Females are more likely than males to have complex presentations of ADHD, potentially leading to delayed diagnosis and treatment, according to new research published in the Journal of Attention Disorders. The study found that females with ADHD are more likely than males to have inattentive ADHD, are diagnosed at older ages, and have higher rates of anxiety and depression diagnoses both before and after their ADHD diagnoses. ¹

The retrospective observational study was conducted using data from four U.S. health databases. The researchers sought to explore the relationship between sex as well as ADHD subtype and diagnosis timing. They also hoped to assess whether receiving an ADHD diagnosis had an impact on pre-existing diagnoses of depression and anxiety in women and girls, who receive treatment for these comorbidities at higher numbers.

Age of ADHD Diagnosis Rates by Sex and Subtype

The study revealed:

• The average age of ADHD diagnosis by gender:
  • Females:16 to 29 years
  • Males: 11 to 23 years
• Across both sexes, the average age of diagnosis by ADHD type:
  • Inattentive Type: 17 years to 27 years
  • Hyperactive impulsive Type: 10 years to 20 years
• Females were substantially more likely than males to be diagnosed with inattentive ADHD

How Mood Disorders Fit Into the Diagnostic Picture

• Females were twice as likely as males to have depression or anxiety diagnoses and treatments in the year before their ADHD diagnosis.
• Females were more likely than males to receive new diagnoses or treatments for depression or anxiety in the year following an ADHD diagnosis.
• The number of females with pre-existing depression or anxiety diagnoses with symptoms that did not continue after their ADHD diagnosis was higher than the number of males. In these cases, ADHD may have been misdiagnosed as anxiety or depression.
• Patients with inattentive ADHD were more likely to receive a prior diagnosis of depression or anxiety:
  • Inattentive ADHD: 13% to 18% (depression) and 17% to 26% (anxiety)
  • Hyperactive impulsive ADHD: 5% to 12% (depression) and 9% to 20% (anxiety)

Repercussions of Delayed Diagnosis

The study’s finding that females are diagnosed five years later than males, on average, together with other key data points lead researchers to conclude that diagnoses in females tend to occur “only once ADHD symptoms become more severe,” and underscores the importance of addressing this gap in health equity.

The consequences of undiagnosed ADHD are dire, especially for women.

“Women who live undiagnosed until adulthood experience significant negative outcomes in the areas of self-esteem, social interaction, and psychosocial wellbeing beginning in childhood and continuing into adulthood,” concluded the authors of a systematic review of research published in March 2023. “Women in these studies engaged in less task-oriented coping and more emotion-oriented coping and often turned to recreational drugs, alcohol, nicotine, and sex to self-medicate for symptoms of undiagnosed ADHD.” ²

A female ADDitude reader explains the lived experience of late diagnosis this way: “I have lived with the misleading belief that I was a loser, lazy, incompetent. What are the long-term impacts of these self-defeating beliefs?”

The Complicating Presence of Mood Disorders

The connection between ADHD and mood disorders, including depression, is well-established. According to a recent study in BMJ Mental Health: ³

• People with ADHD are 9% more likely to have MDD
• An MDD diagnosis increases the risk for ADHD by 76%

These findings are echoed in the responses to a recent ADDitude survey of 6,810 adults, which found that 72% reported having anxiety and 62% having reported depression.

In addition to the over-representation of mood disorders among individuals with ADHD, previous research has documented that women in general are twice as likely as men to suffer from MDD and General Anxiety Disorder (GAD).

While rates of mood disorders are unequivocally higher among women with ADHD than either men with ADHD or women without the condition, the new study lends credence to what many women have reported anecdotally: They are also more likely than men to have ADHD initially misdiagnosed as depression or anxiety.

“Because of stigma and thoughts related to gender role presentations, when females do present with ADHD symptoms, it can be thought that it’s more likely due to anxiety or depression, because those are presentations that people are used to seeing in females early on,” explained Dave Anderson, Ph.D., in the ADDitude webinar “ADHD Then and Now: How Our Understanding Has Evolved.” “So, people say, ‘She’s distracted because she’s anxious or sad,’ not because she has ADHD. That’s something that we’re actively trying to fight, even in clinician bias.”

The new study, and research like it, helps shed light on the unique toll exacted on women by ADHD. More investigation is desperately needed, explains Dawn K. Brown, M.D., in the ADDitude article, We Demand Attention! A Call for Greater Research on Women with ADHD.

“Further research regarding these topics is indeed crucial,” Brown explains. “By conducting in-depth investigations into the gender-specific nuances of ADHD presentation and impact, healthcare professionals, policymakers, and advocates can promote greater awareness, understanding, and tailored support for women with ADHD.”

Read on to learn about the Top 10 research priorities detailed in ADDitude’s groundbreaking, cross-platform initiative : We Demand Attention! A Call to Action for Greater Research on Women with ADHD.

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

1. Sex Difference in ADHD
2. The Health Consequences of Delayed ADHD Diagnoses on Women
3. How Hormonal Changes Impact ADHD Symptoms in Women
4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
5. The Elevated Risk for PMDD and PPD Among Women with ADHD
6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

Sources

¹  Siddiqui, U., Conover, M. M., Voss, E. A., Kern, D. M., Litvak, M., & Antunes, J. (2024). Sex Differences in Diagnosis and Treatment Timing of Comorbid Depression/Anxiety and Disease Subtypes in Patients With ADHD: A Database Study. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547241251738

²  Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of Attention Disorders, 27(7), 645-657. https://doi.org/10.1177/10870547231161533

³  Meisinger, C. & Freuer, D., (2023) Understanding the Causal Relationships of Attention Deficit/Hyperactivity Disorder with Mental Disorders and Suicide Attempt: A Network Mendelian Randomisation Study. BMJ Mental Health. doi.org/10.1136/bmjment-2022-300642

New research proposes that ADHD may increase the risk of gaming disorder (GD) in college students, hindering academic success and sleep. ¹

The study, published in the journal PLOS ONE, reported that 35.7% of college students with GD display ADHD symptoms compared to 23.3% of students without gaming disorder.

Gaming disorder is a mental health condition marked by excessive and compulsive engagement in Internet games, which can significantly disrupt relationships, school, and work. The behavior must be present for at least 12 months (or shorter in severe cases) to receive a GD diagnosis.

After surveying 383 university students in Lebanon, the researchers determined that ADHD symptoms directly affect academic performance and indirectly increase the risk of GD. Among students classified as high academic performers with GPAs of 3.2 and above, only one met the criteria for symptoms of GD or ADHD.

“The absence of GD and ADHD symptoms among high academic performers suggests that academic engagement and success may be protective factors against these conditions,” the study’s authors wrote. “Alternatively, it may be that the symptoms of these disorders disrupt academic performance, which would be consistent with the negative correlation observed between disorder prevalence and academic excellence.”

Gaming behaviors may distract college students from academics as they prioritize playing video games over studying. The study reported that students with a gaming disorder spend more time gaming on weekdays and weekends than do those without the disorder. “The correlation between GD and gaming hours, particularly on non-school days, suggests that free time may exacerbate gaming behaviors, potentially leading to disorder,” the study’s authors wrote. “This finding has practical implications for the management of GD, as it highlights the importance of structured time and alternative leisure activities as part of the therapeutic approach.” ²

Gaming Disorder Affects College Students’ Sleep Habits

According to the researchers, GD also impacts students’ sleep quality and duration. On average, students with GD sleep 6.1 hours; 64.3% wake up in the middle of the night to game. In comparison, those without GD sleep between 6.8 to 7.2 hours, with negligible nocturnal awakenings for males and none for females.

“The high incidence of nocturnal awakenings in the disordered gaming group (DGG) to continue gaming is a concerning trend that warrants attention due to the critical role of sleep in cognitive function, emotional regulation, and overall health,” the study’s authors wrote. ³

Findings also indicate that ADHD is more predictive of GD in females than in males, though other factors beyond ADHD may contribute to the development of GD, especially in females. These results echo a study published in June 2023 in the Journal of Attention Disorders. That study found a staggering 82% of individuals with GD had ADHD; more than half of the participants with ADHD (57%) had GD. ⁴

Why Gaming Appeals to College Students with ADHD

Why are students with ADHD symptoms more susceptible to gaming and, consequently, gaming disorder?

“From escapism and socialization to competition, video games are highly engaging, reinforcing, and stimulating by design,” said Jeremy Edge, LPC, IGDC, during the 2023 ADDitude webinar, “Addictive Technology and Its Impact on Teen Brains.” “Prolonged, excessive exposure to immediate rewards and dopamine hits in gaming may diminish the number of dopamine receptors in the brain over time, which can lead to tolerance and further stimulation seeking. ⁵ Gamers who are motivated by both escapism and achievement and who consider gaming part of their identity, are most at risk for problematic or disordered gaming.”

While the PLOS ONE study suggests a strong link between ADHD symptoms and GD, the study’s design does not establish causality and relies on self-reported data, which may introduce bias. In addition, the prevalence of ADHD in the sample is also higher than typical epidemiological estimates.

“More longitudinal studies are needed to clarify the causal relationships between ADHD and GD and to track how these relationships evolve,” the study’s authors wrote.

Edge emphasized that anyone showing signs of gaming disorder should talk to a doctor or mental health professional. “While still a growing field, help for technology addiction is available and ranges from psychotherapy and inpatient treatment clinics to recovery programs, support groups, and even medication,” he said.

Sources

¹ Hawai, N., Samaha, M. (2024). Relationships of Gaming Disorder, ADHD, and Academic Performance in University Students: A Mediation Analysis. PLOS ONE. https://doi.org/10.1371/journal.pone.0300680

² Buono, F.D., et al. (2020). Gaming and Gaming Disorder: A Mediation Model Gender, Salience, Age of Gaming Onset, and Time Spent Gaming. Cyberpsychology, Behavior, and Social Networking, 23(9): p. 647–651. https://doi.org/10.1089/cyber.2019.0445

³ Bourchtein, E., Langberg, J.M., Cusick, C.N., Breaux, R.P., Smith, Z.R., Becker, S.P. (2019). Technology Use and Sleep in Adolescents With and Without Attention-Deficit/Hyperactivity Disorder. J Pediatr Psychol. https://doi.org/10.1093/jpepsy/jsy101

⁴ Hong, J. S., Bae, S., Starcervic, V., & Han, D. H. (2023). Correlation Between Attention Deficit Hyperactivity Disorder, Internet Gaming Disorder or Gaming Disorder. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547231176861

⁵ Sussman, C. J., Harper, J. M., Stahl, J. L., & Weigle, P. (2018). Internet and Video Game Addictions: Diagnosis, Epidemiology, and Neurobiology. Child and Adolescent Psychiatric Clinics of North America,27(2), 307–326. https://doi.org/10.1016/j.chc.2017.11.015

The ongoing shortages of generic ADHD medications and chemotherapy drugs are addressed in new draft legislative proposal released on May 3 by Senate Finance Committee Ranking Member Mike Crapo (R-Idaho) and Chair Ron Wyden (D-Oregon), who said the proposed legislation would “tear down regulatory barriers that are preventing families from accessing critical drugs like those needed to combat ADHD.”

The draft legislation was announced on the same day the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP), and Children’s Hospital Association (CHA) sent a letter to the U.S. Department of Health and Human Services and Drug Enforcement Administration expressing their continued concern about the ongoing stimulant medication shortages.

“Families that rely on generic stimulant medications have been disproportionately affected by the ongoing stimulant shortages,” the letter said. “This situation only exacerbates existing health disparities among economically disadvantaged families who are enrolled in Medicaid and CHIP.”

The proposed legislation establishes a Medicare Drug Shortage Prevention and Mitigation Program, wherein hospitals, healthcare providers, group purchasing organizations, drug manufacturers, and others could earn payment incentives for improving their purchasing and contracting practices across the supply chain for generic drugs, including generic versions of ADHD medications such as Adderall and Vyvanse. The proposed legislation would also limit inflationary rebates under the Medicaid Drug Rebate Program (MDRP) for certain generic drugs susceptible to shortages.

“It is unacceptable that America is consistently running out of affordable and essential generic medicines,” Wyden said in a press release. “Once again, monopolistic middlemen have put market power and profit over families’ healthcare.”

Associations Urge Government to Address ADHD Medication Shortage

In their letter on ADHD medication shortages, the AAP, AACAP, and CHA call on the federal government to “convene all relevant stakeholders for a forum to discuss the impact these shortages are having on patients, families, and their providers and identify actionable solutions that will alleviate these shortages.”

“Pediatric providers, including child and adolescent psychiatrists, pediatricians, and children’s hospitals, along with the patients and families they serve, face an insurmountable struggle with stimulant medication shortages,” the letter said. “Untreated ADHD can contribute to worsening mental and behavioral health disorders, including mood and substance-use disorders, unintended injuries resulting from ADHD-related impulsivity and long-term impacts on relationships-building, educational achievement, and professional success. Parents and families may also be negatively impacted by the disruption that untreated ADHD can cause in the home, school, and work environments.”

According to the American Society of Health-System Pharmacists (ASHP), 323 medicines are currently in short supply, the highest number of ongoing and active drug shortages since the organization began tracking data in 2021.

ASHP reported that “new DEA quota changes, along with allocation practices established after opioid legal settlements, are exacerbating shortages of controlled substances (12% of all active shortages).” The Drug Enforcement Agency (DEA) classifies stimulant ADHD medications, such as Adderall and Vyvanse, as “Schedule I,” which indicates drugs with a high potential for abuse.

FTC, HHS Seeks Public Input on ADHD Medication Shortage

The Federal Trade Commission (FTC) and U.S. Department of Health and Human Services (HHS) are seeking public input to understand how the practices of pharmaceutical middlemen contribute to drug shortages and impact patients, hospitals, healthcare providers (including small healthcare providers and rural hospitals), pharmacies, generic manufacturers, and other suppliers.

Sixty-three percent of the more than 6,200 public comments already submitted mention ADHD.

The deadline to submit public comments is May 30, 2024. Add your testimony at Regulations.gov.

The public can also demand an end to the ADHD medication shortage by writing letters to representatives, the DEA, and the FDA using templates provided by ADDitude.

The lives of girls and women with ADHD are jeopardized by exponentially higher rates of self-harm, suicidality, and intimate partner violence, as compared with their neurotypical counterparts or with neurodivergent boys and men.

“ADHD in girls portends continuing problems through early adulthood that are of substantial magnitude across multiple domains of symptomatology and functional impairment,” write the authors of the Berkeley Girls ADHD Longitudinal Study (BGALS) follow-up study.¹ “The sheer range of negative outcomes is noteworthy; the most striking include the high occurrences of suicide attempts and self-injury in the ADHD sample, confined to the childhood-diagnosed combined type.”

What We Know About Self-Harm

This is an arresting statistic, particularly considering how self-harm and suicidality have spiked in adolescent girls in general. The most recent CDC Youth Risk Behavior Survey (YRBS) report found that 1 in 10 girls has attempted suicide, and 1 in 3 of girls seriously considered suicide during the past year, which is an increase of nearly 60% from a decade ago.

Research suggests that neurodivergent girls face a significantly higher risk for self-harm than do neurodivergent boys, or neurotypical people of any gender. A 2020 study in European Child & Adolescent Psychiatry found that the rate of self-harm was four times greater in females than it was in males (8.7% vs 2.2%).²  A 2022 ADDitude survey found reports of self-harm among 18% of girls with ADHD versus 9% of boys with ADHD.

The correlation between teen girls with ADHD and self-harm is so strong that a 2021 study published in Child and Adolescent Mental Health proposed that all teen girls treated for self-harming behavior should be screened for ADHD:³ A full 83% of teen patients admitted to the hospital for self-harm were girls, the study found.

Indeed, early diagnosis and treatment of ADHD is critical to mitigating the risk of self-harm. “Girls and women with untreated ADHD are at double the risk for engaging in self-harm and significantly more likely to attempt suicide,” says Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD.

What We Know About Intimate Partner Violence

Low self-esteem, high rejection sensitive dysphoria (RSD), and social skill deficits put women and girls with ADHD at heightened risk for intimate partner violence (IPV). A study published in the Journal of Abnormal Child Psychology found that: ⁴

• Girls with ADHD were five times more likely to be victims of physical intimate partner violence than non-ADHD girls (30% vs. 6%)
• Greater ADHD symptom severity in childhood was associated with increased risk for physical victimization

“Findings indicate that in young women, childhood ADHD is a specific and important predictor of physically violent victimization in their intimate relationships,” write the authors of the study. “Given the devastating impact of intimate partner violence, additional research on how to empower females with ADHD in their social and romantic relationships is greatly needed.”

What We Know About Substance Use

The connection between SUD and ADHD has been well-established through research. We know that:

• People with ADHD are three times more likely to develop an SUD then those without⁵
• 25% of adults with SUD have ADHD⁶ 
• SUD is often more severe in individuals with ADHD⁷

Among the general population, we know that teen girls are more likely to use substances than are teen boys. According to the CDC’s YRBS:

• Alcohol: 27% of teen girls reported drinking in the last month vs 19% of boys
• Vaping: 21% of girls reported vaping in the last month vs 15% of boys
• Illicit drugs: 15% of girls reported ever using illicit drugs vs 12% of boys
• Misuse of prescription opioids: 15% of girls reported ever misusing opioids vs 10% of boys

That said, studies on the prevalence of SUD among girls and women with ADHD have resulted in mixed findings. An elevated risk of substance use was found in a large-scale study led by Joseph Biederman, M.D.,⁸  however no such association was found in the BGALS follow-up.

Most recently, researched at the University of Minnesota conducted a study investigating how ADHD symptoms may influence substance use in women and men, and it found a stronger association between alcohol use and ADHD for young adult women than for young adult men.⁹

“The current study confirms that ADHD-associated risk for adult substance problems is consistently greater in magnitude for women,” the authors of the study write. “The presence of adult ADHD increases risk for substance problems in women more than men.”

What We Don’t Know

No research exists on the relative efficacy of interventions that may reduce the risks for self-harm, suicidality, intimate partner violence, and substance use among girls and women with ADHD. Without fully understanding where these threats begin and how they escalate, we cannot devise and adjust solutions.

The BGALS follow-up study found elevated risks of self-harm and suicidality only among girls with combined-type ADHD, and not among those with inattentive symptoms alone, which leads researchers to speculate that impulsivity is associated with higher risk. Researchers also posit that psychosocial factors, such as the teen’s environment, contribute to the likelihood of self-harm. Longitudinal research is needed, however, to confirm this.

“What are the transition points — psychologically, family or school-related, community-wide — that predict impairment vs. resilience for girls with ADHD as they transition through adolescence to adulthood?” asks Hinshaw. “What are the strategies and supports that teen girls and women with ADHD find most helpful in self-advocacy and thriving?”

In the British Journal of Psychiatry,¹⁰ Hinshaw and doctoral student Sinclaire O’Grady call for longitudinal research on long-term correlated outcomes, such as the development of borderline personality disorder, as well as research into the intergenerational transmission of risk for negative outcomes in the children of women with ADHD.

Further research is needed to answer the following questions:

• What are the specific predictors and mediators of the high risk for self-harm in girls and women with ADHD?
• Does screening self-harming teens for ADHD reduce the occurrence of self-harm?
• What, exactly, makes early adulthood a time of heightened risk for substance use issues, specifically for women with ADHD?
• What are the impacts of ADHD treatment on intimate partner violence victimization?
• What psychosocial interventions, specific to girls and women with ADHD, may mitigate risk of intimate partner violence victimization?

Why It Matters

Researching suicidality, self-harm, intimate partner violence, and substance abuse among women with ADHD will, quite literally, save lives.

A study led by Russell Barkley, Ph.D., published in the Journal of Attention Disorders, found that life expectancy was 13 years lower for patients with combined-type ADHD diagnosed in childhood and with persistent symptoms, relative to control children.¹¹

However, because of the severely limited number of females in the study, the findings are largely not relevant. No major study has investigated the impact of ADHD on life expectancy specifically in women.

With dramatically higher rates of self-harm and suicidality, as well as intimate partner violence, this research is desperately needed to protect women from bodily harm, as well as devastating emotional consequences.

What ADDitude Readers Tell Us

Feelings of loneliness, RSD, emotional dysregulation, anxiety, and low self-worth exert a crushing emotional burden — and prompt some readers to harm themselves, to abuse substances, and to maintain toxic relationships.

“I made poor choices that led to abuse,” says Debs, an ADDitude reader in the United Kingdom. “I’ve taken substances to make the pain less, and I have self-harmed to try to take away the pain.”

“The inner turmoil just seems to get louder and louder and more difficult to turn down, which leads to unhealthy ways of coping like self-harm to help manage the stress,” shares Laura, an ADDitude reader in Texas.

“I abuse cannabis,” explains ADDitude reader Elizabeth, in the United Kingdom.

“Sometimes I feel worthless and want to self-harm because of RSD, assuming I’m not loved by my loved ones.”

“I get myself in relationships that aren’t good for me as I’m just happy that somebody finally loves me despite my flaws,” explains ADDitude reader Annika in Germany. “Self-harm comes into play when I feel like a failure because the relationship is rocky, and I get invalidated or criticized.”

“I constantly feel like I’m failing, which makes the thoughts about self-harm pop up often, although I haven’t given in to those for a while now,” says Lizzy in the Netherlands.

“I drink a lot right now,” says Nicole, an ADDitude reader in Washington. “I know it is unhealthy, but it is the only way for me to cope.”

“I have a history of self-harm, which was sometimes brought on my intense feelings of worthlessness and loneliness,” shares an anonymous ADDitude reader.

What ADHD Experts Say

The long-term ravages of underdiagnosed and undertreated ADHD in women are dire — a matter of life and death in some cases. To develop effective interventions, research is essential.

“There is a critical need for studies into how increasing degrees of isolation, shame, and despair lead to self-harm and earlier mortality, exploring the relationships to early chronic trauma, impulsivity, poor self-care,” says Ellen Littman, Ph.D. “Research must respond to outcomes signaling such a significant public health crisis.”

“Too little is known about later-adult outcomes of females with ADHD,” write Hinshaw and O’Grady. “Overall, we contend that the extraordinarily high risk for self-harm incurred by girls with ADHD as they mature requires a shift in clinical perspective.”

“Girls and women with untreated or undertreated ADHD — or those who have been misdiagnosed with other conditions — have been put at higher risk for an array of negative outcomes including higher rates of depression and anxiety, intimate partner victimization, and risky sexual behaviors resulting in teen and unplanned pregnancies,” says Schechter. “Research specifically devoted to girls and women with ADHD is not only an issue of equity but a life-or-death issue for some girls and women.”

Self Harm & Intimate Partner Violence: Related Resources

• 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

Related Reading

• Teen Girls Are Not Alright. ADHD Magnifies the Crisis.
• ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks
• Why Do Toxic Relationships Swallow People with ADHD?
• Girls and Women with ADHD: Unique Risks, Crippling Stigma
• Substance Use Disorders and ADHD: 5 Key Facts and Additional Resources
• “If the Story of My Unplanned Pregnancy Helps Just One Person, It Was Worth Sharing.”

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

1. Sex Difference in ADHD
2. The Health Consequences of Delayed ADHD Diagnoses on Women
3. How Hormonal Changes Impact ADHD Symptoms in Women
4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
5. The Elevated Risk for PMDD and PPD Among Women with ADHD
6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

Sources

¹ SP, Owens EB, Zalecki C, Huggins SP, Montenegro-Nevado AJ, Schrodek E, Swanson EN. Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. J Consult Clin Psychol. 2012 Dec;80(6):1041-1051. doi: 10.1037/a0029451. Epub 2012 Aug 13. PMID: 22889337; PMCID: PMC3543865.

² Ohlis, A., Bjureberg, J., Lichtenstein, P. et al. Comparison of suicide risk and other outcomes among boys and girls who self-harm. Eur Child Adolesc Psychiatry 29, 1741–1746 (2020). https://doi.org/10.1007/s00787-020-01490-y

³ Ward JH, Curran S. Self-harm as the first presentation of attention deficit hyperactivity disorder in adolescents. Child Adolesc Ment Health. 2021 Nov;26(4):303-309. doi: 10.1111/camh.12471. Epub 2021 May 3. PMID: 33939246.

⁴ Guendelman MD, Ahmad S, Meza JI, Owens EB, Hinshaw SP. Childhood Attention-Deficit/Hyperactivity Disorder Predicts Intimate Partner Victimization in Young Women. J Abnorm Child Psychol. 2016 Jan;44(1):155-66. doi: 10.1007/s10802-015-9984-z. PMID: 25663589; PMCID: PMC4531111.

⁵ Wilens T. E. (2004). Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues. The Psychiatric clinics of North America, 27(2), 283–301. https://doi.org/10.1016/S0193-953X(03)00113-8

⁶ Charach, A., Yeung, E., Climans, T., & Lillie, E. (2011). Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 9–21. https://doi.org/10.1016/j.jaac.2010.09.019

⁷ Wilens, T. E., & Morrison, N. R. (2011). The intersection of attention-deficit/hyperactivity disorder and substance abuse. Current opinion in psychiatry, 24(4), 280–285. https://doi.org/10.1097/YCO.0b013e328345c956

⁸ Biederman J, Monuteaux MC, Mick E, Spencer T, Wilens TE, Klein KL, Price JE, Faraone SV. Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study. Biol Psychiatry. 2006 Nov 15;60(10):1098-105. doi: 10.1016/j.biopsych.2006.02.031. Epub 2006 May 19. PMID: 16712802.

⁹ Elkins IJ, Saunders GRB, Malone SM, Wilson S, McGue M, Iacono WG. Differential implications of persistent, remitted, and late-onset ADHD symptoms for substance abuse in women and men: A twin study from ages 11 to 24. Drug Alcohol Depend. 2020 Jul 1;212:107947. doi: 10.1016/j.drugalcdep.2020.107947. Epub 2020 Feb 27. PMID: 32444170; PMCID: PMC7293951.

¹⁰ O’Grady SM, Hinshaw SP. Long-term outcomes of females with attention-deficit hyperactivity disorder: increased risk for self-harm. Br J Psychiatry. 2021 Jan;218(1):4-6. doi: 10.1192/bjp.2020.153. PMID: 33019955; PMCID: PMC7867565.

¹¹ Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of Attention Disorders, 23(9), 907-923. https://doi.org/10.1177/1087054718816164

Hormonal contraceptives (HC) may help stabilize the fluctuations in estrogen and progesterone that occur during the menstrual cycle and in perimenopause that are particularly impairing for neurodivergent women, however research has found a correlation between some types of oral HC use and higher rates of depression in women with ADHD.

The impact of sex hormones, including estrogen and progesterone, on ADHD symptoms in women has only recently become the subject of scientific inquiry. A recent study found that various ADHD symptoms wax and wane depending on the menstrual phase. Researchers found that estrogen has a protective effect for both cognition and emotional regulation, and that ADHD symptoms tend to worsen when estrogen drops. ¹

These findings are reflected in the lived experience of ADDitude readers. In a recent survey, a full 98% of respondents reported experiencing hormone-related changes in cognitive function and/or mood, including changes in focus, attention and memory as well as emotional regulation.

Oral HC, or birth control pills, typically contain synthetic estrogen and progesterone. In addition to preventing pregnancy, they are often used to treat heavy menstrual bleeding, painful cramps, irregular periods, polycystic ovarian syndrome, and acne. In addition, some clinicians prescribe oral HC to stabilize hormone levels in women and treat premenstrual syndrome (PMS) and/or premenstrual dysphoric disorder (PMDD), which impact two-thirds of women with ADHD, according to an ADDitude survey.

Until recently, the implications of oral HC use for women with ADHD were entirely uninvestigated, however a recent study published in Journal of the American Academy of Child and Adolescent Psychiatry (JAACP),² revealed that:

• Women with ADHD who used combined oral contraceptives (COC) or progestogen-only pills (POP) had more than five times the risk for depression compared to women without ADHD who did not use hormonal contraceptives.
• This elevated risk was not found among women with ADHD who used non-oral HCs, such as hormonal IUDs or progestogen implants. These women had the same risk of developing depression as did their non-ADHD counterparts.
• This elevated risk was also not found among women without ADHD who used oral HC.
• Women taking HC for medical reasons (heavy bleeding, irregular periods, PCOS) were twice as likely to develop depression as those who took it primarily to prevent pregnancy. Taking HC for medical reasons was more common in women with ADHD than it was in women without ADHD.

“Systemic hormonal contraception contains progestins that inhibit the ovulatory cycle and thereby ‘smoothens’ the hormonal profile, but it may also mimic the negative mood symptoms experienced from natural progesterone during the luteal phase of the menstrual cycle,” explains Lotta Burg Skoglund, M.D., Ph.D., a lead author on the study. “However, most women do not experience these negative mood effects and, somewhat counterintuitively, some progestins may even alleviate symptoms of PMDD.”

An ADDitude survey of nearly 5,000 women revealed that 93% of respondents aged 45 and older experienced elevated and aggravated ADHD symptoms in perimenopause and/or menopause. More than half of these women said their ADHD symptoms — including feelings of overwhelm, procrastination, and memory issues — had a “life-altering impact” in menopause. We know that for hormone replacement therapy (HRT) can effectively alleviate common symptoms of menopause, such as hot flashes, mood lability, and insomnia, and it may offer other benefits.

“Studies show that HRT, if initiated within 10 years of menopause, reduces all-cause mortality and risks of coronary disease, osteoporosis, and dementia,”³ explains Jeanette Wasserstein, Ph.D., in the ADDitude article, “Menopause, Hormones & ADHD: What We Know, What Research is Needed.” “Overall, recent research suggests that the risk in using any type of HRT is lower than previously reported in literature.”

Research has revealed heightened risk for some cancers associated with some forms of HRT, so Wasserstein highlights that a thorough consultation with a medical provider is critical before beginning HRT.

What We Don’t Know

No studies have probed the implications of HRT use for climacteric women with ADHD and we know very little about the potential benefits or risks of HC for women with ADHD.

“ADHD is a common illness, but few studies have looked at the association of hormonal stages and ADHD symptoms,” write the authors of a systematic review of sex hormones, reproductive stages, and ADHD published in Archives of Women’s Mental Health.⁴ “Notably, we did not find any studies investigating ADHD symptoms in other female physiological states such as pregnancy or menopause or looking at the response of patients with ADHD to hormonal treatments such as hormone replacement therapy.”

The small puzzle pieces of existing data are surrounded by questions. Why, for example, did women with ADHD on oral HC experience far higher rates of depression while those on hormone implants or IUDs did not? Until more research is conducted, researchers are left to theorize.

“It may be that, when taking oral birth control, women with ADHD might be extra susceptible to forget to take their birth control pills or may take them irregularly, causing hormonal fluctuations that may destabilize mood,” explained Skoglund in her ADDitude webinar, “The Emotional Lives of Girls with ADHD.” Also, a woman’s hormonal levels will fluctuate during assumed pill-free intervals.”

Some anecdotal reports suggest the use of oral HC, which minimize hormonal fluctuations, may improve ADHD symptoms in some women.

“I was surprised and amazed by the extent to which my focus and my executive functioning improved since I started hormonal birth control,” said Silvia, an ADDitude reader in Italy. “I totally reshaped my life: I decided to start coaching people again, joined a company and am thinking of going back to university again to obtain a second degree. I don’t experience mood swings anymore and I feel less exposure to RSD.”

These anecdotal reports offer promise. But without research, clinicians lack a solid foundation of data to make treatment recommendations.

“We need to find out why some women feel better with oral contraceptives and others feel depressed,” says J.J. Sandra Kooij, M.D., Ph.D. “It is about hormone sensitivity, and how hormones interact with neurotransmitters such as dopamine in women with ADHD, but exactly what drives this difference is still unclear.”

Given a total lack of research studies, there is virtually no reliable science regarding the risks and benefits of HRT for peri- and post-menopausal women. Among the many questions that remain unanswered are the following:

• Does HRT improve symptoms of ADHD in climacteric women?
• Does HRT pose unique risks, either physiological or psychological, to women with ADHD?
• Does HRT impact the efficacy of stimulant or non-stimulant medication for ADHD?
• Are there women with ADHD for whom oral HCs mitigate ADHD symptoms? If so, what is known about this patient profile that can help clinicians make treatment recommendations? What types of oral HCs are most effective and least disruptive for this group?
• What factors account for the increase in depression in some women with ADHD on HC? If oral contraceptives are taken daily as indicated, does the risk decrease?
• Does oral or non-oral HC impact the efficacy of stimulant or non-stimulant medication for ADHD?

Why It Matters

Hormonal contraceptives are among several first-line treatments for PMS and PMDD, which impact women with ADHD with heightened frequency and intensity.⁵ Symptoms of these mood disorders are frequently debilitating, and include suicidal ideation. A comprehensive understanding of possible treatment options for these women could significantly improve quality of life and reduce the risk of self-harm.

Reliable, well-tolerated contraception is also critical for girls and women with ADHD because they are six times more likely to give birth as teenagers compared with women without this diagnosis, according to a recent study led by Skoglund. ⁶

These dramatically heightened rates of unplanned pregnancy were also found in the groundbreaking Berkeley Girls with ADHD Longitudinal Study, led by Stephen P. Hinshaw, Ph.D., professor of psychology at the University of California, Berkeley. “By the time they reached their mid to late 20s, about 43% of the BGALS participants in the ADHD group had one or more unplanned pregnancies,” Hinshaw told ADDitude.

Research has found that experiencing unwelcome psychological side effects is the most commonly reported reason for the discontinuation of hormonal contraception, a decision which could have far-reaching implications.⁷

“Unwanted pregnancy undermines women’s schooling, health and social status and is directly linked to the negative psychosocial impact of ADHD on health, autonomy, academic performance, and quality of life,” Skoglund says. “Averting underage parenthood through effective contraception methods will likely benefit women’s education, empowerment, health and quality of life, their families, offspring, and society from a health economic perspective and have broad and public health benefits, extending far beyond the targeted group.”

What ADDitude Readers Tell Us

Hormonal contraceptives earn mixed reviews from readers, some of whom find them helpful in balancing mood and reducing ADHD symptoms; others report that HC use increases in anxiety, irritability and depression, among other intolerable side effects.

“Hormonal birth control affected me so negatively that I went off of it. It was highly disruptive to my mood and overall wellbeing,” says Jen, a reader in Utah. “I don’t mess with the hormones — even though they love to mess with me.”

“I had an IUD for 7 years. Within a few days, I could not believe the change in my mood. I felt more emotionally even and steady than I had felt in years,” shares ADDitude reader Anne.

“My PMDD was exacerbated by any hormone preparation, including the pill. The low-dose Mirena was an absolute nightmare for me,” says Nicole, an ADDitude reader. “I’m so hesitant to try anything to manage impending menopause, which has me ever more on edge, and I’m not sure yet how to advise my teen on these matters.”

“I started birth control due to PMDD. The mini-pill has been fantastic for my ADHD. I have fewer hormonal fluctuations,” says Karen, an ADDitude reader in Idaho. “I can finally rely on myself to be functional every day (as long as I get enough sleep and take my ADHD meds).”

“I detested the combined pill. It wrecked my mental health, and gave me dangerous migraines),” offers another ADDitude reader. “I was still disorganized, unmotivated with the added bonus of all the physical and mental downsides of the combined pill.”

ADDitude readers often report improved brain fog, memory issues, and mood swings while on HRT, though some say their doctors resist prescribing hormone replacement.

“As I approach menopause, my ADHD symptoms have worsened exponentially — severe memory and concentration problems, plus brain fog, mood swings, acne, sleep problems, fatigue. I’ve been barely able to work for almost a year now,” says Jennifer, an ADDitude reader in California. “I begged my doctor for HRT, but they won’t prescribe it since I’m not technically in menopause yet. They put me back on the pill to see if that would help, but it didn’t help at all with any of my current symptoms and gave me terrible cramps and made me feel crappy the whole time.”

“I am really glad to be on estrogen HRT because it is preventing the double-whammy of menopause and ADHD, at least for now,” says Jaime, an ADDitude reader in North Carolina.

“I have recently started on hormones for women in (peri)menopause, and the horrendous brain fog I’ve been dealing with for the past 18 months has lifted a great deal,” says Isabella, an ADDitude reader in the Netherlands.

“I am postmenopausal, and take estrogen replacement daily,” says Amy, an ADDitude reader in Michigan. “I think my ADHD is worse on days that I miss my dose of estrogen.”

What ADHD Experts Say

Given the known relationship between fluctuating hormones and ADHD symptoms, researchers must explore how we can safely employ HC and HRT to ameliorate both mood and cognitive symptoms.

“Given the increased risk of depression in women with ADHD, which may be further increased by oral HC use, future clinical trials on contraception need to include women with mental health problems, including ADHD, to guide prescribers on the best available choices for these women,” write the authors of the JAACP study.

“In medicine, women are still understudied because they are considered less reliable research subjects than men, due to hormonal changes during the lifespan,” explains Kooij in “Hormonal Sensitivity of Mood Symptoms in Women with ADHD Across the Lifespan.”⁸ “Women with ADHD have been even more understudied, while exactly their hormonal mood changes and increased severity of ADHD urgently need our research attention.”

“Females with ADHD are usually excluded from studies on contraceptive effectiveness and tolerability,” Skoglund explains. “As contraception is a burden for women to carry due to male methods being less effective, lack of knowledge on how different contraceptives affect women with ADHD may create an undue burden.”

Next Steps

• Contribute to research on the impact of perimenopause and menopause on ADHD symptoms by completing ADDitude’s ADHD in Menopause survey.
• Download this free resource: ‘Interventions for Treating ADHD During Perimenopause and Menopause’
• Read these new recommended reads on menopause:
  • The Menopause Brain: New Science Empowers Women to Navigate the Pivotal Transition with Knowledge and Confidence, by Lisa Mosconi, Ph.D.
  • The New Menopause: Navigating Your Path Through Hormonal Change with Purpose, Power, and Facts, by Mary Claire Haver, M.D.

HRT, Birth Control & ADHD: Related Reading

• Q: “Can Hormonal Birth Control Cause Depression?”
• Women, Hormones, and ADHD
• Depression Risk Higher for Women with ADHD on Birth Control: Study
• Menopause, Hormones & ADHD: What We Know, What Research is Needed
• Hormonal Changes & ADHD: A Lifelong Tug-of-War
• PMDD Has Affected My Whole Life
• PMS and ADHD: How the Menstrual Cycle Intensifies Symptoms

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

1. Sex Difference in ADHD
2. The Health Consequences of Delayed ADHD Diagnoses on Women
3. How Hormonal Changes Impact ADHD Symptoms in Women
4. How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
5. The Elevated Risk for PMDD and PPD Among Women with ADHD
6. The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
7. How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
8. The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
9. How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
10. Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

Sources

¹ Eng, A.G., Nirjar, U., Elkins, A.R., Sizemore, Y.J., Monticello, K.N., Petersen, M.K., Miller, S.A., Barone, J., Eisenlohr-Moul, T.A., & Martel, M.M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and Behavior, 158(105466). ISSN 0018-506X. https://doi.org/10.1016/j.yhbeh.2023.105466

² Lundin, C., Wikman, A., Wikman, P., Kallner, H. K., Sundström-Poromaa, I., & Skoglund, C. (2023). Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 62(6), 665–674. https://doi.org/10.1016/j.jaac.2022.07.847)

³ Langer, R. D., Hodis, H. N., Lobo, R. A., & Allison, M. A. (2021). Hormone replacement therapy – where are we now?. Climacteric : The Journal of the International Menopause Society, 24(1), 3–10. https://doi.org/10.1080/13697137.2020.1851183

⁴ Camara, Bettina, et al. “Relationship between sex hormones, reproductive stages and ADHD: a systematic review.” Archives of Women’s Mental Health, vol. 25, no. 1, Feb. 2022, pp. 1+. Gale OneFile: Health and Medicine

⁵ Ali SA, Begum T, Reza F. Hormonal Influences on Cognitive Function. Malays J Med Sci. 2018 Jul;25(4):31-41. doi: 10.21315/mjms2018.25.4.3. Epub 2018 Aug 30. PMID: 30914845; PMCID: PMC6422548.

⁶ Skoglund C., Kopp Kallner H.,,Skalkidou A. et al. Association of attention-deficit/hyperactivity disorder with teenage birth among women and girls in Sweden. JAMA Netw Open. 2019; 2e1912463 https://doi.org/10.1001/jamanetworkopen.2019.12463

⁷ Lindh I., Hognert H., Milsom I. The changing pattern of contraceptive use and pregnancies in four generations of young women. Acta Obstet Gynecol Scand. 2016; 95: 1264-1272 https://doi.org/10.1111/aogs.13003

⁸ Kooij JS. Hormonal sensitivity of mood symptoms in women with ADHD across the lifespan. Eur Psychiatry. 2023 Jul 19;66(Suppl 1):S23. doi: 10.1192/j.eurpsy.2023.92. PMCID: PMC10417850.

The U.S. Drug Enforcement Administration (DEA) has issued a proposal to reclassify marijuana from the most tightly regulated Schedule I category to the less stringent Schedule III group of the Controlled Substances Act (CSA). The historic reclassification, if enacted, would recognize the medical uses of cannabis and acknowledge that its potential for abuse is lower than that of other drugs. However, some worry that reclassification could also increase the risk for substance use disorder, particularly in individuals with ADHD.

Marijuana has fallen under the Schedule I classification since 1971. DEA defines Schedule I substances as drugs with no accepted medical use and a high potential for abuse; the category includes heroin, methamphetamines, and LSD, among other drugs. The move to a Schedule III classification puts cannabis in the same category as Tylenol with codeine, steroids, and testosterone.

Cannabis and ADHD

A Schedule III reclassification would not legalize marijuana for recreational use, but it would make it easier to conduct studies and research the medical benefits of the drug.

Looser restrictions could make cannabis seem less harmful than it is, which concerns some ADHD experts.

Olivadia explained in the ADDitude webinar “Marijuana and the ADHD Brain: How to Identify and Treat Cannabis Use Disorder in Teens and Young Adults” that “the adverse effects of cannabis are especially amplified in people with ADHD…Contemporary marijuana has concentrations of THC higher than historically reported, which exacerbates this.”

Studies show that more than half of daily and non-daily cannabis users have ADHD,²and about one-third of adolescents with ADHD report cannabis use.³ People with ADHD are also three times more likely than their neurotypical peers to have ever used marijuana.⁴ The risk of developing cannabis use disorder (CUD), a problematic pattern of cannabis use linked to clinically significant impairment, is twice as high in people with ADHD³.

Further, a new study presented in April at the European Psychiatric Association Congress 2024 found that offspring of mothers with prenatal CUD have up to a 98% increased risk of developing ADHD, a 94% increased risk of autism spectrum disorder (ASD), and a 46% increased risk of intellectual disability (ID) compared to non-exposed offspring. Researchers from Curtin University in Australia analyzed data from more than 222,000 mother-offspring pairs for the study.

“Cannabis can also interact significantly with some ADHD medications,” Olivardia said in the ADDitude webinar.

Research studies have shown that methylphenidate (Ritalin, Concerta) reacts significantly with cannabis and may increase strain on the heart.⁵ Other studies have found that cannabis use can decrease the effect of a stimulant medication.⁶

The increased risk of suicide associated with cannabis use further complicates the use of marijuana by individuals with ADHD, who already face an elevated risk for self-harm and suicide compared to neurotypical individuals.⁷

“I am not so concerned about the reclassification, in part, because it will be much easier for scientists to examine the positive and negative impact of cannabis in randomized controlled trials,” says Timothy Wilens, M.D., chief of child and adolescent psychiatry, and co-director of the Center for Addiction Medicine at the Massachusetts General Hospital. “Currently, it is very difficult to study cannabis, due to very tight restrictions given its Schedule I status. With reclassification, one will be able to study cannabis under the typical regulations for any controlled substance, which will inevitably enhance our understanding of basic mechanisms, medicinal uses, and/or potential harm of cannabis.”

In March, Wilens co-authored a paper published in the Journal of the American Academy of Child and Adolescent Psychiatry that found legalization of recreational marijuana, but not medicinal cannabis, increases the use of cannabis by youth, the effects of which are more dire for young adults and teenagers.⁸

“Youth using cannabis has a number of negative outcomes,” Wilens says. “Our group and others have also shown longer-term negative effects of early cannabis use on cognitive executive functioning — already a problem for many kids with ADHD — and structural brain changes. Other concerns are functional changes in how the brain operates, which highlight difficulties with cognitive performance, such as driving for up to six to eight hours after ingesting cannabis.  Such findings are not surprising given the increased rate of minor and fatal motor vehicle accidents associated with cannabis consumption.”⁹, ¹⁰, ¹¹

Another study of young adults with and without ADHD found that individuals who started using before age 16 fared worse on measures of executive functioning and other cognitive outcomes than did those who began using marijuana later — an especially worrisome finding given that the study participants with ADHD were more likely than their counterparts to report cannabis use before age 16.¹²

Wilens noted that researchers at the National Institutes of Health are studying this issue as part of a project called the Adolescent Brain and Cognitive Development Study (ABCD), the largest long-term study of brain development and child health ever conducted in the United States.

What Draws People with ADHD to Cannabis?

“Cannabis activates the brain’s reward system and releases dopamine at levels higher than typically observed. In low-dopamine ADHD brains, THC thus can be very rewarding,” Olivardia explained. “People with ADHD, whose brain development is delayed by slowly maturing frontal lobes, are thus more vulnerable to cannabis’ effects on neuronal connections.”

ADDitude asked members of its Reader Panel to report their experiences using cannabis. Several readers reported that the benefits of using cannabis outweighed the negatives.

“I self-medicated with weed for many years for mood swings, PMDD, endometriosis, and ADHD before I was diagnosed,” a reader said. “I have a medical card now for my PMDD and other chronic pain issues. It can be a very helpful tool, but I am mindful of my use. If I’m not, it is easy to watch my day — and my energy — slip from my grasp.”

“I have begun trying marijuana edibles about an hour before bedtime after recreational marijuana was legalized in my state this year,” wrote another ADDitude reader. “I have found that a nano-dose of 2 to 3 milligrams of THC clears my head of the usual noise and lets me drop into a deep and restful sleep. I am 45 and (insufficiently) manage my ADHD with non-stimulant medication only.”

Another reader first tried cannabis during the early months of the pandemic and now uses it alongside Strattera. “I do not consume cannabis while working, but I do occasionally use CBG and/or CBD,” the reader said. “THC helps with my symptoms a great deal. Sativa strains are energizing; they help me get up and get things done around the house that I would otherwise procrastinate, such as chores and yard work. Indica strains are relaxing; they help quiet my inner chatter and make it easier for me to meditate and do gentle forms of yoga… Some strains amplify my hyperactive/impulsive tendencies… [but] with the right strains, cannabis can help a great deal with ADHD symptoms.”

Marijuana Rescheduling Next Steps

It’s unlikely that the DEA will reclassify cannabis as a Schedule III drug quickly. First, the White House Office of Management and Budget must review the reclassification proposal and conduct a 60-day public comment period. The proposal then will be reviewed by an administrative law judge, who could decide to hold a hearing before the rule is approved.

The marijuana rescheduling decision was the result of President Joe Biden’s 2022 request for the U.S. Department of Health and Human Services (HHS) and the Attorney General (who oversees the DEA) to review the drug’s classification.

The recreational use of cannabis is legal in 24 states, and 38 states have legal medical marijuana programs.

Sources

¹Jeffers, A.M., Glantz, S., Byers, A.L., Keyhani, S. (2024). Association of Cannabis Use With Cardiovascular Outcomes Among US Adults. J Am Heart Assoc.5;13(5):e030178. https:doi.org/10.1161/JAHA.123.030178
²Loflin, M., et. al. (2014). Subtypes of Attention Deficit-Hyperactivity Disorder (ADHD) and Cannabis Use. Substance Use & Misuse, 49(4), 427-434, https://doi.org/10.3109/10826084.2013.841251
³Francisco, A.P., Lethbridge, G., Patterson, B., Goldman Bergmann, C., & Van Ameringen M. (2023). Cannabis Use in Attention-Deficit/Hyperactivity Disorder (ADHD): A Scoping Review. J Psychiatr Res,157, 239-256. https://doi.org/10.1016/j.jpsychires.2022.11.029
⁴Wilens T. E. (2004). Attention-Deficit/Hyperactivity Disorder and the Substance Use Disorders: The Nature of the Relationship, Subtypes at Risk, and Treatment Issues. The Psychiatric Clinics of North America, 27(2), 283–301. https://doi.org/10.1016/S0193-953X(03)00113-8
⁵Kollins, S. et. al. (2015). An Exploratory Study of the Combined Effects of Orally Administered Methylphenidate and Delta-9-Tetrahydrocannabinol (THC) on Cardiovascular Function, Subjective Effects, and Performance in Healthy Adults. Journal of Substance Abuse Treatment, 48(1), 96-103. https://doi.org/10.1016/j.jsat.2014.07.014
⁶Volkow, N. D., Wang, G. J., Telang, F., Fowler, J. S., Alexoff, D., Logan, J., Jayne, M., Wong, C., & Tomasi, D. (2014). Decreased Dopamine Brain Reactivity in Marijuana Abusers is Associated with Negative Emotionality and Addiction Severity. Proceedings of the National Academy of Sciences of the United States of America, 111(30). https://doi.org/10.1073/pnas.1411228111
⁷Balazs, J., & Kereszteny, A. (2017). Attention-Deficit/Hyperactivity Disorder and Suicide: A Systematic Review. World Journal of Psychiatry, 7(1), 44–59. https://doi.org/10.5498/wjp.v7.i1.44
⁸Pawar, A.K.S., Firmin, E.S., Wilens, T.E., & Hammond, C.J. (2024). Systematic Review and Meta-Analysis: Medical and Recreational Cannabis Legalization and Cannabis Use Among Youth in the United States. Journal of the American Academy of Child and Adolescent Psychiatry. https:/doi.org/10.1016/j.jaac.2024.02.016
⁹ Gruber, S. A., Sagar, K. A., Dahlgren, M. K., Racine, M., & Lukas, S. E. (2012). Age of Onset of Marijuana Use and Executive Function. Psychology of Addictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 26(3), 496–506. https://doi.org/10.1037/a0026269
¹⁰Filbey, F. M., Aslan, S., Calhoun, V. D., Spence, J. S., Damaraju, E., Caprihan, A., & Segall, J. (2014). Long-term Effects of Marijuana Use on the Brain. Proceedings of the National Academy of Sciences of the United States of America,1 11(47), 16913–16918. https://doi.org/10.1073/pnas.1415297111
¹¹lbaugh MD, Ottino-Gonzalez J, Sidwell A, et al. Association of Cannabis Use During Adolescence With Neurodevelopment. JAMA Psychiatry. 2021;78(9):1031–1040. https://doi.org/10.1001/jamapsychiatry.2021.1258
¹²Tamm, L., Epstein, J. N., Lisdahl, K. M., Molina, B., Tapert, S., Hinshaw, S. P., Arnold, L. E., Velanova, K., Abikoff, H., Swanson, J. M., & MTA Neuroimaging Group (2013). Impact of ADHD and Cannabis Use on Executive Functioning in Young Adults. Drug and Alcohol Dependence, 133(2), 607–614. https://doi.org/10.1016/j.drugalcdep.2013.08.001

It is indefensible how little is known about ADHD in women today. Research is nearly non-existent in the way ADHD symptoms change with the hormonal fluctuations of puberty, pregnancy, menopause, and beyond. And experts who study ADHD are deeply concerned — outraged even — about the persistent lack of research on a population that is chronically underdiagnosed and misdiagnosed.

“For decades, girls and women with ADHD have missed out on critical interventions to help manage their ADHD symptoms, primarily because they have largely been left out of ADHD research studies,” says Julia Schechter, Ph.D., co-director of the Duke Center for Girls and Women with ADHD. “Females with untreated ADHD have been put at higher risk for depression and anxiety, intimate partner victimization, and risky sexual behaviors resulting in teen and unplanned pregnancies. Research devoted to girls and women with ADHD is not only an issue of equity but of life or death for some.”

Here, leading experts weigh in on where research is critically needed to guide accurate diagnosis and effective treatment of ADHD in females.

ADHD Research Priority: Defining Sensitive and Precise Screening Tools

Julia Schechter, Ph.D., co-director of the Duke Center for Girls and Women with ADHD

There are numerous research topics related to girls and women with ADHD that deserve thorough investigation. Three specific areas of research that span the life course include:

1. Developing more sensitive and precise screening tools that can better identify girls and women who may have ADHD and require comprehensive evaluation. Many screening tools — particularly those that are freely available — ask raters to report on overt behaviors that align with DSM-5 criteria. Yet, this approach may not be as effective for girls and women. Females with ADHD often compensate for and “mask” their symptoms, making it difficult for observers to rate how frequently a symptom is occurring or whether it is present at all. Research can also focus on developing additional prompts that could be incorporated into existing tools to help raters consider how symptoms may present differently in girls and women (e.g., more likely to be hyperverbal rather than hyperactive). Once developed, these gender-sensitive tools need to be free to use, easy to implement, provide gender or sex-based norms, and be interpretable by those without specialty mental health backgrounds (e.g., teachers, pediatricians).

2. Investigating the role of hormones in ADHD symptom expression in girls and women. This research should examine hormonal levels across the reproductive lifespan including puberty onset, menstrual cycle, pregnancy, postpartum period, and menopause, and post-menopause.

3. Assessing the degree to which girls and women with ADHD require additional or unique treatment approaches. For example, studies can investigate the efficacy of ADHD medication type and dose for girls and women and whether medication effectiveness might interact with hormone levels. With regard to behavioral treatments, research questions might include whether additional modules of CBT for ADHD or behavioral parent training potentially targeting emotion dysregulation could enhance the effectiveness of these psychosocial interventions. In addition, research can explore whether there are certain treatment delivery formats, such as group therapy (vs. individual therapy), that might be more effective for girls and women with ADHD.

[Join Our Call for Greater Research on Women with ADHD]

ADHD Research Priority: Why ADHD Exacts a Greater Toll on Women

Ellen Littman, Ph.D., clinical psychologist and co-author of Understanding Girls with ADHD

The overarching research question is: Why does ADHD exact a far greater toll on women? Why have researchers refused to explore the dramatic sex/gender differences in outcomes — and how can we compel researchers to care?

Here is the most urgent research needed to improve care for females:

• Studies that will increase recognition and understanding of the widest continuum of presentations, complex trajectories, hormonal mediation, cumulative mood-based impairments, and severity of outcomes.
• How do cycling hormones impact all aspects of female behavior and impairment —including PMS and PMDD (premenstrual dysphoric disorder), and the postpartum, perinatal, and menopause stages?
• To what degree do isolation, shame, and despair lead to self-harm and earlier mortality in females?
• How can we identify symptoms earlier in girls?

These findings will provide a basis for revised, inclusive diagnostic criteria and rating scales to assess internalizing symptoms, functional impairments, masking, and symptom proliferation after puberty.

ADHD Research Priority: Understanding the Core Symptoms of ADHD in Women

Maggie Sibley, Ph.D., psychologist, and researcher at the University of Washington School of Medicine

• What are the core symptoms of ADHD in girls and women across the lifespan?
• What is the typical trajectory of onset for ADHD in girls and women?
• What are the key points of intervention for women with ADHD (in terms of times in their lives and domains of impairment)?

[Survey: How Does Your Menstrual Cycle Impact Your ADHD Symptoms?]

ADHD Research Priority: The Impact of Hormonal Fluctuations on Women with ADHD

J.J. Sandra Kooij, M.D., Ph.D., founder, and chair of the European Network Adult ADHD

• Why do some women feel better with oral contraceptives and others feel depressed?
• How do hormones interact with neurotransmitters, such as dopamine, in women?
• What is most helpful for women with PMDD: an antidepressant, increased stimulant dosage in the last week of the cycle, taking birth control pills, or a progesterone antagonist? Same for perimenopausal women with ADHD: Which treatment would be best?
• Why do women with ADHD have higher rates of polycystic ovary syndrome, which is associated with fertility problems and hormonal disturbances, and primary ovarian insufficiency, which is associated with early-onset menopause?

ADHD Research Priority: Sexual and Reproductive Health for Females with ADHD

Lotta Borg Skoglund, M.D., Ph.D., author, associate professor at Uppsala University, Department for Women’s and Children’s Health, principal investigator at GODDESS ADHD, and author of ADHD Girls to Women

• Are negative sexual and reproductive outcomes and functional somatic symptoms more prevalent in females with ADHD compared to females without ADHD and how are they influenced by age at diagnosis and ADHD treatment?
• What daily life challenges do females with ADHD experience, and are negative sexual and reproductive outcomes and functional somatic symptoms related to low daily life functioning?
• What barriers do females with ADHD face regarding their sexual and reproductive health?
• How are cyclic variations of hormones during the menstrual cycle or the use of hormonal contraceptives related to:
  • ADHD symptom levels
  • Use of ADHD medication
  • Comorbid and functional somatic symptom levels
  • The effects of ADHD medication

ADHD Research Priority: Treatment Efficacy for Women with ADHD

Kathleen Nadeau, Ph.D., author of Still Distracted After All These Years

• ADHD, mood, and menses: Following adolescent and young adult women through several monthly menstrual cycles to report issues related to mood, focus, memory, and emotional regulation.
• Better DSM profile: Conducting a large-scale survey of high school girls, female college students, and adult women with ADHD to tell us their biggest struggles so that, at the very least, the next updated Diagnostic and Statistical Manual of Mental Disorders (DSM) can incorporate these features for females.
• Efficacy of treatment: Asking women with ADHD to rate the effectiveness of treatment with stimulant medication, psychotherapy, group therapy, and lifestyle changes—sleep, exercise, and stress-busting activities.

ADHD Research Priority: The Transition Points That Predict Impairment Versus Resilience for Girls

Stephen Hinshaw, Ph.D., distinguished professor of psychology at the University of California, Berkeley, and author of Straight Talk About ADHD in Girls: How to Help Your Daughter Thrive

• What are the transition points — psychological, family- or school-related, community-wide — that predict impairment versus resilience for girls with ADHD as they transition through adolescence to adulthood?
• What are the pros and cons of social media-related promotion of ADHD information for women, leading to valid diagnosis and treatment?
• What are the pros and cons of self-reported screenings, with the potential for receiving mail-order stimulants?
• What are the strategies and supports that help teen girls and women with ADHD thrive?

ADHD Research Priority: Gender Differences in ADHD

Dawn K. Brown, M.D., owner/CEO of ADHD Wellness Center and Mental Healthletics

• Gender differences between the presentation and coping mechanisms of girls and women with ADHD compared to boys and men.
• The adverse long-term outcomes of untreated or inadequately managed ADHD in women, including academic underachievement, unemployment, relationship difficulties, inappropriate treatment, and increased risk of substance abuse and mental health disorders.
• How society’s expectations of gender roles e.g., cultural norms around femininity, such as the pressure to be organized and focused, may influence ADHD presentations and exacerbate the challenges faced by women with ADHD
• How fluctuations in hormone levels across the menstrual cycle and during pregnancy can impact ADHD symptoms in women.
• How the combination of  ADHD and hormonal-related conditions (e.g., PMS, PMDD, and PCOS) can lead to an overlooked diagnosis and can complicate treatment in women.
• Recognizing and addressing comorbid conditions in women with ADHD, such as depression, anxiety, and eating disorders.
• How ADHD can significantly affect academic, professional, and financial success in women.
• The interplay between ADHD symptoms, parenting stress, and family dynamics of women with ADHD who are parents of children with ADHD.
• How stigma, lack of awareness, and gender bias continuously contribute to delays in diagnosing ADHD in women.

ADHD Research Priority: The Impact of Perimenopause and Menopause on ADHD Symptoms

Jeanette Wasserstein, Ph.D., clinical assistant professor of psychiatry, at the Icahn School of Medicine at Mount Sinai

An ADDitude survey found that an enormous number of women are diagnosed with ADHD during the perimenopausal and menopausal years and that those who were previously diagnosed experienced a worsening of symptoms. These observations correlate with a period of significant underlying hormonal changes. Since ADHD is a neurodevelopmental disorder thought to be typically present during the childhood or teen years, this apparently ‘new onset’ or worsening of ADHD implies an important role for sex hormones in the expression of some ADHD symptoms.

Such observations also imply that there may even be two types of women who are diagnosed with ADHD during this period: Those who were borderline ADHD their whole lives but did not meet criteria until their symptoms worsened and those who are entirely ‘new onset.’ Unfortunately, almost no research exists regarding the role of hormones on ADHD during the climacteric. Since women represent 50% of the world’s population and all will experience menopause if they live into their 60’s the impact of perimenopause and menopause on ADHD symptoms is an enormously unrecognized and important topic in global female health.

ADHD Research Priority: Diagnostic and Treatment Gaps for Women of Color

Sharon Saline, Psy.D., clinical psychologist and author of  What Your ADHD Child Wishes You Knew: Working Together to Empower Kids for Success in School and Life

• Addressing diagnostic and treatment gaps for women of color, including common cultural issues and difficulties with access to care.
• Developing tools for earlier detection of ADHD in girls, teens, and women including more effective options for detecting the internalizing, inattentive symptoms.
• Examining the connection between the rise of peri and post-menopausal women and how estrogen and progesterone affect the dopamine and norepinephrine receptors and pathways in the brain.
• Exploring how the socialization and gender identity of women affect the increased accounts of perfectionism, imposter syndrome, and low self-esteem.

ADHD Research Priority: Early Identification of ADHD in Girls and Women

Andrea Chronis-Tuscano, Ph.D., professor at the University of Maryland and director of the UMD ADHD Program and UMD SUCCEEDS College ADHD Clinic

• How can we raise awareness about ADHD in girls and women among parents, teachers, pediatricians, and other healthcare providers so they can be identified earlier and get the help they need?
• How can we support women through the transition to parenthood so that we can help not only them but also their children who are at risk for ADHD?

ADHD Research: Next Steps

• Download: Free Menstrual Cycle Workbook for Women with ADHD
• Read: Why Research Is Needed on Sex Differences in ADHD
• Read: The Fate of Females with ADHD Is Improving Too Slowly

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Women with ADHD can continue using the stimulant medication dexamphetamine and the painkiller acetaminophen (brand name: Tylenol) during pregnancy, according to two recent studies that refute a long-standing medical consensus.

An observational study published in the Archives of Women’s Health found that use of dexamphetamine (DEX), the main ingredient in brand-name ADHD medications such as Adderall, Dexedrine, Zenzedi, and ProCentra, does not put women or their babies at increased health risks. However, women who ceased using DEX during pregnancy were more than twice as likely to have a threatened abortion (mild to moderate bleeding during the first trimester) compared to those who continued DEX or who did not use the stimulant during pregnancy.¹

“This could indicate a possible association with DEX withdrawal,” the study’s authors wrote. “However, this is something that requires further investigation due to the small sample size, difficulties examining timing, and the inability to examine spontaneous abortion.”

The researchers analyzed a cohort of 1,688 women diagnosed with ADHD who gave birth in Western Australia between 2003 and 2018. Of the participants, 65% (547) ‘continuers’ took dexamphetamine throughout their pregnancy; 35% (297) ‘ceasers’ stopped using DEX before the end of the second trimester. A matched ‘unexposed’ group of 844 women had prescriptions for dexamphetamine before but not during pregnancy.

The three groups shared similar maternal health and labor and delivery characteristics, such as the onset of labor and delivery method. Complications during pregnancy, such as threatened pre-term labor, premature rupture of membranes, and bleeding in the second trimester, did not differ between the ‘ceasers’ and the ‘unexposed.’

Compared to the ‘continuers’ and ‘ceasers,’ the ‘unexposed’ group had a lower risk of:

• preeclampsia
• hypertension
• postpartum hemorrhage
• neonatal special care unit admittance
• fetal distress

While the findings illustrate the possible benefits of ceasing DEX before conception, the study’s authors noted that discontinuing ADHD medication puts pregnant people with ADHD at a higher risk for depression, anxiety, feelings of isolation, and family conflict. ²

“The results indicated that continuing to take dexamphetamine did not put women or their babies at increased health risks,” said Dani Russell, the study’s lead author, and a Ph.D. student from the University of Western Australia School of Population and Global Health. “Pregnancy can be a really stressful period for women with ADHD, so it is good to know that stopping their medication during pregnancy may not always be necessary.”

This research is part of a larger body of work investigating different ADHD treatments during pregnancy. The study’s authors said that more investigations are needed on the topic.

Acetaminophen Use in Pregnancy Not Linked With ADHD

A new study published in JAMA found that acetaminophen exposure during pregnancy does not increase the risk of autism, ADHD, or intellectual disability in children; however, factors such as genetics and the environment do. ³ This is the largest nationwide cohort study to date on acetaminophen usage during pregnancy. The study challenges prior research claiming that acetaminophen exposure during pregnancy may increase the risk of neurodevelopmental disorders in children. ⁴, ⁵

Scientists from the Karolinska Institute of Sweden and Drexel University’s Dornsife School of Public Health analyzed the prenatal and medical records of nearly 2.5 million children born in Sweden from 1995 to 2019, with follow-up through 2021. Of the 185,909 children exposed to acetaminophen in pregnancy, nearly 9% were diagnosed with autism, ADHD, or an intellectual disability, compared to about 7.5% of children whose mothers did not use the medication while pregnant. Children exposed to acetaminophen had marginally higher rates of diagnoses compared to those not exposed (1.53% vs. 1.33% for autism, 2.87% vs. 2.46% for ADHD, and 0.82% vs. 0.70% for intellectual disability).

The research team used the same database to conduct a second study focused on pairs of siblings whose mothers used acetaminophen during one pregnancy but not the other. This sibling control analysis found no evidence of increased risk of autism, ADHD, or intellectual disability associated with acetaminophen use during pregnancy.

“Associations observed in models without sibling control may have been attributable to confounding,” they wrote. “Results suggested that there was not one single ‘smoking gun’ confounder, but rather that multiple birthing parents’ health and sociodemographic characteristics each explained at least part of the apparent association.”

The study found acetaminophen had similar risks for neurodevelopmental disorders as non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and anti-migraine medicines. (The FDA recommends against using NSAIDs, such as Aspirin and Ibuprofen, in the third trimester of pregnancy because they may cause a blood vessel in the fetus to close prematurely.)

The researchers said that, despite the study’s large sample size and long duration, their reliance on self-reported and prescription dispensing data introduced several limitations. Still, these findings coincide with the American College of Obstetricians and Gynecologists, which maintains that acetaminophen is safe for pregnant women to use.

The Archives of Women’s Health and JAMA studies highlight the importance of pre-conception or early pregnancy counseling, individualized treatment plans, and medication management and recommend that patients discuss all medication decisions with their doctor.

Sources

¹ Russell, D.J., Wyrwoll, C.S., Preen, D.B. et al. (2024). Investigating Maternal and Neonatal Health Outcomes Associated with Continuing or Ceasing Dexamphetamine Treatment for Women with Attention-Deficit Hyperactivity Disorder During Pregnancy: A Retrospective Cohort Study. Arch Womens Ment Health. https://doi.org/10.1007/s00737-024-01450-4

²Damer, E.A., Edens, M.A., van der Loos, M.L.M., van Esenkbrink, J., Bunkers, I., van Roon, E.N., Ter Horst, P.G.J. (2021). Fifteen Years’ Experience with Methylphenidate for Attention-Deficit Disorder During Pregnancy: Effects on Birth Weight, Apgar Score and Congenital Malformation Rates. Gen Hosp Psychiatry. https://doi.org/10.1016/j.genhosppsych.2021.09.003

³Lee, B.K., et al. (2024). Acetaminophen Use During Pregnancy and Children’s Risk of Autism, ADHD, and Intellectual Disability. JAMA. https://doi.org/10.1001/jama.2024.3172

⁴Ji, Y., et al. (2019). Association of Cord Plasma Biomarkers of In Utero Acetaminophen Exposure with Risk of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in Childhood. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2019.3259

⁵Bauer, A.Z., Swan, S.H., Kriebel, D. et al. (2021) Paracetamol Use During Pregnancy — A Call for Precautionary Action. Nat Rev Endocrinol. https://doi.org/10.1038/s41574-021-00553-7

The diagnostic criteria for ADHD are largely based on studies of young white boys. The symptoms spelled out in the DSM-5 — i.e., Is often “on the go” acting as if “driven by a motor” — do not reflect the lived experiences of many adults with the condition. This gap between clinical guidance and real-life symptoms has contributed to a decades-long problem with misdiagnosis, missed diagnoses, and inadequate treatment for individuals who slipped under the ADHD radar in childhood.

ADHD persists into adulthood for up to 90% of children with the condition. Symptoms evolve and change, but they do not magically disappear. In fact, the Centers for Disease Control and Prevention calls ADHD a “public health concern” with long-term repercussions. The longevity of ADHD is confirmed by scientific research, as is the fact that three boys are diagnosed with ADHD for every one girl with the condition. As a result, we now have a surging population of adults seeking a first-time diagnosis for lifelong symptoms of ADHD that may have become more debilitating, or at least distressing, with age.

“It’s not that ADHD symptoms necessarily get worse with age,” said David Goodman, M.D., assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine, during an ADDitude webinar in April 2024. “But when you are younger, ADHD symptoms are disruptive and inconvenient to others; as you age, ADHD symptoms become disruptive and inconvenient to you.”

Pent-up demand for ADHD evaluations among adult patients continues to grow, yet clinicians today have no reliable, standardized metrics for evaluating those symptoms. The DSM-5 contains some guidance for diagnosing adults, but it is controversial and largely considered inadequate. In addition, only 33% of pediatricians, 30% of family practitioners, 25% of nurse practitioners, and 22% of internists said that they received adequate training on ADHD in medical school, according to data presented by the American Professional Society of ADHD and Related Disorders (APSARD) at its 2024 conference.

“ADHD is the second most common psychiatric disorder in adults, but it is rarely focused on” by health care providers, Goodman said during the ADDitude webinar, titled “ADHD in Older Adults: Clinical Guidance and Implications.” “Older patients should not be easily discounted as having age-related cognitive decline and dismissed.”

First-Ever Adult ADHD Guidelines

APSARD is working to remedy this huge obstacle to care. In 2023, it established a 27-member task force that is devising clinical practice guidelines for the diagnosis and treatment of ADHD in adults. According to Goodman, who is leading the medical subcommittee for the task force, the adult ADHD guidelines have the greatest chance at widespread adoption if they are research based, clinically informed, and patient focused.

However, few research studies exist on adults over the age of 50, women, people of color, and minority populations, such as autistic adults with ADHD. If the APSARD guidelines are built on a framework of scientific research, and little, if any, unbiased scientific research exists on huge populations of patients, how thorough or helpful can those guidelines be?

“I wouldn’t say that we are going to write ‘good’ guidelines,” Goodman said during a presentation at the annual APSARD conference in January 2024, “because ‘good’ is defined in the present as what is supported by evidence. We are setting a basic standard of care… these guidelines will evolve as we learn more.”

Even so, APSARD’s clinical practice guidelines for ADHD in adults stand to impact far more than diagnosis and treatment rates. Some experts believe that formal guidelines based on high-quality scientific evidence will compel insurance companies to fully cover the medical treatment of ADHD in adults, which is seldom the case now. Others believe the guidelines could influence nationwide quotas for Schedule II controlled substances set by the Drug Enforcement Administration (DEA), opening the door for greater availability of stimulant medications used to treat ADHD. And many advocates are hopeful that adult ADHD guidelines will contribute to greater public awareness, better medical training, less stigma, and improved mental health outcomes for patients.

The adult guidelines, which are slated for release in late 2024 or early 2025, will take into consideration many of ADHD’s major comorbid conditions, according to committee member Frances Levin, M.D., of the Columbia University Irving Medical Center. Levin confirmed that her subcommittee is meeting with subject-matter experts on substance abuse, depression, and bipolar disorder, among other ADHD-related conditions.

For each psychiatric comorbidity diagnosed alongside ADHD, a patient’s risk of premature death rises exponentially, according to Goodman. The risk of premature death is 1.56 times higher for an adult with ADHD compared to one without ADHD, and it is 29.29 times higher for an adult with ADHD and four comorbid conditions, he said, citing a 2019 study published in JAMA Psychiatry.¹

The Concept of Subthreshold ADHD

The notion of “subthreshold” ADHD was introduced by task force members at the APSARD conference as well. Subthreshold ADHD may not meet the necessary DSM-5 criteria for a diagnosis in childhood, but mild symptoms may become severe due to the stress of parenthood or the hormonal swings that accompany menopause, said Maggie Sibley, Ph.D., head of the diagnosis and assessment subcommittee. People with subthreshold ADHD may not exhibit impairing symptoms before age 12, as required in the current DSM-5 for a diagnosis. However, these undiagnosed, untreated adults may experience significant distress later in life and face an elevated risk for substance abuse, burnout, and professional and personal problems as a result, Sibley argued during a presentation at the 2024 APSARD conference.

“People with subthreshold ADHD may be massively impaired even though they don’t quite meet the criteria for a diagnosis,” said Stephen Faraone, Ph.D., a distinguished professor in the Departments of Psychiatry and Neuroscience & Physiology at SUNY Upstate Medical University, during the APSARD presentation.

Citing 2022 research showing that 63.8% of people with ADHD experienced symptom fluctuations throughout their lives, Sibley said, “We need to recognize that ADHD symptoms are not stable; they wax and wane over the lifespan.”²

Removing or adjusting the DSM requirement that ADHD symptoms must be present before age 12 is one way to improve diagnosis and treatment. Another approach may be to expand the symptom criteria for adult ADHD to include emotional dysregulation, a common and impairing ADHD trait not currently included in the DSM-5. Some experts like Anthony Rostain, M.D., point out that “other DSM disorders allow ‘suffering’ or ‘distress’” due to persistent symptoms as justification for a diagnosis, “but an ADHD diagnosis requires impairment. Can we use impairment or distress instead?”

Implications for Treatment and Care

Though the APSARD task force is squarely focused on developing clinical practice guidelines for the diagnosis and treatment of ADHD in adults, it will also likely “address the issue of prescriptions for older adults with ADHD,” Goodman said. A primary concern is the safety of stimulant medication use among older adults, and the risk for introducing or exacerbating cardiovascular problems. In 2023, JAMA published a meta-analysis of 19 observational studies, involving 3.9 million participants, that found ADHD medications — both stimulants and non-stimulants — do not place patients of any age at greater risk for cardiovascular events, including heart failure and hypertension. The study found that there was no statistically significant association between ADHD medications and cardiovascular disease (CVD), even among middle-aged and older adults.³ Still, some prescribers hesitate or refuse to prescribe ADHD medications to patients older than age 50.

Perhaps surprisingly, the average duration of treatment for adults with ADHD is currently just seven months, said APSARD Past President Ann Childress, M.D., during a presentation on the topic of treatment barriers for adults with ADHD. More than half of adults stop taking their ADHD medication due to “suboptimal management of ADHD symptoms,” she said, citing a 2022 study published in BMC Psychiatry.⁴ 

To reverse this trend, Childress suggested greater clinician education regarding the benefits of long-acting stimulant medication for patients who would benefit from symptom control in professional and personal settings. Currently, 48% of adult ADHD patients are taking a short-acting stimulant, said APSARD President Greg Mattingly, M.D., an associate clinical professor at Washington University School of Medicine. Mattingly reported during an APSARD presentation that long-acting stimulants, sometimes in combination with a non-stimulant medication, are more effective for many of his patients.

APSARD is partnering with Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) to develop clinical tools based on the forthcoming adult ADHD guidelines that clinicians can use to aid the evaluation process, Goodman said.

Mattingly added that ADHD screenings should become a routine part of annual doctors’ visits.

“Five years ago, 20% of pediatricians were screening for depression, and now it is a ubiquitous quality measure,” he said. “ADHD screening has a higher rate of reliability, and it can be a quality measure, too.”

Sources

¹Sun, S., Kuja-Halkola, R., Faraone, S.V., D’Onofrio, B.M., Dalsgaard, S., Chang, Z., Larsson, H. (2019) Association of Psychiatric Comorbidity With the Risk of Premature Death Among Children and Adults With Attention-Deficit/Hyperactivity Disorder. JAMA Psychiatry.76(11):1141-1149. https://doi.org/10.1001/jamapsychiatry.2019.1944

²Sibley, M.H., Arnold, L.E., Swanson, J.M., Hechtman, L.T., Kennedy, T.M., Owens, E., Molina, B.S.G., Jensen, P.S., Hinshaw, S.P., Roy, A., Chronis-Tuscano, A., Newcorn, J.H., Rohde, L.A. (2022). MTA Cooperative Group. Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD. Am J Psychiatry. https://doi.org/10.1176/appi.ajp.2021.21010032

³Zhang, L., Yao, H., Li, L., et al. (2022). Risk of Cardiovascular Diseases Associated with Medications Used in Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis. JAMA Netw Open. https://doi.org/10.1001/jamanetworkopen.2022.43597

³Schein, J., Childress, A., Cloutier, M., Desai, U., Chin, A., Simes, M., Guerin, A., Adams, J. (2022) Reasons for Treatment Changes in Adults with Attention-Deficit/Hyperactivity Disorder: A Chart Review Study. BMC Psychiatry. https://doi.org/10.1186/s12888-022-04016-9

Adults and caregivers harmed by the ongoing ADHD medication shortage have contributed thousands of impassioned, irate impact statements to a joint Request for Information (RFI) issued by the Federal Trade Commission (FTC) and U.S. Department of Health and Human Services (HHS) seeking public comment on drug prices and availability. Of the more than 5,600 public comments submitted so far, 62% (nearly 3,500) have mentioned ADHD and/or the stimulant shortage ongoing since October 2022.

Open through May 30, the RFI asks patients to submit comments, documents, and data regarding how the practices of two types of pharmaceutical drug intermediaries — group purchasing organizations (GPOs) and drug wholesalers — may contribute to generic drug shortages, including how both entities may influence the pricing and availability of pharmaceutical drugs. The RFI does not specifically ask about ADHD medications.

More than 300 medications, including chemotherapy drugs, medic drugs, antibiotics, and psychostimulants, are in short supply, according to David W. Goodman, M.D., LFAPA, an assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine. The RFI comments are overwhelmed with ADHD patients, in part, because “the shortage of ADHD medications has extended so long that there are more people actively engaged ‘in the conversation,’” he says.

“The ADHD drug shortage is now over a year old and continues to be problematic,” says Timothy Wilens, M.D., an associate professor of psychiatry at Harvard Medical School. “It is tiring to patients and clinicians, and it puts individuals at risk for academic and occupational difficulties and a myriad of other issues. In my practice, people are totally fed up with tracking down medications every month.”

Stimulant shortages continue to be a problem for many of the patients Ann Childress, M.D., treats at her private practice in Las Vegas. Childress, who is the current president of the American Professional Society of ADHD and Related Disorders (APSARD) says, “Each week, I have to rewrite several prescriptions to send to an alternative pharmacy because the patient’s regular pharmacy does not have the medication needed in stock. Many insurances will not cover brand-name medication in stock even when the generic is not available. I don’t think the shortage is going away any time soon.”

ADHD Patients Express Anger, Fear, Frustration in RFI

Harrowing personal stories of treatment disruptions and anxiety around finding — and paying for — ADHD medications were found easily in the comments submitted to the RFI.

“I get it: the FDA and DEA are looking to avoid Opioid Crisis II: The Stimulant Years. But attempting to absolve yourselves of your past failures at the expense of current patients is not the answer,” wrote Tiffany from Texas. “Especially considering ADHD patients are the least well-equipped to navigate complicated, multi-step tasks like calling multiple pharmacies — who often refuse to divulge inventory information without a valid script — and doctors who want us to verify a pharmacy has the drug in stock before they’ll send the script; finding and completing the necessary forms with insurance companies to beg for brand name coverage exceptions. And if, by some stroke of luck, we successfully amble through this Byzantine process with a filled prescription, we have exactly 29 days before we get to start it all over again, and all the while, our federal government is trying to gaslight us into believing there’s sufficient supply to meet demand.”

“When I try to fill my prescription, I’m made to feel like some kind of drug-seeker or addict,” wrote Susan from Washington. “People treat my diagnosis as spurious. People assume that I’m simply unwilling to tolerate the normal challenges of life and expect medication to make things easier. It’s hard not to wonder if people in power are deliberately creating this situation because they dislike people with my diagnosis, or if they don’t care enough about our needs to make a real effort.”

“This ADHD drug shortage has severely affected me,” wrote one anonymous commenter. “There have been many times I have been unable to fill my prescription. I work in a hospital with critically ill patients. Without medication, my inattention puts people’s lives at risk.”

“The shortage of necessary medication for ADHD is a huge problem for my family,” wrote Julia from New York. “Both my spouse and child take different medications to manage their ADHD symptoms. They choose not to medicate on days it would help but isn’t ‘necessary’ so that they can save medication for the most ‘necessary’ days. This kind of self-denial and hoarding is a ridiculous solution to a problem they did not create. My 18-year-old child is trying their best in school but feels they are not living up to their potential because they cannot participate appropriately. My child does not deserve to have their self-esteem eroded because a necessary medication that they deserve is not available to them.”

“My day-to-day living is unmanageable without Adderall,” wrote Sara from Florida. “I tried to go without medication for a few months because it was such a challenge to find… and I hated being treated like a drug addict at pharmacies. After a few months without meds, my impulsive spending led to an inability to pay my bills. I lost my home and endangered my job. All I did was think about the things I had to do and not do any of them.”

“I have had to leave one of my two jobs because I could not function at the level I needed to without my medication, and I suffered from a severe mental health crisis,” wrote Jennifer from Oregon. “My current insurance no longer covers the copay for Vyvanse, which costs upward of $400 for 28 pills. I have been relying on and thriving on this medication for half of my life, and it now costs more than my monthly car payment. Because of the astronomical costs, I have been unable to afford the medication that I need to function.”

“The ADHD medication shortage has negatively impacted every single part of my life and my child’s,” wrote Kelly from Iowa. “Attempting to fill prescriptions in the past two years or so has been an absolute nightmare. I have been forced to bundle my child up and drive up to 45 minutes away (one way) from our city to acquire our ADHD medication on many occasions. We have gone without or with a fraction of our prescribed dose for many days. I have spent time I could not spare searching for our ADHD medication. I have constant anxiety when one of our ADHD medications starts getting low each month. We have missed healthcare appointments, events, and social gatherings. We have lost friendships. My small business has suffered.”

According to an ADDitude survey of 11,013 adults and caregivers, at least 20% of ADHD patients were still impacted by the stimulant shortage in the summer of 2023. (Learn more about how the ADHD medication shortage has impacted ADDitude readers “Stop Treating Us Like We’re Addicts!” and “A Daily Nightmare:” One Year into the ADHD Stimulant Shortage.)

The deadline to submit public RFI comments is May 30, 2024. Add your testimony at Regulations.gov.

The public can also demand an end to the ADHD medication shortage by writing letters to representatives, the DEA, and the FDA using templates provided by ADDitude.

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

Lower Risk of Death from All Causes

An observational study from Sweden, published in JAMA, followed nearly 150,000 adults and adolescents with a diagnosis of ADHD, tracking participants for two years following diagnosis.

The researchers found that use of ADHD medication:

• Reduced overall risk of death by 19%: Among people with ADHD who did not receive medication, there were 48 deaths for every 10,000 people, contrasted with 39 deaths per 10,000 people within the medicated cohort.

• Reduced risk of overdose by 50%: Medication use also reduced the risk of death from other unnatural causes, including accidental injuries, accidental poisoning such as drug overdoses, and suicide. This trend was particularly pronounced among men and significant in the category of accidental poisoning, where risk of death was lowered by almost 50%.

• Reduced risk of death from natural causes for women: ADHD medication use reduced the risk of death from natural causes, such as medical conditions, for women. Though it did not reduce this risk for men, medication use did not increase risk either. This is an important finding that may alleviate long-standing worries about the impact of stimulant use on cardiovascular health, among other concerns.

While the authors of the study caution that these findings show correlation, not causation, the results are encouraging for patients and clinicians with reservations about ADHD medication use, especially later in life.

Fewer Hospitalizations

A second Swedish study sought to investigate the effect of a variety of ADHD medications on rates of hospitalizations. Published in JAMA Network Open, the cohort study used nationwide medical and administrative databases to identify 221,000 people with ADHD, 56% of whom had a psychiatric comorbidity including anxiety or stress-related disorder (24%), and depression or bipolar disorder (20%). These individuals were then followed for up to 15 years.

The study found that a patient’s use of amphetamine, lisdexamphetamine, dexamphetamine, and/or methylphenidate significantly lowered the risk of:

• Suicidal behavior
• Psychiatric hospitalization
• Non-psychiatric hospitalization

Untreated ADHD in Adults Leads to “Dire Consequences”

The authors of the study featured in JAMA Network Open believe that the decrease in hospitalizations reflects the fact that ADHD medication use is associated with decreased risk for suicide attempts,³ substance use disorder,⁴ depression,⁵ car accidents,⁶ and unintentional injuries.⁷

“Impulsivity in adults can lead to dire consequences. The idea is that by improving impulsiveness and executive functioning, people are able to make better decisions,” explains Frances Levin, M.D., author of the JAMA editorial “Treating Attention-Deficit/Hyperactivity Disorder Matters,” ⁸ in a recent interview. “If you’re dealing with a substance use disorder (SUD) population, treating the ADHD allows them to better utilize clinical treatment for their SUD, and therefore reduce their risk of substance use and reduce accidental poisoning or overdose.”

“A Significant Public Health Problem”

The mortality risk study emphasizes the importance of treating ADHD, Levin explains: “Unlike other conditions, there’s often a sense that ADHD is over-hyped or it’s not a big deal, but this article demonstrates that this group is at higher risk of having both substantial morbidity as well as mortality.”

ADHD expert Russell A. Barkley, Ph.D., echoes this sentiment, stressing that ADHD is the number one factor affecting mortality for people with the condition. In other words, ADHD is not just a mental health issue; it’s a significant public health problem.

Barkley published a study in the Journal of Attention Disorders that found adults with ADHD could expect an 11- to 13-year reduction in life expectancy compared to neurotypical peers of a similar age and health profile.⁹

However, most of the ADHD-related factors impacting life expectancy — impulsivity, risky behavior, and inattention, to name a few — can be improved with interventions. Behavioral programs designed to improve overall health will also improve life expectancy, but only if ADHD symptoms are under control first, Barkley says. That requires more accurate diagnosis and more thoughtful treatment.

“When adults ask me questions about why they should try medication to manage their ADHD, my answer always comes down to two words: Medication works,” Barkley says in the ADDitude article, “Adult ADHD Treatment Options.” “When you find the right medicine, you can experience substantial improvements in your ADHD symptoms.”

Sources

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

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

³ Chang  Z, Quinn  PD, O’Reilly  L,  et al.  Medication for attention-deficit/hyperactivity disorder and risk for suicide attempts. Biol Psychiatry. 2020;88(6):452-458. doi:10.1016/j.biopsych.2019.12.003PubMedGoogle ScholarCrossref

⁴ Chang  Z, Lichtenstein  P, Halldner  L,  et al.  Stimulant ADHD medication and risk for substance abuse.  J Child Psychol Psychiatry. 2014;55(8):878-885. doi:10.1111/jcpp.12164PubMedGoogle ScholarCrossref

⁵ Chang  Z, D’Onofrio  BM, Quinn  PD, Lichtenstein  P, Larsson  H.  Medication for attention-deficit/hyperactivity disorder and risk for depression: a nationwide longitudinal cohort study. Biol Psychiatry. 2016;80(12):916-922. doi:10.1016/j.biopsych.2016.02.018PubMedGoogle ScholarCrossref

⁶ Chang  Z, Quinn  PD, Hur  K,  et al.  Association between medication use for attention-deficit/hyperactivity disorder and risk of motor vehicle crashes.  JAMA Psychiatry. 2017;74(6):597-603. doi:10.1001/jamapsychiatry.2017.0659ArticlePubMedGoogle ScholarCrossref

⁷ Ghirardi  L, Chen  Q, Chang  Z,  et al.  Use of medication for attention-deficit/hyperactivity disorder and risk of unintentional injuries in children and adolescents with co-occurring neurodevelopmental disorders. J Child Psychol Psychiatry. 2020;61(2):140-147. doi:10.1111/jcpp.13136PubMedGoogle ScholarCrossref

⁸ Levin FR, Hernandez M, Mariani JJ. Treating Attention-Deficit/Hyperactivity Disorder Matters. JAMA. 2024;331(10):831–833. doi:10.1001/jama.2024.1755

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

ADHD symptoms in children are associated with unusual interactions between the frontal cortex and deep centers of the brain where information is processed, according to a recent report in the American Journal of Psychiatry.¹ These findings may help inform additional research into the ADHD brain that leads to more effective treatments and interventions.

A research team from the National Institute of Mental Health (NIMH) and National Human Genome Research found children with ADHD demonstrated heightened connectivity between brain structures involved in learning, movement, and reward, and frontal areas of the brain that regulate emotion, attention, and behavior.

“The present findings suggest that these brain alterations are specifically associated with ADHD and are not indicative of general features of childhood psychopathology or influenced by comorbid symptoms,” the study’s authors wrote.

Researchers have long suspected that ADHD symptoms result from atypical interactions between the frontal cortex and these deep information-processing brain structures. However, the study’s authors noted that prior studies testing this model returned mixed results, possibly due to the small size of the studies they suggested.

The present study examined more than 10,000 functional brain images of 1,696 youth with ADHD and 6,737 without ADHD aged 6 to 18. It was the “largest study to date on changes in subcortical-cortical connectivity in ADHD,” the study’s authors wrote.

The findings underscore the need for more research regarding the association between brain connectivity and ADHD symptoms, the genetic aspects of ADHD, and how brain connectivity patterns relate to treatment outcomes.

Source

¹Luke J. Norman, Gustavo Sudre, Jolie Price, Philip Shaw. (2024). Subcortico-Cortical Dysconnectivity in ADHD: A Voxel-Wise Mega-Analysis Across Multiple Cohorts. American Journal of Psychiatry. DOI: 10.1176/appi.ajp.20230026

ADHD traits such as distractibility and impulsivity may have benefited our ancestors as they foraged for food, and they continue to play a crucial role in how people with ADHD adapt and survive, suggests new research published in the journal Proceedings of the Royal Society B Biological Sciences.¹

University of Pennsylvania researchers recruited 457 study participants to play an online virtual berry-picking game. The goal was to collect as many berries as possible within eight minutes by hovering their cursor over bushes. The players could stay at a bush or move to another, which would incur a brief timeout.

Slightly less than half (45%) of the participants screened positive for symptoms consistent with an ADHD diagnosis, though this did not constitute a diagnosis because it was a self-reported assessment. Those participants spent shorter periods in each patch and achieved higher reward rates than did participants who did not exhibit ADHD traits.

The results indicated that populations with nomadic lifestyles that benefited from exploring tended to have genes associated with ADHD. Those ADHD traits continue to serve a function today.

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

While the study had limitations, the theory as to why ADHD exists — and prevails — may be validating for people with ADHD. Could ADHD traits needed for exploration, such as distractibility, impulsivity, or restlessness, help adults or children with ADHD adapt and thrive? Might this research help educate others about the condition? We asked ADDitude readers for their viewpoints.

“There Is Power in Understanding”

“Yes! I love this theory. I can see how flitting from berry bush to berry bush with my ‘Oooh, look over there!’ brain could have helped my clan thrive.”

“I find it very validating that we are ‘wired for survival.’”

“I absolutely think this theory can help educate others about the condition. However, it’s important not to minimize the struggles that come with ADHD because our modern world is geared toward neurotypical individuals. Put the ADHD mind in an environment it was made for (i.e., foraging), and it will thrive! We need to have a more inclusive view of ADHD and acknowledge both the struggles and the strengths.”

“I find this so validating! Our society and culture make me feel like I’m never good enough. I wish it were the norm to celebrate our unique strengths. We still have a long way to go, but I feel there’s a shift in that direction.”

“As an end-of-career psychotherapist, I got so excited when I read this research. There is power in understanding that we did (and do) indeed belong in the human circle.”

“I loved learning about this theory and that we would have been the ones to think outside the box and find solutions.”

“ADHD Traits Help Me Adapt and Thrive”

“I do feel like my ADHD traits have helped me adapt and thrive. Because of my restlessness and distractibility, I keep up with the latest information in my career. My impulsiveness has allowed me to take risks in my job and other areas of my life, which have turned out incredible (e.g., finding the love of my life, ending up in a career I never imagined that I love, etc.).”

“I travel and have moved a lot for work. If it weren’t for my ADHD, I wouldn’t be as successful as I am today and okay with constantly moving and changing my environment and structure.”

“Because of my ADHD, I have a much wider knowledge base on a self-reported assessment, which is useful when searching for an innovative solution to a problem. The downside is that my ADHD traits have hindered me from becoming an expert in a single subject.”

“Theories Are Great, But Attitudes Need to Change”

“I found the theory interesting and a little validating. I’d really like to see research on the potential evolutionary advantages of two other ADHD traits: hyperfocus and time-blindness.”

“I find it somewhat validating, but more often, I wish my brain would ‘get with the times.’”

“We live in a linear world. I’ve lost out on more jobs because I couldn’t give a linear answer in a job interview and seemed scattered and disorganized. Theories are great, but it’s the attitudes out there and stereotypes that need to change.”

“We Shouldn’t Have to Justify ADHD”

“Frankly, we shouldn’t have to justify ADHD based on a theoretical evolutionary advantage. I’m sick to death of having to sell the validity of disabled people as human beings to an uncaring mainstream. To be considered ‘fully human,’ the average neurotypical person does not have to demonstrate their utility (or the utility of people who shared their traits in the ancestral environment). I don’t think it’s great advocacy to lean on this stuff heavily today.”

“The theory sounds preposterous to me. Distraction, impulsiveness, and depression ruined what might have been a productive life worth living.”

“I don’t buy into the theory at all! Being distracted or impulsive while foraging for food means I’d get eaten first by the lion while those without ADHD would have run to safety.”

“This isn’t helpful. No matter what we tell ourselves to make us feel better, ADHD is not a positive trait. The people with ADHD that we see thriving in the media are the unicorns, not the norm. It won’t help educate others, but it will be a fun fact to tell my son, who has ADHD.”

“I don’t appreciate people saying that the things I struggle with daily are an evolutionary trait or ‘superpower.’ Living in the world with ADHD is hard, and it makes my life more difficult. I wish I didn’t have ADHD.”

“This theory is only validating if it leads to improvements or advances in treatment or ways to handle ADHD symptoms. Is it going to help me get stuff done? Will it help my child succeed in school, be a competent and caring adult, and have meaningful friendships? If not, it might be interesting to think about, but otherwise, it doesn’t matter much to me.”

Sources

¹Barack, D.L., Ludwig, V.U., Parodi, F., Ahmed, N., Brannon, E.M., Ramakrishnan, A.M., and Platt, M.L. (2024). Attention Deficits Linked with Proclivity to Explore While Foraging. Proceedings of the Royal Society B Biological Sciences.doi.org/10.1098/rspb.2022.2584.

High-intensity exercise treats depression as effectively as do cognitive behavior therapy (CBT) and medication, according to a new study that found combining SSRIs, a type of antidepressant, with exercise improved depressive symptoms more than medication alone.¹

The systematic review and meta-analysis led by a research team from the University of Queensland, Australia, found that the more intense the physical activity, the more effective it was at managing depression. More specifically, vigorous exercises (e.g., running, interval training, strength training, mixed aerobic exercise) reduced depression symptoms in participants more than light physical activity (e.g., walking and hatha yoga), although the latter did provide some benefit.

These findings emerged from examinations of 218 randomized controlled trials, including 14,170 participants diagnosed with depression, to determine the effectiveness of exercise, psychotherapy, and antidepressants in treating depression.

When the researchers narrowed their analysis by demographics, they discovered that strength training and cycling positively impacted more women than men, and yoga or qigong provided more benefits to men than women. Yoga appeared more effective among older adults, and younger adults received better results from strength training. The duration and frequency of exercise did not affect the results.

The study also suggested that men appeared to benefit more than women from combining yoga, Tai Chi, or aerobic exercise with psychotherapy. Yoga and aerobic exercise combined with psychotherapy seemed more effective among older adults.

Participants gained the most benefits from group classes or scheduled exercises. The more autonomy participants had over their exercise programs, the weaker the outcome. “When provided with more freedom, the low self-efficacy that is symptomatic of depression may stop patients from setting an appropriate level of challenge (e.g., they may be less likely to choose vigorous exercise),” the study’s authors wrote.

The researchers cautioned that definitive conclusions are impossible to draw, and more studies are needed. “Our review did not uncover clear causal mechanisms, but the trends in the data are useful for generating hypotheses,” they wrote. “It is unlikely that any single causal mechanism explains all the findings in the review.”

“Exercise should be considered alongside traditional interventions as a core treatment for depression,” report author Michael Noetel, Ph.D., said in a press release. “No matter how often people exercised, whether they had other health issues or how severe their depression was, in all scenarios, exercise had a meaningful impact on their depression. Of course, anyone getting treatment for depression should talk to their doctor before changing what they are doing, but most people can start walking without many barriers.”

Exercise and Depression

Members of ADDitude’s reader panel confirm several findings from the study published in The BMJ (British Medical Journal).

“Strenuous full-body aerobic activities like boxing, karate, swimming, or boulder climbing help me get my thoughts in the right place and boost my mood and energy,” one panelist wrote. “Physical activity also helps me fall asleep and feel less stressed overall.”

“Running helps with my anxiety and depression,” another reader said. “It’s like a vacation for my overstimulated brain.”

A recent retiree who goes to the gym six days a week for group fitness classes and strength training sessions with a personal trainer shares that physical activity helps him feel calmer and more focused. “Exercise gives me a sense of accomplishment and community,” he says. “It is truly my second medication.”

Exercise Benefits Children and Teens with ADHD

The benefits of physical activity are not limited to adults; exercise improves the mental health of children and adolescents with neurodevelopmental disorders (NDDs), including ADHD, learning and motor disorders, autism spectrum disorder (ASD), and intellectual disability, according to a recent systematic review and meta-analysis published in JAMA Pediatrics.²

The researchers found that high-frequency (more than 27) 40-minute sessions of physical activity significantly benefited cognitive function, psychological well-being (e.g., self-esteem, quality of life), internalizing (e.g., anxiety and depression), and externalizing (e.g., aggression and disruptive behavior disorders) behaviors in children and adolescents aged 5-17 years with NDDs. They examined 59 studies with more than 3,000 participants.

ADDitude caregivers recognized similar results from their children after participating in physical activities.

One reader takes their son to the YMCA at least three times per week. “Depression can really take hold of my 10-year-old son,” the parent said. “We see great improvements after physical activity. He enjoys the elliptical, rower, spin bikes, automatic stepper, and treadmill.”

“My daughter has been playing hockey since she was young,” a reader said. “She says she can slow her brain down when she’s on the ice and think more clearly, and it’s as if her ‘ADHD evaporates.’”

“Intense cardio activities, like cross-country skiing and soccer, help my son burn off some of his boundless energy, and he gains self-confidence by being good at something nonacademic,” a reader said.

Another reader said, “My oldest is a distance runner. He is committed and gets up early to run his miles or workout. Running gives him that needed dopamine hit to keep his ADHD symptoms under control at the start of the school day.”

Incorporating Exercise in Depression Treatment Plans

A 2023 treatment survey of 11,000 ADDitude readers reaffirms both studies’ findings. Roughly half of the respondents who use this treatment rated exercise as “extremely” or “very” effective. A staggering 94% of caregivers and 95% of adults recommend exercise to treat ADHD symptoms. Yet only 13 % of these respondents said a doctor had recommended exercise to reduce symptoms, and only 37% of all respondents said physical activity was part of their treatment plan.

The BMJ study encourages clinicians to consider exercise a viable alternative to drug treatment or adjuvant for those already taking medication. “The findings support the inclusion of exercise, particularly vigorous exercise, in clinical practice guidelines for depression,” they wrote. “This may help bridge the gap in treatment coverage by increasing the range of first-line options for patients and health systems.”

Sources

¹Noetel, M., Sanders, T., Gallardo-Gómez, D., Taylor, P., del Pozo Cruz, B., van den Hoek, D. et al. (2024). Effect of Exercise for Depression: Systematic Review and Network Meta-Analysis of Randomised Controlled Trials. BMJ. doi:10.1136/bmj-2023-075847.

²Liu C, Liang X, Sit CHP. (2024). Physical Activity and Mental Health in Children and Adolescents with Neurodevelopmental Disorders: A Systematic Review and Meta-Analysis. JAMA Pediatr. doi:10.1001/jamapediatrics.2023.6251.

We know that wild swings in estrogen levels dramatically worsen ADHD symptoms and that symptom severity grows more pronounced with age, according to more than 2,000 women aged 18 to 82 who participated in ADDitude’s research on the impact of hormonal fluctuations on female ADHD symptoms.

Most experts believe that hormonal fluctuations during the menstrual cycle exacerbate different symptoms of ADHD depending on the phase (menstruation, follicular, ovulatory, or luteal). ¹ However, research has not adequately addressed this relationship.

Which is why the ADDitude editorial team is fielding a survey of menstruating readers to discover how ADHD symptoms shift, spike, wane, and change during the four phases of the menstrual cycle. If you’re interested in contributing to ADDitude’s research on hormones and ADHD, please do the following:

1. Download the Menstrual Cycle Workbook.
2. Chart your symptoms for two months.
3. Fill out this short, anonymous survey.

Your experiences and insights will not only empower you to make more informed treatment decisions with your doctor, but it will add to a much-needed area of research about women with ADHD.

We will publish an analysis of the survey results later this year. Please know that ADDitude never shares personal medical information without explicit permission, and it never publishes survey respondents’ full names.

Source

¹ Eng et al. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Horm Behav, 158, 105466.