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

When administered at carefully selected dosages in clinical settings, and combined with therapy before and after treatment, psychedelics have been found to provide rapid relief from some of the most painful and difficult-to-treat mental health conditions. Ketamine is being used for depression and suicidality in clinical trials. MDMA is treating severe post-traumatic stress disorder (PTSD), and psilocybin is being used for treatment-resistant depression, alcohol use disorder, and more.

However, important questions remain about the long-term efficacy and safety of psychedelics, as well as patient suitability. Several large-scale studies are now under way to address these concerns, including the first-ever phase 3 clinical trial on psilocybin-assisted therapy — the largest randomized, controlled, double-blind study on the drug, with more than 800 participants. Initial results are expected this summer.

How Do Psychedelics Work?

Research shows that psychedelics improve many neuropsychiatric disorders, but the way they work is less clear. Functional MRIs and laboratory studies offer possible explanations:

• Ketamine binds to NMDA receptors in the brain, increasing levels of a mood-regulating neurotransmitter called glutamate.¹
• MDMA increases oxytocin, dopamine, and other chemical messengers related to positive emotions.²
• Psilocybin stimulates the brain’s serotonin 2A receptors, appearing to decrease activity across the default mode network.³

But these biochemical explanations don’t tell the full story, says Gül Dölen, M.D., Ph.D., professor of psychology and researcher at University of California Berkeley’s Center for the Science of Psychedelics. Psychedelics only reliably improve psychiatric conditions when administered with therapy. “Therapy is the context to get the cure,” Dölen explains. “You can’t take MDMA and go to a rave and expect it to cure your PTSD.”

Indeed, when taken on their own, psychedelics aren’t hugely effective, according to studies; therapy unlocks the drugs’ enduring benefits. Also, there are serious risks to taking the drugs without medical supervision.

[Read: The Truth About Lion’s Mane, Psychedelics & Caffeine]

A Brand-New Framework

Most psychiatric medications must be taken daily, often for a lifetime. By contrast, a single dose of certain psychedelics paired with therapy can result in full-blown remission. This claim appears too good to be true when viewed through the traditional “biochemical imbalance” model of neuropsychological disease that has dominated the field for the past 50 years. “The idea is that depression, for example, is a biochemical imbalance in serotonin,” Dölen says. “So, we’ll restore serotonin levels with a pill, and you’ll get better.”

But what if there were an approach that treated depression by restoring the fundamental ability to learn (and unlearn) behaviors and ways of thinking, and not by raising serotonin levels? It’s an entirely different framework for understanding neuropsychiatric disorders — the learning model — and Dölen says it’s the best way to comprehend how psychedelics work.

Psychedelics act like master keys unlocking what scientists call “critical periods” of learning—specific times when individuals have a heightened ability to soak in new information. During brain development, these are the critical windows in which we acquire vision, language, motor development, and more. And after these critical windows close, they remain locked.

Or so we thought.

Psychedelics Restore Child-Like Learning

In a study that involved giving mice MDMA, Dölen found that the drug unlocks a critical period for social reward learning, restoring adult mice to child-like levels of openness for social development.⁴ Dölen’s next study uncovered the potential of all psychedelics—including LSD, psilocybin, ketamine, and ibogaine—to open these critical periods.⁵

[Watch: “Psychedelic Therapy for Mood Disorders: Research & Potential”]

“This is a big deal,” says Dölen. “And if it’s true, it’s going to revolutionize things, but only if we understand what a critical period is. It’s not that you take a pill and you speak Japanese. It’s that you take a pill and you restore the ability to learn Japanese.”

The drugs open the mind to learning. The therapy provides the learning itself.

“Patients talk about how they had an epiphany, how the trip enabled them to see how they’d built their lives around a foundational myth that wasn’t true, whether about their relationship to other people, their personality, their deserving to be in the world,” Dölen says. The post-trip therapy, in turn, allowed them to identify how that myth led to maladaptive ways of interacting with the world, and understand how to integrate that knowledge into their daily lives.

The potential of psychedelics to re-open critical periods has far-reaching implications. Dölen’s lab is exploring the possibilities of treating conditions like stroke and blindness with psychedelics through a project called PHATHOM (Psychedelic Healing: Adjunct Therapy Harnessing Opened Malleability).

“Psychedelics are not going to be the magic bullet that fixes everything, but we’re excited about the possibilities,” Dölen says. “Being able to restore child-like learning is a major therapeutic opportunity.”

Psychedelics Therapy and Mental Health: Next Steps

• Self-Test: Symptoms of Depression in Adults
• Free Download: Signs of Depression That May Surprise You
• Read: Real Stories of Using Ketamine for Depression, Anxiety, PTSD

Nicole C. Kear is Consumer Health Editor at ADDitude.

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

Sources

¹ Matveychuk D, Thomas RK, Swainson J, Khullar A, MacKay MA, Baker GB, Dursun SM. Ketamine as an antidepressant: overview of its mechanisms of action and potential predictive biomarkers. Ther Adv Psychopharmacol. 2020 May 11;10:2045125320916657. doi: 10.1177/2045125320916657. PMID: 32440333; PMCID: PMC7225830.

² Mitchell, J.M., Bogenschutz, M., Lilienstein, A. et al. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nat Med 27, 1025–1033 (2021). https://doi.org/10.1038/s41591-021-01336-

³ Smausz R, Neill J, Gigg J. Neural mechanisms underlying psilocybin’s therapeutic potential – the need for preclinical in vivo electrophysiology. J Psychopharmacol. 2022 Jul;36(7):781-793. doi: 10.1177/02698811221092508. Epub 2022 May 30. PMID: 35638159; PMCID: PMC9247433.

⁴ Nardou, R., Lewis, E.M., Rothhaas, R. et al. Oxytocin-dependent reopening of a social reward learning critical period with MDMA. Nature 569, 116–120 (2019). https://doi.org/10.1038/s41586-019-1075-9

⁵ Nardou, R., Sawyer, E., Song, Y.J. et al. Psychedelics reopen the social reward learning critical period. Nature 618, 790–798 (2023). https://doi.org/10.1038/s41586-023-06204-3

ADHD doesn’t travel alone. Most teens with ADHD also have a co-occurring condition like anxiety or depression. Sometimes the co-existing condition is a result of the ADHD, and other times it operates alongside ADHD.

When a patient presents these conditions together, it can create a varied clinical picture because each diagnosis impacts, and is impacted by, the other. This can sometimes lead to misdiagnosis or inadequate treatment for at least one condition. The challenge in diagnosis and treatment can also be complicated by puberty.

In this webinar, you will learn:

• The symptoms of depression and anxiety disorders, and how to distinguish them from ADHD and normal child and adolescent development
• How depression or anxiety affects ADHD symptoms
• How ADHD can actually lead to, or affect, depression and anxiety
• How to devise a treatment plan when ADHD exists alongside anxiety or depression

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Depression, Anxiety, & ADHD in Teens: More Resources

• Download: A Parent’s Guide to Depression in Teens
• Replay: The ADHD-Depression Connection in Adults with Dr. Roberto Olivardia
• Learn: Why Anxiety Disorder Is So Often Misdiagnosed
  
• Q&A: New Approaches to Treating Depression and ADHD

Obtain a Certificate of Attendance

If you attended the live webinar on April 9, 2024, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker

Roberto Olivardia, Ph.D., is a Clinical Psychologist and Clinical Instructor of Psychology at Harvard Medical School. He maintains a private psychotherapy practice in Lexington, Massachusetts, where he specializes in the treatment of attention deficit hyperactivity disorder (ADHD), executive functioning issues, and issues that face students with learning differences.

He also specializes in the treatment of Body Dysmorphic Disorder (BDD), Obsessive-Compulsive Disorder (OCD) and in the treatment of eating disorders in boys and men. He is co-author of The Adonis Complex, a book which details the various manifestations of body image problems in men. (#CommissionsEarned) Read more here.

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

Listener Testimonials

“All of the webinars are very good. This was one of the best!”

“A fantastically rich and engaging presentation! I firmly believe that I’m now significantly better informed of the interaction and distinctions between anxiety, depression, and ADHD. Thank you, Dr. Olivardia and ADDitude!”

“Good info and good mention of cannabis findings at the end as a surprise inclusion. Did not know any of that.”

Webinar Sponsor

The sponsor of this ADDitude webinar is…

Play Attention: ADHD and Executive function challenges can lead to anxiety, and this anxiety can further impair executive functioning by affecting the brain’s processing and decision-making abilities. That’s why Play Attention offers a personalized program designed to enhance executive function and improve self-regulation. Backed by research from Tufts University School of Medicine, Play Attention empowers individuals to improve attention, emotion regulation, and overall performance. Our NASA-inspired technology ensures tailored support for every aspect of life. Take our ADHD test or schedule a consultation to start your journey toward improved executive function and emotion regulation with Play Attention. Call 828-676-2240. www.playattention.com

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The number of clinics offering infusions of ketamine — the only psychedelic that is legal nationwide — has exploded. Research on the drug known as ecstasy, or MDMA (3,4-methyl-enedioxymethamphetamine), has shown such promise for treating severe PTSD that pharmaceutical companies are preparing to seek FDA approval.¹ Experts say psilocybin, the psychoactive ingredient in magic mushrooms that has shown efficacy for treatment-resistant depression,² may not be far behind.

Used under medical supervision and paired with pre- and post-drug therapy, these psychedelics have been life-changing in alleviating symptoms for many patients. Bob, an ADDitude reader in Arizona, took part in a clinical trial involving psilocybin for obsessive-compulsive disorder (OCD). “I have not had OCD symptoms since I finished the trial over a year ago,” he says.

Bob has also been receiving ketamine treatments for depression, anxiety, ADHD, and complex PTSD. He says the treatments have been more effective than cognitive behavioral therapy and prescription antidepressants, and without the “difficult side effects.”

While many patients like Bob report profound benefits from psychedelics, some psychiatrists and researchers fear that the pharmaceutical industry is moving too quickly toward legalization, while important questions about long-term efficacy and safety remain.

[Read: Real Stories of Using Ketamine for Depression, Anxiety, PTSD]

Psychedelic Therapy: A Blast from the Past

Psychedelics have an ancient history of medicinal use by the Aztecs and other civilizations. In Western culture, the groundbreaking potential of psychedelics to heal disorders of the mind took root around 1950, when the first English-language paper citing their therapeutic benefits was published. By 1960, Sandoz Pharmaceuticals had begun manufacturing psilocybin and LSD, substances later popularized, in part, by iconic Harvard psychologist Timothy Leary, Ph.D.

For years, he and other therapists embraced these experimental drugs for their potential to aid patients. At the same time, LSD played a major role in the counterculture movement of the 1960s. When then-President Richard Nixon outlawed all psychedelics in 1970, the drugs became associated with criminality. That effectively ended most research into psychedelics’ therapeutic value for 30 years.

In 2000, a new era of research began when scientists from Johns Hopkins University secured regulatory approval to study the effect of psychedelics on behavior, brain function, learning and memory, and mood. In 2020, Johns Hopkins opened a psychedelics research center. Since then, most of the country’s elite universities have followed suit. Researchers at Yale, Stanford, Universities of California Berkeley and San Francisco, and New York University have conducted clinical trials investigating the therapeutic benefits of psychedelics on mental health disorders.

[Read: LSD, MDMA, Magic Mushrooms Clinical Trial Guidelines Released by FDA]

“Monumental Results”

For patients diagnosed with depression and in acute distress, waiting six weeks for commonly prescribed antidepressants to begin working may not be feasible, says Gregory Barber, M.D., a psychiatrist in Bethesda, Maryland, and author of “Ethical and Practical Implications of Psychedelics in Psychiatry,” a scientific review that was published recently in the American Psychiatric Association’s Psychiatric Services journal.³ Ketamine, however, has been shown to improve mood sometimes after only one or two infusions.

“With psychedelics, there is some evidence to suggest that even single doses have medium- to long-term effects,” Barber says. “The ability to simplify treatment in this way would be a real paradigm shift.”

Karlyn, an ADDitude reader, knows this first-hand. Diagnosed with bipolar disorder and ADHD, she had been taking antidepressants for 16 years. “My psychiatrist recommended ketamine infusions in 2021 when I was acutely suicidal. It was the best drug that I have ever used for depression. By the fourth infusion, I felt relief,” she says.

Eight percent of Americans suffer from major depressive disorder (MDD). While a majority of individuals seek treatment, about 30 percent find no relief from antidepressants.⁴ This means that millions of Americans struggle with troubling symptoms like sadness, hopelessness, and suicidality.

Elizabeth Wolfson, Ph.D., a California psychotherapist who has been in practice for 30 years, says she has integrated ketamine into her therapy with “monumental” results. “It augments and deepens the work that people do in psychotherapy and accelerates the process in a way that I see as transformative,” she says.

Psychedelic Therapy: Investigating Risks

Psychedelics’ powers to heal have been heralded in countless headlines, so it’s no surprise that the drugs have recently enjoyed a surge in popularity. According to the National Survey on Drug Use and Health, 7.1 million Americans used hallucinogens in 2020. Proof of a changing public perception is apparent in Oregon and Colorado, where citizens have voted to legalize psilocybin.

The drugs, however, are not without risk. When psychedelic use takes place outside therapeutic settings, the symptoms people are trying to improve may actually worsen. The “therapy” part of psychedelic-assisted therapy is essential to positive outcomes.

In clinical trials and at carefully selected doses, ecstasy, ketamine, and psilocybin have produced generally mild side effects. When taken at higher doses, these drugs can cause disorientation, paranoia, and panic, which can lead to dangerous behavior, accidents, self-harm, and even suicidality. Other adverse effects include the potential for hallucinogen persisting perception disorder (a rare condition in which patients previously exposed to hallucinogenic drugs continue to experience distorted perceptions of the world around them months or years later), misuse, and abuse.

“The clinical trials have had very exciting results, but those results came in carefully controlled research settings with mental health professionals who have hundreds of hours of training,” Barber says. “It doesn’t mean that you will get similar benefits in other settings.”

Important Questions Remain

Experts agree that large-scale research on the long-term effects of psychedelics is needed. Many aspects of how the drugs work, their long-term outcomes, safety concerns, and patient suitability for treatment are still not known.

“I’ve seen psychedelics transform people positively very quickly, but I’ve also seen it be very challenging for people both in the moment and after the experience,” Barber says. “Psychedelics are not going to be for everyone nor solve every problem.”

Patient Suitability

People who have the following conditions or history are not considered good candidates for psychedelic-assisted therapy:

• a personal or family history of psychosis
• unstabilized bipolar disorder
• high blood pressure
• heart disease
• thyroid disease

Psychedelics Research Timeline

1943: LSD’s psychoactive effects are discovered by Swiss chemist Albert Hoffman.

1950: First English-language publication suggests LSD may aid psychotherapy.

1957: The term “psychedelic” is coined. Life magazine publishes “Seeking the Magic Mushroom.”

1960: Harvard psychologist Timothy Leary begins experiments with psilocybin.

1963: LSD is sold on the street in sugar cubes. Timothy Leary is fired by Harvard.

1965: Sandoz stops manufacturing LSD and psilocybin.

1997: Swiss scientists publish new research on the effects of psilocybin on humans.

2000: Johns Hopkins researchers secure regulatory approval to resume psychedelics research.

2017: FDA grants “breakthrough” status to MDMA and psilocybin, putting the drugs on a fast track for approval.

2023: Findings of Phase 3 clinical trials on MDMA for PTSD are published.

Psychedelic Therapy & Mental Health: Next Steps

• Self-Test: Symptoms of Depression in Adults
• Read: Treatments for Depression and ADHD-New and Forthcoming Approaches
• Read: The Relationship Between PTSD and ADHD

Nicole C. Kear is Consumer Health Editor at ADDitude.

Sources

¹Mitchell, J.M., Bogenschutz, M., Lilienstein, A. et al. MDMA-Assisted Therapy for Severe PTSD: A Randomized, Double-Blind, Placebo-Controlled Phase 3 Study. Nat Med. 2021(27),1025–1033.

²Goodwin, G., Aaronson, S., Alvarez, O. et al. Single-Dose Psilocybin for a Treatment-Resistant Episode of Major Depression. N Engl J Med. 2022 Nov 3.; 387:1637-1648. DOI: 10.1056/NEJMoa2206443

³Barber GS, Dike CC. Ethical and Practical Considerations for the Use of Psychedelics in Psychiatry. Psychiatr Serv. 2023 Aug 1;74(8):838-846. doi: 10.1176/appi.ps.20220525. Epub 2023 Mar 29. PMID: 36987705.

⁴Zhdanava M, Pilon D, Ghelerter I, Chow W, Joshi K, Lefebvre P, Sheehan JJ. The Prevalence and National Burden of Treatment-Resistant Depression and Major Depressive Disorder in the United States. J Clin Psychiatry. 2021 Mar 16;82(2):20m13699. doi: 10.4088/JCP.20m13699. PMID: 33989464.

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

I just want to validate how hard this is and the importance of advocating for your student by moving him to a different school and trying to set him up for success.

Sometimes, smaller-group social interaction, even with one or two other peers who have similar interests, is better than trying to jump into a larger group or sports team. So, if your student likes basketball and he meets another student who likes the sport, your son might invite them to shoot hoops after school. You also might want to think about less competitive activities, like musical performances, that encourage positive peer interactions.

It gets more complicated in high school. Teachers typically don’t recognize shared interests among students like elementary school teachers do, but after-school clubs and activities can help your child identify and interact with like-minded peers in a safe space. Sometimes, once they gain confidence from a successful club or online interaction, a teen can move on to a one-on-one friendship.

Bullying Risk Factors

School bullying remains a serious problem in U.S. schools, particularly for students with ADHD, autism, learning differences, and other comorbidities. In an ADDitude survey, 61% of more than 1,000 caregivers said their neurodivergent child was bullied at school.

[Free Guide: Help Your Child Make Friends]

Children are at greater risk of becoming a bully, or being bullied, if they have:

• ADHD, anxiety, and/or autism
• Poor inhibition
• Developmental delays
• Difficulty making friends
• Poor self-regulation

In an ADDitude survey, 61% of more than 1,000 caregivers said their neurodivergent child was bullied at school. Children were bullied beyond school in the following environments:

• Social media 32%
• School bus 30%
• Text messages 27%
• Club/sports team 19%

Bullying was perpetrated by:

• Child’s classmate 66%
• Multiple students 49%
• A friend 29%
• A teacher, school staff member, or coach 26%

While bullies target neurodivergent children, few are punished at school, ADDitude readers say.

“The school always blamed my child for causing issues,” says one reader. “His peers knew how to wind my son up, and then he would get the blame. He had no control over his emotions.”

Says another reader, “Once a teacher starts to bully a child, it becomes open season for peer social abuse and torment.”

Most survey respondents (71%) were unsatisfied with the school’s response to bullying, which included:

• Never acknowledged the bullying 37%
• Gave a verbal warning to the bully 30%
• Spoke to the child about being bullied 28%
• Punished the child who was bullied 15%
• Disciplined the bully 12%
• Provided support services for the child 9%

“I work with my child to resolve the conflict himself first, and then if the bullying continues, we involve the school,” says a reader.

[Free eBook: Time to Change? Great Schools for ADHD Kids]

Q2: “My teen won’t open up to me about what’s happening at school. I know there has been drama with her friends. How can I help her when she refuses to talk?”

Let your teen come to you when she’s ready; don’t force it. That dreaded question, “How was your day at school?” is not a good way to encourage openness. Try to find times when talking happens naturally, like during car rides or while making dinner. Open those conversations by asking, “What are you looking forward to today?” or “Is there anything that you’re worried about today?”

Over time, when she does come to you with problems, make sure that you’re providing supportive responses and not trying to just jump in and fix things. Sometimes, teens just want to be heard and validated. You might say, “What do you need right now? Do you just want me to listen? Do you want me to help you solve this? Do you just want to vent?” Being able to meet her where she’s at, in that moment, is key.

School Bullying and Social Anxiety: Next Steps

• Read: Bullying Is the Norm. So Is an Inadequate Response.
• Read: Will My Child Find a Best Friend This School Year?
• Download: Free Guide: Social Anxiety Facts and Falsehoods
• Watch: “My Child Is Being Bullied at School!” Strategies for Parents

Rosanna Breaux, Ph.D., is a licensed clinical psychologist, director of the Virginia Tech Child Study Center, and assistant professor of psychology.

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

Anxiety is one of the most common comorbidities in teens and college students with ADHD, especially for girls. More than half of girls with ADHD will have some level of anxiety.

When I’m considering how to proceed with treating comorbid ADHD and anxiety, I always think: “What’s driving the bus?”

[Read: ADHD and Anxiety – Symptoms, Connections & Coping Mechanisms]

For some people, the anxiety is a true, primary diagnosis. This would include cases where the anxiety takes the form of OCD or panic disorder. In those cases, I would likely start by treating the anxiety, and then move on to treating the ADHD.

Then there are other situations where the anxiety may be directly related to the ADHD. In these cases, the anxiety may arise because the patient is feeling out of control, unable to manage time, unable to keep all these different balls in the air. Is the patient anxious because they’re overwhelmed by these things? If so, treatment of ADHD can help quite a bit with anxiety.

[Self-Test: Generalized Anxiety Disorder in Adults]

In these cases, I’ll usually start by treating the ADHD. While stimulants can sometimes exacerbate anxiety in some patients, this can typically be avoided by using long-acting, smooth-release formulations of stimulants and by starting low and going slow as you titrate dosage, monitoring anxiety throughout. Atomoxetine or viloxazine can also be effective at treating ADHD in people with co-occurring anxiety disorders. If other options don’t prove effective, guanfacine is an ADHD treatment option that doesn’t exacerbate anxiety.¹

Anxiety in Teens: Next Steps

• Read: 5 Ways to Reframe Anxiety for Your Worried Teen
• Read: What If You Are Enabling Your Child’s Anxiety?
• Watch: Anxiety in Children: Overlooked Signs and Effective Supports
• Read: 6 Types of Anxiety

The content for this article was derived from a webinar presented by The American Professional Society of ADHD and Related Disorders (APSARD) titled “ADHD Treatment in the Primary Care Setting: The Teenage Years” with Greg Mattingly, M.D., which was broadcast on October 13, 2023.

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Sources

¹Mattingly, G., Wilson, J., Ugarte, L., & Glaser, P. (2021). Individualization of attention-deficit/hyperactivity disorder treatment: Pharmacotherapy considerations by age and co-occurring conditions. CNS Spectrums, 26(3), 202-221. doi:10.1017/S1092852919001822

By Russell Barkley, Ph.D.

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

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

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

DSM-5 ADHD Criteria Challenged: Related Resources

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

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

By William French, M.D., DFAACAP

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

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

Irritability in Children: Related Resources

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

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

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

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

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

Treatments for Depression: Related Resources

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

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

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

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

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

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

Bipolar Disorder and ADHD: Related Resources

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

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

By Joel Nigg, Ph.D.

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

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

What Causes ADHD? Related Resources

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

6. The Future of ADHD Research Looks Like This

By Peter Jensen, M.D.

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

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

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

ADHD Research Updates: Related Resources

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

7. Sobering Advice: How to Treat ADHD Alongside SUD

By Timothy Wilens, M.D.

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

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

Substance Use Treatment with ADHD: Related Resources

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

8. First-Ever Adult ADHD Guidelines Forthcoming

By Carole Fleck

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

Continue reading “First-Ever Adult ADHD Guidelines Forthcoming”

ADHD Treatment & Diagnosis Guidelines: Related Resources

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

9. How Undiagnosed ADHD Triggers Depression and Anxiety

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

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

Continue reading “How Undiagnosed ADHD Triggers Depression and Anxiety”

Untreated ADHD in Adults: Related Resources

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

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

By ADDitude Editors

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

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

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

ADHD Medication Shortage: Related Resources

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

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

While research indicates that ADHD is associated with driving risks, it doesn’t mean every single individual with ADHD is doomed to experience problems behind the wheel. With that in mind, the first issue here may be how your teen perceives his ADHD.

Your child should understand the realities and challenges of living with the condition, but not to the point where he becomes overwhelmed and develops a doom-and-gloom, defeatist perspective on life. The best way to curb these limiting beliefs is to talk to your child about his ADHD from a strengths-based approach. Over time, he’ll develop a strong sense of self and confidence in his ability to adapt to the inevitable challenges of living with ADHD.

[Read: “‘Your Brain Is Amazing!’ 5 Things All Neurodivergent Teens Need to Hear”]

He should also know that there are risk factors outside of ADHD that impact driving, and researchers (like myself) are studying ways to make driving safer for teens like him. We know, for example, that being actively medicated drastically improves driving performance in individuals with ADHD.¹ We’ve also successfully trained teens with ADHD to reduce time spent looking away from the road and, in doing so, saw a huge drop in the number of crashes/near-crashes for this group.² Other tools, like driving contracts and tracking apps, can also encourage safe driving. In all, there’s a lot more in your teen’s control to promote safe driving than he probably thinks.

Finally, avoidance only builds and maintains fear and anxiety. I encourage your teen to practice driving in safe conditions for as long as it takes for him to feel comfortable. If it’s challenging for you to remain supportive and calm in the passenger seat, have your child work with a professional driving instructor instead.

Driving Anxiety and ADHD: Next Steps

• Free Download: Driving Contract Template for Teen Drivers with ADHD
• Read: Is Your Teen Ready to Drive? How to Tell
• Read: How to Steer Your Teen Toward Safe Driving

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “Teen Driving Rules: ADHD Guardrails to Avoid Distractions and Accidents” [Video Replay & Podcast #455] with Annie Artiga Garner, Ph.D., which was broadcast on May 18, 2023.

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

¹ Garner, A. A. (2020). Driving in adolescents with ADHD and the road to intervention. In S. P. Becker (Ed.), ADHD in adolescents: Development, assessment, and treatment (pp. 255–277). The Guilford Press.

² Epstein, J. N., Garner, A. A., Kiefer, A. W., Peugh, J., Tamm, L., MacPherson, R. P., Simon, J. O., & Fisher, D. L. (2022). Trial of Training to Reduce Driver Inattention in Teens with ADHD. The New England journal of medicine, 387(22), 2056–2066. https://doi.org/10.1056/NEJMoa2204783

Episode Description

The holiday season is usually portrayed as a joyous time of year. But many experience the holidays differently.  The “holiday blues, can include heightened depression, anxiety, and other mental health symptoms.

In this informational webinar, John Whyte, M.D., will talk about the holiday blues, and what to do if you or someone you love struggles with them. Dr. Whyte will share information about what this condition is (and what it’s not), including its symptoms and triggers, who is at risk, treatment, prevention, tips for coping, and when to seek professional help.

In this WebMD webinar, you’ll learn about:

• What holiday blues are, how long symptoms can last, and whether they can lead to serious long-term mental health issues
• How many people are affected and who’s at risk for experiencing the holiday blues
• What factors can trigger the holiday blues
• How to know if you’re experiencing the holiday blues or something more serious like clinical anxiety or clinical depression
• When and how to get professional help
• Tips to avoid the holiday blues and protect your mental health this holiday season

Click here to view the full list of on-demand and upcoming WebMD webinars.

More on Holidays & Mental Health

• Download: Scripts to Use When Emotionally Dysregulated
• Resource Center: Mental Health Out Loud
• Read: “Holiday Stress and Anxiety Affect My Kids. How Can We Strike a Healthy Balance?”
• Read: Does Your ADHD Help or Hurt During the Holidays?

Meet the Expert Speaker

WebMD Chief Medical Officer John Whyte, M.D., M.P.H., has communicated with the public about health issues for nearly two decades. He leads efforts to develop and expand strategic partnerships that create meaningful change around important and timely public health issues. Prior to WebMD, he was Director of Professional Affairs and Stakeholder Engagement at the Center for Drug Evaluation and Research at the U.S. Food and Drug Administration (FDA).

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Treatment rates worldwide are consistently low for children and adolescents with diagnosed mental disorders, according to an international study published by JAMA Open Network¹ that showed significant variations in treatment by age, income level, and region.

The meta-analysis included data for 310,583 children across 40 studies from 1984 to 2017. The lowest combined treatment rate was reported for youth diagnosed with anxiety disorders (31% treated), followed by depressive disorders (36%), behavior disorders (49%), and ADHD (58%).

Timely treatment of common mental disorders reduces the risk of negative outcomes later in life, such as substance abuse. Despite rising global health concerns, mental disorders continue to go untreated for many children and teens. The severity of this issue is unclear because prevalence rates reported by published studies can vary widely, according to researchers. Combining data can help guide public health efforts and resources.

“Our findings provide important evidence for constructing evidence-based, targeted intervention policies and measures that aim to improve treatment rates for mental disorders among children and adolescents,” the researchers wrote.

Anxiety, Depression, and Age

The combined treatment rates for mood disorders varied significantly based on the age of participants. The proportion of children treated for anxiety disorders was more than three times higher than it was for adolescents. The inverse was true for depressive disorders; compared to children, more than three times as many adolescents with depression received treatment.

“The onset of childhood depression can be subtle: children may express irritability and frustration through tantrums and behavioral problems rather than verbally expressing their feelings,” the researchers wrote. But children with anxiety “are more prone to experiencing physical symptoms such as shortness of breath, headaches, stomach pain, and heart palpitations, which may prompt parents to seek assistance.”

In her recent ADDitude webinar on depression in teens, Karen Swartz, M.D., said that the onset of depressive symptoms is typically followed by an eight-year delay in getting treatment. The episodic nature of depressive disorders makes it easier to overlook. “You don’t have symptoms continuously that whole time. What you have is a period of symptoms and then it goes away, and then it comes back, and then it goes away, and then it comes back.”

“A teenage episode gets written off as being teenage angst,” she continued. “And then maybe a college episode, people will party through it and say, ‘Oh, you were just partying too much.’ So, it’s later when someone wants to focus on raising their family, keeping their job, doing those things, that they’ll get into treatment.”

Other Factors: Income Level and Region

Significant differences in depression and anxiety treatment rates were also found among income groups and regions. However, only high-income countries reported treatment rates for ADHD and behavior disorders. Cumulative social disadvantages and relative income poverty increase the risk of ADHD,² underscoring the need for reporting practices and additional resources in countries and regions of relatively lower income.

“Compared with high-income countries, mental health services are severely underfunded in low- and middle-income countries: according to the World Health Organization 2020 Mental Health Atlas, government annual mental health expenditure per capita was $52.73 in high-income countries, compared with $3.29 in upper-middle-income countries and $0.08 in low-income countries.”

Treatment rates for depression were higher in the Americas than in Europe and the Western Pacific region, even when controlling for income. The researchers said that negative biases against people with mental disorders are common in Western European countries, citing an unwillingness by European adults to seek professional help for emotional distress (41% to 45%) compared to U.S. adults (23%).

Other common treatment barriers cited in the study include lack of public awareness, social stigma, costs, and logistical concerns. An ADDitude survey of 1,187 caregivers conducted in 2022 found scheduling conflicts, lack of accessibility, and long wait lists also influence access to and use of mental health services.

Limitations and Future Research

“Despite the consensus on the more hazardous effect of mental disorders on youths, compared with adults, the coverage of mental health services is inadequate,” the researchers said.

Future targeted interventions for youth were recommended:

• Incorporating cultural factors when devising domestic intervention policies
• At the government level, increasing allocation of mental health spending and public education in low- and middle-income countries
• Consideration of proven interventions such as telemedicine options for patients and skills training for primary care providers

PubMed, Web of Science, PsycINFO, Scopus, and Embase were used to locate studies. The meta-analysis included 40 studies in total: 20 reported treatment rates for depressive disorders, 17 for “any mental disorder” (including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders), 10 for ADHD, 9 for anxiety disorders, and 7 for behavior disorders. The combined treatment rate for “any mental disorder” was reported in the results. Girls accounted for 61% of participants. Children and adolescents were included if they had an existing diagnosis.

Caution should be taken when generalizing the results of the meta-analysis. The number of studies available varied across subgroups, which could compromise the representativeness of the sample. Other limitations included potential publication bias, and the exclusion of less common disorders including bipolar disorder, borderline personality disorder, and autism spectrum disorder.

Sources

¹ Wang, S., Li, Q., Lu, J., et al. (2023). Treatment rates for mental disorders among children and adolescents: a systematic review and meta-analysis. JAMA Netw Open, 6(10), e2338174. doi:10.1001/jamanetworkopen.2023.38174

²Keilow, M., Wu, C., & Obel, C. (2020). Cumulative social disadvantage and risk of attention deficit hyperactivity disorder: Results from a nationwide cohort study. SSM Popul Health, 10, 100548. doi: 10.1016/j.ssmph.2020.100548. PMID: 32072007; PMCID: PMC7016018.

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

Untreated ADHD Causes Feelings of Inadequacy

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

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

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

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

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

Women with ADHD Are at Greater Risk for Depression

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

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

The Importance of Recognizing ADHD, Depression, and Anxiety

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

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

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

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

Untreated ADHD in Adults: Next Steps

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

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

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

Sources

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

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

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

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

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

The first research on ketamine’s potential as a fast, effective antidepressant was published in 2006. Six years later, the first ketamine clinic opened, offering intravenous infusions of the dissociative agent, paired with therapy administered before and after. There are now hundreds of such clinics across the country, and many at-home treatment companies that will deliver ketamine lozenges directly to your doorstep.

Experts stress the importance of more large-scale, long-term research on ketamine. However, since the drug is FDA-approved as an anesthetic, it is legal to use it off-label for depression and other mental health conditions. And though ketamine can be costly, the rapid relief many people experience from conditions like treatment-resistant depression and suicidality is worth the price, they say.

We asked our readers to share details of their experiences with ketamine for mental health challenges. Here’s what they told us:

“My psychiatrist recommended ketamine in 2021, when I was acutely suicidal. It was the best drug that I have ever used for the treatment of depression. After about 9 infusions, I stopped taking antidepressants, which I had been using for 16 years. I have not had any negative effects of the drug itself. Ketamine has changed my life.” —Karlyn, South Africa

[Download: 6 Unexpected Signs of Depression]

“I run a ketamine clinic for transgender/neurodivergent patients and recommend psychedelic integration therapy together with ketamine. It is absolutely helpful for the right person. It worked for me.” —Pippi, Utah

“At first, my psychiatrist offered one-off IV ketamine treatments as a stop-gap measure for patients with treatment-resistant depression who likely would have checked themselves into a psychiatric hospital. Later, he began offering weekly ketamine therapy. Both have helped me immensely with depression and anxiety; though this wasn’t targeted by my psychiatrist, my ADHD symptoms have begun to improve as well.” —Bob, Arizona

“I took ketamine through Mindbloom for C-PTSD, depression, and suicidal ideation. It helped massively in changing my mindset, helping me know that I’m not a bad person and I don’t deserve the mistreatment I’ve received, that I’m struggling because my environment is not conducive to success and not because I’m doing something wrong.” —Mia, Texas

[Read: A Playbook for Post-Traumatic Growth]

“My partner has had ketamine treatments done. They were very intense and seemed to really open up all these walls he had put up that were preventing him from growing and healing. However, it did not help as long as it could have because he did not receive the proportionate therapy. Neuroplasticity is real, but if you’re not working through the emotional barriers that held you back, you will likely sink back to where you were.” —Lena, Florida

“This has been life-changing for my friend who used to call me all of the time in tears from some emotional drama or another. I used to have to talk her off a cliff, now we just talk like healthy people.” —Beth, Colorado

Ketamine & Treatment for Depression: Next Steps

• Self-Test: Depression in Adults
• Read: Is It ADHD, Depression, or Both?
• Read: What’s Behind the “Depression Gap” Impacting Women?

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

Just as overeating can overwhelm our digestive systems and cause us to develop symptoms of indigestion, traumatic experiences can get “stuck” in our nervous system, leading to ongoing distress and negative emotions and beliefs. Eye movement desensitization and reprocessing (EMDR) therapy helps individuals heal from the experiences that haunt them rather than simply learn to cope with them.

EMDR can be especially beneficial for adults with ADHD or comorbid conditions, such as anxiety, depression, or post-traumatic stress disorder (PTSD), because it targets underlying traumatic experiences (i.e., childhood abuse, shame, neglect, bullying, etc.) that may contribute to symptoms. The evidence-based therapy works by engaging several neurophysiological processes, which is a fancy way of saying that EMDR relies on the nervous system’s natural healing abilities to reprocess a distressing memory or experience, ultimately reducing or eliminating debilitating symptoms.¹

The key component of EMDR is bilateral stimulation (BLS) — the therapy doesn’t work without it. BLS stimulates both sides of the brain through eye movements, tapping, or listening to alternating tones. It stimulates similar processes experienced during the rapid eye movement (REM) sleep phase, an essential part of memory consolidation. BLS “taxes” or “breaks” a targeted memory, making it hard for a client to focus on it causing the memory to lose its negative emotional charge. A client can still recall a negative memory just without the negative feelings.

How Does EMDR Work?

A misconception about EMDR is that it’s a magic bullet and will work seamlessly for everyone. That’s not true. The therapy takes time and preparation to work effectively. The client and therapist focus on building coping skills and a safe therapeutic relationship before identifying memories to target and treat using EMDR techniques.

In total, EMDR therapy consists of eight phases, including: ²,³

EMDR Phase 1: Client History

The therapist takes a detailed client history to identify their readiness and suitability for treatment.

EMDR Phase 2: Preparation

The therapist sets reasonable expectations and trains the client on various self-control techniques to maintain stability between and during the sessions.

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EMDR Phase 3: Assessment

The client and therapist jointly identify the target memory on which they will work.

EMDR Phase 4: Desensitization

The client uses BLS to change the targeted memory’s trauma-related sensory experiences and associations.

EMDR Phase 5: Installation

The client identifies the new positive statements and associations they hold about the experience, now that it’s resolved.

EMDR Phase 6: Body Scan

The client scans their body for any somatic response related to the targeted memory. If present, the therapist targets this body sensation for further processing.

EMDR Phase 7: Closure

The therapist explains what to expect between sessions and asks the client to record any disturbances experienced between sessions. The therapist also takes time to help relieve any distress from the session so the client feels regulated upon leaving the session.

EMDR Phase 8: Reassessment

The therapist evaluates the EMDR treatment’s effectiveness.

A typical EMDR session lasts one hour; however, some therapists offer intensive sessions for 90 minutes or several hours. It may take several sessions to process a targeted memory. Clients who have experienced complex trauma may need several months of EMDR therapy; clients who already have coping skills and aren’t afraid to feel emotions and body sensations may rapidly move through EMDR treatment in a few weeks. It depends on the client’s goals, the strength of their nervous system, and how many memories need to be processed.

After a successful EMDR session, my clients typically experience reduced distress and vividness associated with the negative memory and report that a previously difficult experience “no longer bothers them.” They also report reduced symptoms associated with the memory and more peace and joy in their lives.

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EMDR for Children

EMDR therapy is not only appropriate for adults. It is a child-friendly and developmentally appropriate therapy for children and adolescents. Therapists can tailor EMDR treatment to meet the needs of each child by using fun and engaging techniques, such as storytelling, drawing, and play therapy, to help children feel safe and comfortable while processing their traumas.

More importantly, EMDR therapy can help children with ADHD and comorbid conditions develop coping skills and strategies to manage their symptoms more effectively. For example, it can teach them relaxation techniques to reduce anxiety, improve their ability to focus and complete tasks, and help them develop healthy communication and relationship skills.

It is important to note that EMDR can be an overwhelming and vulnerable therapy; treatment should only occur with a trained EMDR professional — and only after both the professional and client are ready for it.

By helping individuals process and release negative emotions associated with traumatic experiences, EMDR therapy can alleviate anxiety, depression, and PTSD symptoms and even reduce some symptoms associated with ADHD. While EMDR will not alleviate an ADHD diagnosis, it can help those who struggle with ADHD symptoms live a happier, more productive life. EMDR helps clients to develop a more positive self-image, self-confidence, and live a better quality of life.

To find a licensed EMDR professional, visit emdria.org.

EMDR Therapy: Next Steps

• Free Download: Alternative Natural Therapy Options 
• Read: The Relationship Between PTSD and ADHD: Symptoms, Diagnosis, Treatment
• Read: Childhood Trauma Happens More Than We Think. Here’s How to Treat It.

Rebecca Kase, MSW, LCSW, RYT, a member of emdria.org, and an emdria-approved trainer and consultant.

The opinions expressed in ADDitude Guest Blogs are solely those of the User, who may or may not have medical or scientific training. These opinions do not represent the opinions of ADDitude. Blogs are not reviewed by an ADDitude physician or any member of the ADDitude editorial staff for accuracy, balance, objectivity, or any other reason except for compliance with our Terms and Conditions. Some of these opinions may contain information about treatments or uses of drug products that have not been approved by the U.S. Food and Drug Administration. ADDitude does not endorse any specific product, service or treatment.

Do not consider ADDitude Blogs as medical advice. Never delay or disregard seeking professional medical advice from your doctor or other qualified healthcare provider because of something you have read on ADDitude. You should always speak with your doctor before you start, stop, or change any prescribed part of your care plan or treatment. ADDitude understands that reading individual, real-life experiences can be a helpful resource, but it is never a substitute for professional medical advice, diagnosis, or treatment from a qualified health care provider. If you think you may have a medical emergency, call your doctor or dial 911 immediately.

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Sources

¹Psychological and Physical Symptoms Stemming from Adverse Life Experiences. (2014). Perm J. https://doi.org/10.7812/tpp/13-098

²Shapiro F. EMDR Therapy Training Manual. Watsonville, CA: EMDR Institute; 2012.

³Menon, S.B., Jayan, C. (2010) Eye Movement Desensitization and Reprocessing: A Conceptual Framework. Indian J Psychol Med. https://doi.org/10.4103/0253-7176.7851

In an effort to identify and treat anxiety disorders early on, clinicians should screen adults ages 19 to 64 in primary care settings, according to a new recommendation by the U.S. Preventive Services Task Force released in June and published in JAMA.^{1, 2} The task force also recommended routine screenings for major depressive disorder among adults, including pregnant and postpartum people.

It was the first time the task force, an independent panel of clinicians whose recommendations influence doctors’ standard practices and insurance plans, called for anxiety screenings in adults. The recommendations will help clinicians identify and provide, or refer treatment, for adults who do not appear to exhibit recognized signs of depression or anxiety.

The task force said that anxiety and depression often overlap, citing one study’s findings in which 67% of individuals with a depressive disorder also had an anxiety disorder. Yet a lack of “underdetection appears to be common,” the task force said. Only 11% of adults with an anxiety disorder started treatment with the first year of onset; the median time of treatment initiation was 23 years, according to the task force. Women, Black and non-Hispanic people, as well as those in poor socioeconomic conditions, were more likely to experience higher rates of anxiety, the task force said.³

Screening for Anxiety and Depression

Evidence-based screening recommendations were made for the following groups:

• For anxiety: Adults aged 19 to 64, including those who are pregnant or postpartum
• For depression: Adults aged 19 or older, including older adults over the age of 65 and those who are pregnant or postpartum

The task force also reviewed the evidence on suicide risk screening in adults and older adults in primary care but did not make a recommendation.

The statements on suicide risk and depression remain consistent with those released in 2014 and 2016, respectively. In its previous and updated recommendations, the task force found fair evidence to support depression screenings for the general adult population (“B” grade), but not enough to screen for suicide risk (“I” statement). A systematic review commissioned by the task force cited critical gaps in research, including the potential harms of suicide risk interventions and the need for treatment studies in populations with positive screening results.⁴ Suicide is the tenth leading cause of death for adults in the U.S.⁵

The Impact on Adults with ADHD

Adults with ADHD are at an increased risk for developing comorbid depression and anxiety.⁶ As a result, clinicians should give special attention to identifying and differentiating the symptoms of each condition during healthcare screenings and in follow-up care. This is especially true for women who commonly go undiagnosed or misdiagnosed, which may be due in part to internalizing or masking their ADHD symptoms.⁷

In a survey of 1,542 people conducted by ADDitude in 2022, more than half of adults reported feelings of depression, mood changes, and excessive worry. More than 70% reported diagnoses of anxiety, depression, or both. Yet more than one-third (35%) said they were not receiving mental health care to address these symptoms. Time restraints (including wait lists) and high costs were most often cited as barriers to care.

Depression and anxiety also disproportionately affect pregnant women with ADHD, who are six times more likely to experience postpartum anxiety and five times more likely to experience postpartum depression than women without ADHD.⁸

Implications and Additional Recommendations

In the latest task force recommendations, adults who test positive in depression and anxiety screening results should be followed up with diagnostic assessments and evidence-based care. Anxiety disorders reviewed include generalized anxiety disorder, social anxiety disorder, and panic disorder.

Treatments for anxiety disorders and depression can include cognitive behavioral therapy and antidepressant medication. If left untreated, anxiety and depression disorders can interfere with daily living.

If you are experiencing thoughts of suicide, you can reach the 988 Suicide & Crisis Lifeline by calling or texting 988, or by visiting https://988lifeline.org/.

Sources

¹US Preventive Services Task Force. Screening for Anxiety Disorders in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. Published online June 20, 2023. doi:10.1001/jama.2023.9301

²US Preventive Services Task Force. Screening for Depression and Suicide Risk in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(23):2057–2067. doi:10.1001/jama.2023.9297

³US Preventive Services Task Force. (2023) Final recommendation statement: Anxiety disorders in adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/anxiety-adults-screening

⁴O’Connor EA, Perdue LA, Coppola EL, Henninger ML, Thomas RG, Gaynes BN. Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023;329(23):2068–2085. doi:10.1001/jama.2023.7787

⁵Ivey-Stephenson AZ, Crosby AE, Hoenig JM, Gyawali S, Park-Lee E, Hedden SL. Suicidal thoughts and behaviors among adults aged ≥18 years—United States, 2015-2019. MMWR Surveill Summ. 2022;71(1):1-19.

⁶Katzman MA, Bilkey TS, Chokka PR, Fallu A, Klassen LJ. Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC Psychiatry. 2017 Aug 22;17(1):302. doi: 10.1186/s12888-017-1463-3. PMID: 28830387; PMCID: PMC5567978.

⁷Young, S.et al (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry, 20(1), 404. https://doi.org/10.1186/s12888-020-02707-9

⁸Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069