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

Art is Hayley Wall’s love language. Since Wall was a young child, she has found her footing as a communicator through drawing. Wall struggled academically as a child due to dyslexia and undiagnosed ADHD and autism, but she says, “What I did have was this gift where I could create images and I could tell stories.”

When Wall graduated from university and considered where to take her art, she was drawn to the topic of disability. “I was exploring the things I felt were important, the things that needed to be spoken about,” Wall explains. “My mom is disabled, so that’s been around me for a long, long time and it’s felt like people with disabilities are always the last to be thought of.”

Wall was asked to illustrate an article on chronic illness for the cover of Sick magazine, and then another on the same topic for It’s Nice That. These illustrations caught the attention of The New York Times, which commissioned Wall to illustrate a package celebrating the anniversary of The Americans with Disabilities Act. Her work became known for her signature bodies — large, gender-fluid forms, typically without faces, that exude strength, joy, and confidence.

As Wall’s art career gained momentum, so too did her personal journey to understand her own neurodivergence. Though Wall struggled with mental health challenges all her life, it wasn’t until she was 34 that she received a diagnosis of ADHD and autism.

Below, Wall shares her creative process, the challenges and joys of being a neurodivergent artist, and her commitment to a future that celebrates different minds and bodies.

[Read: “Happily Neurodivergent — at Last”]

Q: How did your diagnoses come about?

I’ve always wondered, ‘What’s wrong with me?’ and always struggled with my mental health. It was a feeling of being too much — too emotional, too sensitive, I always carried this feeling of, I just don’t fit in.

When I was 30, I sat down with my partner at the time, and was like, ‘I found this article about adults that have been diagnosed with ADHD and I’ve just done multiple quizzes. Can you do the quiz as well, please?’ They did, and they scored really low. I was like, ‘So you don’t do that? And that?’ It made me think, ‘OK, I think something’s going on.’ I approached my general practitioner, and from there, it took four years to get a diagnosis.

When I was 36, a year ago, I got diagnosed with autism and a mental health condition. I’m coming to terms with all these diagnoses and trying to understand how to navigate them. To me, what’s more important is not the label but just working out what I need.

Credit: Hayley Wall, illustrator

[Self-Test: Autism Test for Adults – Signs of ASD]

Q: When did your love of art begin?

I was a kid who bounced off the walls, I had so much energy. I wouldn’t shut up, and I would cry and scream. To calm me down, my parents would give me pens and paper and I would draw. It was the one time I was calm and focused.

Q: How does your ADHD inform your work?

After graduating, it took me 8 to 10 years to establish myself. I’ve done so many random jobs. I’ve worked as a nanny, in factories, in cafes. But running parallel to that was my hyperfocus, which kept me on track to pursue art. My hyperfocus is the reason I’ve been able to turn art into a career.

My work is all about bodies, usually gender ambiguous bodies. They are these big bodies that take up space — maybe because I’ve always felt really small and inferior. The bodies in my work are powerful. I can live through them.

The whole ‘taking up space’ idea is a big f&*k you to society for being like, ‘You have to be like this, or like that.’ It’s, ‘No, we can be whomever we want to be.’

Q: Can you tell us about your creative process?

A commission will come through and it’s like jumping on a roller coaster. There’s a voice that goes, ‘Here we go.’

I center myself and breathe to remove any negative voices and let the process take me.

As I read the commission, the visuals start coming, and my brain is joining dot-to-dots. I have a background in dance, and the dancing lives in my work now. Sometimes I’ll get myself or my friends into different positions and I’ll draw from that. I create loose, playful hand-rendered drawings and textures, and then I bring it onto my computer to work with.

Once I’ve got my concept down, I enter the most playful part of the process. I can enjoy coming to the end of the roller coaster nice and slowly.

Q: What’s the hardest part of your job?

The first bit of the process, mind-mapping concepts, is hard because I’ve got so many ideas, and I need to hone in. It’s the organization of thoughts that’s hard.

What crushes mind-mapping is impostor syndrome, a feeling I’ve carried of being inferior. I wish I was able to remove that saboteur voice that creeps in to say, ‘You’re not good enough,’ so I could just let my brain run free.

Q: What ADHD supports have you found helpful?

Freelance work is definitely hard because you don’t have HR, you don’t have colleagues to turn to. You are your absolute everything, and it’s really tough.
I was doing it for a long time all by myself, and I reached burnout. My mental health crashed.

In the UK, we are very lucky in terms of the benefits we get from the government. The ‘Access to Work’ program offers a sort of grant or reimbursement scheme to cover the cost of a support worker. It has been very helpful to me, and I’ve used that to have somebody support me through the admin tasks.
I never want to go back to a point where I’m trying to manage it all alone.

Q: Any advice for other artists with ADHD?

If you can tune into your voice and communicate your story, that’s when you’re going to create something nobody’s ever seen before.

Q: Where are you now on your journey of understanding your neurodivergence?

With the community I’ve found, I have a feeling of being able to unmask, to be my true self, to be able to be too much, weird, overly emotional, and sensitive.

Recently, I did a commission for a London museum and library called The Wellcome Collection. They asked me to respond to an article written by a person who was diagnosed with autism as an adult, and because this piece was so personal to my experience, I really wanted to place myself in the work. It was a three-part series: before, during and after diagnosis.

For the final image, I Photoshopped my face in quite a warped way onto the figure. I’ve hid behind my work for years, so to put my own face on this figure felt quite important. It was like, ‘I’m unmasking now. I’m showing myself. I’m allowing myself to actually come through. This is me.’

ADHD, Art, and Mental Health: Next Steps

• Read: Stifled Creativity and Its Damaging Impact on the ADHD Brain
• Read: Why ADHD Masking Is a Form of Self-Sabotage
• Read: “I’m Not Hiding My ADHD Anymore”

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

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

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.

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

Sources

¹ 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

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

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

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

In this webinar, you will learn:

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

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

Meet the Expert Speaker

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

OCD in Children with ADHD: More Resources

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

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Teens with social anxiety disorder experience persistent and excessive fear in social settings that goes beyond shyness or nervousness. They worry so much about being judged, embarrassed, or humiliated in front of others that they avoid activities they would otherwise enjoy. Social anxiety often manifests as physical symptoms like sweating, trembling, or a racing heart, as well as emotional signs like irritability, self-doubt, and withdrawal from social interactions.

Social anxiety disorder is associated with other mental health conditions, including ADHD. “Many teens and young adults with ADHD are susceptible to social anxiety due to executive functioning challenges that impair emotional control, working memory, and self-awareness (metacognition),” writes Sharon Saline, Psy.D. “They may avoid specific triggering situations such as in-person classes or feel intensely nervous and uncomfortable in any social environment.”

Recognizing the signs of social anxiety disorder in your child is crucial for early intervention and support. Answer the questions in this self-test to help you assess whether your teen may be showing symptoms of social anxiety disorder. Share the results with your child’s doctor.

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Can’t see the self-test questions above? Click here to open this test in a new window.

The questions in this social anxiety test for teens are informed, in part, by criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This social anxiety test for teens is designed to screen for the possibility of SAD symptoms, and it is intended for personal use only. This social anxiety test for teens is not intended as a diagnostic tool.

Social Anxiety Test: Next Steps

• Get This Free Download: Social Anxiety Facts and Falsehoods
• Read: Where Does ‘Introvert’ End and Social Anxiety Begin?
• Read: 5 Ways to Reframe Anxiety for Your Worried Teen
• Find: Specialists or Clinics Near You

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

¹ National Institute of Mental Health. Social Anxiety Disorder. https://www.nimh.nih.gov/health/statistics/social-anxiety-disorder#part_2642

The mall was chaos. It was December, so everything was decked out in bright lights and brighter colors. The same five cheesy songs played on full blast over the loudspeakers. The halls were packed with loud holiday shoppers who kept bumping into us (and us into them). My sweater, perfect for chilly weather, weighed down on me indoors while my winter coat over my arm made me even more warm and sweaty.

And then, in the middle of the food court that reeked of greasy food and fake pine fragrance, my 3-month-old twin brothers started screaming. Everyone nearby shot us dirty looks, my head hurt from the noise and the smell and the heat and —

I snapped.

“Will you SHUT THEM UP?!”

My dad and stepmom looked at me like I was the jerk, and not the victim.

“Is this about your mouth?” Dad asked. “I told you to ask for more meds.”

ADHD and Overstimulation: My Sensory Meltdowns

That sums up every experience I’ve had with overstimulation or sensory overload: I’m too tired or upset to regulate my emotions, I’m assaulted on all sides with stimuli, I can’t stop anything, and people around me act like I’m crazy when I can’t take it anymore.

[Get This Free Download: Am I a Highly Sensitive Person?]

From an outside perspective, it probably does look like I’m insane. I appear fine until I’m not, over something small, no less. Nobody likes crowded stores or sharing a busy office, but millions of people deal with the chaos without freaking out. Even if there’s too much going on, a bit of deep breathing and mindful realignment should calm me down, right?

Too bad that doesn’t help. The problem with ADHD is that I not only have trouble paying attention, but I also have trouble shutting things out. I am constantly aware and reminded of every odd little thing around me. Like that one coworker who hits “reply all” just to send a smiley emoji, my mind sends unnecessary alerts to let me know that my left shoe is just a little too loose, that my coworker is loudly eating an apple, that there’s a flickering light way across the room, and other status updates I could really do without.

It’s a feeling of being trapped. I can’t turn the world off, can’t stop thinking, and can’t stop feeling worse thinking about how I can’t stop. The more trapped I feel in my mind and body, the harder it is to communicate why I’m upset or how to fix it.

What a fun Catch-22.

This is partially why I really don’t want help solving the problem in the moment. If I’m overwhelmed, my responses are entirely reactionary. I don’t feel comforted by back rubs or someone asking if I’m OK, it only adds fuel to the fire.

[Read: Why You Feel Too Much (and How to Cope)]

What to Do When ADHD Overstimulation Strikes

I’ve learned that it’s better for others to approach me when I’m able to articulate my needs. Asking ahead, well before an overstimulation meltdown, is especially touching.

My best coping strategies were planned significantly far in advance for this exact reason. Demanding that everyone else stops isn’t exactly doable. But I’ve learned how to quietly and successfully remove myself from the situation or prevent overstimulation.

I have an extensive toolkit: noise-cancelling headphones, a mini fan, sunglasses, soft sweaters and jackets, quiet rooms, and a handful of other odds and ends. I must look strange to my coworkers, making dozens of adjustments to my area throughout the day. I’m relieved that my workplace allows me to self-accommodate like this.

This is why awareness matters. The next time you see someone snap over something small, or look increasingly uncomfortable with everything, assume that they’re overstimulated (and that ADHD may be in the picture). Perhaps that will stop you from loudly asking why someone is wearing sunglasses indoors or running for the nearest closet or empty room. Give us grace, and you’ll be able to work with the neurodivergent people in your life and make the world a more accommodating place for us. The steps are small, but the results are magnificent.

ADHD and Overstimulation: Next Steps

• Get This Free Download: Sensory Issues — Triggers, Symptoms & Types of SPD
• Take This Self-Test: Sensory Processing Disorder Signs
• Read: “Please Don’t Hug Me! Seriously. And More Weird Things That Trigger My Hypersensitive ADHD”>

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Gus Walz’s expression of pure love and joy should have been seen for what it was: an unfiltered and positive emotional response to a big moment. Sadly, the moment served as yet another opportunity to divide Americans. While most people saw Gus’s reaction as an historic moment for neurodiversity, a vocal minority sneered, criticized, and hurled insults at an innocent young person.

What Does Neurodivergence Mean?

Neurodivergence is a word used to describe naturally occurring differences in how the human brain develops that result in variations in “wiring” and how we process information. These differences may affect around 20% of the population and occur in people with ADHD, dyslexia, autism, and nonverbal learning disorder (NVLD). These and other conditions can lead to challenges with functioning in key life areas. In young people like Gus, these differences may result in variations in how they process nonverbal information, recognize patterns, develop social skills and awareness, process sensory information, and engage in executive function tasks.

[Take This Test: Nonverbal Learning Disorder (NLD) in Children]

It’s not uncommon for the neurodivergent community, particularly children and young adults, to battle stigma, insults, and misconceptions about their conditions. Gus’s reaction to his father’s speech was another example of how kids who learn and think differently are vulnerable to cruelty — even in their most benign or joy-filled moments. Only this moment was televised. Frankly, I’m glad it was.

Neurodivergence is a relatively new term, but it’s becoming more commonplace in American society. This is likely due to increases in diagnoses and perhaps increases in social media use to amplify individuals’ experiences. For example, a 2022 report from the CDC revealed that about 1 million more children received an ADHD diagnosis in 2022 than did in 2016. Even so, neurodivergence isn’t discussed nearly enough, making it easier for people to make false assumptions that impact children and their families every day.

Parents of neurodivergent children often face challenges in accessing accurate and reputable resources to help them in their day-to-day lives, resulting in feelings of isolation and loneliness. In the absence of awareness and widespread education, navigating learning and thinking differences can be a nightmare for the child — and a massive source of stress for their parents. Understood.org’s Neurodiversity and Stigma survey from 2022 found that nearly 70% of parents felt stigmas surrounding their child’s differences affected their mental health negatively. Another 2024 survey revealed that 96% of parents with neurodivergent children reported feeling stressed during the back-to-school season.

How to Help Neurodivergent Children Navigate Stigmas

As a licensed psychologist with more than 20 years of experience working with neurodivergent people, I’ve participated in dozens of programs designed to help educate the public and reduce stigmas for people with differences. Here are a few takeaways I share with parents:

• Educate yourself on current evidence-based information about your child’s learning and thinking differences.
• Talk to your child about their differences and how it affects them.
• Provide an informational bridge between home and school to help educate and inform teachers about thinking and learning differences and to help your child access accommodations.
• Advocate for inclusion and use of Universal Design for Learning strategies to support neurodivergent and neurotypical students in shared learning environments.
• Provide direct strategies for identifying challenges and asking for help. Role-playing or practicing with a script can help kids and adults ask for what they need to thrive.

[Free Download: Signs of Dyslexia at Every Age]

When I watched Gus Walz’s reactions to his father’s nomination, I was brought to tears by this pure and amazing display. Politics aside, this moment provides us with a remarkable opportunity to amplify and support neurodivergent individuals by having an open dialogue in our country about what it means to learn and think differently. Let’s not let this moment slip by.

Gus Walz and Nurturing sNeurodivergent Children: Next Steps

• Free Download: Is It an LD? Your Free Guide
• Read: Why Nonverbal Learning Disorder Is So Often Mistaken for ADHD
• Read: 19 Parenting Tips for Raising Neurodivergent Children
• Watch: “Parenting Styles That Work for Neurodivergent Children”

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

To study this emerging issue, our team at the Simons Foundation analyzed 25 datasets collected across 18 studies that involved 600 children with autism. We created and ran an algorithm to identify differences between kids with autism and their neurotypical counterparts. We then correlated the microbiome against so-called cytokines, which are immune markers, to see how the gut microbiome is linked to individuals’ immunity and inflammation. ¹

This is important because many chronic disorders, such as inflammatory bowel disease and diabetes, demonstrate components of immune dysfunction. Identifying the immune-microbe link in autism not only creates new opportunities for managing autism symptoms, but it also introduces ideas regarding how the microbiome could be manipulated to regulate immune response.

Gut Microbiota May Signal Autism

When we looked at the microbes predicted to be associated with autism and compared them with microbiota likely associated with neurotypical controls, we observed a strong difference between the two groups. Further investigation suggested that we could distinguish accurately between individuals with autism and neurotypical controls just by using their measured gut microbiota. This means that future research might unlock autism diagnoses through gut microbiome analysis, potentially guiding symptom management and therapeutic developments.

[10 Foods (and Supplements and Vitamins!) to Boost Your ADHD Brain]

When we compared the gut-brain axis — the gut microbiota and human brain pathways, or the enzymes responsible for the breakdown of products in the brain — we observed a strong overlap between pathways detected in the gut and those detected in the brain. This suggests that diet affects gut diversity and brain function, from thinking to mood.

GI and Sleep Problems

Many children with autism have gastrointestinal (GI) and sleep problems. In one study, researchers found that the chances for behavioral problems substantially increase when children have GI and sleep problems. ²

Parents should track foods eaten, bowel movements, and sleep patterns to establish connections between these factors and their child’s symptoms. Preventing or treating GI symptoms may provide children with some relief and help them sleep through the night.

Research into the gut-brain axis, and what this correlation can tell us about certain conditions like autism and depression, is still new. In the near future, it is possible that knowledge of gut bacteria will help determine predictive biomarkers of disease, with implications for new therapeutics. What we know about the gut-brain axis will look very different 5 to 10 years from now.

Autism and Gastrointestinal Issues: Next Steps

• Download: Autism Evaluation Checklist
• Read: The ADHD Diet Plan — Healthy Foods and Supplements for Kids & Adults 
• Read: Autism vs. ADHD — A Parent’s Guide to Tricky Diagnoses

Jamie Morton, Ph.D., is an independent consultant who has previously worked for the National Institute of Child Health and Human Development.

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

Sources

¹ Morton, James T., Dong-Min Jin, Robert H. Mills, Yan Shao, Gibraan Rahman, Daniel McDonald, Qiyun Zhu, et al. (2023). Multi-Level Analysis of the Gut–Brain Axis Shows Autism Spectrum Disorder-Associated Molecular and Microbial Profiles. Nature Neuroscience 26 (7): 1208–17. 10.1177/1087054718816169

² Leader, G., Barrett, A., Ferrari, C., Casburn, M., Maher, L., Naughton, K., Arndt, S., Mannion, A. (2021). Quality of Life, Gastrointestinal Symptoms, Sleep Problems, Social Support, and Social Functioning in Adults with Autism Spectrum Disorder. Res Dev Disabil.;112:103915. 10.1016/j.ridd.2021.103915

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

It’s important to diagnose and treat eating disorders early to prevent prolonged malnourishment and to improve a child’s prognosis.

Eating Disorders and Their Symptoms

Anorexia nervosa

The defining feature of this eating disorder is not actually being underweight or thin; it’s a fear of weight gain or becoming fat, so much so that people eat less and less throughout the day. A warning sign you might notice is that the person is skipping meals, or eating less than what is typical for them.

Atypical anorexia nervosa

This is a diagnosis of anorexia nervosa but in higher weight bodies. These individuals are at risk for going undetected with anorexia nervosa because of their physical appearance.

[Read: Eating Disorders in Children and Teens]

Avoidant/restrictive food intake disorder (ARFID)

This diagnosis is given to people who are not meeting their nutritional needs, but not because they fear weight gain, as in anorexia nervosa. Rather, they don’t prioritize eating. They might say, “I’m hungry, but I just don’t care enough to get myself something to eat” or “I can’t motivate myself to get up and make myself a meal.”

Sensory issues, such as the texture or smell associated with certain foods, may repel adolescents with ARFID, who start eliminating those foods from their diet to the point where they can become malnourished. Other people with ARFID have a fear-based reaction to food. Maybe they’re afraid of choking if this happened in the past, or perhaps they fear bad bouts of stomach upset.

One possible warning sign is a sudden refusal to eat anything but “safe foods” that patients and families feel certain they could eat day in and day out. Some folks with ARFID are very specific about how the food is prepared, or even specific brands and shapes.

[Self-Test: ARFID in Children]

Binge-eating disorder

This affects people who have repeated binge-eating episodes and feel out of control. They cannot stop eating once they’ve started, and they often feel guilty, ashamed, or disgusted with themselves afterward.

Bulimia nervosa

Bulimia involves binge-eating episodes paired with self-induced vomiting, abuse of laxatives or diuretics, and/or exercise to get rid of or make up for the calories that they’ve eaten.

Other specified feeding and eating disorder (OSFED)

This is the most common diagnosis for people who present with some but not all symptoms from several types of eating disorders.

ARFID, Anorexia & Bulimia: Next Steps

• Download: The Eating Disorders Associated with ADHD
• Read: “Foods Can’t Touch on My Plate:” On Life with ARFID and Food Aversions
• Watch: “Eating Disorders Comorbid with ADHD: What You Need to Know About ARFID, Anorexia, and Others”

Christine Peat, PH.D., is the Director of the National Center of Excellence for Eating Disorders (NCEED) and an Associate Professor of Psychiatry at the University of North Carolina at Chapel Hill.

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Teens and young adults with ADHD fall into cannabis use for many reasons. Some do it to achieve quick relief from boredom, racing thoughts, and uncomfortable feelings. Some claim it helps them focus and sleep. Some use cannabis to feel “normal.”

Chronic users are especially resistant to and defensive over suggestions to discontinue or reduce cannabis use. Some may deny that their cannabis use is a problem, or that it’s dangerous at all. Others may claim that cannabis is the only thing that helps them — and why stop something that delivers relief?

The truth is this: Chronic cannabis use causes more harm than good in the long run, and there are better, more effective ways to get relief.

How to Help Teens Who Rely on Cannabis

1. Understand what draws your teen to cannabis. One of the best ways to engage anybody in a conversation about substance use is to ask about its appeal and perceived benefits. What does your teen like about cannabis? Why did they start? What do they get out of using it? Are there aspects of cannabis that they don’t like? Expect to have ongoing conversations about cannabis with your child.

2. Has your teen tried to quit? Unsuccessful efforts to cut down or limit cannabis is a possible sign of problematic use. But many don’t know where they stand, since they’ve never actually tried to quit.

[Read: What Should My Teen Know About Marijuana and ADHD?]

If your teen doesn’t see an issue with their cannabis use and is resistant to quitting, present a short challenge. Say, “If it’s not a problem, can you see how you feel if you don’t use it for three days? What if you delay the first use of the day?” The goal is to get your teen to see what they’re like on and off cannabis.

Abstaining for a few days or a week may result in improved memory and attention. At the same time, acute cannabis use affects judgment. Over time, it’s difficult for users to notice how they may have accommodated their life to fit cannabis use. Work with your teen to help them notice changes.

3. Make it inconvenient. Barriers of any kind can help, especially if your teen struggles to reduce cannabis use because of availability. Encourage your teen to let their supply completely run out. If willpower and accountability are issues, consider storing cannabis in a time-lock safe.

4. Help your teen get better sleep. Sleep disturbances may drive cannabis use, but cannabis use only worsens sleep problems over time. Help your teen build healthy sleep habits, like adhering to regular sleep-wake times, avoiding screens close to bedtime, and practicing relaxation exercises prior to sleep. Spending time in natural light can help regulate the sleep-wake cycle.

Heavy users may experience insomnia when reducing or quitting cannabis — a common withdrawal symptom that can last up to three weeks. Talk to your teen’s doctor about a temporary sleep aid if this happens. In addition, targeted sleep interventions from CBT for insomnia to chronotherapy are available. Work with a doctor to find the right fit for your teen.

5. Is your teen’s ADHD being treated? Chronic cannabis use may be your teen’s way of coping with ADHD, depression, anxiety, a sleep disorder, and/or other underlying conditions. Is your teen’s cannabis use linked to any of these conditions? If so, are the conditions being treated optimally? Identifying and effectively treating all underlying issues can reduce your teen’s motivation to use cannabis to self-medicate.

6. Discuss relevant benefits of sobriety. How will refraining from cannabis use help your teen be present for activities and experiences that matter to them? From playing a sport to driving a car, your teen will need access to their full physical and cognitive abilities to engage, which won’t be possible if they’re under the influence.

7. Band with other parents who are in the same boat. It will be more challenging for your teen to stop or reduce cannabis use if their friends are also using. If circumstances allow for it, collaborate with the parents of your teen’s friends to collectively curb their cannabis use.

8. Make your teen aware of the truth. Teens may think themselves immune to any negative outcomes from cannabis use, especially when it provides them with quick relief. But your teen needs to know some potentially sobering truths: Chronic cannabis use changes the brain, zaps motivation, and worsens executive functioning, which is already impaired in ADHD, and it triggers other outcomes.^{1 2 3} It alters the brain’s reward center so that cannabis becomes the only thing the brain may find rewarding, and barely at that.

Your teen may be using cannabis to distance themselves from their problems, but the unfortunate reality is that chronic use only attracts more problems and impairs your teen’s distress tolerance skills. Reducing cannabis use will allow your teen to feel discomfort – a necessary motivator for change – and perhaps recognize that they can withstand tough feelings or learn to tolerate them with the help of a doctor. Either way, there are better, healthier ways of coping.

How to Stop Smoking Weed: Next Steps for Parents of ADHD Teens

• Self-Test: Signs of Substance Use Disorder
• Read: Better Sleep May Reduce Cannabis Use in ADHD Adolescents
• Read: How to Treat a Teen Self-Medicating ADHD and Anxiety with Marijuana

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.

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

Sources

¹ Burggren, A. C., Siddarth, P., Mahmood, Z., London, E. D., Harrison, T. M., Merrill, D. A., Small, G. W., & Bookheimer, S. Y. (2018). Subregional hippocampal thickness abnormalities in older adults with a history of heavy cannabis use. Cannabis and Cannabinoid Research, 3(1), 242–251. https://doi.org/10.1089/can.2018.0035

²Broyd, S. J., van Hell, H. H., Beale, C., Yücel, M., & Solowij, N. (2016). Acute and chronic effects of cannabinoids on human cognition-a systematic review. Biological Psychiatry, 79(7), 557–567. https://doi.org/10.1016/j.biopsych.2015.12.002

³Peraza, N., Smit, T., Garey, L., Manning, K., Buckner, J. D., & Zvolensky, M. J. (2019). Distress tolerance and cessation-related cannabis processes: The role of cannabis use coping motives. Addictive Behaviors, 90, 164–170. https://doi.org/10.1016/j.addbeh.2018.10.047