

The truth is that one of those cited studies, and its limitations, gave expert commentators pause when it first appeared seven years ago.² For one, the adult sample included 18- and 19-year-old subjects, a razor-thin slice of young adulthood. Moreover, the study’s authors used only self-reports in structured interviews to establish the existence of adult ADHD. Yet, we know self-reports to be unreliable until subjects reach their late 20s and 30s.³ By contrast, the study established childhood ADHD diagnoses using parent reports and structured interviews. Therefore, using self-reports risks under-identifying ADHD persistence into young adulthood.

A more recent study of ADHD persistence followed children originally diagnosed between ages 7 and 10.⁴ Researchers administered eight thorough re-evaluations from ages 10 to 25, on average. The results showed that most children went through an up-and-down pattern of remission. That is, results sometimes fell below full DSM diagnostic criteria but at other times fulfilled criteria. Only 10% of children with ADHD achieved full, sustained remission at young adulthood. That left 90% with persistent residual symptoms of ADHD into adulthood.

The waxing and waning of symptoms likely reflects treatment effects as well as the nature of ADHD being overly sensitive to environmental factors affecting symptom expression. Factors might include supportive teachers or bosses, or, on the other hand, the stress of starting middle school or college. Hormonal changes may also play a role in ADHD symptom severity.

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

Adult ADHD Is Not New, but Psychiatry Has Not Caught Up

Let’s flip the script here: The diagnosis of ADHD (then called hyperkinetic reaction of childhood or adolescence) first appeared in the DSM-II.⁵ That same year saw a published study of minimal brain dysfunction (another early name for ADHD) in young adult patients, some having persistent symptoms since adolescence.⁶ In other words, adult ADHD is not a diagnosis du jour, as Ghaemi and Ruffalo assert, but part and parcel of ADHD from the start. That said, a different issue could be considered: Why has diagnostic criteria for adult ADHD lingered so far behind the work already done in the field for 55 years?

For example, a decade ago the age-of-onset criterion for an ADHD diagnosis was finally raised from 7 to 12 years old. Still, even the older cutoff misses the adolescent phase, which brings increased demands for attention, impulse control, organization, and overall self-regulation. ADHD-related difficulties often become more apparent during middle school, following years of challenges going masked and unrecognized. Indeed, we find evidence that 16 is a better age threshold for symptom emergence.⁷

At the same time, clinicians are still evaluating adults using ADHD symptom criteria developed for children, which under-represent indicators of executive dysfunction. Even the term ADHD obscures the consensus that the condition is better understood as a neurodevelopmental syndrome of self-dysregulation. ADHD is a chronic delay in the onset and efficient employment of self-regulation capacities and skills. Empirically based reviews of adult ADHD specific symptoms have addressed this issue.⁸ Yet, the absence of adult-specific criteria constrains adult diagnoses and thereby access to evidence-based treatments.

[Read: ADHD Symptoms Checklist – Signs of Hyperactive, Inattentive, Combined Subtypes]

The Effects of Biases Against ADHD

Finally, the framing and wording used in “The Making of Adult ADHD” repeats the stigma and biases many adults with ADHD (diagnosed or not) encounter in daily life. Every day, they endure skeptical comments by loved ones and the public, on social media and via other outlets. This “denialism” can and does wield a profound negative effect. Research on the effects of stigmatization and dismissal of ADHD-related concerns)^9,10 has shown that unconstructive criticisms cause individuals to experience withdrawal from others and heightened sensitivity, hindering their coping skills and preventing them from reaching out for professional support.

In fact, a psychiatrist-in-training published his experience with recognizing his own adult ADHD after harboring misconceptions about it.¹¹ He observed first-hand the bias against the diagnosis (and against mental health issues generally) within healthcare and within his own specialty, which stoked his fears of disclosure. He courageously recounts his coming to terms, seeking help, and benefitting from specialized treatment.

To this psychiatrist and to other adults with ADHD, the diagnosis is well-established,¹² even as behavioral health fields are still catching up. There is more work to do, no doubt. A heartening development underway is the first set of U.S. empirically based guidelines for the assessment and treatment of adult ADHD and corresponding practice tools tailored to support these patients. I am hopeful that these guidelines (used alongside many existing international ones) will offer a helpful hand to those who are working to support adults with ADHD.

Adult ADHD Symptoms Are Real: Next Steps

• Read: How the DSM-5 Fails People with ADHD — and a Better Way to Diagnose
• Read: ADHD Is a Whole-Life Experience. The DSM Needs to Reflect That.
• Learn: What do I need to understand about ADHD that is not fully represented in the DSM?

Disclosure: Dr. Ramsay is on the scientific advisory board of ADDitude magazine. He has no conflicts of interest relevant to the content of this commentary.

Sources

¹Ruffalo, M. L., & Ghaemi, N. (2023): The making of adult ADHD: The rapid rise of a novel psychiatric diagnosis. Psychiatric Times, 40(9), 18-19.
²Faraone, S. V., & Biederman, J. (2016). Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry, 73(7), 655-656. doi:10.1001/jamapsychiatry.2016.0400.
³Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. Guilford.
⁴Sibley, M. H., et al. (2022). Variable patterns of remission from ADHD in the Multimodal Treatment Study of ADHD. American Journal of Psychiatry, 199, 142-151.doi: 10.1176/appi.ajp.2021.21010032
⁵American Psychiatric Association (1968). Diagnostic and statistical manual (2nd ed.)
⁶Harticollis, P. (1968). The syndrome of minimal brain dysfunction in young adult patients. Bulletin of the Menninger Clinic, 32, 102-114.
⁷Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. Guilford.
⁸Fedele, D. A., et al. (2010). Potential symptoms of ADHD for emerging adults. Journal of Psychopathology and Behavioral Assessment, 32, 385-396. doi: 10.1007/s10862-009-9173-x
⁹Beaton et al. (2022). Experiences of criticism in adults with ADHD: A qualitative study. PLoS ONE, 17(2), e0263366. doi: 10.1371/journal.pone.0263366;
¹⁰Morley, E., & Tyrrell, A. (2023). Exploring female students’ experiences of ADHD and its impact on social, academic, and psychological functioning. Journal of Attention Disorders, 27(10), 1129-1155. doi: 10.1177/10870547231168432
¹¹Klein, E. J. (2020). When the edges blur: A future psychiatrist’s perspective on Attention-Deficit/Hyperactivity Disorder. Psychological Services, 19(1), 29-31. doi: 10.1037/ser0000446
¹²Faraone, S. V., & Biederman, J. (2016). Can attention-deficit/hyperactivity disorder onset occur in adulthood? JAMA Psychiatry, 73(7), 655-656. doi:10.1001/jamapsychiatry.2016.0400.

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

“Most people, clinicians included, have only a vague understanding of what ADHD means. They assume it equates to hyperactivity and poor focus, mostly in children. But when we step back and ask, What does everyone with ADHD have in common, that people without ADHD don’t experience? a different set of symptoms take shape. From this perspective, three defining features of ADHD emerge: an interest-based nervous system, emotional hyperarousal, and rejection sensitivity.”

• Continue reading 3 Defining Features of ADHD That Everyone Overlooks

2. 5 Overlooked Signs of ADHD – the Inattentive Type

by Sharon Saline, Psy.D.

“People with inattentive ADHD are not lazy, stupid, unwilling, or oppositional. They are creative, outside-the-box thinkers whose minds stray from uninteresting tasks. They have a biologically based challenge with attending to an uninteresting task, maintaining their focus, and sticking with it until finished. All too often, their brains tire more quickly.”

• Continue reading 5 Overlooked Signs of ADHD – the Inattentive Type

3. The 5 Things Every Doctor (and Parent) Should Know About Girls and ADHD

by Ellen Littman, Ph.D.

“The tendency of girls with ADHD to mask their inattentive traits and internalize their feelings make their symptoms harder to recognize. As a result, they are often diagnosed later in life, after comorbidities have begun to interfere with healthy behaviors, when unhealthy coping skills start to undermine their sense of self. When in treatment, girls tend to censor themselves. They hesitate to articulate their feelings to a doctor without encouragement. They may respond to questions by saying ‘fine,’ when what they mean is ‘there’s no way I’m telling you these pills aren’t working.’”

• Continue reading 5 Things Every Doctor (and Parent) Should Know about Girls and ADHD

4. Intention Deficit Disorder: Why ADHD Minds Struggle to Meet Goals with Action

by Russell Barkley, Ph.D.

“Think of ADHD as a performance disorder. People with ADHD know what they need to do, but they struggle – greatly, at times – to transform intention into action, whether that’s preparing for a test or finalizing an important project at work. It’s an issue directly tied to the executive function difficulties inherent in ADHD. And yet, this very real challenge of ADHD is often mistaken for laziness and lack of motivation, which many breed low self-esteem and even depression.”

• Continue reading Intention Deficit Disorder

5. Carrots vs. Sticks: The Science of Reward and Punishment for Children with ADHD

by Gail Tripp, Ph.D.

“Science suggests that children with ADHD differ from their neurotypical peers in their responses to positive reinforcement and punishment. The central differences: Children with ADHD are not effectively motivated by promises (of privileges to be earned or lost); and positive reinforcement is particularly powerful, but also ephemeral, in ADHD brains. In most scenarios, positive reinforcement is a more effective motivator than is punishment, which may carry serious long-term consequences if the child’s emotion regulation skills are weak.”

• Continue reading The Science of Reward and Punishment for Children with ADHD

6. How Can We Improve Outcomes for College Students with ADHD?

by Kevin Antshel, Ph.D.; Anne Stevens, Ph.D.; Michael Meinzer, Ph.D.; and Will Canu, Ph.D.

“The population of college students with ADHD has increased substantially in the past 20 years — from roughly 2 percent of the student body to about 11.6 percent. ADHD in college is also associated with a range of challenges. According to clinical psychologist Arthur Anastopoulos, college freshmen with ADHD encounter a ‘perfect storm’ of increased interpersonal and cognitive demands alongside decreased parental involvement and support, all with lingering executive function challenges and symptoms of inattention and impulsivity/hyperactivity.”

• Continue reading How Can We Improve Outcomes for College Students with ADHD?

7. ADHD Minds Are Trapped in Now (& Other Time-Management Truths)

by Ari Tuckman, Psy.D.

“Life brings a constant barrage of stimuli competing for our attention and goals needing our efforts. It is hard to disconnect from the distractions and temptations of the moment to create the space where we can mull over our options and make the best decision. Individuals with ADHD are more absorbed than others by what is happening now. It’s harder to create that space to give the future its due until the future becomes the present and the scramble begins.”

• Continue reading ADHD Minds Are Trapped in Now

8. Face It — People with ADHD Are Wired Differently

by Oren Mason, M.D., Tamara Rosier, Ph.D.

“For decades, we weren’t sure how ADHD brains worked, and this led to many misunderstandings about the syndrome. Many doctors, therapists, social workers, and coaches tried to teach children with ADHD to slow down using the self-control methods that neurotypical children use. ‘Take a deep breath and press the following buttons on your activity thermostat’ makes sense if the wiring is standard, but not if the wires are connected differently, as they are in children and adults with ADHD. The most current research on brain imaging is starting to let us trace the wiring, so we can untangle the misconceptions that experts, as well as those with ADHD, have about the disorder and the brain.”

• Continue reading Face It — People with ADHD Are Wired Differently.

9. Don’t Mistake Your Child’s ADHD Symptoms for Bad Behavior

by James M. Greenblatt, M.D.

“Bottom line: Your child is not a bad child. You are not a bad parent. Nobody is to blame for ADHD. Therefore, assigning blame for your child’s bad behavior — and trying to correct it with criticism — is useless. But how do you stop yourself from being ‘overly critical?’ How do you show your child respect rather than subjecting him to a barrage of negativity? How do you change your behavior to help your child’s behavior? The strategy I’ve used with many parents is called SAIL.”

• Continue reading Don’t Mistake Your Child’s ADHD Symptoms for Bad Behavior

10. How Autism in Women Is Different: Unique ASD Symptoms, Risks

by Theresa Regan, Ph.D.

“A woman with autism may show a larger range of emotion in her face and voice. She might be able to adopt social standards fairly well but find it exhausting and stressful. The drama of female peer relationships can feel really overwhelming and not enjoyable. Autism in women can also present with an eating disorder. In fact, research shows that around 23% of females with eating disorders are on the autism spectrum.”

• Continue reading How Autism in Women Is Different

11. Fight, Flight, Freeze … or Fib?

by Monica Hassall, R.N., and Barbara Hunter, M.Ed.

“Faced with a threat, the human brain must react in a split second; deciding how to best protect itself. This is widely referred to as the ‘Fight, flight or freeze’ response.Today, psychologists are beginning to observe and document a fourth ‘F’ that manifests in times of real or perceived danger for children, adolescents, and even adults with ADHD: ‘fib.’ Often, a ‘fib’ or ‘fabrication’ does allow an individual to escape from fear, embarrassment, judgment, guilt, or shame — at least for the time being.”

• Continue reading Fight, Flight, Freeze … or Fib?

12. New Insights Into Rejection Sensitive Dysphoria

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

“Rejection sensitive dysphoria (RSD) is one of the most common and disruptive manifestations of emotional dysregulation — an under-researched and oft-misunderstood symptom of ADHD, particularly in adults. Dysphoria is the Greek word meaning unbearable; its use emphasizes the severe physical and emotional pain suffered by people with RSD when they encounter real or perceived rejection, criticism, or teasing. The emotional intensity of RSD is described by my patients as a wound. The response is well beyond all proportion to the nature of the event that triggered it.”

• Continue reading New Insights Into Rejection Sensitive Dysphoria

13. Why the ADHD Brain Chooses the Less Important Task — and How CBT Improves Prioritization Skills

by J. Russell Ramsay, Ph.D.

“A combination of ‘procrastinate’ and ‘activity,’ the term ‘procrastivity’ aptly describes a tussle common among adults with ADHD who are always busy but never seem to make headway on life’s important goals. At its root is an implementation problem: the individual knows what they need to do, but they won’t or can’t do it, so they keep occupied with more palatable but less critical tasks.”

• Continue reading Why the ADHD Brain Chooses the Less Important Task

14. The Social Executive Function Skills That Elude Kids with ADHD

by Ryan Wexelblatt, LCSW

“Dominating conversations. Not showing interest in others. Telling cringey jokes. Struggling in unstructured social situations. Children and teens with ADHD know these social struggles and misunderstandings too well. Navigating social interactions requires various mental processes, or executive function skills. Deficits and delays in these skills – which I refer to as social executive function skills – are common in ADHD, and they explain many of our kids’ problems in the social realm.”

• Continue reading The Social Executive Function Skills That Elude Kids with ADHD

15. ADHD and Eating Disorders: Research, Diagnosis & Treatment Guidelines

by Roberto Olivardia, Ph.D.

“Numerous studies show that individuals with ADHD are at three to six times greater risk for developing eating disorders compared to non-ADHD individuals. In a study of patients being treated for bulimia, a quarter of subjects had ADHD. What’s more, eating disorders appear to grow in severity alongside ADHD symptoms. Several factors – biological, cognitive, behavioral, and emotional – may explain why ADHD predisposes individuals to eating disorders and challenges. Understanding these factors is essential when devising an appropriate and effective treatment plan.”

• Continue reading ADHD and Eating Disorders: Research, Diagnosis & Treatment Guidelines

16. 7 Surprising Ways ADHD Shows Up in the Classroom

by Mark Bertin, M.D.

“A student who doesn’t seem to have a learning disability isn’t progressing in reading. A student seems to be disliked by her peers, is socially isolated, and eats alone. A teacher gives a two-minute warning to the class that independent reading time is about to end, and a student does not stop reading. These are all less-recognized ways ADHD symptoms show up at school — and here are productive ways to address each one.”

• Continue reading 7 Surprising Ways ADHD Shows Up in the Classroom

17. The Dyslexia-ADHD Overlap: Why Evaluators Confuse the Conditions

by Cheryl Chase, Ph.D.

“Considerable overlap exists between dyslexia and ADHD – from reading challenges to heritability – and both conditions frequently co-occur. ADHD and dyslexia are both linked to problems in school and with learning, but for different reasons. Ultimately, these overlapping traits complicate evaluations for ADHD and dyslexia, especially when both conditions are present. A thorough evaluation that carefully considers each symptom cluster is critical to receive appropriate support.”

• Continue reading The Dyslexia-ADHD Overlap: Why Evaluators Confuse the Conditions

18. ADHD Needs a Better Name. We Have One.

by Edward Hallowell, M.D., and John Ratey, M.D.

“ADHD is an inaccurate — and potentially corrosive — name. The term ‘deficit disorder’ places ADHD in the realm of pathology, or disease. Individuals with ADHD do not have a disease, nor do they have a deficit of attention; in fact, what they have is an abundance of attention. The challenge is controlling it. Therefore, we argue that a more accurate descriptive term is needed — and we have it.”

• Continue reading ADHD Needs a Better Name. We Have One

19. ADHD and Trauma: Untangling Causes, Symptoms & Treatments

by Kerry J. Heckman, LICSW

“Imagine the intricate complexities of a spider’s web — one thread attaches to dozens of others; pull just one silky strand and the entire web collapses. Living with ADHD and trauma can feel similar — the symptoms are so intertwined a single tug may cause the whole thing to cave in.”

• Continue reading ADHD and Trauma: Untangling Causes, Symptoms & Treatments

20. The Educator’s Guide to Executive Functions: How to Understand and Support Students in Need

by Karen Hubert, M.Ed., and Maureen Bechard, M.S.

“Executive functioning refers to the mental processes that allow us to concentrate, plan, organize, complete tasks, and more. They often unlock — or preclude — success in the classroom. Executive dysfunction is ubiquitous in children with ADHD, which helps to explain why so many students with attention deficit are reprimanded for forgotten homework, disorganized projects, running out of time on tests, and more. But students with ADHD aren’t the only ones who struggle with EF skills. Educators should teach executive functioning language to all classroom learners, not just those who show deficits. When educators assist students with identifying their executive functioning strengths and areas of need, they also teach them how to advocate for their own needs in the classroom and beyond.”

• Continue reading The Educator’s Guide to Executive Functions

21. Secrets of Your ADHD Brain

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

“Attention deficit hyperactivity disorder is a confusing, contradictory, inconsistent, and frustrating condition. My work for the last decade suggests that we have been missing something important about the fundamental nature of the ADHD brain — the feature that everyone with ADHD has, and that neurotypical people don’t have. That feature is the ADHD nervous system, a unique and special creation that regulates attention and emotions in different ways than the nervous system in those without the condition.”

• Continue reading Secrets of Your ADHD Brain

22. The Damaging Effects of Cannabis on the ADHD Brain

by Roberto Olivardia, Ph.D.

“The risk of developing cannabis use disorder (CUD), a problematic pattern of cannabis use linked to clinically significant impairment, is twice as high in people with ADHD. Contrary to popular belief, individuals can be mentally and chemically dependent on and addicted to cannabis. Contemporary marijuana has concentrations of THC higher than historically reported, which exacerbates this. What’s more, the adverse effects of cannabis are especially amplified in people with ADHD.”

• Continue reading The Damaging Effects of Cannabis on the ADHD Brain

23. Everything You Never Knew About the ADHD Brain

by Alison Kravit, Psy.D.

“The prefrontal cortex (PFC) is the intersection through which attention, behavior, judgment, and emotional responses run (I think of them as cars). A person with ADHD will likely react to whatever is in his focus at that moment — in other words, the faster car. For people with ADHD, the PFC is unregulated; there are no traffic lights or stop signs controlling which message (car) gets through first. You could be the smartest, most motivated student ever, but if the teacher says ‘This species of dog…’ and your thought switches to ‘I wonder what my dog is doing right now?’ you get distracted.”

• Continue reading Everything You Never Knew About the ADHD Brain.

24. What Is Auditory Processing Disorder? Symptoms, Comorbidities, and Exercises

by Beverley Holden Johns

“Auditory processing disorder (APD) throws a child’s ears and brain out of sync. This misalignment can cause a range of challenges – struggles with auditory discrimination, with listening in noisy environments, with remembering what you’ve heard, and with recalling the sequence of words spoken. APD may cause communication difficulties, but it does not show up in traditional auditory tests for hearing loss. It is a misunderstood and largely overlooked condition that may appear in 3% to 5% of all children.”

• Continue reading What Is Auditory Processing Disorder?

25. The ADHD Medication Stopped Working! How to Troubleshoot Treatment

by Thomas E. Brown, Ph.D.

“Studies show that ADHD medication safely and effectively improves communication between neurons in the ADHD brain. Amphetamine has been around since 1937, and methylphenidate since 1956. There are more research studies done on these types of medicines than on any other medicine you will ever take. Most of the work of ADHD prescribers involves adjusting the titration, especially in the early weeks. In the process, we hear these questions most frequently from patients.”

• Continue reading The ADHD Medication Stopped Working!

Honorable Mention: What is Sensory Processing Sensitivity? Traits, Insights, and ADHD Links

by Bianca Acevedo, Ph.D.

“Recent research suggests that there may be three groups of sensitive people. About 40 percent of people fall into a moderately sensitive group (tulips). Low-sensitive individuals (dandelions) make up about 30 percent of individuals, and highly-sensitive individuals (orchids) make up another 30 percent. Some markers of highly sensitive people include needing privacy from stimulation, being easily overwhelmed by bright lights, strong smells, loud noises, clothing materials, and other stimuli, being affected by other people’s moods and feeling overwhelmed when asked to do too many things at one time.”

• Continue reading What is Sensory Processing Sensitivity?

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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.