Sleep problems in children are associated with restless behavior and iron deficiency, two problems more common in patients with ADHD, according to a small study published in the journal Nutrients.¹

The study followed 199 patients referred to a Sleep/Wake Behavior Clinic between 2021 and 2023. It found that patients with ADHD were nearly twice as likely as their neurotypical counterparts to have restless leg syndrome (RLS). The most common psychiatric comorbidities among patients with sleep disorders included ADHD (46%), autism (45%), and anxiety disorder (41%).

Most patients in the study had an iron deficiency (94%), and 41% knew someone in their family who did. When comparing ADHD patients only, a family history of iron deficiency increased the patient’s risk of having RLS and insomnia.

“Recently, iron has received increasing attention due to its role in sleep disorders, as well as wake behaviors associated with mental health and/or neurodevelopmental disorders such as ADHD, autism spectrum disorder, and prenatal alcohol exposure/fetal alcohol spectrum disorder,” the research authors wrote.

RLS was the most common sleep disorder (74%) in the study, followed by:

• Chronic insomnia: 61%
• Signs of sleep-disordered breathing: 50%
• Restless sleep or PLMS: 30%
• Circadian rhythm sleep disorder (CRSD): 16%
• Probable painful RLS: 11%

Sleep and ADHD

Nearly three-quarters of children with ADHD experience a sleep problem or disorder.² For many children, sleep problems last into adolescence and can aggravate ADHD symptoms during the day.

“By the time they get into adolescence, we know that teens with ADHD are more likely than their peers without ADHD to get insufficient sleep on school nights,” said Stephen Becker, Ph.D., in his 2021 webinar with ADDitude, “Why Am I Always So Tired? The Latest Science on Improving Sleep in Children and Teens with ADHD.”

“We’ve also shown that poor sleep impacts academics, including academic performance, organization, and lower grades based on report cards that we’ve acquired from schools and college institutions,” Becker said. “In some of our work with young teens, even after we account for a teen’s initial levels of depressive symptoms or oppositional behaviors, those teens who had sleep problems went on to experience an increase in depressive symptoms and oppositional behaviors over time.”

Restlessness, defined as the “urge to move,” was a strong risk factor for sleep problems in children with and without ADHD in the present study. Hypermotor restlessness and hyper-arousal are central to ADHD and RLS but are often missed in pediatric patients, according to the authors. Symptoms of restlessness are based on adult criteria and do not account for physical differences that may be present in children.

“Characterizing hyper-motor restlessness during sleep as a new diagnostic entity supports our understanding that disorders presenting with hypermotor restlessness and/or hyper-arousability need an in-depth phenotyping approach from a pediatric sleep medicine perspective,” the authors wrote.

Limitations & Future Research

Standard diagnostic evaluations for sleep disorders typically do not assess for iron levels, according to the authors. Testing iron levels using blood tests could help improve treatment outcomes, as many patients in the present study were shown to be deficient. The authors noted that iron supplementation is often an effective treatment approach.

Evening activities, screen time, stimulant medication, homework stress, and inconsistent sleep/wake times may also make it difficult for children with ADHD to wind down at night.

Patients ages 3 months to 23 years and/or their family members answered questions upon intake about bedtime habits, excessive daytime sleepiness, nighttime awakenings, routines, sleep-disordered breathing, quality of sleep, and other non-specific concerns. The Sleep Disturbance Scale for Children (SDSC) and ADHD Rating Scale-IV were also administered.

The study has several limitations, including the absence of a control group and a small sample size. Additionally, medication use was not controlled, and there was no distinction made between anemic and non-anemic individuals with iron deficiency, nor between maternal and paternal family histories. Future research should explore the causes of iron deficiency. Inadequate nutrition, inflammation, and malabsorption were listed as potential contributors to iron deficiency.

Findings associated with other psychiatric disorders, including autism, were also shared in the study and can be found here.

Sources

¹ Ipsiroglu, O.S., Pandher, P.K., Hill, O., McWilliams, S., Braschel, M., Edwards, K., Friedlander, R., Keys, E., Kuo, C., Lewis, M.S., et al. (2024). Iron deficiency and restless sleep/wake behaviors in neurodevelopmental disorders and mental health conditions. Nutrients, 16(18):3064. https://doi.org/10.3390/nu16183064

² Sung, V., Hiscock, H., Sciberras, E., Efron, D. (2008). Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med, 162(4):336–342. https://doi.org/10.1001/archpedi.162.4.336

More than half of individuals with ADHD — and significantly more women than men — were diagnosed in adulthood, according to new data published in the U.S. Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR).¹ These findings constitute the CDC’s first update on the prevalence and age of diagnosis for ADHD in nearly 20 years.

The CDC report, which found that 6 percent of U.S. adults have a current ADHD diagnosis, identified several gender-based discrepancies regarding the age of diagnosis. Sixty-one percent of women received their ADHD diagnosis during adulthood, compared to 40 percent of men. One-quarter of women received an ADHD diagnosis before age 11, compared to 45 percent of men.

“Taken together, these data highlight the significant public health burden of ADHD and challenges experienced by adults with this diagnosis,” said Greg Mattingly, M.D., president of the American Professional Society of ADHD and Related Disorders (APSARD), and Ann Childress, M.D., past president of APSARD, in an article published in Psychiatric Times.²

The MMWR analyzed data collected from the National Center for Health Statistics Rapid Survey System (RSS) from October through November 2023 on the prevalence, treatment barriers, and telehealth usage of adults with ADHD.

Consequences of Undiagnosed Adult ADHD

Once considered a childhood condition, ADHD is now recognized as one of the most common mental health conditions in adults, affecting men and women almost equally. ³,⁴ A new national survey of 1,000 American adults by The Ohio State University Wexner Medical Center and College of Medicine revealed that as many as one in four adults suspect they may have undiagnosed ADHD, however, only 13 percent have consulted a doctor about their suspicions. The researchers say the findings raise concerns that self-diagnosis may lead to incorrect treatment.

“In recent years, the number of adults diagnosed with ADHD has risen significantly – thanks, in part, to decades of research that has advanced awareness of ADHD as a lifelong disorder,”⁵ wrote APSARD secretary Maggie Sibley, Ph.D., in the ADDitude article, “Why We Need U.S. Guidelines for Adults with ADHD.” “Though ADHD is commonly detected in childhood, later-in-life diagnoses are providing clarity and relief for many adults with once unexplained, misunderstood, or overlooked lifelong struggles.”

Untreated adult ADHD symptoms may impair individuals personally and professionally, and they may exacerbate comorbidities like depression, anxiety, bipolar disorder, insomnia, substance use disorders, and trauma-related conditions. ⁶, ⁷

“ADHD does not happen in a vacuum, and its effects are far more impairing when the condition goes undiagnosed, untreated, or improperly treated,” said Nelson M. Handal, M.D., DFAPA, in the ADDitude webinar, “New Insights Into and Treatments for Comorbid Depression” “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.”

Even with an ADHD diagnosis, adults face barriers to care amid the ongoing stimulant shortage. Approximately 7 in 10 adults treating ADHD with stimulant medications reported difficulty obtaining their prescriptions, the CDC found.

The CDC’s findings suggest that telemedicine may improve access to healthcare and decrease systemic discrepancies in care. Nearly half of adults with a current ADHD diagnosis said they received some of their ADHD healthcare via telemedicine.

“These benefits must, however, be balanced with the need for thorough diagnostic evaluation and follow-up for both the in-person and virtual models of care,” said Mattingly and Childress.

“Some telehealth companies are under federal investigation for their prescribing practices, highlighting a need for clarity on appropriate practices for the prescription of stimulants – a first-line treatment for ADHD,” Sibley wrote. “APSARD’s forthcoming adult ADHD guidelines will address this urgent need for providers and patients alike — making evaluations more thorough, diagnosis more reliable, and treatment safer.”

Importance of Adult ADHD Guidelines

The Ohio State study and CDC data underscore the need for adult ADHD diagnosis and treatment guidelines, which APSARD is working to finalize by late this year or early 2025.

“These will be the first U.S. guidelines for the diagnosis and treatment of adults with ADHD, and they will provide a valuable framework of treatment for clinicians and families,” said Mattingly and Childress. “While many unanswered questions remain, these findings bring us one step closer to a deeper understanding of the needs of adults with ADHD.”

The impact of the APSARD guidelines may be felt most profoundly by adult women.

“Many women do not recognize that they have ADHD or seek evaluations until their children are diagnosed,” wrote Childress in an ADDitude article earlier this year. 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.”

Sources

¹taley, S.B., Robinson, L.R., Claussen, A.H., et al. Attention Deficit/Hyperactivity Disorder Diagnosis, Treatment and Telehealth Use in Adults – National Center for Health Statistics Rapid Surveys System, United States, October – November 2023. MMWR Morb Mortal Wkly Rep. 2024;73(40)

² Mattingly, G., Childress, A. (2024). Clinical Implications of Attention-Deficit/Hyperactivity Disorder in Adults: What New Data on Diagnostic Trends, Treatment Barriers, and Telehealth Utilization Tell Us. J Clin Psychiatry; 85(4): 24com15592. https://doi.org/10.4088/JCP.24com15592

³Ayano, G., Tsegay, L., Gizachew, Y, et al. (2023). Prevalence of Attention Deficit Hyperactivity Disorder in Adults: Umbrella Review of Evidence Generated Across the Globe. Psychiatry Res; 328:115449. https://doi.org/10.1016/j.psychres.2023.115449

⁴Faraone, S.V., Bellgrove, M.A., Brikell, I., et al. (2024). Attention Deficit/Hyperactivity Disorder. Nat Rev Dis Primers; 10(1):11. https://doi.org/10.1038/s41572-024-00495-0

⁵Sibley, M.H., Arnold, L.E., Swanson, J.M., Hechtman, L.T., Kennedy, T.M., Owens, E., Molina, B.S., Jensen, P.S., Hinshaw, S.P., Roy, A., Chronis-Tuscano, A. (2022). Variable Patterns of Remission from ADHD in the Multimodal Treatment Study of ADHD. American Journal of Psychiatry;179(2):142-51. https://doi.org/10.1176/appi.ajp.2021.21010032

⁶Kessler, R.C., Berglund, P., Chiu, W.T., et al. (2004). The US National Comorbidity Survey Replication (NCS-R): Design and Field Procedures. Int J Methods Psychiatr Res; 13(2):69–92. https://doi.org/10.1002/mpr.167

⁷Katzman, M.A., Bilkey, T.S., Chokka, P.R., et al. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC Psychiatry. 17(1):https://doi.org/10.1186/s12888-017-1463-3

ADHD and dyslexia share 174 genes and 49 genetic regions, according to a new study published in Molecular Psychiatry. The findings suggest that ADHD more closely resembles a learning difference than a psychiatric disorder.¹

Led by a team of researchers from the University of Edinburgh, UK, the study aimed to find common genes underlying dyslexia and 10 neurodevelopmental and psychiatric conditions, including ADHD, autism, anorexia nervosa, anxiety, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, schizophrenia, and Tourette syndrome.

The researchers identified five genetically linked clusters, known as latent genomic factors, that revealed ADHD to be more significantly associated with attention and learning issues than it is with neurodevelopmental conditions, such as autism and Tourette syndrome.

Further analysis showed that dyslexia and ADHD share 49 genetic regions, 40 of which were newly discovered, and 174 genes, including 121 previously unidentified ones.

Dyslexia and ADHD

Dyslexia is a language-based learning disorder with neurodevelopmental origins. It is characterized by reduced accuracy and speed in reading and spelling. Dyslexia and ADHD are highly comorbid. Roughly one-quarter to 40% of individuals with ADHD also have dyslexia.²

“Considerable overlap exists between dyslexia and ADHD,” said Cheryl Chase, Ph.D., in the ADDitude webinar “When Dyslexia and ADHD Overlap: Symptoms, Misconceptions, and Interventions.” “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. Nevertheless, a thorough evaluation that carefully considers each symptom cluster is critical to receive appropriate support.”

Strong heritability exists for both dyslexia and ADHD. Twin studies of dyslexia estimate its heritability at 60% to 70%.³, ⁴ Heritability for ADHD ranges from 77% to 88%.⁵

Previous genome-wide association studies have struggled to identify genes common to people with dyslexia and ADHD, largely because such research would require a substantial sample size. The UK study examined large public anonymized datasets of genetic data from the Psychiatric Genomics Consortium genome-wide association study and dyslexia genetic statistics from an analysis of roughly one million people in collaboration with 23andMe, a U.S.-based consumer genetics company.

The researchers also leveraged the findings of a 2022 study that included data from more than 1.1 million individuals (51,800 dyslexia cases). The 2022 study identified 42 genes responsible for dyslexia and confirmed its genetic link to ADHD. Of the 42 genetic variants identified, 15 were in genes linked to cognitive ability/educational attainment and 27 were new, suggesting that individuals with more genetic variants were more likely to have dyslexia.⁶

The UK study used a combined sample of 453,408 cases and 2,374,026 controls.

“This is the first time that genetic links to dyslexia have been studied in the context of psychiatric traits,” says Austėja Čiulkinytė, a translational neuroscience Ph.D. student at the University of Edinburgh, who led the study. “In the future, other learning difficulties such as dyscalculia or dysgraphia should be included to allow for a more nuanced understanding of their relationships.”

Sources

¹ Čiulkinytė, A. et al. (2024). Genetic Neurodevelopmental Clustering and Dyslexia. Molecular Psychiatry. https://doi.org/10.1038/s41380-024-02649-8

² DuPaul, G.J., Gormley, M.J., & Laracy, S.D. (2013). Comorbidity of LD and ADHD: Implications of DSM-5 for assessment and treatment. Journal of Learning Disabilities; 46(1), 43–51. https://doi.org/10.1177/0022219412464351

³ Hawke, J.L., Wadsworth, S.J., DeFries, J.C. (2006). Genetic Influences on Reading Difficulties in Boys and Girls: The Colorado Twin Study. Dyslexia; 12:21–29. https://doi.org/10.1002/dys.301

⁴ Hensler, B.S., Schatschneider, C., Taylor, J., Wagner, R.K. (2010). Behavioral Genetic Approach to the Study of Dyslexia. J Dev Behav Pediatrics; 31:525–32.https://doi.org/10.1097/DBP.0b013e3181ee4b70

⁵ Faraone, S.V., & Larsson, H. (2019). Genetics of Attention Deficit Hyperactivity Disorder. Molecular Psychiatry; 24(4), 562–575. https://doi.org//10.1038/s41380-018-0070-0

⁶ Doust, C., Fontanillas, P., Eising, E. et al. (2022). Discovery of 42 Genome-Wide Significant Loci Associated with Dyslexia.Nat Genet.https://doi.org/10.1038/s41588-022-01192-y

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

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

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

Non-Cognitive Skills

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

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

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

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

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

Genetic Influence

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

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

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

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

Mental Health & ADHD

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

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

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

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

Limitations and Future Research

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

Sources

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

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

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

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

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

At the same time, the medical community has its work cut out for it. We’ve barely begun to scratch the surface on ADHD and autism — conditions with strikingly similar traits and challenges that also happen to co-occur at significant rates. We primarily understand these conditions in white males, and we have a long way to go to ensure that women, people of color, and gender-diverse individuals are represented in research and published findings.

As our understanding of ADHD, autism, and neurodivergence evolves, I share my insights on where we are and where the field should be headed.

1. Most Providers Are Not Trained in ADHD or Autism

My first introduction to diagnosing and supporting ADHD and autism wasn’t until my pre-doctoral internship, after I had already spent four years in graduate school. A lot of what I have learned since then about ADHD and autism has been through clinical experience with patients and ongoing self-education.

Until 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM) did not even allow for co-diagnosis of both ADHD and autism. With the publication of DSM-5 that year came significant changes to the diagnostic criteria for both conditions.

[Get This Free eBook: The Truth About Autism in Adults]

• Autism spectrum disorder was once divided into several distinct disorders, including autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). The DSM-5 consolidated these categories into a single diagnosis: autism spectrum disorder.
• With the DSM-5, the age by which ADHD symptoms must be present to qualify for a diagnosis changed from age 7 to age 12. Additionally, the DSM-5 said adults need to show five symptoms of inattention and/or hyperactivity/impulsivity, compared to the six required by children for diagnosis. These and other changes have helped to capture more girls and women in the diagnostic process.

That ADHD and autism were kept separated for so long invariably affected clinical work and research, which we are still working to rectify. Neurodevelopmental conditions are not a standard part of medical training in the first place, and many medical providers, especially those who have not sought training in these conditions, remain unaware of how the diagnostic categories have evolved and how to diagnose and support these conditions.

2. The ADHD-Autism Overlap Is Significant — and Seriously Under-recognized

Autism and ADHD are highly comorbid and share a staggering number of traits and symptoms, many of which are not reflected in diagnostic criteria for either condition.

Autism and ADHD: Shared Symptoms, Traits, and Challenges

• inattention to non-preferred tasks; hyperfocus on interests
• hyperactivity and restlessness
• impulsivity
• executive dysfunction (manifested by issues with organization, time management, planning, etc.)
• hypo or hypersensitivity to sensory input
• social and communication issues, including fear of rejection
• inflexibility; difficulty with change and transitions
• emotional dysregulation; meltdowns
• sleep problems
• self-esteem issues
• anxiety
• masking
• perfectionistic tendencies
• dichotomous, all-or-nothing thinking

[Read: “A Living Contradiction” — the AuDHD Experience]

While distinct, multidimensional, and complex conditions, ADHD and autism overlap so much that I sometimes view them along the same spectrum. This does not mean that I think everyone who has ADHD is also autistic, or the inverse. It’s just that, when we look closely, we see that a vast number of people with ADHD frequently exhibit autistic traits, and vice versa.

As clinicians, we need to educate ourselves beyond the basic mechanics of diagnosis for either condition, seek experience and supervision when necessary, and include clinical judgment in our decision-making matrices. We cannot rely only on test or scores. We need to learn about behaviors and traits that we know clinically exist in both ADHD and autism but may not be currently reflected in diagnostic criteria.

3. ADHD and Autism Are Routinely Overlooked in Girls and Women

Boys are more likely than girls to be diagnosed with ADHD and autism. Girls and women, who often display more subtle, internalizing symptoms, tend to be overlooked because clinicians and researchers largely continue to view these conditions from a male-centric view. Female manifestations of either condition are often misdiagnosed, misinterpreted, and normalized. Gender and societal norms also mean that girls and women are more likely to overcompensate and mask their symptoms and challenges of ADHD and/or autism.

To understand female presentations and potential signs of neurodivergence (e.g., emotional dysregulation, low self-esteem, overwhelm, perfectionism, social anxiety) clinicians must take a different, nuanced approach when evaluating girls and women for ADHD and/or autism. It can be helpful to see patients across multiple sessions during the diagnostic process and ask about functioning in different settings.

4. How We Talk About Autism and Neurodiversity Matters Greatly

• Be the paradigm shift. Changes are underway in how we collectively understand autism, ADHD, learning differences, and other neurodevelopmental conditions. We see this in the growing use of the term “neurodivergence” — language that aims to normalize and de-stigmatize, not pathologize, differences in thinking and functioning. While we must pay attention to medicalized and pathologized language, we must also retain the idea that neurodivergent individuals may need specific kinds of support, especially if their symptoms and traits interfere with functioning and cause distress.
• Identity-first vs. person-first language. Individuals can label themselves however they want to. But many autistic individuals — viewing autism as a fundamental part of their identity that shapes all aspects of life — prefer identity-first language over person-first language. That is, most of the time, people want to be referred to as “autistic,” not as “having autism.” With ADHD, however, person-first language appears to dominate. Patients may feel more respected when they hear medical professionals use these terms.
• The medical community must listen to patients. Understanding — not undermining — the lived experiences of those who live with ADHD and/or autism is critical. The experiences, traits, symptoms, and challenges of our patients do not always align with textbook definitions and available research findings, and firsthand accounts can offer a more accurate and comprehensive understanding of these conditions. Listening to patients helps us appreciate the nuances and variations in symptoms and offer personalized treatment plans. When patients feel heard and respected, they are more likely to engage in their care and advocate for themselves, leading to better outcomes.

5. Those Who Don’t Diagnose Still Play a Role

Licensed and trained medical and mental health providers who specialize in neurodevelopmental conditions can properly and comprehensively evaluate, diagnose, and treat ADHD and/or autism. It also bears repeating that those outside of healthcare— a patient’s family members, friends, teachers, and so on — absolutely cannot diagnose or treat these conditions.

And yet, non-specialists and those outside of healthcare still hold tremendous influence over a patient’s outcomes. Pediatricians and primary care providers, regardless of specialization in ADHD or autism, should be able to notice signs of these conditions, perform preliminary screenings, and refer patients to specialists. At the same time, family, friends, and teachers are often first to notice if someone is exhibiting signs that would warrant speaking to a medical professional. These individuals are often part of the clinical evaluation process.

While important people in a patients’ lives can serve as catalysts for diagnosis and support, they can also derail the process, especially when they are uninformed or misinformed about ADHD and autism. Family, friends, teachers, and even medical providers may miss the signs. Even worse, they can deny them, which can cause harm by derailing the path to evaluation and diagnosis on a child, adolescent, or adult’s health journey. Without a label or diagnosis, neurodivergent individuals are at greater risk of mental health issues, lack of appropriate and needed supports, and co-occurring issues like depression, anxiety, and self-harm.

My suggestion to all non-specialists and those outside of medicine: Don’t put individuals in a position where they begin to doubt themselves and their health providers. Instead, be curious. Educate yourself and ask how you can be supportive. Listen and be respectful of peoples’ experiences.

6. We Need to Pay Close Attention to Gender-Diverse Populations

Research is beginning to uncover what many clinicians and patients have observed: That gender diversity is present more frequently in autistic individuals and in those with ADHD.^{1 2} To be clear, research is limited in this area.

Nonetheless, his is an important connection because gender-diverse populations are already vulnerable to mental health issues — from depression and anxiety to self-harm and loneliness — due to stigma, discrimination, and social rejection. Living with ADHD or autism can compound these challenges.

The association between gender diversity and neurodivergence shines a light on the importance of inclusive, affirming care among ADHD and autism specialists. This includes asking patients for their pronouns, updating intake forms to include more gender options, self-monitoring for gender bias, and committing to ongoing education, among other approaches. Clinicians must also be careful about diagnostic overshadowing, whereby a patient’s emotional and behavioral issues are attributed to their experiences related to gender identity as opposed to other co-occurring conditions. As all of available studies on ADHD and autism are based on binary gender, researchers should include gender diverse options in studies and testing.

7. Social Media Can Open the Door to Understanding

There is a lot of misinformation on social media, and we should always view what’s online through a critical lens.

That being said, there is also lots of excellent, valid, and vital discussion online around the neurodivergent experience. On social media, individuals speak openly about their lived experiences with ADHD and/or autism — conversations that create transformative communities of understanding, friendship, support, and belonging while helping the undiagnosed begin to put a name to their experiences. (It’s my view that conversations in these spaces have and will continue to inform research on ADHD, autism, and neurodivergence.) From a health equity perspective, these online spaces offer support when access to evaluations, treatments, and health insurance is difficult.

As medical providers, we should refrain from making blanket statements about the “harms” of social media when it is a tool that has helped many. At the same time, patients should remember that people online are sharing their own unique experiences that may not apply to others. All-or-nothing statements about ADHD and autism should raise an eyebrow or two, as should anything that is offered as a “cure” for neurodivergence.

The ADHD-Autism Overlap: Next Steps

• Take This Self-Test: Female Autism Test — “Am I Autistic?”
• Autism in Kids Self-Test: Early Signs of ASD
• Free Download: Autism Evaluation Checklist
• Read: Stop Fighting Your Child’s Neurodiversity

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “AuDHD Guidance: Why Autism is So Difficult to Diagnose in Women and Girls with ADHD” [Video Replay & Podcast #511] with Karen Saporito, Ph.D., which was broadcast on June 27, 2024.

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Sources

¹ Warrier, V., Greenberg, D. M., Weir, E., Buckingham, C., Smith, P., Lai, M. C., Allison, C., & Baron-Cohen, S. (2020). Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nature communications, 11(1), 3959. https://doi.org/10.1038/s41467-020-17794-1

² Kahn, N. F., Sequeira, G. M., Garrison, M. M., Orlich, F., Christakis, D. A., Aye, T., Conard, L. A. E., Dowshen, N., Kazak, A. E., Nahata, L., Nokoff, N. J., Voss, R. V., & Richardson, L. P. (2023). Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents. Pediatrics, 152(2), e2023061363. https://doi.org/10.1542/peds.2023-061363

Vyvanse and its generic equivalents (lisdexamfetamine dimesylate) may be more readily available at pharmacies following a decision by the Drug Enforcement Administration (DEA) to allow expanded production of the stimulant medication used to treat ADHD and moderate-to-severe binge-eating disorder (BED) in adults. About one-quarter of the 24% (6,236 kg) production increase in lisdexamfetamine will address domestic demand, and the remaining 75% will address foreign demand.¹

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

The DEA’s decision arrives amid a stimulant shortage that has disrupted treatment for millions of patients with ADHD for nearly two years. The U.S. Food and Drug Administration (FDA) first reported a shortfall of Adderall (the brand name for the immediate-release formulation of amphetamine mixed salts used to treat ADHD) due to manufacturing delays at Teva Pharmaceutical Industries in October 2022. The nationwide Adderall shortage triggered a domino effect, with ADHD patients struggling to fill prescriptions for other stimulant medications, such as Vyvanse and Ritalin.

In August 2023, the FDA granted approval for 15 manufacturers to produce generic Vyvanse capsules and chewable tablets after Takeda Pharmaceuticals’ U.S. patent for the medication expired.² (The FDA stipulates that generic ADHD medications contain exactly the same active ingredients as their name-brand counterparts; however, compounds in generic drugs are allowed to include different binding chemicals, fillers, and colors.) However, one year later, the promise of generic Vyvanse has done little to ease the stimulant shortfall.

As of September 9, the American Society of Health-System Pharmacists (ASHP) reported lisdexamfetamine dimesylate capsule shortages among nine drug manufacturers. Eight attributed the shortage to an “issue with the active ingredient.”

Controversy Surrounding APQs

The DEA sets yearly aggregate production quotas (APQs) for stimulant medications, which are classified as Schedule II controlled substances due to their high potential for abuse. The process has drawn the ire of many drug manufacturers, clinicians, and patients with ADHD, who cite production limits as the main reason for the stimulant shortage.

“The DEA is the only governmental agency that sets production and distribution quotas for every drug company manufacturing controlled medication,” William Dodson, M.D., LF-APA, wrote in an ADDitude Op-Ed earlier this year. “The DEA decides how much of each medication can be released to pharmacies in any given month. Therefore, this problem traces its roots and long tendrils back to the DEA alone. No other agency has the authority to create and prolong it.

“This process tries to predict in March of 2024 how much medication will be needed 21 months later in December of 2025,” Dodson continued. “It is a crude and inadequate system that the DEA is too inflexible to relinquish.”

Stimulant Drug Manufacturers Speak Out

Mounting frustration over the stimulant shortage has begun influencing some positive change.

The public comment period for the DEA’s “Proposed Aggregate Production Quotas for Schedule I and II Controlled Substances” drew 4,699 comments, according to The Federal Register. (Last year, the DEA received 357 comments.)

Commentators included patients with ADHD, drug manufacturers, members of U.S. and Australian professional associations, representatives from the Royal Australian and New Zealand College of Psychiatrists, and others. They expressed concerns about the ongoing ADHD medication shortage and the DEA’s lack of transparency in setting quotas, among other issues. ³

In response, the DEA said it is “considering methods that might increase transparency in its quota-setting process,” including public notification and an opportunity for public input when prescribing rates for controlled substances substantially deviate from FDA’s estimate of medical needs. The agency is also considering regulatory changes to gain access to more real-time data, such as monthly updates in the Automated Reports and Consolidated Ordering System (ARCOS), a database where manufacturers and distributors report their controlled substances transactions to the DEA.

However, an association representing drug manufacturers asserted that the DEA’s practice of allocating procurement quotas based on a company’s historical drug sales disadvantages generic lisdexamfetamine drug manufacturers because they lack an established sales history.

The DEA disputed the claim. “DEA has always been cognizant that new manufacturers entering the market for the first time would not have any established sales history, and thus the manufacturer’s past sales history is not a factor when determining the quota needed to launch a new product,” it said in the January 3 issue of The Federal Register.³

The federal agency also denied that APQs are causing the stimulant shortage. “The DEA utilizes the available, reliable data and information received by the agency at the time APQs are proposed and proactively monitors drug production, distribution, and supply during the year,” it said. “Drug shortages may occur subsequently due to factors outside of DEA control such as manufacturing and quality problems, processing delays, supply chain disruptions, or discontinuations.”

Drug manufacturers’ hands are not necessarily tied after the DEA releases its yearly APQs. Any DEA-registered manufacturer may apply for an increase in the manufacturing quota for a basic class of controlled substance in Schedule I or II throughout the year. The DEA must review such requests within 30 days of receipt.

The decision to raise the APQs of name brand and generic Vyvanse came at the behest of the FDA and a DEA-registered manufacturer earlier this summer. In October 2023, the DEA raised the production limits of methylphenidate (brand names: Ritalin, Concerta) by 27% after receiving requests from the FDA and a DEA-registered drug manufacturer.

It is too early to tell if the expanded Vyvanse APQs will inspire more DEA-registered drug manufacturers to request quota reviews. In the meantime, the increased production of Vyvanse and its generic equivalents will promise welcome relief to the estimated one million Americans regularly taking the stimulant.

Vyvanse was the most popular prescription stimulant, according to ADDitude’s 2023 treatment survey. Nearly one-quarter of respondents said they (or their child) were taking Vyvanse to treat ADHD symptoms, outnumbering other prescription stimulants used by ADDitude readers, including Concerta (15%), Adderall (15%), Adderall XR (13%), and Ritalin (10%).

Among ADDitude survey respondents taking Vyvanse, 44% said the medication is extremely or very effective at treating their ADHD symptoms.

“Vyvanse has, without exaggeration, changed my life and made me into the kind of person I’ve always wanted to be,” one survey respondent said.

Sources

¹Adjustment to the Aggregate Production Quota for Lisdexamfetamine and dAmphetamine (for Conversion) for 2024. Drug Enforcement Administration. The Federal Register. September 5, 2024. https://public-inspection.federalregister.gov/2024-20114.pdf

¹FDA Approves Multiple Generics of ADHD and BED Treatment. FDA. Published August 28, 2023. Accessed August 28, 2023. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-multiple-generics-adhd-and-bed-treatment?utm_medium=email&utm_source=govdelivery

¹Established Aggregate Production Quotas for Schedule I and II Controlled Substances and Assessment of Annual Needs for the List I Chemicals Ephedrine, Pseudoephedrine, and Phenylpropanolamine for 2024. Drug Enforcement Administration. The Federal Register. January 3, 2024. https://www.federalregister.gov/documents/2024/01/03/2023-28962/established-aggregate-production-quotas-for-schedule-i-and-ii-controlled-substances-and-assessment

Peer acceptance, a sense of self-efficacy, and a stress-is-enhancing mindset are strong predictors of resilience in older teens with ADHD, according to a small longitudinal study published in Child Psychiatry & Human Development.¹

The study, which followed 113 adolescents with ADHD from 10th to 12th grade, found that higher levels of peer acceptance, self-efficacy, and a growth mindset in 10th or 11th grade predicted higher levels of resilience 1.5 to 2 years later.

Peer Acceptance & Mechanisms of Resilience

Participants from the present study were assessed at three points:

• Fall/winter of 10th grade for peer acceptance
• Spring of 10th or 11th grade for self-efficacy, a stress-is-enhancing mindset, and baseline resilience
• Spring of 11th or 12th grade for follow-up on resilience

Peer acceptance at the start of the study explained 24% of the variance in resilience at follow-up. Teens with less severe ADHD symptoms were significantly more likely to report feelings of peer acceptance.

Resilience was measured using the Brief Resilience Scale (BRS), which asked teens to measure their agreement with statements such as “I tend to bounce back quickly after hard times” and “I take a long time to get over setbacks in my life.”

Self-Efficacy

Self-efficacy mediated the relationship between peer acceptance and resilience, accounting for 39% of the variance in resilience at follow-up.

“Greater self-efficacy has been associated with positive outcomes for children and adolescents with ADHD, including lower levels of depression and internalizing symptoms, and reported higher quality of life,” wrote Elizabeth Chan, lead author of the study.

Though ADHD symptom severity did not change the positive effect of self-efficacy on resilience, existing research shows that ADHD symptoms can negatively impact self-esteem.

A Stress-Is-Enhancing Mindset

A stress-is-enhancing mindset accounted for 31% of the variance in resilience. Individuals with this mindset view obstacles as opportunities for learning and development. Teens with more severe ADHD symptoms needed at least a moderate stress-is-enhancing mindset to promote resilience.

A Positive Mindset Has Broad Impact

“One of the key attributes of resilient children and adults is when problems come up, they view these problems as challenges to be solved rather than overwhelmed by,” said Robert Brooks, Ph.D., a leading expert on resilience and motivation.

Healthy peer relationships are also critical for kids with ADHD, many of whom struggle to initiate and maintain friendships. Children tend to experience increased interpersonal problems as they enter adolescence.¹ Between 50% and 80% experience peer rejection, according to one study, which found classmates’ opinions of ADHD students are developed within the first 30 minutes and persist long after.²

“We have to help our children become much better problem solvers and believe in themselves… to start to feel that there are these problems, but there are [also] things we can do,” said Brooks during his 2022 ADDitude webinar “Nurturing Resilience and Motivation in Children with ADHD: The Search for ‘Islands of Competence.”

Existing research on ADHD has associated adaptive outcomes with a growth mindset, as noted by the authors. A growth mindset — the belief that one can change their abilities and circumstances — predicts fewer negative emotions, greater efficacy, and less avoidant coping.^{3, 4}

In contrast, those with a stress-is-debilitating mindset view stress consequentially and are more likely to act on impulse — a core symptom of ADHD. A study published by Society for Research in Child Development and cited by the authors found that, among 1,343 adolescents, more adverse life events predicted greater distress and decreased self-control.⁵ When participants viewed stress as beneficial, they were less likely to respond impulsively to negative events.

Support from Caregivers

No significant interaction was found between a stress-is-enhancing mindset and peer acceptance. According to research cited by the authors, support from parents and teachers may be more influential than support from peers in promoting this enhancing mindset, ^{6, 7} particularly when caregivers praise effort over ability.

Additionally, the presence of a charismatic adult — someone from whom children gather strength — has been associated with resilience in kids with ADHD.⁸ “In the absence of a good co-regulator, a solid, charismatic adult… we know that the likelihood of going on to have positive outcomes goes down,” said Cheryl Chase, Ph.D., in her 2022 webinar with ADDitude on how stress and trauma impact child development. “One charismatic adult can make a massive difference.”

“Despite the adverse outcomes associated with ADHD, some adolescents with ADHD perform as well as or better than their non-ADHD peers in one or more functional domain(s),” wrote Chan et al. “These individuals appear to exhibit resilience, or a pattern of positive adaptation, with some thriving despite the neurobehavioral risks associated with their diagnosis.”

Limitations & Future Research

This was the first study to look at peer acceptance as a predictor of resilience and self-efficacy as a mediator. It was also the first to examine a stress-is-enhancing mindset in the context of ADHD.

Analyses controlled for sex, ADHD symptoms, baseline resilience, and cohort. To be included, participants were required to meet DSM-5 criteria for ADHD combined or inattentive type. Adolescents were excluded if they had a previous or existing diagnosis of autism spectrum disorder, bipolar disorder, dissociative or psychotic disorder, or an organic sleep disorder.

Future research should examine the potential causes of gender discrepancy in levels of resilience, which were significantly lower among females with ADHD. A more diverse sample is also needed, as the population was mostly male (67%) and White or Non-Hispanic (81%). A large percentage of the variance in resilience (61%) was unaccounted for; researchers should consider other contributing factors. Self-report scales were used as a primary measure; more objective reporting tools should be considered for future studies. Exploring interventions that encourage greater peer acceptance and a stress-is-enhancing mindset would benefit the study population.

Sources

¹Chan, E.S.M., Dvorsky, M.R., Green, C.D., et al. (2024). Predictors and mechanisms of resilience for high school students with ADHD: a prospective longitudinal study. Child Psychiatry Hum Dev. https://doi.org/10.1007/s10578-024-01704-3

²Ferretti N.M., King S.L., Hilton D.C., Rondon A.T., & Jarrett M.A. (2019). Social functioning in youth with attention-deficit/hyperactivity disorder and sluggish cognitive tempo. Yale J Biol Med, 92(1), 29-35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6430168/

³ Burnette, J.L., Babij, A.D., Oddo, L.E., &Knouse, L.E. (2020). Self-regulation mindsets: relationship to coping, executive functioning, and ADHD. Journal of Social and Clinical Psychology, 39(2), 101-116. https://doi.org/10.1521/jscp.2020.39.02.101

⁴ Pay, C. (n.d.). How can I foster a growth mindset in my ADHD kids? Utah State University. https://extension.usu.edu/relationships/faq/how-can-i-foster-a-growth-mindset-in-my-adhd-kids

⁵ Park, D., Yu, A., Metz, S.E., Tsukayama, E., Crum, A.J., & Duckworth, A.L. (2018). Beliefs about stress attenuate the relation among adverse life events, perceived distress, and self-control. Child Dev 89(6), 2059–2069. https://doi.org/10.1111/cdev.12946

⁶ Haimovitz, K., & Dweck, C.S. (2016). What predicts children’s fixed and growth intelligence mindsets? Not their parents’ views of intelligence but their parents’ views of failure. Psychol Sci 27(6), 859–869. https://doi.org/10.1177/0956797616639727

⁷ Park, D., Gunderson, E.A., Tsukayama, E., Levine, S.C., & Beilock, S.L. (2016). Young children’s motivational frameworks and math achievement: relation to teacher-reported instructional practices, but not teacher theory of intelligence. J Educ Psychol 108(3), 300. https://doi.org/10.1037/edu0000064

⁸ Ofiesh, N.S., & Mather, N. (2023). Resilience and the child with learning disabilities. In: Goldstein, S., & Brooks, R.B. (Eds.). Handbook of resilience in children. Springer, Cham. https://doi.org/10.1007/978-3-031-14728-9_25

Adolescents exhibiting comorbid ADHD and ODD (oppositional defiant disorder) symptoms face higher unemployment rates, sick days, and lower incomes in adulthood than do their neurotypical peers, suggests new research from Finland. ¹

The longitudinal study, published in the Journal of Attention Disorders, identified 6,985 participants (aged 15 to 16) from the Northern Finland Birth Cohort 1986. ² The researchers sorted participants into groups based on symptom presentation — ADHD, ODD, comorbid ADHD and ODD, or the control group. Researchers analyzed sick and unemployed days from 2006 to 2010 (when participants were 20 to 24 years old) and from 2011 to 2019 (when participants were 25 to 33).

Between the ages of 25 and 33, males from all symptomatic groups experienced more unemployment and sick days than did their neurotypical peers, but those symptoms did not directly impact their income levels. During the same age range, females with symptoms of ADHD and comorbid ADHD and ODD reported higher rates of unemployment. However, the study found that younger females (between the ages of 20 and 24) among all symptomatic groups were likelier to report sick days than the controls. (The study did not include participants identified as non-binary or transgender.)

The researchers pointed to previous studies suggesting that “symptoms of ODD and ADHD are associated with substance use disorder, different types of injuries, and an increased risk of undergoing psychiatric hospitalization during one’s life” as likely causes of increased sick leave from work. ³, ⁴, ⁵

The ADHD-ODD Link

ODD is highly comorbid with ADHD. Studies estimate that ODD co-occurs with ADHD in approximately 50% to 60% of population-based samples. ⁶, ⁷

“Oppositional defiant disorder is characterized by persistent patterns of anger and irritability, argumentative behaviors, and vindictiveness toward others,” said William Dodson, M.D., LF-APA, during the 2021 ADDitude webinar, “How Oppositional Defiant Disorder Ruptures Families — and How You Can Learn to Manage It.” “ODD is listed as a childhood disorder, but it commonly persists into adult life and continues to be highly impairing with symptoms impacting a person’s functioning and causing significant distress to family, friends, and educators.”

Income Disparities

The study also identified income disparities among the study participants. Male and female participants with comorbid ADHD and ODD consistently had lower annual incomes compared to all other symptomatic groups. Interestingly, participants with ADHD reportedly earned more than the control group between the ages of 20 and 24. Those results flipped by age 30.

“Young adults with ADHD symptoms tend to enter the labor market more quickly than their peers without ADHD symptoms, potentially explaining these results,” the researchers wrote. “Individuals without ADHD typically delay entering the workforce at 20 years of age, as they often pursue higher education.”

The results of a 2020 ADDitude survey of nearly 1,450 adults with ADHD painted a slightly different picture. Almost one-third of respondents had an annual household income of $100,000 or higher, and more than half exceeded the U.S. median income ($74,580 in 2022). Though some studies do indicate that young adults with ADHD are less likely to enroll in college, 72% of respondents completed an undergraduate degree, and more than one-third have an advanced degree.

To the researchers’ knowledge, this was the first study underscoring the importance of early recognition of ADHD and oppositional defiant disorder symptoms due to their long-term impact on employment and income in adulthood.

Many ADDitude readers said in a recent survey that they relate to the study’s results.

“I spent a lifetime failing at every job I ever tried,” said Lester, from Idaho. “I was either fired, lost interest, or was injured and had to quit.”

“I am currently unemployed and looking for gainful employment,” said Lindsey, from Indiana. “I’m a single mom with ADHD, and my kids have it, too. I had to work part-time and stay home with my kids for a few years. Now it’s harder than ever to get hired since I took time off.”

Natalie, from Texas, said, “I have had a hard time holding down a job due to my inconsistent attendance and performance. I have been driving for Uber and Lyft for the last few years. It worked out on the first year, but now I’m drowning because I have zero motivation.”

Accommodating ADHD and ODD in the Workplace

Early diagnosis and treatment of ADHD and ODD symptoms during adolescence may improve employment prospects and financial stability later in life.

It also helps when employers foster more inclusive and supportive workplace environments.

“There is plenty that companies can do right now — from shifting perspectives to changing workplace policies — to support neurodivergent employees and those with invisible differences,” said Jessica Hicksted, Ph.D., said during the 2023 ADDitude webinar “Invisible’ Disabilities at Work: How to Foster Neurodivergent Advocacy and Acceptance.”

“All employees benefit when a company embraces multiple methods and processes for getting things done,” she continued. “Whether it’s allowing employee-set schedules, remote work, or non-disruptive changes to the office environment, flexibility can make or break an employee’s experience. A company culture built on flexibility can allow neurodivergent employees to really shine and get work done without battling standards that don’t consider the non-neurotypical experience.”

Sources

¹ Seppä, S., Huikari, S., Korhonen, M., Nordström, T., Hurtig, T., & Halt, A.-H. (2024). Associations of Symptoms of ADHD and Oppositional Defiant Disorder (ODD) in Adolescence With Occupational Outcomes and Incomes in Adulthood. Journal of Attention Disorders, 28(10), 1392-1405. https://doi.org/10.1177/10870547241259329

² Miettunen, J., Haapea, M., Björnholm, L., Huhtaniska, S., Juola, T., Kinnunen, L., Nordström, T. (2019). Psychiatric Research in the Northern Finland Birth Cohort 1986 – A Systematic Review. International Journal of Circumpolar Health, 78(1). https://doi.org/10.1080/22423982.2019.1571382

³ Hurtig, T., Ebeling, H., Jokelainen, J., Koivumaa-Honkanen, H., Taanila, A. (2016). The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986. Journal of Attention Disorders, 20(1), 3–10. https://doi.org/10.1177/1087054713486699

⁴ Mustonen, A., Rodriguez, A., Scott, J. G., Vuori, M., Hurtig, T., Halt, A. H., Miettunen, J., Alakokkare, A. E., Niemelä, S. (2023). Attention Deficit Hyperactivity and Oppositional Defiant Disorder Symptoms in Adolescence and Risk of Substance Use Disorders: A General Population-Based Birth Cohort Study. Acta Psychiatrica Scandinavica, 148(3), 277–287. https://doi.org/10.1111/acps.13588

⁵ Nordström, T., Hurtig, T., Moilanen, I., Taanila, A., Ebeling, H. (2013). Disruptive Behaviour Disorder with and Without Attention Deficit Hyperactivity Disorder Is a Risk of Psychiatric Hospitalization. Acta Paediatrica, International Journal of Paediatrics, 102(11), 1100–1103. https://doi.org/10.1111/apa.12383

⁶ Kessler, R. C., Adler, L. A., Berglund, P., Green, J.G., McLaughlin, K. A., Fayyad, J., Russo, L. J., Sampson, N. A., Shahly, V., Zaslavsky, A. M. (2014). The Effects of Temporally Secondary Co-Morbid Mental Disorders on the Associations of DSM-IV ADHD with Adverse Outcomes in the U.S. National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Psychological Medicine, 44(8), 1779–1792. https://doi.org/10.1017/S0033291713002419

⁷ Reale, L., Bartoli, B., Cartabia, M., Zanetti, M., Costantino, M. A., Canevini, M. P., Termine, C., Bonati M. (2017). Comorbidity Prevalence and Treatment Outcome in Children and Adolescents with ADHD. European Child & Adolescent Psychiatry, 26(12), 1443–1457. https://doi.org/10.1007/s00787-017-1005-z

⁸ Kuriyan, A. B., Pelham, W. E., Jr, Molina, B. S., Waschbusch, D. A., Gnagy, E. M., Sibley, M. H., Babinski, D. E., Walther, C., Cheong, J., Yu, J., & Kent, K. M. (2013). Young Adult Educational and Vocational Outcomes of Children Diagnosed with ADHD. Journal of Abnormal Child Psychology, 41(1), 27–41. https://doi.org/10.1007/s10802-012-9658-z

The mental health of U.S. high school students is trending upward after a decade of unprecedented  depression, violence, and suicidality among adolescents. Still, the youth mental health crisis is far from over, as more teens are experiencing school-based violence and school absenteeism, according to a new report by the Centers for Disease Control and Prevention (CDC) comparing 10-year trends and data from the 2021-2023 Youth Risk Behavior Survey (YRBS).¹

Among the 20,000 public and private high school students surveyed, 40% said they experienced persistent sadness or hopelessness in 2023, down from 42% in 2021. Suicidality rates also fell slightly: One-fifth of students seriously considered suicide, compared to 22% two years ago.

Survey results broken down by students’ sexual and gender identity revealed that depressive symptoms remained stable or declined in most subgroups:

• 65% of LGBTQ+ students experienced sadness or hopelessness, down from 69%.
• 53% of female students experienced sadness or hopelessness, down from 57%.
• 41% of LGBTQ+ students seriously considered suicide, down from 45%.
• 28% of male students experienced sadness or hopelessness, unchanged from 2021.
• 27% of teen girls seriously considered suicide, down from 30%.
• 14% of male students seriously considered suicide, unchanged from 2021.

The Mental Health Status of Girls

Though the changes appear small, these incremental decreases represent potentially significant changes in teen mental health, especially for girls. Just last year, the CDC reported that nearly 60% of teen girls “were suffering through an unprecedented wave of sadness and trauma,” which was double the rate reported a decade ago and twice the rate in boys.²

Girls with diagnosed and undiagnosed ADHD are at a much higher risk for depression, suicidal thoughts and behaviors, and sexual violence than their neurotypical peers. According to the Berkeley Girls ADHD Longitudinal Study (BGALS), girls with combined type ADHD are three to four times more likely to attempt suicide than their neurotypical peers, and they are 2.5 times more likely to engage in non-suicidal self-injuring behavior.³

“Girls and women with untreated ADHD are at double the risk for engaging in self-harm and significantly more likely to attempt suicide,” said Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD.

A 2022 ADDitude survey of 1,187 caregivers shared similar findings: Eighteen percent of girls with ADHD had engaged in self-harm within the past two or three years compared to 9% of boys.

“The emotional toll of ADHD on teen girls is profound — especially when it isn’t diagnosed early,” said Lotta Borg Skoglund, M.D., Ph.D., during the 2024 ADDitude webinar, “The Emotional Lives of Girls with ADHD.” “And, for teens who menstruate, we can’t ignore fluctuating hormones, which invariably affect emotions, behaviors, and functioning. Is it any wonder that so many teen girls and young women say that regulating emotions and energy levels are their biggest ADHD-related problems?”

“Being a teen girl sucks. Being a teen sucks. ADHD intensifies everything,” said an ADDitude reader from Kansas.

“Schools should do a better job acknowledging the needs of teen girls,” said an ADDitude reader from Florida. “There needs to be better support to accommodate their needs that filters into clubs, after-school sports, etc.”

The improved state of adolescent mental health, especially for girls, is encouraging, but it is no cause for celebration. “As seen in 2021, female students are faring more poorly than male students across almost all measures of substance use, experiences of violence, mental health, and suicidal thoughts and behaviors,” the CDC report stated.

Disparities persist among students who identify as (LGBTQ+). The report found that LGBTQ+ students still experience more violence, signs of poor mental health, and suicidal thoughts and behaviors than their male, cisgender, and heterosexual peers.

Rise in School Violence and Bullying

“These data show that we’ve made some progress in tackling these issues in recent years, which proves that they are not insurmountable,” said Kathleen Ethier, Ph.D., director of the CDC’s Division of Adolescent and School Health. “However, there’s still much work ahead.”

Returning to school was a welcome relief for caregivers and students after the COVID-19 pandemic. However, in-person classes have created more opportunities for physical encounters — and consequently more school violence and bullying, the CDC says. From 2021 to 2023, bullying in school grew from 15% to 19%. In 2023, 16% of students experienced electronic bullying via text, Instagram, SnapChat, or other social media channels.

“School bullying remains a serious problem in U.S. schools, particularly for students with ADHD, autism, learning differences, and other comorbidities,” said Rosanna Breaux, Ph.D., during the 2023 ADDitude webinar, “Teen Bullying Solutions: Help for Neurodivergent Adolescents.”

In a 2022 ADDitude survey, 61% of more than 1,000 caregivers said their neurodivergent child was bullied at school. Kids were also bullied through social media (32%), on the school bus (30%), and via text messages (27%).

“My girl is anxious and worries about bullying, girls pranking her, and kids saying she is ‘fat,’” shared an ADDitude reader from South Carolina.

Upward trends in injuries with a weapon on school property and sexual violence among high school students are cause for concern. LGBTQ+ students reported significantly higher rates of sexual violence than their cisgender and heterosexual peers. Of the 9% of high school students who had ever been physically forced to have sexual intercourse, 17% identified as LGBTQ+ compared to 13% of female and 4% of male students. In addition, 11% of high school students said they were forced to perform sexual activities (including kissing, touching, etc.); of those, one-fifth identified as LGBTQ+.

Increases in School Refusal Behaviors

Alongside bullying and violence, rates of school avoidance have risen sharply as well. According to the CDC,

• School absenteeism due to students feeling unsafe at school or traveling to and from school rose from 9% to 13%.
• Female students who missed school because of safety concerns increased from 10% to 16%.
• Male students who missed school because of safety concerns increased from 7% to 10%.

“It’s so important that children get treatment for school refusal behaviors,” said Alana Cooperman, LCSW, senior social worker for the Anxiety Disorders Center at the Child Mind Institute during the recent ADDitude webinar, “School Avoidance & Refusal: Root Causes and Strategies for Parents and Educators.”

School refusal can begin with negative self-talk and quickly spiral to self-harm or suicidality. The long-term effects of school avoidance can lead to declining grades, peer alienation, and increased tension at home. “These struggles don’t go away,” Cooperman said. “They follow children as they become adults. We see increases in anxiety and depression and potential substance abuse as adults.”

“Our girls are not okay,” said an ADDitude reader from California. “My 11-year-old daughter with ADHD was the victim of sexual harassment at her school. As a result, she developed PTSD. She had extreme emotional dysregulation, experienced suicidal ideation, and refused to go to school out of fear. She has not returned to her school since.”

Cooperman recommends treating school refusal behaviors with cognitive behavioral therapy (CBT) and that caregivers work collaboratively with their child’s school and therapist to develop a comprehensive treatment plan.

Mental Health Resources

The CDC recommends the following programs to help schools and communities improve adolescent health, well-being, and safety.

• What Works in Schools
• Promoting Mental Health and Well-Being in Schools: An Action Guide for School and District Leaders
• Violence Prevention in Practice: | VetoViolence (cdc.gov)
• Youth Violence Prevention Resource for Action (cdc.gov)

Get Help

Suicide &Crisis Lifeline: Call or Text 988
988lifeline.org

National Sexual Assault Helpline: 1-800-656-HOPE

National Substance Abuse Helpline: 1-800-662-HELP

Stop Bullying

Contact the 988 Suicide & Crisis Lifeline if you are experiencing mental health-related distress or are worried about a loved one who may need crisis support.

If you or someone you know may be considering suicide or be in crisis, call or text 988 to reach the 988 Suicide & Crisis Lifeline

Sources

¹Centers for Disease Control and Prevention. Youth Risk Behavior Survey Data Summary & Trends Report: 2013–2023. U.S . Department of Health and Human Services; 2024 https://www.cdc.gov/yrbs/dstr/index.html

²Centers for Disease Control and Prevention (2023). U.S. Teen Girls Experiencing Increased Sadness and Violence. Youth Risk Behavior Survey cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf

³Hinshaw, S. P., Nguyen, P. T., O’Grady, S. M., & Rosenthal, E. A. (2022). Annual Research Review: Attention-Deficit/Hyperactivity Disorder in Girls and Women: Underrepresentation, Longitudinal Processes, and Key Directions. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 63(4), 484–496. https://doi.org/10.1111/jcpp.13480

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

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

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

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

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

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

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

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

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

Putting a Spotlight on Chronic Fatigue

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

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

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

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

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

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

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

Sources

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

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

Still, clinicians have the power to improve care for Black patients by taking the time to understand and mitigate barriers. Education and action are the foundation.

ADHD in Context: Unseen Factors in the Room

No two patients, even from the same cultural background, are alike in their medical needs. That said, Black patients are disproportionately impacted by the following factors and contributing health issues, which often go unnoticed or ignored but greatly impact outcomes.

Trauma and Poverty

Black individuals are more likely than white individuals to experience childhood adversity, and children who have these experiences are more likely to struggle in school and have emotional and behavioral challenges.¹ Black children are more likely to live in poverty and in disadvantaged neighborhoods, where poor access to quality foods and close proximity to facilities that produce hazardous waste increase health risks.^{2 3} Poor sleep quality is also linked to poverty.⁴ A patient who has experienced or is experiencing one or many of these factors can absolutely have issues with focus, attention, behavior, and learning — issues that mimic, aggravate, and/or overlap with ADHD.

ADHD Stigma

Negative attitudes toward mental health conditions and their treatment are prevalent in Black communities.⁵ Some individuals believe, for example, that ADHD isn’t a real diagnosis — that it’s been made up by white people to get Black children in trouble. This is a belief I’ve seen in my own practice.

[Read: Evaluating and Treating ADHD in African American Children — Guidance for Clinicians]

I was performing an ADHD evaluation on a young Black child whose teachers and school counselor — all white — suspected that he was showing symptoms. His rating scales indeed indicated that he had ADHD. The patient’s mother told me, a Black clinician, “You think like those white folk.” These negative attitudes can erect barriers around somebody who needs help — even if the news is coming from a clinician of the same racial or ethnic background as the patient. Some communities, in addition, may look to faith instead of the medical system to address and overcome mental health concerns.

Medical Mistrust and Misinformation

Black communities may fear the medical system — and with good reason. Their fears are the lasting legacy of past abuses by the medical system (the Tuskegee Study is a harrowing example) and ongoing medical racism that leaves Black patients with worse health outcomes than patients from other groups.⁶ One of the most common and pervasive myths I have to dispel for my patients is that ADHD medication causes children to become addicts. I’ve also heard families express fears that medication is a mind-control tactic.

Fear of Labels

Many Black individuals and families regard the ADHD label and other mental health diagnoses as the start of the end. Parents fear that their newly diagnosed child will be held back and targeted academically — beliefs that must be viewed from the context of the school-to-prison pipeline, which impacts Black students with disabilities more than other students.^{7 8}

Clinician Bias

Clinician bias can skew evaluation and treatment outcomes. Black youth, for example, are more likely to be diagnosed with disruptive behavior disorders like oppositional defiant disorder (ODD) and conduct disorder (CD) and are less likely to be diagnosed with ADHD.⁹ In my experience, I’ve seen these diagnoses given when ADHD doesn’t respond to medication as expected and when emotional dysregulation, including anger, is present. In other words, many clinicians think, “If we can’t get it right, then it must be ODD or CD.” Sadly, many patients spend years with inadequately treated ADHD when success is simply a matter of increasing, adjusting, or changing the medication for better symptom control.

[Read: Why We Need Clinicians of Color to Normalize ADHD in BIPOC Communities]

Clinician bias also affects how much a doctor invests in treating a patient, an issue that impacts Black patients the most, as doctors are more likely to describe Black patients with negative descriptors (e.g., “difficult,” “not compliant,” “agitated”).¹⁰ When this is the case, patients are cut off from options that can better treat symptoms and improve functioning and wellbeing.

Communication Styles

Some patients and families may communicate issues using a certain vernacular, colloquialisms, verbiage, and/or a dialect that clinicians may misunderstand or misinterpret. Without any clarifying follow-up, there could be a missed diagnosis or misdiagnosis.

Racial Disparities in Health Care: How Clinicians Can Improve ADHD Care

1. Identify your blind spots. We all have them, and it’s our responsibility as physicians to go out of our way to check them regularly in order to better address our patients’ needs. Implicit bias training can help you identify your blind spots. Take the free Implicit Association Test (IAT) to learn about your hidden attitudes and beliefs. As you learn about and acknowledge your blind spots, tell yourself before you start your workday, “I know I have biases, but I am going to go above and beyond for my patients to make sure I do my job correctly.”

2. Don’t be afraid to ask questions. Questions communicate interest, not ignorance. When you ask a patient about themselves, and how their identity and intersects with their health and wellbeing, it shows that you are paying attention to who they are and it builds trust.

3. It’s your duty to get information out of your patient. Recognize that patients may express health concerns in ways you’re not accustomed to hearing. A comprehensive clinical interview is vital for understanding and clarifying your patient’s concerns, including issues that may mimic or co-occur with ADHD. Rating scales alone won’t cut it. Also remember that patients often have to jump through several hoops to make medical appointments; no one shows up to an appointment (a costly one at that if they don’t have insurance or full coverage) because they feel like it. Think twice before you deem patients “noncompliant” or judge their motivations for being there. There are real concerns to be addressed, and it’s your job to uncover those needs.

4. Ensure all medical decision makers are in the room. In some families, a child’s grandparents — not their parents — may be the ones who ultimately decide on treatment. Take time to understand a patient’s family dynamics.

5. Help patients and families understand the benefits of an ADHD diagnosis. Parents should understand that ADHD is treatable, and that a diagnosis will allow their child to get the services to which they are entitled. Families should run to, not away from, special education services and their tailored resources. Explain to concerned parents that all educational services requiring funding — from gifted and talented programs to resources for students with disabilities — go through special education.

6. Obtain consent and ensure transparency. If you believe a patient will benefit from additional medical and wellbeing services, inform them and only put in an order after obtaining their approval.

7. Understand a patient’s circumstances and expectations. Do not assume that your approach, model, or ideas are the best fit. Really listen to what your patient identifies as their top issues, what they expect out of treatment, and what circumstances will allow them to pursue. Then devise a comprehensive treatment plan that covers those needs. Behavior parent training, for example, may necessitate an alternative approach if caregiver schedules and stressors interfere with the consistent application of positive reinforcement and discipline. No matter the plan, ensure that you, your patient, and other decisionmakers are on the same page.

8. Empower patients to advocate for their health. Most ADHD cases are treated by primary care physicians, but there are a host of providers — from nurse practitioners to psychiatrists — who can help. While insurance plans and financial circumstances may limit where patients choose to go, they should still be aware of these options. Comfort and compatibility are key when choosing professionals, so remind patients that there is nothing wrong with seeking second opinions. Often, the best way to find doctors — especially culturally competent providers — is by asking friends, relatives, faith and community leaders, and other trusted individuals for recommendations. BlackPsychiatryDirectory.com is a helpful resource.

9. Commit to ongoing education. As a psychiatrist, I consider myself a social scientist, and I invite all clinicians to take this approach. Be interested in people and cultures outside of your own. Books, news, films, television shows, and podcasts are all great ways to gain exposure to different cultures and identities.

Racial Disparities in Health Care: Next Steps

• Read: Why ADHD Is Different for People of Color
• Read: ADHD Clinicians Must Consider Racial Bias in Evaluation and Treatment of Black Children
• Read: We Need to Talk About ADHD Stigma in BIPOC Communities

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “Health Equity in ADHD: Addressing Racial Disparities in Diagnosis & Treatment” [Video Replay & Podcast #495] with Napoleon B. Higgins, Jr., MD, which was broadcast on March 7, 2024.

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Sources

¹ Bethell, C. D., Davis, MB, Gombojav, N, Stumbo, S, Powers, K. (2017). A national and across state profile on adverse childhood experiences among children and possibilities to heal and thrive. Retrieved from http://www.cahmi.org/projects/adverse-childhood-experiences-aces/.

² Shrider, E., Creamer, J. (2023). Poverty in the united states: 2022. U.S. Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2023/demo/p60-280.pdf

³ Fleischman, L, Franklin, M. (2017). Fumes across the fence-line: the health impacts of air pollution from oil & gas facilities on african american communities. NAACP and CATF. Retrieved from http://www.catf.us/wp-content/uploads/2017/11/CATF_Pub_FumesAcrossTheFenceLine.pdf

⁴ Jehan, S., Myers, A. K., Zizi, F., Pandi-Perumal, S. R., Jean-Louis, G., Singh, N., Ray, J., & McFarlane, S. I. (2018). Sleep health disparity: the putative role of race, ethnicity and socioeconomic status. Sleep medicine and disorders : international journal, 2(5), 127–133.

⁵ Buser, J. K. (2009). Treatment-seeking disparity between African Americans and Whites: Attitudes toward treatment, coping resources, and racism. Journal of Multicultural Counseling and Development, 37(2), 94–104. https://doi.org/10.1002/j.2161-1912.2009.tb00094.x

⁶ Macias-Konstantopoulos, W. L., Collins, K. A., Diaz, R., Duber, H. C., Edwards, C. D., Hsu, A. P., Ranney, M. L., Riviello, R. J., Wettstein, Z. S., & Sachs, C. J. (2023). Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. The western journal of emergency medicine, 24(5), 906–918. https://doi.org/10.5811/westjem.58408

⁷ U.S. Commission on Civil Rights. (2019). Beyond Suspensions: Examining School Discipline Policies and
Connections to the School-to-Prison Pipeline for Students of Color with Disabilities. Retrieved from https://www.usccr.gov/files/pubs/2019/07-23-Beyond-Suspensions.pdf

⁸ Center for Civil Rights Remedies of the Civil Rights Project at UCLA. https://civilrightsproject.ucla.edu/resources/projects/center-for-civil-rights-remedies

⁹ Fadus, M. C., Ginsburg, K. R., Sobowale, K., Halliday-Boykins, C. A., Bryant, B. E., Gray, K. M., & Squeglia, L. M. (2020). Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 44(1), 95–102. https://doi.org/10.1007/s40596-019-01127-6

¹⁰ Sun, M., Oliwa, T., Peek, M. E., & Tung, E. L. (2022). Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record. Health affairs (Project Hope), 41(2), 203–211. https://doi.org/10.1377/hlthaff.2021.01423

Information about depression found online is commonly misleading. Many popular health websites mislabel depression as a cause of symptoms rather than a description of those symptoms, according to a study published in Psychopathology.¹

Thirty organizations, including top institutions such as the American Psychiatric Association (APA) and the World Health Organization (WHO), were included in the study. Descriptions of depression from each website were classified into one of three groups: causally explanatory, descriptive, or unspecified.

More than half (53%) of websites presented depression as explicitly causing symptoms or used language that was both descriptive and causal. The remainder (46%) used language that was not clearly defined. Examples of each category include:

• Causally explanatory: A website states that “depression causes feelings of low mood, loss of pleasure, fatigue…”
• Descriptive: A website states that “depression describes a pattern of psychiatric symptoms including low mood, loss of pleasure…”
• Unspecified: A website states that “people with depression experience a low mood, loss of pleasure…”

Psychiatric diagnoses are purely descriptive; yet, none of the organizations directly referred to depression in this way. “The American Psychiatric Association, in the DSM-5, makes explicitly clear that the diagnostic criteria of mental disorders are descriptive in nature because the underlying pathologies are not known,” wrote authors Jani Kajanojaa and Jussi Valtonenb.

Rather, the authors noted that many leading health authorities used circular reasoning — a logical fallacy — when referencing depression. Circular reasoning occurs when a condition (or claim) and its cause (or evidence) are made synonymous. Circular reasoning is also commonly associated with ADHD ² — a disorder that is highly comorbid with depression. People with ADHD are three times more likely to experience depression compared to those without ADHD.

“While it would be entirely correct to say that the human experiences that the diagnostic criteria describe can feel like an illness, it is different from claiming that an identified external biomedical pathological entity is really causing the symptoms.”

What Is Depression?

Depression is one of the most prevalent mental disorders impacting 6.7% of U.S. adults. There is no single proven cause; its onset is nuanced and its presentation can vary. To say otherwise is scientifically inaccurate.

Per the results, however, descriptions of depression are not clear and can easily misguide readers and patients. This can, in turn, impede public trust in medical authorities during a time when online information about mental health is already poor, according to the authors. ³⁴

Social media further compounds this issue. A 2022 study published by The Canadian Journal of Psychiatry and reported on by ADDitude found that at least half of trending videos about ADHD on TikTok — a platform that attracts more than 1 billion active monthly users — are misleading. Although none of the videos were uploaded by major health organizations, they exemplify the need for reliable information on the Internet.

Understanding mental illness and its potential causes has been shown to help patients and readers regulate negative emotions, according to a recent study in Psychological Science cited by the authors. ⁵ Education complements treatment plans, which typically incorporate psychotherapy and medication ― although this combination can vary, says Karen Swartz, M.D.

“For some individuals, it’s psychotherapy alone,” she said in an ADDitude webinar on depression in teens. “For others, it’s primarily medication. That’s very individualized. But almost every study that’s looked at this has found that the combination is far superior to either one alone.”

“Part of it is that you need to learn about yourself and how to manage your symptoms, recognize them, and understand what it means to have a serious medical problem… In addition to these treatments, it’s important to include education and support so people understand what they have and how they’re going to manage it.”

By contrast, misleading causal claims can impede a patient’s ability to regulate their emotions. The authors note that viewing depression as having a known pathological disease process can impair treatment outcomes by discouraging patients and “effectively obscuring the links between mental distress, personal history, meaning, and cultural context.”

One approach to avoid circular reasoning is to frame depression within the context of stressful life experiences. Traumatic events have been associated with an increased risk of depression; thus, depression may be described as an “adaptive response,” “functional signal,” or “meaningful reaction” to adversity.

Similarly, ADHD has been associated with adverse life events, or “ACEs,” said Cheryl Chase, Ph.D., in the following clip from her ADDitude webinar about brain development under stress.

Still, it’s essential for professionals to be clear about what a descriptive diagnosis is. Accurate depictions include: ⁶

• “Depression is not a word that describes just one state of mind, but refers to a whole array of different feelings and thoughts…”
• “The experience we call depression is a form of distress…”

Doing so “provides more room, not less, to explore the various potential ways in which individuals can seek to understand the meaning of their lived experiences,” the authors wrote.

Limitations & Future Research

The analysis included 30 organizations: 13 governmental institutions, 9 non-governmental organizations, 3 professional psychiatric associations, 3 universities, and 2 intergovernmental bodies. Google was used to identify the top websites most likely to appear when users search “depression.”

Future research should include a systematic review of leading health websites. The process of searching for and analyzing popular health organizations in the present study was not exhaustive, thus limiting the scope of the results. Additional studies should further explore the impact of misleading information about mental health diagnoses, including the use of circular reasoning, on readers’ beliefs and treatment outcomes.

Sources

¹ Kajanojaa, J., & Valtonen, J. (2024). A descriptive diagnosis or a causal explanation? Accuracy of depictions of depression on authoritative health organization websites. Psychopathology. DOI: 10.1159/000538458

² Meerman S. T., Freedman, J. E., & Batstra, L. (2022). ADHD and reification: Four ways a psychiatric construct is portrayed as a disease. Frontiers in Psychiatry, 13. DOI: 10.3389/fpsyt.2022.1055328

³ Reavley, N.J., & Jorm, A.F. (2011). The quality of mental disorder information websites: a review. Patient Educ Couns, 85(2):e16–25. https://doi.org/10.1016/j.pec.2010.10.015

⁴ Demasi, M, & Gøtzsche, P.C. (2020). Presentation of benefits and harms of antidepressants on websites: a cross-sectional study. Int J Risk Saf Med, 31(2):53–65. https://doi.org/10.3233/JRS-191023

⁵ Millgram, Y., Nock, M. K., Bailey, D. D., & Goldenberg, A. (2023). Knowledge about the source of emotion predicts emotion-regulation attempts, strategies, and perceived emotion-regulation success. Psychological Science, 34(11), 1244-1255. https://doi.org/10.1177/09567976231199440

⁶  Bowden, G,, Holttum, S., & Shankar, R. (2020). Understanding depression: why adults experience depression and what can help. British Psychological Society. https://cms.bps.org.uk/sites/default/files/2022-07/Understanding%20depression.pdf

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

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

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

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

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

ASL-MRI’s Potential to Diagnosis ADHD

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

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

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

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

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

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

Sources

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

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

Heavy social media use and poor sleep quality can alter brain activity related to executive function and reward processing in adolescents, suggest findings from the American Academy of Sleep Medicine (AASM) presented last month at the SLEEP 2024 annual meeting.

The findings demonstrate a strong correlation between greater social media use, shorter sleep duration, and lower activity in the inferior and middle frontal gyrus regions in the prefrontal cortex of adolescents ages 10 to 14. The inferior frontal gyrus brain region influences inhibitory control; weakness in this region may impact how teens assess and respond to social media’s rewarding stimuli. The middle frontal gyrus region is tied to executive function and decision-making, impacting how teens balance the immediate dopamine hits of social media with other priorities, like sleep. AASM researchers analyzed data from the Adolescent Brain Cognitive Development Study of 6,516 adolescents for the study.

Prior research established a link between poor sleep hygiene and social media engagement. A 2022 survey from the AASM found that 93% of Gen Z members (people born between the late 1990s and early 2010s) have lost sleep by staying up “past their bedtime” to view or participate in social media.

Poor sleep quality due to excessive screen time is especially concerning for adolescents with ADHD since they spend more time on digital media and have more severe symptoms of problematic internet use compared to youth without ADHD.¹

“Among teens, high-frequency use of multiple forms of modern digital media (texting, visiting social media platforms, streaming videos, etc.) is associated with increased odds of ADHD symptom occurrence,” said Jeremy Edge, LPC, IGDC, during the ADDitude webinar “Addictive Technology and Its Impact on Teen Brains.”²

Poor Sleep Hygiene May Lead to Cannabis Use in Teens with ADHD

Some teens and young adults with ADHD use cannabis as a sleep aid, despite research showing that neurodivergent teens face an outsized risk for developing cannabis use disorder.³

“Cannabis is an unsurprising motivator given the extraordinarily high prevalence of sleep problems and disturbances associated with ADHD, from sleep apnea and insomnia to delayed sleep phase disorder and more,” Mariely Hernandez, Ph.D., explained during the ADDitude webinar “How Cannabis Use Affects ADHD Symptoms and Sleep in Adolescents.” ⁴

“In the short term, cannabis can help with sleep,” Hernandez continued. “But frequent cannabis use builds up tolerance; more and more of it is required to exert the same effect on sleep. Ultimately, chronic cannabis use only worsens sleep and feeds a vicious cycle. ⁵ Poor sleep increases cravings for cannabis and dampens the cognitive resources that allow an individual to resist cravings, make better choices, and curb impulsivity.”⁶

Sleep Hygiene Tips for ADHD Teens

Sleep interventions may help teens with ADHD improve their sleep quality and maintain a healthy relationship with social media. The AASM recommends that adolescents do the following:

• Get 8 to 10 hours of sleep per night.
• Disconnect from devices at night. Turn off all electronics at least 30 minutes before bedtime.
• Follow a relaxing nighttime routine. Take a warm bath or shower, read, or journal to help wind down.
• Leave phones in another room. Remove the temptation to get on the phone by keeping it in a separate room at night. If phones are used as a morning alarm, consider using an alarm clock instead.
• Turn off push notifications. If phones must be in bedrooms at night, turn off push notifications and sound to avoid phone usage.
• Set time limits on social media. Many phones and apps allow users to activate limits that notify them when they have reached their designated time amount on a site.
• Have a sleep schedule. Go to bed and get up at the same time. Don’t let scrolling stop you from getting precious hours of sleep.

Sources

¹ Werling, A. M., Kuzhippallil, S., Emery, S., Walitza, S., & Drechsler, R. (2022). Problematic Use of Digital Media in Children and Adolescents with a Diagnosis of Attention-Deficit/Hyperactivity Disorder Compared to Controls. A Meta-Analysis. Journal of Behavioral Addictions, 11(2), 305–325. https://doi.org/10.1556/2006.2022.00007

² Ra, C. K., Cho, J., Stone, M. D., De La Cerda, J., Goldenson, N. I., Moroney, E., Tung, I., Lee, S. S., & Leventhal, A. M. (2018). Association of Digital Media Use With Subsequent Symptoms of Attention-Deficit/Hyperactivity Disorder Among Adolescents. JAMA, 320(3), 255–263. https://doi.org/10.1001/jama.2018.8931

³ Zaman, T., Malowney, M., Knight, J., & Boyd, J. W. (2015). Co-Occurrence of Substance-Related and Other Mental Health Disorders Among Adolescent Cannabis Users. Journal of Addiction Medicine, 9(4), 317–321. https://doi.org/10.1097/ADM.0000000000000138

⁴ Hernandez, M., & Levin, F. R. (2022). Attention-Deficit Hyperactivity Disorder and Therapeutic Cannabis Use Motives.The Psychiatric Clinics of North America, 45(3), 503–514. https://doi.org/10.1016/j.psc.2022.05.010

⁵ Kaul, M., Zee, P. C., & Sahni, A. S. (2021). Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders. Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics, 18(1), 217–227. https://doi.org/10.1007/s13311-021-01013-w

⁶ Graupensperger, S., Fairlie, A. M., Ramirez, J. J., Calhoun, B. H., Patrick, M. E., & Lee, C. M. (2022). Daily-Level Associations Between Sleep Duration and Next-Day Alcohol and Cannabis Craving and Use in Young Sdults. Addictive Behaviors, 132, 107367. https://doi.org/10.1016/j.addbeh.2022.107367

What’s sleep got to do with cannabis use? A whole lot.

Many teens and young adults with ADHD turn to cannabis to help them sleep, an unsurprising motivator given the extraordinarily high prevalence of sleep problems and disturbances associated with ADHD, from sleep apnea and insomnia to delayed sleep phase disorder and more.¹

In the short term, cannabis can help with sleep. But frequent cannabis use builds up tolerance; more and more of it is required to exert the same effect on sleep. Ultimately, chronic cannabis use only worsens sleep and feeds a vicious cycle.² Poor sleep increases cravings for cannabis³ and dampens the cognitive resources that allow an individual to resist cravings, make better choices, and curb impulsivity. Insomnia, a common symptom of cannabis withdrawal, can drive further cannabis use.

Another potential outcome of chronic cannabis use? Dependence. Youth with ADHD — a group that may be far more likely to use cannabis daily to try to get some shut-eye because of condition-related sleep issues — are at greater risk for developing cannabis use disorder compared to neurotypical peers.⁴

[Take This Self-Test: Symptoms of Substance Use Disorder]

So what can be done? Improving sleep may be key to curbing cannabis use and even increasing adherence to substance use treatment.

A Primer on Sleep Interventions

First, assess the following dimensions of sleep quality in adolescent patients with ADHD. Developed by Dr. Daniel Buysse, the RuSATED acronym can be used to recall elements of multidimensional sleep health:

• Regularity — does the patient go to bed and get up around the same time daily?
• Satisfaction — does the patient feel well-rested after sleep?
• Alertness — how alert or sleepy is the patient during the day?
• Timing — does the patient feel sleepy/fall asleep around the same time regularly?
• Efficiency — how much time in bed is spent sleeping?
• Duration — How many hours of sleep does the patient get, including naps?

Next, consider the following sleep interventions for improving one or more dimensions of sleep quality:

• Sleep hygiene education
• Cognitive behavioral therapy for insomnia
• Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)
• Chronotherapy (light therapy)
• Brief Behavioral Treatment of Insomnia (BBTI)

[Read: Sleep Problems in Teens with ADHD — Causes and Solutions]

A benefit of behavioral sleep interventions is that they can be started immediately, even as the patient is still using cannabis. It may not take long to see incremental results. In addition to using these interventions, properly treating ADHD and other comorbid conditions that impact sleep and functioning is crucial. Patients may be less motivated to use cannabis if underlying causes of sleep problems are effectively treated.

Anxiety and pain may be other motivators of cannabis use, so be sure to inquire about other reasons your patient may be using. Pharmacologic or behavioral interventions to treat these concerns can be part of your patient’s treatment plan alongside reducing cannabis use.

Cannabis and Sleep for ADHD Adolescents: Next Steps

• Free Download: Sleep Disorders Linked to ADHD
• Read: How to Treat a Teen Self-Medicating ADHD and Anxiety with Marijuana
• Read: How to Fall Asleep with a Rowdy, Racing ADHD Brain

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “How Cannabis Use Affects ADHD Symptoms and Sleep in Adolescents” [Video Replay & Podcast #504] with Mariely Hernandez, Ph.D., which was broadcast on May 7, 2024.

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Sources

¹ Hernandez, M., & Levin, F. R. (2022). Attention-Deficit Hyperactivity Disorder and Therapeutic Cannabis Use Motives. The Psychiatric clinics of North America, 45(3), 503–514. https://doi.org/10.1016/j.psc.2022.05.010

² Kaul, M., Zee, P. C., & Sahni, A. S. (2021). Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics, 18(1), 217–227. https://doi.org/10.1007/s13311-021-01013-w

³ Graupensperger, S., Fairlie, A. M., Ramirez, J. J., Calhoun, B. H., Patrick, M. E., & Lee, C. M. (2022). Daily-level associations between sleep duration and next-day alcohol and cannabis craving and use in young adults. Addictive behaviors, 132, 107367. https://doi.org/10.1016/j.addbeh.2022.107367

⁴ Zaman, T., Malowney, M., Knight, J., & Boyd, J. W. (2015). Co-Occurrence of Substance-Related and Other Mental Health Disorders Among Adolescent Cannabis Users. Journal of addiction medicine, 9(4), 317–321. https://doi.org/10.1097/ADM.0000000000000138