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.

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

“ADHD is widely studied and recognized — except when it occurs in older adults. For a variety of reasons, research on ADHD in older age has historically lagged, resulting in a dearth of relevant diagnostic and treatment tools. Regardless of research deficits, it is abundantly clear that older adults with ADHD have unique needs and characteristics – including age-related cognitive changes, co-existing psychiatric and medical conditions, and more – that influence evaluation and treatment for the disorder.”

• Continue reading ADHD in Older Adults: Distinct Diagnostic and Treatment Considerations

2. What Is Inattentive ADHD? Symptoms, Characteristics, Diagnostic Considerations

by Mary V. Solanto, Ph.D.

“Individuals with inattentive type ADHD do not exhibit the stereotypical symptoms of ADHD — namely physical hyperactivity and impulsivity. Their executive dysfunction is easily blamed on carelessness or laziness, and their social struggles may be attributed to growing pains or character idiosyncrasies. All of this contributes to a chronic problem of underdiagnosis and inadequate treatment for inattentive type ADHD, particularly in girls and women.”

• Continue reading What Is Inattentive ADHD?

3. Why We Must Achieve Equitable ADHD Care for African American and Latinx Children

by Tumaini Rucker Coker, M.D., MBA

“As rates for ADHD diagnosis increase across the population, a growing body of literature highlights barriers to ADHD diagnosis and treatment – from the clinical level to systemic factors – that disproportionately impact children and adolescents of color. These inequities have created and deepened societal divides that put Black and Latinx children at greater risk of poor educational outcomes. Sufficiently addressing disparities in care starts with an understanding of why racial and ethnic imbalances matter, the roots of these inequities, and their consequences for overall health and well-being.”

• Continue reading Why We Must Achieve Equitable ADHD Care for African American and Latinx Children

4. Traumatic Stress Alongside ADHD: 5 Reasons Clinicians Need to Consider Trauma

by Michelle Frank, Psy.D.

“Traumatic stress and ADHD share significant associations, according to a growing body of research. Studies show that people with ADHD score higher than their neurotypical peers on the Adverse Childhood Experiences (ACEs) questionnaire, which measures the impact of negative, stressful, or traumatic events on well-being. This means that they are likely to report troubling events like domestic violence, caregiver substance abuse, physical or sexual abuse, neglect, mental illness, poverty, and community violence. Experiences of racism, discrimination, and oppression can also lead to trauma. So, what is the connection between trauma and ADHD? How do we tease apart the diagnoses? What do their similarities mean for symptoms, diagnosis, and treatment?”

• Continue reading Traumatic Stress Alongside ADHD

5. ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks

by Stephen Hinshaw, Ph.D.; Ellen Littman, Ph.D.; and Andrea Chronis-Tuscano, Ph.D.

“Empirical evidence on female manifestations of ADHD – including findings on self-harm, peer relationships, trauma, and more – reveal crucial aspects of the condition that are as devastating as they are under-appreciated. Along with a recognition of general sex and gender differences, these factors must inform future research practices and clinical approaches for this group. The bottom line: Our approach to ADHD in women and girls has been broken for too long. To fix it, we must challenge everything we know about the assessment, diagnosis, and treatment of ADHD today.”

• Continue reading ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks

6. ADHD in Teens: How Symptoms Manifest as Unique Challenges for Adolescents and Young Adults

by Timothy Wilens, M.D.

“The delayed frontal lobe development associated with ADHD in the teenage years makes regulating the limbic system – the circuitry associated with emotion, anxiety, reward, and risky behavior – more difficult. This differential brain development may explain some observable dysregulation and instability in adolescents with ADHD, and it builds a case for why families still need to remain involved and vigilant through the teen’s development in this period.”

• Continue reading ADHD in Teens: How Symptoms Manifest as Unique Challenges for Adolescents and Young Adults

7. Menopause, Hormones & ADHD: What We Know, What Research is Needed

by Jeanette Wasserstein, Ph.D.

“How do the hormonal changes of menopause uniquely affect women who have ADHD? Unfortunately, despite increased and hugely warranted interest, there are no studies that specifically examine menopause in females with ADHD, and that is a serious medical problem. But what we do know – about menopause in general, the role of estrogen, and the effects of hormonal fluctuations on ‘ADHD-like’ symptoms – may help us understand the menopausal transition for women with ADHD, and how clinicians can approach treatment and care for this group.”

• Continue reading Menopause, Hormones & ADHD

8. Treatment for Depression and ADHD: Treating Comorbid Mood Disorders Safely

by Roberto Olivardia, Ph.D.

“Comorbid depression and ADHD present a unique set of risks and challenges. For people with mood disorders, having comorbid ADHD is associated with an earlier onset of depression, more frequent hospitalizations due to depression, more recurrent episodes, and higher risk of suicide, among other markers. Proper management and treatment of both ADHD and depression is, therefore, crucial.”

• Continue reading Treatment for Depression and ADHD

9. The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations

by Joel Nigg, Ph.D.

“Even when controlling for related comorbid conditions, individuals with ADHD experience disproportionate problems with anger, irritability, and managing other emotions. These problems walk in lock step with the general difficulties in self-regulation that characterize ADHD. Recent findings, however, suggest that problems with emotional regulation, including anger and negative emotions, are genetically linked to ADHD, too. Ultimately, emotional dysregulation is one major reason that ADHD is subjectively difficult to manage, and why it also poses such a high risk for other problems like depression, anxiety, or negative self-medication.”

• Continue reading The ADHD-Anger Connection

10. A Clinician’s Guide to Tic Disorders in Children: Symptoms, Comorbidities & Treatments

by John Piacentini, Ph.D., ABPP

“Persistent tic disorders, including Tourette’s disorder, affect about one in fifty children in the U.S. according to the latest research. What’s more, tic disorders are highly comorbid. More than 80% of children with Tourette’s disorder have a co-occurring mental, behavioral, or developmental disorder, with ADHD and anxiety topping the list of commonly diagnosed conditions. These facts and figures suggest that clinicians are more likely than not to encounter tic disorders when caring for pediatric patients.”

• Continue reading A Clinician’s Guide to Tic Disorders in Children

11. The Choice to Medicate for ADHD: A Clinician’s Guide to Navigating Parental Concerns

by Roberto Olivardia, Ph.D.

“The issue of medication for children with ADHD — more than with any other condition that I treat — is controversial and murky. For parents, the question of adding medication to their child’s treatment plan is one that weighs heavily. They research the pros and cons of ADHD medication, but their findings are colored by feelings of guilt and fear of judgment from others. While it’s important to educate parents on how medications work and why they might be used, it’s equally critical for clinicians to support parents by being mindful of the concerns that are often present, though not always overtly stated, as they navigate the decision-making process.”

• Continue reading The Choice to Medicate for ADHD: A Clinician’s Guide to Navigating Parental Concerns

12. We Need to Talk About ADHD Stigma in BIPOC Communities

by Evelyn Polk Green, M.S.Ed.

“Stigma in Black and other marginalized communities spurs resistance to ADHD diagnoses and treatment. Parents believe an ADHD diagnosis implies their child has an intellectual disability. They also fear an ADHD diagnosis will relegate their child to special education. Black and Latinx children are assigned disproportionately to these programs, often with poor outcomes. Historical and institutional medical maltreatment also informs decisions about treatment. These fears are not without justification, but they bring devastating results. They often lead to parents refusing medication in an ADHD treatment plan.”

• Continue reading We Need to Talk About ADHD Stigma in BIPOC Communities

13. A Critical Need Ignored: Inadequate Diagnosis and Treatment of ADHD After Age 60

by Kathleen Nadeau, Ph.D.

“ADHD doesn’t diminish — like your hairline or stamina — with age. In fact, symptoms of ADHD may flare and grow after midlife — especially when mixed with normal age-related cognitive decline, worsening physical health, and the lack of structure that often comes with retirement. Why then, do the unique needs of this large (and growing) population of adults with ADHD remain largely ignored in diagnostic tests, accepted treatment practices, and peer-reviewed research?”

• Continue reading A Critical Need Ignored: Inadequate Diagnosis and Treatment of ADHD After Age 60

14. Sleep and ADHD Medication Use: A Clinician’s Guide to Mitigating Side Effects in Children

by Mark A. Stein, Ph.D.

“Research confirms the increased prevalence of sleep problems among children with ADHD, and clinical experience shows us that ADHD symptoms and characteristics – difficulty ‘shutting down’ the mind, for instance – plus comorbid psychiatric disorders like anxiety and oppositional defiant disorder can cause or aggravate sleep problems as well. In addition, sleep problems, such as insomnia, are a common side effect associated with ADHD medications. In other words, ADHD symptoms and the first-line interventions to treat those symptoms both elevate an individual’s risk for poor sleep.”

• Continue reading Sleep and ADHD Medication Use: A Clinician’s Guide to Mitigating Side Effects in Children

15. The Science of Fear: Probing the Brain Circuits That Link ADHD and PTSD

by Joseph Biederman, M.D.; Mohammed R. Milad, Ph.D.; and Andrea Spencer, M.D.

“Our systematic review and meta-analysis of several studies examining the relationship between ADHD and PTSD reveals a bidirectional association between the two disorders. The relative risk for PTSD in individuals with ADHD is four times greater compared to normal controls; it is close to 2 against psychiatric controls, and 1.6 against traumatized controls. The risk for ADHD in individuals with PTSD is twice that observed in normal controls.”

• Continue reading The Science of Fear: Probing the Brain Circuits That Link ADHD and PTSD

16. Professional Guidelines for Diagnosing Autism Spectrum Disorder

by Theresa Regan, Ph.D.

“While ‘autism awareness’ is growing, what we’re really lacking is holistic ‘autism recognition.’ Few medical professionals and mental health care professionals can confidently say: ‘I know what autism looks like in the classroom, in the medical clinic, in families, and in neighborhoods.’ Since ASD presents with multiple behavioral characteristics, professionals often miss the big picture of autism and, instead, diagnose small pieces of the picture separately — for example, obsessive compulsive disorder (OCD), social anxiety, eating disorder, bipolar disorder, or ADHD.”

• Continue reading Professional Guidelines for Diagnosing Autism Spectrum Disorder

17. How a Physician Treats ADHD with Combination Therapy

by Oren Mason, M.D.

“I discovered ‘combination therapy’ by accident. The term refers to using a stimulant and a non-stimulant to reduce ADHD symptoms. There were no lectures in medical school on this therapy and no studies of it yet, in 2000, when I started my ADHD practice. I learned about it from my patients, who noticed that it did a very effective job of helping them manage symptoms.”

• Continue reading How a Physician Treats ADHD with Combination Therapy

18. When a Mood Disorder Looks Like ADHD — and Vice Versa: Differentiating Signs of Emotional Dysregulation

by Thomas E. Brown, Ph.D., and Ryan J. Kennedy

“Emotional dysregulation and moodiness are not included in the diagnostic criteria for ADHD – a detrimental omission, according to many researchers and clinicians. The reality is that children and adults with ADHD commonly experience irritability, low frustration tolerance, and mood lability. However, emotional dysregulation is not exclusive to ADHD. Chronic moodiness is also a central component of mood disorders like bipolar disorder, which may complicate the evaluation, diagnosis, and treatment process. Differentiating moodiness as it appears in ADHD, bipolar disorder, and similar disorders is critically important — and not always straightforward.”

• Continue reading When a Mood Disorder Looks Like ADHD — and Vice Versa

19. ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.

by Russell Barkley, Ph.D.

“The ADHD symptoms listed in the DSM were developed for children. We can see this in the phrasing of certain symptoms, such as ‘can’t play quietly’ or ‘driven by a motor’ in the hyperactive/impulsive items. These phrasings don’t translate well to the adult experience. Few adults with ADHD would use these terms to describe their daily experience with the condition, leaving clinicians to extrapolate these items into clinical practice with adults.”

• Continue reading ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.

20. The Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth

by Elena Man, M.D.; Amy Dryer, M.D.; and Rachel Sayer, LCPC, PCIT-C

“LGBTQIA+ youth face an elevated risk for experiencing serious mental health issues.¹ Depression and anxiety impact more than half of all youth who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, or asexual, according to a 2022 survey by the Trevor Project. In addition, 45% of LGBTQIA+ adolescents and young adults say they have seriously considered attempting suicide in the past year, according to the same survey. To end this devastating trend and save lives, LGBTQIA+ youth need many things — primary among them is support.”

• Continue reading The Clinicians’ Guide to Serving and Protecting LGBTQIA+ Youth

21. 11 Steps to Prescribing and Using ADHD Medication Effectively

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

“The most recent Practice Parameters update on ADHD from the American Academy of Child and Adolescent Psychiatry recommends medication as a primary therapy for ADHD because it shows detectable, lasting benefit over multi-modal treatment. In other words, ADHD medication works. Yet, 93% of psychiatry residencies don’t mention ADHD in four years of training, and a full 50% of pediatric residencies don’t mention ADHD. So how is a physician supposed to understand and adjust treatment plans without a rich background in ADHD?”

• Continue reading 11 Steps to Prescribing and Using ADHD Medication Effectively

22. The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD

by Roberto Olivardia, Ph.D.; Jannice Rodden, and ADDitude Editors

“Bipolar disorder (BD) often co-occurs with ADHD, with comorbidity figures as high as 20% Recent research also suggests that about 1 in 13 patients with ADHD has comorbid BD, and up to 1 in 6 patients with BD has comorbid ADHD. This comorbidity rate is significant enough to justify dual evaluations for virtually every patient, yet bipolar disorder is often missed or misdiagnosed, in part because several depressive and manic symptoms of bipolar disorder and ADHD symptoms closely resemble each other.”

• Continue reading The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD

23. Beyond the Core Symptoms of ADHD in Children: Comorbid Screening and Treatment Guidance

by Adelaide S. Robb, M.D.

“ADHD rarely exists in isolation. As treating clinicians, we must properly screen for and address ADHD and its comorbidities at the same time. ADHD and its common comorbid conditions are best diagnosed through a comprehensive psychological evaluation. These fuller evaluations — in contrast to the lone rating scales many pediatricians use — extract a wealth of information about a patient’s ADHD symptoms and any present comorbidities, like learning and language disabilities, early in the evaluation process.”

• Continue reading Beyond the Core Symptoms of ADHD in Children: Comorbid Screening and Treatment Guidance

24. Migraines and ADHD: The Overlooked Connection to Headaches

by Sarah Cheyette, M.D.

“Children with ADHD may be twice as likely to experience headaches as are children without ADHD. Children with ADHD are also at greater risk for migraines than are children without ADHD, and frequency of migraine headaches may be directly linked to risk of ADHD. The issue extends into adulthood as well. One study estimates that migraines occur with ADHD about 35% of the time in adult patients. Headaches, including migraine headaches, do seem to be triggered by ADHD.”

• Continue reading Migraines and ADHD: The Overlooked Connection to Headaches

25. 4 Reasons Adults Give Up on ADHD Medication: Solving Nonadherence and Treatment Inconsistency

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

“ADHD medications work dramatically well. Still, medication nonadherence is a serious – and often unnoticed – problem among adult patients, regardless of age or prescription. According to a recent study, fewer than half of adult patients could be considered ‘consistently medicated’ for ADHD, based on prescription renewal records. Prescribers must understand and address the barriers to ADHD medication adherence to provide the best care possible for patients and improve long-term outcomes.”

• Continue reading 4 Reasons Adults Give Up on ADHD Medication

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.

In people who have comorbid ADHD and bipolar disorder, treating both conditions leads to the best outcome, but deciding whether to use stimulants to treat ADHD in people with bipolar can be complicated. The prevailing concern has been that stimulants can de-stabilize a person with bipolar and, while this is a valid concern for people who are not on optimized mood stabilizers, recent research suggests the risk may be low for bipolar patients whose symptoms are well-managed with medication.

The study that’s frequently cited to justify the use of stimulants in stabilized bipolar disorder is the Swedish National Registry, which involved 2,300 patients over the course of 8 years.¹ These were patients who were admitted into the hospital for mania or a change in their mood-stabilizing medication. They were studied from zero to three months, and then from three to six months. This is important because if you add in even a short-acting medication like a stimulant, the effect of that medication on the stability of the patient may not become evident right away.

The study found that, for people with bipolar and ADHD, when methylphenidate was added in:

• Among those not on a mood stabilizer, the risk of relapse grew six- to seven-fold.
• Among those on a mood stabilizer, the risk of relapse was almost nonexistent.

[Self-Test: Bipolar Disorder in Adults]

The Canadian Network for Mood and Anxiety Treatment and the International Society for Bipolar Disorder put the same recommendations in their 2018 guidelines, saying that stimulants may be used for ADHD in stable youth with bipolar taking optimal doses of anti-manic medication. Within controlled trials, both mixed amphetamine salts and methylphenidate were well tolerated and shown to be effective in addressing symptoms of ADHD in these people.²

A study published in Current Psychiatry Reports conducted by a research group in Italy also concluded that in patients with comorbid ADHD and bipolar, the bipolar should be treated first. Unless mood stabilizers are optimized first, stimulants are not recommended in patients with comorbid ADHD and bipolar.³

We understand from this that international researchers are looking at different data sets, bringing to bear different clinical experiences, and coming to the same conclusion. Certainly, we need further studies, but this offers preliminary evidence that stimulants may not destabilize bipolar ADHD patients who are on optimized mood stabilizers.

[Read: The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD]

In my clinical practice, I stabilize the bipolar disorder first, then evaluate the cognitive aspects of the patients’ ADHD, before proceeding with treatment of ADHD. It’s important to re-visit the cognitive symptoms after optimizing the bipolar treatment because, if a patient has untreated bipolar disorder and untreated ADHD, there will be cognitive deficits that are attributable to both disorders, not just the ADHD. Once you stabilize the bipolar disorder, you’ll see what residual ADHD cognitive symptoms remain. That’s when you establish your target ADHD symptoms and treat accordingly with stimulants, starting low and going slow for best results.

Bipolar Disorder and ADHD: Next Steps

• Read: What Is Bipolar Disorder?
• Self-Test: Bipolar Disorder in Adults
• Read: Treatment for the Symptoms of Bipolar Disorder
• Read:What Is Complex ADHD? Symptoms, Diagnosis & Treatment

The content for this article was derived, in part, with permission from “ADHD, Bipolar and Substance Use: Translating Data from Clinical Data into Your Practice.” presented by David Goodman, M.D., LFAPA at the APSARD 2023 Annual Conference.

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 Viktorin A, Rydén E, Thase ME, Chang Z, Lundholm C, D’Onofrio BM, Almqvist C, Magnusson PK, Lichtenstein P, Larsson H, Landén M. The Risk of Treatment-Emergent Mania With Methylphenidate in Bipolar Disorder. Am J Psychiatry. 2017 Apr 1;174(4):341-348. doi: 10.1176/appi.ajp.2016.16040467. Epub 2016 Oct 3. Erratum in: Am J Psychiatry. 2016 Nov 1;173(11):1154. PMID: 27690517; PMCID: PMC6641557.

² Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, Sharma V, Goldstein BI, Rej S, Beaulieu S, Alda M, MacQueen G, Milev RV, Ravindran A, O’Donovan C, McIntosh D, Lam RW, Vazquez G, Kapczinski F, McIntyre RS, Kozicky J, Kanba S, Lafer B, Suppes T, Calabrese JR, Vieta E, Malhi G, Post RM, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018 Mar;20(2):97-170. doi: 10.1111/bdi.12609. Epub 2018 Mar 14. PMID: 29536616; PMCID: PMC5947163.

³ Perugi, G., Vannucchi, G., Bedani, F. et al. Use of Stimulants in Bipolar Disorder. Curr Psychiatry Rep 19, 7 (2017). https://doi.org/10.1007/s11920-017-0758-x

Accuracy of 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.

According to a recent meta-analysis of 71 studies in 18 countries published in Neuroscience and Biobehavioral Reviews, 1 out of 13 people with ADHD also had bipolar disorder. Among patients with bipolar, 1 out of 6 also had ADHD.¹ The co-existence is clearly present. So, if you run a mood disorders clinic and you tell me you don’t have ADHD patients, I’ll say maybe you don’t see patients for their ADHD, but you certainly have ADHD patients.

In terms of differentiating the two disorders, there’s much talk about executive function subsumed under ADHD, and about emotional dysregulation subsumed under mood disorders, including major depression and bipolar disorder. However, we know that cognitive symptoms and executive dysfunction exist in patients with bipolar disorder. We also know that emotional dysregulation is a component of ADHD; the more severe the ADHD, the more severe the emotional dysregulation.

This connection is borne out by a recent study conducted with 150 ADHD patients, 335 adult bipolar patients, and 48 controls, in which subjects used two self-report scales. Adult ADHD patients displayed higher emotional dysregulation, and emotional responsiveness at levels equal to that seen in the patients with bipolar disorder.² So, if you rely on levels of emotional dysregulation or executive dysfunction to differentiate the disorders, you may be led amiss diagnostically.

This confusion is partly a result of the shortcomings of descriptive psychiatry. Descriptive psychiatry is the use of words to describe the psychological experience. According to the DSM-5, patients with bipolar disorder experience the following: increased talkativeness, racing thoughts, distractibility, fidgety and restless, increased risky behavior, impulsive decisions. Certainly, the experts who wrote the DSM-5 endeavored to use language specific to the diagnostic entity, but it’s clear that these descriptions could just as easily be used to describe ADHD. In other words, it’s very difficult to make these diagnostic distinctions solely based on symptom checklists or a clinical interview that focuses only on the immediate symptoms.

[Read: The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD]

Making an Accurate Differential Diagnosis

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. 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. Diagnostic accuracy is further increased by considering symptom trajectory over time (periodicity and chronicity) and family psychiatric history.

Carefully Consider Medical and Family History

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP) study looked at 1,000 adults with bipolar disorder. The overall lifetime prevalence of comorbid ADHD in this group of bipolar patients was 9% to 10%, and the onset of bipolar disorder came approximately five years earlier for those with ADHD versus those without ADHD.³ The meta-analysis published in Neuroscience and Biobehavioral Reviews revealed similar findings: bipolar disorder onset was four years earlier in the presence of ADHD.

Let’s translate that clinically. You’re treating a 15-year-old, diagnosed at age 10 with ADHD, who has just had their first major depressive episode. Do you consider the depressive episode as an outcome of ADHD because the teen is having difficulties at school? The psychological circumstances of the psychosocial stressors would make it seem legitimate that this is a major depressive episode. But we also know that, in patients with ADHD and bipolar disorder, bipolar emerges years earlier than we might otherwise expect and is usually experienced first as a depressive episode. If we consider that the patient has a family history of bipolar disorder, the diagnostic outlook changes, along with the pharmacologic considerations.

[Learn: The Clinicians’ Guide to Differential Diagnosis of ADHD]

Ask About “Experiences,” Not “Symptoms”

If you’ve ever had a psychiatric illness, you’ll understand that you don’t have symptoms. You have experiences. So, when patients use the term anxiety or depression or ADHD, I don’t ask, “What are the symptoms of your anxiety, or depression, or ADHD?” I ask them, “Tell me how you experience that.” This addresses the phenomenologic experience of the patient and aids the clinician in discerning the most likely diagnostic category to consider.

This, in turn, allows you to identify the unique target experiences (symptoms) that can be tracked during the course of treatment options. For the ADHD individual, these target symptoms are unique to them and fall into the categories of cognitive difficulties, emotional reactivity, and executive functioning. From a clinical perspective, it becomes clear that a phenomenological approach to symptoms makes it easier to sort out diagnostic comorbidities. In doing so, the target symptoms for each disorder become clear, thereby making easier the assessment of improvement for each disorder. This approach facilitates the sequence of pharmacologic and psychotherapeutic treatment options. Given the complexity of this thought process, formal clinical training for health care providers is critical.

Bipolar Disorder and ADHD: Next Steps

• Read: What Is Bipolar Disorder?
• Self-Test: Bipolar Disorder in Adults
• Read: Treatment for the Symptoms of Bipolar Disorder
• Read:What Is Complex ADHD? Symptoms, Diagnosis & Treatment

The content for this article was derived, in part, with permission from “ADHD, Bipolar and Substance Use: Translating Data from Clinical Data into Your Practice.” presented by David Goodman, M.D., FAPA at the APSARD 2023 Annual Conference.

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Sources

¹Schiweck C, Arteaga-Henriquez G, Aichholzer M, Edwin Thanarajah S, Vargas-Cáceres S, Matura S, Grimm O, Haavik J, Kittel-Schneider S, Ramos-Quiroga JA, Faraone SV, Reif A. Comorbidity of ADHD and adult bipolar disorder: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2021 May;124:100-123. doi: 10.1016/j.neubiorev.2021.01.017. Epub 2021 Jan 27. PMID: 33515607.
² Richard-Lepouriel H, Etain B, Hasler R, Bellivier F, Gard S, Kahn JP, Prada P, Nicastro R, Ardu S, Dayer A, Leboyer M, Aubry JM, Perroud N, Henry C. Similarities between emotional dysregulation in adults suffering from ADHD and bipolar patients. J Affect Disord. 2016 Jul 1;198:230-6. doi: 10.1016/j.jad.2016.03.047. Epub 2016 Mar 15. PMID: 27031290.
³ Bowden CL, Perlis RH, Thase ME, Ketter TA, Ostacher MM, Calabrese JR, Reilly-Harrington NA, Gonzalez JM, Singh V, Nierenberg AA, Sachs GS. Aims and results of the NIMH systematic treatment enhancement program for bipolar disorder (STEP-BD). CNS Neurosci Ther. 2012 Mar;18(3):243-9. doi: 10.1111/j.1755-5949.2011.00257.x. Epub 2011 Jun 7. PMID: 22070541; PMCID: PMC6493527.

COMORBIDITIES: What co-existing conditions should my child’s doctor consider when evaluating for ADHD?

A: ADHD rarely exists in isolation. Clinicians must properly screen for and address ADHD and its comorbidities… | Keep reading on ADDitude »

DEPRESSION: What distinguishes ADHD from depression in children?

A: Clinical depression is more than just the blues. It’s a serious illness, and it affects more young people than parents realize… | Keep reading on ADDitude »

ANXIETY: What distinguishes ADHD from anxiety in children?

A: Some anxiety disorders can be hard to spot in children because symptoms include internal thoughts and feelings that don’t always… | Keep reading on WebMD »

OCD: What distinguishes ADHD from OCD in children?

A: Obsessive-compulsive disorder is marked by repetitive thoughts or fears (obsessions) that may turn into repetitive behaviors… | Keep reading on WebMD »

BIPOLAR: What distinguishes ADHD from bipolar disorder in children?

A: Medical science is learning more about bipolar disorder in children and teens. But the condition is still difficult to diagnose. That’s especially true for teenagers in whom irritability and moodiness… | Keep reading on WebMD »

DMDD: What are the symptoms of disruptive mood dysregulation disorder in children?

A: DMDD causes children to experience unstable emotions they cannot regulate, including extreme outbursts of anger, leading to temper tantrums. These outbursts often occur in response to… | Keep reading on WebMD »

FIRST-PERSON: “How I Calmed My Daughter’s Anxiety Attack”

“It’s critical that you accept the attack as real. The dizziness, sweating, chest pain, racing heart — all of it is real. Don’t tell her that it’s just in her head or that she’s OK. So what can you do? Start by holding her close.” | Keep reading on ADDitude »

RELATED RESOURCES

SYMPTOM TEST: Generalized Anxiety Disorder in Children

Every child worries sometimes — about monsters or tests or new experiences. A child with anxiety feels anxious about nearly everything. | Take the self-test on ADDitude »

SYMPTOM TEST: Depression in Children

Does your child say they’re ‘too tired’ to do activities they used to love? Have trouble making even simple decisions? | Take the self-test on ADDitude »

8-Part Guide to ADHD Diagnosis in Children, from WebMD x ADDitude:

DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
DECISION 2: How can I understand the aspects of ADHD that might be new to the doctor?
DECISION 3: How can I improve the odds of an accurate ADHD evaluation for my child?
DECISION 4: How can I find a professional to diagnose and treat my child’s ADHD?
DECISION 5: What should a thorough evaluation for pediatric ADHD include and exclude?
> DECISION 6: How can I be sure my child’s evaluation screens for psychiatric comorbidities?
DECISION 7: How can I be sure my child’s evaluation considers look-alike comorbidities?
DECISION 8: Should my child be screened for the sleep, eating, and other disorders?

DEPRESSION: What distinguishes ADHD from depression?

A: Depression is more than just an occasional case of the blues. It’s deep sadness and despair you feel every day for at least 2 weeks at a time… | Keep reading on WebMD »

ANXIETY: What distinguishes ADHD from anxiety?

A: When you have anxiety along with ADHD, it may make some of your ADHD symptoms worse, such as feeling restless or… | Keep reading on WebMD »

BIPOLAR: What distinguishes ADHD from bipolar disorder?

A: Approximately 20 percent of people with ADHD also suffer from bipolar disorder, characterized by depressive and manic episodes… | Keep reading on ADDitude »

MOOD DISORDERS: What distinguishes ADHD from a mood disorder?

A: Making the distinction between moodiness in ADHD, ODD, DMDD, and other disorders requires studying the mood’s intensity and… | Keep reading on ADDitude »

OCD: What distinguishes ADHD from obsessive-compulsive disorder?

A: Symptoms of OCD include recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions)… | Keep reading on ADDitude »

ODD: What distinguishes ADHD from oppositional defiant disorder?

A: Adults with ODD are more than just aggressive and irritating from time to time. They feel mad at the world every day, and lose their temper… | Keep reading on ADDitude »

FIRST-PERSON: “ADHD: ‘I Really Fouled That Up.’ Anxiety: ‘Hold My Beer.’”

“ADHD means I can’t be productive. Anxiety means I can’t relax. ADHD won’t let me resolve problems. Anxiety makes me think I have problems I don’t actually have. ADHD makes planning difficult. Anxiety convinces me I need to plan everything down to the tiniest of detail.” | Keep reading on ADDitude »

RELATED RESOURCES

SYMPTOM TEST: Generalized Anxiety Disorder in Adults

No two people experience anxiety in the same way, however common symptoms do exist. | Take the self-test on ADDitude »

SYMPTOM TEST: Depression in Adults

Do simple tasks take forever to accomplish? Do you feel irritable all the time, or stuck in life? | Take the self-test on ADDitude »

8-Part Guide to ADHD Diagnosis in Adults, from WebMD x ADDitude:

DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
DECISION 2: How can I understand the aspects of ADHD that might be new to my doctor?
DECISION 3: How can I improve my odds of an accurate ADHD evaluation?
DECISION 4: How can I find a professional to diagnose and treat my ADHD?
DECISION 5: What should a thorough evaluation for adult ADHD include and exclude?
> DECISION 6: How can I be sure my ADHD evaluation screens for psychiatric comorbidities?
DECISION 7: How can I be sure my ADHD evaluation considers look-alike comorbidities?
DECISION 8: Should I also be screened for the sleep, eating, or other disorders?

The Clinicians’ Guide to Differential Diagnosis of ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when evaluating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
• DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
• DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
• DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
• DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

NOTE: This resource is for personal use only.

Inexperienced teen drivers with ADHD face an outsized risk for serious motor vehicle accidents due to attention deficits, impulsivity, and other ADHD-related challenges. Understanding the factors that contribute to elevated driving risk, as well as strategies and training plans that can mitigate these risks, is critical for caregivers and teen drivers.

Adults with ADHD are up to six times more likely than are their neurotypical peers to have Major Depressive Disorder (MDD), which is characterized by extreme sadness, loss of interest, and mania. Not only is MDD more prevalent in adults with ADHD, but the disorder can have an outsized effect on women and girls who have both conditions. MDD is associated with an earlier age of onset, a longer duration, more severe impairment, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization in girls with ADHD.

When treating depression in patients with ADHD, it is critical for clinicians to recognize a patient’s feelings of worthlessness, which, as one study points out, were directly related to suicidal thoughts and planning in adolescents.

In this webinar, you will learn:

• About MDD and other mood disorders that are highly comorbid with ADHD, including bipolar disorder, disruptive mood dysregulation disorder, and emotional dysregulation
• About symptoms of mood disorders and how they co-exist with ADHD
• About new and alternative treatments for MDD, including medication, neurofeedback, and neuromodulation therapy, trans-cranial magnetic stimulation (TMS), and esketamine treatments
• Which therapies are in clinical trials that may hold promise
• About strategies to help people with depression and mood disorders

Watch the Video Replay

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Download or Stream the Podcast Audio

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More on Comorbid Depression and ADHD

• Download: How to Recognize and Treat Depression
• Read: 6 Unexpected & Misunderstood Signs of Depression
• Read: Treating Comorbid Mood Disorders Safely

Obtain a Certificate of Attendance

If you attended the live webinar on May 24, 2023, 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

Nelson Handal, M.D., DFAPA, is the Founder, Chairman, and Medical Director for Dothan Behavioral Medicine Clinic (DBMC) & Harmonex Neuroscience Research (HRX). As a practicing Board Certified Child, Adolescent and Adult Psychiatrist, Dr. Handal has dedicated much of his career to developing and implementing technologies that elevate the quality of patient care.

Dr. Handal participates in extensive clinical research and has been primary investigator in over 85 clinical trials. In the late 1980s, Dr. Handal was president of one of the first telemedicine referral services in the world. This system was featured in Business Week. CliniCom® is an online psychiatric assessment tool Dr. Handal has been developing for the past 10 years and which has been used by over 54,000 patients. In May 2009 Dr. Handal was invited to testify before the United States House Committee on Veterans’ Affairs regarding innovative technologies and treatments for veterans; he spoke about CliniCom®.

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A further complication: youth with ADHD are at higher risk for developing mood disorders, such as disruptive mood dysregulation disorder (DMDD) or oppositional defiant disorder.

During a recent ADDitude webinar on irritability, we asked nearly 1,000 attendees, “What is the most challenging aspect of emotion regulation for your child or patient?” Here are the answers they gave:

• Dysregulation of emotions in the moment (e.g., feelings often subjugate thinking): 37.8%
• Intensity of felt emotions (e.g., sudden, violent outbursts): 34%
• Unrelenting nature of irritability (e.g., always angry, bristly, mean): 14%
• Poor recognition of other people’s feelings (e.g., apparent and/or real lack of empathy): 7.1%
• Frequency of mood changes (e.g., dizzying emotional lability): 6.7%

Comments and questions submitted during the webinar, titled “Emotion Regulation Difficulties in Youth: ADHD Irritability vs. DMDD vs. Bipolar Disorder” provided deeper insight into how ERD impacts youth with ADHD.

Emotion Regulation Manifestation #1: Explosive Outbursts

“My child screams and breaks down over issues with friends.”

“My son is verbally aggressive and used to destroy doors and walls. It is truly hard for me to cope with his crisis.”

“My 11-year-old son’s physical and verbal aggression seems to be reserved for home. He controls himself at school but not at home, where he is very argumentative and defiant. He is easily triggered when he does not get his way (e.g., he pushes, hits, and calls us names).”

“My 14-year-old daughter keeps it together at school but is defensive, aggressive, and explosive with her 11-year-old sister and us (her parents) when we intervene.”

[Self Test: Does My Child Have Disruptive Mood Dysregulation Disorder?]

Explosive Outbursts: Next Steps

• Download: 9 Truths About ADHD and Intense Emotions
• Read: Why Is My Child So Angry?!
• Read: What Is Intermittent Explosive Disorder? 

Emotion Regulation Manifestation #2: Rejection Sensitive Dysphoria

“It is hard for my child with ADHD to not respond in a passive-aggressive, irritating way toward people she feels have rejected her. This might look like getting into others’ personal space by doing things she knows bothers them. This has gotten her in trouble with peers whom she feels are her bullies.”

“My son is 16 and has had explosive emotional outbursts due to environmental factors since he was 18 months old. The emotional outbursts have lessened substantially, but they still happen when he is super frustrated, upset, or gets his feelings hurt by his friends.”

RSD: Next Steps

• Download: Understanding Rejection Sensitive Dysphoria
• Read: How ADHD Ignites Rejection Sensitive Dysphoria
• Self-Test: Could It Be Rejection Sensitive Dysphoria? Symptom Test for ADHD Brains

Emotion Regulation Manifestation #3: Extreme Irritability

“Irritability occurs when there is a change in the child’s expectations of a situation. For example, it is not going to happen or not happening soon enough according to the child’s understanding or expectation.”

“My kid seems to be frequently irritable and grouchy and has angry outbursts.”

“I’ve noticed a big increase in irritability for my 13-year-old son with ADHD.”

“My 12-year-old wants to buy things or have things bought for her. Telling her ‘no’ results in irritability and a major tantrum.”

Extreme Irritability: Next Steps

• Download: 10 Ways to Neutralize Your Child’s Anger
• Read: New Insights Into Emotional Dysregulation and Treatment Considerations
• Read: “My Child’s In a Bad Mood Every Morning!”

Emotion Regulation Manifestation #4: Lack of Flexibility

“My granddaughter is often agitated and gets things stuck in her head, and there is no working around it. Screen time is about all that keeps her focused and calm. Everything is a challenge — routines, grooming, sitting down to dinner. Everything”

“My son is very rigid and has no ability to cope when he doesn’t get his way.”

“I struggle with my daughter’s need to be in control of everything and everyone. So much so, even making doctor’s appointments are hard to do.”

Lack of Flexibility: Next Steps

• Download: Why Is My Child so Defiant?
• Read: What’s Really Behind Your Child’s Bad Behavior?
• Read: Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings

[Self-Test: Does My Child Have ADHD? Symptom Test for ADHD]

Emotion Regulation Manifestation #5: Self-Harm

“I have an 11-year-old daughter who has had explosive outbursts and big highs and lows since age 4. She began expressing suicidal ideation and was self-harming and experiencing intrusive thoughts.”

“During fits, my child makes comments about ‘not wanting to live,’ and ‘can’t take it anymore.'”

Self-Harm: Next Steps

• Download: Easy Mindfulness Exercises for Kids with ADHD
• Read: ADHD & Self-Harm: How to Help the Girls Who Suffer Most
• Read: How Is Your Emotional Resilience? Learning to Cope with Intense ADHD Feelings

Emotion Regulation Manifestation #6: Overly Emotional

“We’re struggling with my son because he’s not combative, just EXTREMELY emotional. He has crying episodes or extended periods of being upset where he cannot regroup for up to an hour.”

“My son does OK in most environments, but at home, he displays a lot more irritability and dysregulation, anger, frustration, and sadness.”

“My son is explosive at times. I remain calm with few words spoken, but he escalates quickly by yelling and running out of the house. This creates a very stressful environment for everyone in the house. I don’t know how to get him out of his terrible moods, where he fixates on ‘small’ things that bother him.”

Overly Emotional: Next Steps

• Download: Evaluate Your Teen’s Emotional Control
• Read: Q: How Do I Teach My Teen to Manage Emotions?
• Read: Calm Starts at Home: How to Teach Emotional Regulation Skills

Emotion Regulation Manifestation #7: Physical Aggression

“My 8-year-old son with ADHD cannot focus or keep still long enough to finish his schoolwork. Then he gets frustrated, which ends with him hitting his peers or teachers.”

“My daughter has a very hard time with aggressive behavior and has had to have the ‘room cleared’ twice this month, along with three in-school suspensions.”

“So often parenting advice recommends setting firm boundaries with kids, such as saying, ‘you can be mad, but I won’t let you throw things/ damage furniture/ etc.” However, with my kid with ADHD, when his lid is flipped, and he’s having a rage outburst, any attempt to say those things seem to ‘feed the fire.’ He just escalates more, often becoming physically aggressive with us.”

Physical Aggression: Next Step

• Download: Free Guide to Ending Confrontations and Defiance
• Read: Anger Is Important — But Only When It’s Managed
• Read: When “Keep Your Hands to Yourself” Doesn’t Work: Fixes for Hitting

More on Emotion Regulation and ADHD

• Free Download: 15 Ways to Disarm (and Understand) Explosive ADHD Emotions
• Read: How Dysregulated Emotions Hijack the Teen ADHD Brain
• Read: ADHD and Emotional Regulation: A Parent’s Guide

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Irritability, moodiness, temper tantrums, or other mood states commonly occur alongside ADHD in youth, but sometimes emotion regulation difficulties (ERD) indicate something more. Caregivers observing frequent mood issues may worry that their child has a mood-related pediatric psychiatric disorder, like DMDD or bipolar disorder, in addition to ADHD. And in fact, youth with ADHD are at elevated risk, compared to unaffected youth, for developing a mood disorder at some point in their lives.

That said, irritability is a non-specific emotional state that can be observed in healthy youth and those who have ADHD or other behavioral challenges, in addition to youth with diagnosed mood disorders. Understanding the significance of irritability in a child with ADHD, consequently, can be quite challenging, even for seasoned clinicians. So it is no surprise that many parents of youth with ADHD and ERD, feel anxious and uncertain about their child’s diagnoses.

In this webinar, caregivers will learn:

• How ERD in youth with ADHD may constitute a diagnostic subtype of the broader ADHD population
• How to view the typical features of pediatric psychiatry disorders associated with irritability in a way that can help caregivers better differentiate the likely source of emotional disturbance they are observing in their child
• Important next steps they can take to help their children experiencing irritability, and other ERD, both from a parenting intervention perspective and through seeking out appropriate clinical expertise

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.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Stitcher; Spotify; Amazon Music; iHeartRADIO.

More on Emotion Regulation Difficulties and ADHD

• Download: Get a Grip on Tough Emotions
• Read: Early Signs of ADD and Emotional Dysregulation
• Read: When a Mood Disorder Looks Like ADHD — and Vice Versa

Obtain a Certificate of Attendance

If you attended the live webinar on December 14, 2022, 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:

William French, MD, DFAACAP, is a board-certified child and adolescent psychiatrist in the Pediatric Clinic at Harborview, Seattle Children’s Hospital, and Odessa Brown Children’s Clinic in the Division of Psychiatry and Behavioral Medicine. He also is an associate professor at the University of Washington.

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The MicroVita® Probiotic Kit contains two probiotics to support focus, attention, healthy gut function, and proper dopamine/serotonin regulation. MicroVita® Focus contains six strains that support attention and focus, while MicroVita® Mood contains six different strains that support mood and emotional regulation. Quality probiotics provide your gut the healthy bacteria it needs to support mental health through the gut-brain axis. | fenixhealthscience.com

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However, emotional dysregulation is not exclusive to attention deficit hyperactivity disorder (ADHD or ADD). Chronic moodiness is also a central component of mood disorders like bipolar disorder, which may complicate the evaluation, diagnosis, and treatment process, particularly for adult patients. Differentiating moodiness as it appears in ADHD, bipolar disorder, and similar disorders is critically important — and not always straightforward.

Emotional Dysregulation Across Disorders

Emotional dysregulation, while present in many conditions, shows up in different ways and in different grades of severity. Making the distinction between characteristics of moodiness in ADHD, ODD, DMDD, and other disorders often requires studying the mood’s intensity and the degree to which it disrupts the individual’s functioning.

ADHD

Chronic Irritability

Many individuals with ADHD report feeling easily irritated and frustrated. Minor frustrations at home, work, and/or school, can cause substantial irritability. (Social pressures outside of the home may keep individuals from lashing out in these settings.) A scenario warranting a 2 on a 10-point scale, for example, can often feel like a 7 or 9 to a person with ADHD. They can be quick to anger, as a result, and may lash out with angry outbursts or through passive-aggressive behaviors. Frustrations, however, are often over quickly. Some may feel upset or regretful later, once the emotional overreaction has subsided.

Oppositional Defiant Disorder (ODD)

ODD is one of the most common comorbidities seen with ADHD. Roughly one-third to one-half of children with ADHD also have ODD, characterized by disruptive, defiant, and irritable behavior. Children with ODD can be quick and impulsive, or sullen and sustained, with their oppositional behaviors toward authority figures. ODD usually becomes apparent around age 12 and lasts until the start of adulthood. Most patients outgrow ODD, but for some, it may turn into conduct disorder, which typically involves delinquent activity, physical aggression, violence, theft, and/or destruction of property.

[ODD vs. ADHD: The Facts About Oppositional Defiant Disorder and Attention Deficit]

Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a relatively new diagnostic category reserved for children over age 6. It is characterized by steady, persistent problems with mood dysregulation. A child with DMDD experiences severe and recurrent temper outbursts, either verbal or behavioral, that are grossly out of proportion and inconsistent with what is typically expected for a child their age. These outbursts typically occur three or more times a week. Between outbursts, children with DMDD are often persistently irritable or angry. To merit a diagnosis, these symptoms need to be chronically present for at least a year.

DMDD is a way of categorizing major mood problems in children without the bipolar label.

Bipolar Disorder

Bipolar I Disorder

A main feature of bipolar I disorder is a distinct period of abnormally and persistently elevated, expansive, or irritable mood. Bipolar I may also be characterized by a period of “hypomania,” or out-of-the-ordinary, increased activity or energy lasting persistently for at least a week. Depressive moods may also occur concurrently or at other times. These moods are severe enough to cause marked impairment in social or occupational functioning, and often warrant psychiatric hospitalization. There may also be increased risk of suicide or suicide attempts.

To merit diagnosis, at least three of the following symptoms must be present:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Pressured speech, racing thoughts
• Extreme distractibility (beyond what is associated with ADHD)
• Increase in agitation (restlessness) or goal-directed activity
• Excessive involvement in risky activity, including over-spending, sexual indiscretions, and/or heavy drinking (the latter often done in an attempt to calm down)

Bipolar I disorder is typically diagnosed around age 18, when a first episode occurs. Many but not all patients go on to experience more episodes.

[Read: Solving the ADHD-Bipolar Puzzle]

Bipolar II Disorder

Bipolar II disorder is usually less severe than bipolar type I, but it can be more complicated to diagnose and significantly impairing. With bipolar type II, there’s at least one hypomanic episode lasting at least four full consecutive days, as well as three or more of the symptoms outlined for bipolar I disorder. These episodes are usually not accompanied by psychotic symptoms; they are not severe enough to cause marked impairment in functioning or to require hospitalization.

Patients with bipolar type II will also meet the criteria for a current or past episode of major depression (MDD). With bipolar I, patients may or may not have accompanying MDD. A major depressive episode is marked by at least 5 of the following symptoms:

• Persistently depressed mood
• Markedly diminished interest or pleasure
• Significant increase or decrease in appetite
• Increased restlessness or slowing down
• Fatigue, loss of energy
• Feelings of guilt or worthlessness
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicide

Bipolar Disorder vs. ADHD

Bipolar disorder and ADHD do share some characteristics of moodiness, irritability, and other aspects of emotionality. The chart below differentiates these characteristics as they usually appear.

• + = presence
• – = absence
• ++ = more present
• +/– = may be present
• +++ = most present

Bipolar Disorder in Children

Bipolar disorder in children is not always marked by clearly defined episodes of severe moods. Another factor complicating diagnosis is that about 80 percent of children and adolescents with bipolar disorder will also have ADHD, ODD, and/or major depressive episodes. This makes it difficult to tell whether a patient with ADHD and serious mood problems has severe ADHD, bipolar disorder, or both.

But aiding diagnosis is the fact that ADHD and bipolar disorder are highly familial. (ADHD has a heritability index of .76; bipolar disorder is between .6 to .85.) Assessing  for history of mood problems can help determine the diagnosis.

Mood Disorders and ADHD: Treatments and Considerations

Emotional dysregulation and severe moodiness in ADHD and bipolar disorder are often treated with medication. This intervention alone, however, is usually not sufficient. Through psychotherapy, patients and families can receive essential support around understanding and addressing problems with mood and emotional dysregulation, including:

• Identifying triggers to episodes involving family systems
• Using strategies to avoid worsening episodes
• Understanding family history of mood problems
• The limitations of medication

Clinicians should also consider that patients with bipolar type II may not warrant or choose to follow the treatments prescribed for bipolar I. In a hypomanic episode, for example, some patients may want to “tap in to” this energy for work or creative projects. In this case, it’s important to have a conversation with patients about recognizing the signs of an episode.

ADHD and Bipolar Medication Options

The first course of action for treating bipolar disorder with ADHD is to stabilize mood, which can be addressed with medications like Lamictal, Abilify, Risperidone, Zyprexa, or Lithium.

Stimulant Medications

Though not explicitly approved to do so, stimulant medications for ADHD often improve moodiness in patients without a mood disorder. A patient’s effective dose is not based on their age, weight, or severity of symptoms, but rather how sensitive the patient’s body chemistry is to a particular medication. This requires monitoring and fine-tuning dosing to fit individual sensitivity as well as the patient’s lifestyle to ensure the medication is active when they most need it.

For patients with ADHD and bipolar disorder, however, stimulants may exacerbate symptoms of emotional dysregulation. If levels of irritability or agitation are made worse on this medication, the clinician should instead prescribe a mood stabilizer to treat and reduce these issues. When the patient’s mood has stabilized but ADHD symptoms persist, stimulants can be added to treatment, but cautiously. The most prescribed stimulants are Vyvanse and Adderall XR.

“Stimulant rebound” is also important factor for clinicians and patients to consider. Patients who report feeling or acting excessively wired and irritable, or who lose their “sparkle” while the stimulant is active, may be taking a dose that is too high or taking medication that does not work for them. But if these effects are occurring as the medication is wearing off, that’s a different issue of “stimulant rebound”, meaning that the medication is dropping off too fast. Usually, this issue can be fixed by administering a small dose of the short-acting version of the medicine, which smoothes its “exit ramp” and avoids these difficulties.

Nonstimulant Medications

Guanfacine-XR (Intuniv) is a nonstimulant approved for ADHD treatment that may help improve restlessness, impulsivity, and hyperactivity in patients with both ADHD and mood problems. This medication dosage needs to be increased slowly to a maximum of 4 mg per day.

SSRIs

Many prescribers are hesitant to add SSRIs to a bipolar treatment plan, as they can increase the risk of a hypomanic or manic episode and cause suicidal thoughts. But if a patient’s mood is stabilized and symptoms of depression persist, an SSRI like fluoxetine may help improve their mood to baseline. SSRIs should be monitored carefully, especially in the first several weeks of administration.

The Role of the Family

Parent Emotional Dysregulation

How families respond to moodiness and emotional outbursts can make a big difference. Should patients, especially children and adolescents, pursue therapy, it is also important to address parental temper and moods as well. Assessing interactions at home can reveal triggers and sensitive scenarios that contribute to mood instability.

Parental Polarization

A patient’s parents may not share the same approach to addressing irritability and moodiness. One parent may insist on patience and support, while the other adopts a “crackdown” approach. Often, each parent ends up taking a more extreme view over time. Both may fail to see how either approach could be right depending on the situation, to the detriment of the child. Therapy can be an appropriate setting for working through these issues.

Mood Disorders: Next Steps

• Read: The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations
• Guide: Where ADHD and Bipolar Disorder Overlap
• Download: Bipolar Disorder and ADHD: How to Tell the Difference

The content for this article was derived from the ADDitude Expert Webinar “Is It Bipolar Disorder or ADHD Moodiness? A Guide to Getting the Right Diagnosis and Treatment” [Video Replay & Podcast #347] with Thomas E. Brown. Ph.D., and Ryan J. Kennedy, DNP, which was broadcast live on March 10, 2021.

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Attention deficit hyperactivity disorder (ADHD or ADD) is three times more common in people with mood disorders compared to those without, according to a meta-analysis published in Acta Psychiatrica Scandinavica.¹ ADHD was also found to be 1.7 times more common in patients with bipolar disorder (BP) compared to those with major depressive disorder (MDD). Bipolar disorder is a serious mental illness that is characterized by extreme mood swings, abrupt changes in energy levels, and distorted decision making. Major depressive disorder is a serious condition that’s symptoms interfere with all aspects of life, such as sleep, work, school, and eating.

A systematic review was conducted on 92 studies including 17,089 individuals. The studies came from PsycInfo and PubMed, published before September 21, 2020. Random‐effect meta‐analyses were used to gauge the prevalence of ADHD by developmental period and disorder.

Researchers found prevalence of ADHD in individuals with BP was 73% (95% CI 66‐79) in childhood, 43% (95% CI 35‐50) in adolescence, and 17% (95% CI 14‐20) in adulthood. Researchers used 52 studies including 16,897 individuals to demonstrate that the prevalence of ADHD in individuals with MDD was 28% (95% CI 19‐39) in childhood, 17% (95% CI 12‐24) in adolescence, and 7% (95% CI 4‐11) in adulthood.

The significant risk for ADHD among individuals with mood disorders led researchers to conclude that individuals with BP and MDD should be routinely assessed for ADHD, which may require the development of additional comprehensive assessment strategies to aide diagnosing ADHD alongside mood disorders.

Sources

¹Sandstrom, Andrea, et al. Prevalence of attention‐deficit/hyperactivity disorder in people with mood disorders: A systematic review and meta‐analysis. Acta Psychiatrica Scandinavica (Feb. 2021) https://onlinelibrary.wiley.com/doi/10.1111/acps.13283

ADHD walks hand-in-hand with emotional dysregulation. Many children, teens, and adults experience persistent moodiness, out-sized frustrations with daily life, protracted sadness, and/or irritability over seemingly minor disappointments.

It’s often unclear whether such emotionality is part of a patient’s personality or current developmental stage, an aspect of their ADHD, a reaction to medication, or a sign of a more serious mood problem like bipolar disorder.

Diagnostic criteria for ADHD don’t mention problems with emotions, though low frustration tolerance, irritability, or moodiness is listed in the DSM-5 as possible associated features of an ADHD diagnosis. When excessive moodiness is persistent and problematic in someone with ADHD, it may be best to talk with your clinician to consider possible causes and treatment options.

In this webinar you will learn:

• How to differentiate moodiness associated with ADHD from that of bipolar disorder
• Why so many with ADHD are misdiagnosed with bipolar disorder
• When moodiness may indicate a need to evaluate for bipolar disorder
• How medications for ADHD can sometimes cause “rebound moodiness”
• How family dynamics can increase or reduce excessive moodiness
• How medication for bipolar disorder alone may not help ADHD symptoms
• Which medications may be helpful for excessive moodiness with ADHD

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.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Stitcher; Spotify; iHeartRADIO.

Read More on Bipolar Disorder and ADHD

• The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD
• Where ADHD and Bipolar Disorder Overlap
• When a Mood Disorder Looks Like ADHD — and Vice Versa: Differentiating Signs of Emotional Dysregulation

Obtain a Certificate of Attendance

If you attended the live webinar on March 10, 2021, 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 Speakers

Thomas E. Brown, Ph.D., is a clinical psychologist who earned his Ph.D. at Yale University and served on the clinical faculty of the Dept. of Psychiatry at Yale School of Medicine for 21 years while operating a clinic in CT for children and adults with ADHD and related problems. In 2017 he relocated to California where he sees patients and directs the Brown Clinic for Attention and Related Disorders in Manhattan Beach, California. Dr. Brown’s most recent books are Smart, but Stuck: Emotions in Teens and Adults with ADHD; and Outside the Box: Rethinking ADD/ADHD in Children and Adults-A Practical Guide. | See expert’s full bio »

Ryan J. Kennedy is a Nurse Practitioner who earned his Doctor of Nursing Practice at Quinnipiac University. For nine years he has collaborated with Dr. Brown for research, publications, and in clinical practice. He is Assistant Director of the Brown Clinic for Attention and Related Disorders where he specializes in assessment, behavioral, and psychopharmacological treatments for children and adults. The clinic website is: www.BrownADHDClinic.com. | See expert’s full bio »

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Listener Testimonials

“Both presenters did an excellent job explaining the diagnoses. This information is so helpful and practical for me as a therapist.”

“Presenters were very knowledgeable and broke down the complex topic of Bipolar and ADHD into easy to understand chunks.”

“The speakers were articulate and had a very caring attitude toward their patient group as human beings.”

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Ultimately, emotional dysregulation is one major reason that ADHD is subjectively difficult to manage, and why it also poses such a high risk for other problems like depression, anxiety, or negative self-medication. Scientific and clinical attention are now increasingly turning to correct the past neglect of this integral aspect of ADHD.

Recognizing this inherent relationship between emotional dysregulation and ADHD is also important when discerning between related and similar conditions, like disruptive mood dysregulation disorder (DMDD), bipolar disorder, intermittent explosive disorder (IED), depression, anxiety disorders, and oppositional defiant disorder (ODD). In all, paying mind to anger issues and emotionality in patients with ADHD is crucial for successful treatment and symptom management in the long term.

Anger Issues and ADHD: Theories & Research

Though separated from ADHD in official nomenclature today, emotional dysregulation and anger were connected to ADHD in the mid-20th century before current diagnostic norms were created, and have continued to form part of personal and clinical experiences. Decades ago, when ADHD was known as “minimal brain dysfunction,” criteria for diagnosis actually included aspects of negative emotionality.

Anger problems and emotional dysregulation in individuals with ADHD are sometimes explained by co-occurring mood disorders, such as anxiety or depression. However, these associated disorders do not explain the near universal anger and emotional issues that ADHD individuals experience.

A critical aspect to consider, then, is ADHD’s nature as a disorder of self-regulation across behavior, attention, and emotion. In other words, any difficulties in regulating our thoughts, emotions, and actions – as is common with ADHD – may explain the irritability, tantrums, and anger regulation issues these individuals experience. And the majority do.

About 70 percent of adults with ADHD report problems with emotional dysregulation¹, going up to 80 percent in children with ADHD². In clinical terms¹, these problem areas include:

• Irritability: issues with anger dysregulation – “tantrum” episodes as well as chronic or generally negative feelings in between episodes.
• Lability: frequent, reactive mood changes during the day. .
• Recognition: the ability to accurately recognize other people’s feelings. Individuals with ADHD may tend to not notice other people’s emotions until pointed out.
• Affective intensity: felt intensity – how strongly an emotion is experienced. People with ADHD tend to feel emotions very intensely.
• Emotional dysregulation: global difficulty adapting emotional intensity or state to situation.

Explaining ADHD and Anger via Emotional Profiles

Emotional dysregulation remains a constant in ADHD even when analyzing personality traits, making the case for emotional profiles or subtypes around ADHD.

[Get This Free Download: Emotional Regulation & Anger Management Scripts]

Our own study of children with ADHD that used computational methods to identify consistent temperament profiles found that about 30 percent of kids with ADHD clearly fit a profile strongly characterized by irritability and anger². These children have very high levels of anger, and low levels of rebound back to baseline – when they get angry, they can’t get over it.

Another 40% had extreme dysregulation around so-called positive affect or hyperactive traits — like excitability and sensation-seeking. Children with this profile also had above-average levels of anger, but not as high as those with the irritable profile.

Thinking of ADHD in terms of temperament profiles also becomes meaningful when considering the role of brain imaging in diagnosing ADHD. Brain scans and other physiological measures are not diagnostic for ADHD because of wide variation in results among individuals with ADHD. However, if we consider brain scans based on temperament profiles, the situation may become clearer. Data from brainwave recordings makes the case that there is distinct brain functioning among children who fall under our proposed irritable and exuberant ADHD profiles².

In eye-tracking tests among the participants, for example, children in this irritable subgroup struggled more than those in any other identified subgroup to take their attention off negative, unhappy faces shown to them. Their brains would activate in the same areas when they saw negative emotions; this did not happen when they saw positive emotions.

Genetic Basis for ADHD and Anger Issues

From a genetics standpoint, it appears that emotional dysregulation is strongly associated with ADHD. Our recent findings suggest that genetic liability for ADHD is related directly to most traits under emotional dysregulation, like irritability, anger, tantrums, and overly exuberant sensation-seeking³. What’s more, irritability appears to have the biggest overlap with ADHD versus other traits, like excessive impulsivity and excitement, in children.

These findings refute the idea that mood problems in ADHD are necessarily part of an undetected depression — even though they do indicate higher future risk for depression as well as higher possibility of depression being present.

Anger Issues: DMDD, Bipolar Disorder & ADHD

ADHD, DMDD, and bipolar disorder are all associated in different ways with anger and irritability. Understanding how they relate (and don’t) is critical to ensuring proper diagnosis and targeted treatment for anger issues in patients.

Anger Issues and Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a new disorder in the DSM-5 primarily characterized by:

• Severe tantrums, either verbal or behavioral, that are grossly out of proportion to the situation
• A baseline mood of persistent grumpiness, irritability, and/or anger

DMDD was established in DSM-5 after a crisis in child mental health in the 1990s in which rates of bipolar disorder diagnoses and associated treatment with psychotropic mediation in children skyrocketed – inaccurately. Clinicians at that time assumed, in error, that irritability in children could be substituted for actual mania, a symptom of bipolar disorder. We now know from further epidemiological work that, in the absence of mania, irritability is not a symptom of hidden bipolar disorder in children. When mania is present, irritability can also emerge as a side feature of the mania. But mania is the primary feature of bipolar disorder.

Mania means a notable change from normal in which a child (or adult) has unusually high energy, less need for sleep, and grandiose or elevated mood, sustained for at least a couple of days — not just a few hours. True bipolar disorder remains very rare in pre-adolescent children. The average age of onset for bipolar disorder is 18 to 20 years.

Thus, DMDD was created to give a place for children older than 6 years of age with severe, chronic temper tantrums who also do not have elevated risk for bipolar disorder in their family or in the long run. It opens the door for research on new treatments targeted these children, most of whom meet criteria for severe ADHD, often with associated oppositional defiant disorder.

DMDD is also somewhat similar to intermittent explosive disorder (IED). The difference is that a baseline negative mood is absent in the latter. IED is also usually reserved for adults.

As far as ADHD, it is important to recognize that most patients who meet criteria for DMDD actually have severe ADHD, sometimes with comorbid anxiety disorder or ODD. This diagnosis, however, is given to help avoid a bipolar disorder diagnosis and take advantage of new treatment insights.

[Self-Test: Could Your Child Have DMDD?]

Anger Issues and ADHD: Treatment Approaches

Most treatment studies for ADHD look at how core symptoms of ADHD change. Treating anger problems in individuals with ADHD has only recently become a major research focus, with useful insights revealed for patient care. Alternative and experimental approaches are also increasingly showing promise for patients with emotional dysregulation and anger issues.

Interventions for Children with Anger Issues

1. Behavioral Therapy⁴

• Cognitive Behavioral Therapy (CBT): Some children with anger issues have a tendency to over-perceive threat – they over-react to an unclear or ambiguous situation (someone accidentally bumps you in line) when no threat is actually present. For these children, CBT can help the child with understanding that something ambiguous isn’t necessarily threatening.
• Counseling: Anger problems can also be caused by difficulties with tolerating frustration. Counseling can help children learn how to tolerate normal frustrations and develop better coping mechanisms.
• Parent Counseling: Parents have a role in how a child’s anger manifests. A parent’s angry reaction can lead to negative and mutual escalation, such that parents and kids both start to lose their balance. This can form a negative loop. With counseling, parents can learn to react differently to their child’s tantrums, which can help reduce them over time.

2. Medication:

Regular stimulant medication for ADHD helps ADHD symptoms much of the time, but is only about half as helpful with anger problems. Selective Serotonin Reuptake Inhibitors (SSRIs) may be next for treating severe anger problems. A recent double-blind study, for example found that children with severe tantrums, DMDD, and ADHD who were on stimulants saw a reduction in irritability and tantrums only after being given Citalopram (Celexa, an SSRI antidepressant) as a second medication⁵. While only one study, these findings do suggest that when mainline stimulant medications are not working, and severe anger problems are a core issue, then adding an SSRI may be a reasonable step.

Interventions for Adults with Anger Issues

Behavioral counseling (as in CBT) has clear evidence pointing to its benefits in treating emotional regulation problems for adults with ADHD. Specifically, these therapies improve skills in the following:

• Interior regulation: refers to what individuals can do within themselves to manage out-of-control anger. The key element here is learning coping skills, practicing them, and checking back with a counselor for refining. Important for patients to understand is that learning about coping skills without practice, or trying some self-help without professional consultation is generally not as effective. Some examples of coping skills include:
  • anticipatory coping, or devising an exit plan to the triggering situation – “I know I’m going to get angry next time this happens. What am I going to plan ahead of time to avoid that situation?”
  • appraisals and self-talk to keep temper under control (“Maybe that was an accident, or they’re having a bad day.”)
  • shifting attention to focus elsewhere instead of on the upsetting situation.
• Exterior supports
  • Social connections – talking to others and having their support –are tremendously beneficial for adults struggling with ADHD and anger
  • Exercise, stress reduction, and other self-care strategies can help.

Strategies with Limited Benefits

• Typical ADHD medication helps with core symptoms, but has only modest benefits on emotional dysregulation for adults with ADHD⁶
• Meditation classes offer some benefits⁷ for managing ADHD symptoms and emotional dysregulation for teens and adults (and for children if parents join in the practice too), but most studies on this intervention tend to be of low quality so it is difficult to draw strong conclusions.
• High-dose micronutrients may help adults with ADHD emotionality, based on a small but robust study⁸. Omega-3 supplementation also appears to have a small effect in bettering emotional control in children with ADHD⁹.

Problems with emotional dysregulation, in particular with anger reactivity, are very common in people with ADHD. You are not alone in struggling in this area. Anger may indicate an associated mood problem but often is just part of the ADHD. Either way, changes in traditional ADHD treatment can be very helpful.

Anger Issues and ADHD: Next Steps

• Read: Why Is My Child So Angry?!
• Learn: Mapping the ADHD Brain – MRI Scans May Unlock Better Treatment and Even Symptom Prevention
• For Clinicians: Comorbid Considerations Q&A – Treating Bipolar Disorder, Depression, Anxiety, or Autism Alongside ADHD

The content for this webinar was derived from the ADDitude Expert Webinar “You’re So Emotional: Why ADHD Brains Wrestle with Emotional Regulation” by Joel Nigg, Ph.D., which was broadcast live on July 28, 2020.

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 Beheshti, A., Chavanon, M. & Christiansen, H. (2020). Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis. BMC Psychiatry 20, 120. https://doi.org/10.1186/s12888-020-2442-7

² Karalunas, S. L., Gustafsson, H. C., Fair, D., Musser, E. D., & Nigg, J. T. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychological Assessment, 31(2), 236–247. https://doi.org/10.1037/pas0000664

³ Nigg, J., et. al. (2019). Evaluating chronic emotional dysregulation and irritability in relation to ADHD and depression genetic risk in children with ADHD. Journal of Child Psychology and Psychiatry 61, 2. https://doi.org/10.1111/jcpp.13132

⁴ Stringaris, A., Vidal-Ribas, P., et. al. (2017). Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. Journal of Child Psychology and Psychiatry, 59 (7). https://doi.org/10.1111/jcpp.12823

⁵ Towbin, K., Vidal-Ribas, P., et. al. (2020). A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3). https://doi.org/10.1016/j.jaac.2019.05.015

⁶ Lenzi, F., Cortese, S. et. al. (2018). Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 84, 359-367. https://doi.org/10.1016/j.neubiorev.2017.08.010

⁷ Xue, J et. al. (2019). A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine 98(23). 10.1097/MD.0000000000015957

⁸ Rucklidge, J., Frampton, C., Gorman, B., & Boggis, A. (2014). Vitamin–mineral treatment of attention-deficit hyperactivity disorder in adults: Double-blind randomised placebo-controlled trial. British Journal of Psychiatry, 204(4), 306-315. doi:10.1192/bjp.bp.113.132126

⁹ Cooper, R., Tye, C. et.al. (2016). The effect of omega-3 polyunsaturated fatty acid supplementation on emotional dysregulation, oppositional behaviour and conduct problems in ADHD: A systematic review and meta-analysis. Journal of Affective Disorders 190, 474-482. https://doi.org/10.1016/j.jad.2015.09.053

Perhaps it’s the innate hyperfocus. Or the adrenaline rush. Or the years we’ve spent working hard to ignore buzzing, beeping, unimportant distractions. For maybe all of these reasons, and many others, ADHD brains tend to shine in times of emergency.

We hear this anecdotally from our readers. There was the woman who kicked into high gear as a hurricane approached, able to coordinate supplies, family members, and contingency plans while the world around her panicked. There was the Army aviator who coordinated an emergency rescue mission requiring hours upon hours of life-or-death air traffic control. And many ADDitude readers are feeling it now — during this pandemic that lacks the heart-pumping thrills but none of the dire consequences of a true emergency.

In a survey of ADDitude readers fielded last week, 39.9% of 1,977 respondents said they view their ADHD as an advantage right now. Some cite their ADHD brains’ uncanny ability to shift from first gear straight into fifth with the slightest injection of dopamine. When news of the pandemic’s severity first broke, they responded swiftly and decisively while neurotypical brains struggled to come to terms with a new, changing reality.

“In the initial crisis, I was able to act quickly and aggregate a huge amount of information in order to advocate for us to close/move to online gatherings before the general public did,” wrote one parent of a young child. “Being activated by a sense of urgency and my capacity to hyperfocus served me well. In the following weeks, my ADHD has been a disadvantage as I struggle to maintain the routines and support that I previously used to treat my ADHD. However, even here, I have advantages in adapting to working remotely over my colleagues, because (of necessity) I had already built myself systems of accountability, collaboration, and support with fellow ADHD folk and now these serve me well.”

This theme of using hyperfocus for good emerged time and time again in the survey comments.

[Free Download: 3 Defining Features of ADHD That Everyone Overlooks]

“Hyperfocus lets me absorb a lot of information about things like viruses, the immune system, and epidemiology,” wrote another reader with ADHD and PTSD. “Some folks might find that daunting, but for me, connecting all these dots gives me greater understanding about our situation, and that keeps me more grounded and calm.”

Though hyperfocus and adaptability may seem strange bedfellows, many ADDitude readers also heralded their ability to shift and modify strategies quickly and nimbly as new information unfolded during this crisis. The energy, creativity, and resilience associated with ADHD, it seems, has proven invaluable.

“I can adapt and modify ‘on the fly;’ I’m open to change,” wrote one reader with ADHD, anxiety, and depression. “The typical daily grind is exhausting, but this ever-changing Corona-world is less exhausting. I’m not sure why.”

“I love that we have had to come up with new ways to do things,” wrote another. “Change doesn’t bother me, I adapt. But, honestly, it seems that the world is now more suited to me and I don’t have to work so hard to fit in, or cope.”

[The Benefits of ADHD: Learning to Love It (and Yourself!)]

This theme of finding peace and calm amid the pandemic surprised us as we encountered it time and time again in the survey comments. Many readers expressed gratitude for the opportunity to slow down and engage in the self-reflection and self-care that is so commonly postponed in ‘real life.’

“The rest of the world has come to a stop, so I can now focus on my world without guilt,” wrote one middle-aged woman with ADHD. “I am learning a lot about myself. It’s as though I’ve been able to take a learning workshop on me.”

Others are using their energy and time to pursue joy inside the hyperfocus that their brains crave — but could rarely enjoy with so many daily responsibilities lying in wait prior to the pandemic.

“For the first time in my life, I don’t feel like an outcast, I don’t feel so alone, and I feel like the world is now moving and experiencing the same slowness that I’ve been stuck in for 2 years,” wrote one women with ADHD, bipolar disorder, and PTSD. “I am a part of the new normal and, for once, I am allowed to just be me. I feel like I don’t have to catch up to the rest of society anymore. My distractibility used to take up so much time, but now we’re in limbo and time doesn’t exist. I get to relax while I am in a hyper-focused creative state – there is no more rush… it feels glorious some days – I feel free.”

Indeed, half of the adult survey respondents said they are using “unstructured time” to pursue hobbies, explore creativity, and tackle long-standing projects. This was true for adults both with and without children at home with them.

“I’m free to be creative, working on artistic projects long delayed, without distractions or pressure of any kind,” wrote an older woman with ADHD and anxiety. “For an ADD creative, with no concept of what it’s like to be bored, this is all weirdly ideal. As an artist, I’m blossoming.”

The majority of survey respondents said they are keeping busy with household projects they’ve long avoided; the most common one is clearing clutter to make sheltering in place more calming (and roomy). These organization projects are not easy by any stretch of the imagination; nor are they neatly tied up with a bow. Almost all respondents who reported tackling home projects said these projects are largely unfinished or in a state of flux; they chip away at them slowly and try to feel good about the daily steps in the right direction.

“Organizing spaces is helping me find calm in the storm,” wrote one mother with three young children at home. “I have to focus on one small space at a time or I get overwhelmed. And I can’t do it every day or it’s too much. I’m learning to show myself a lot of grace right now.”

“I got a good start on two areas (with my husband’s help), but can’t get them finished,” wrote a mother at home with two teens. “Some of the challenge is there’s nowhere to take the things to get rid of them. Also, I cannot get motivated to work on any home projects by myself even though there literally has been no other time in my life, and never will be again, that’s better suited to getting home projects, house cleaning done.”

That sense of guilt — over knowing you should be completing home projects right now, but just can’t get it done due to the distractions, the stress, and the work-life rebalancing going on earnest right now — was also a prevailing theme of the ADDitude survey. More than 11% of respondents said they just don’t have time to take on new projects right now; 10% said they are prioritizing self-care and emotional health over productivity; and nearly 28% said they haven’t embarked on any new projects and they feel guilty about it.

“I keep saying I want to get so much done around the house, but then my panic, extreme stress, and lack of sleep do not help,” wrote one parent of elementary and middle school students with ADHD and autism, respectively.

“I feel overwhelmed by how much I have to do in the home, so I focus on other things, even though I want to organize, and I feel guilty for not doing so,” wrote a young adult with ADHD.

The theme of overwhelm was — well, overwhelming, in the answers shared by the 55.77% of survey respondents who called their ADHD a disadvantage during the pandemic. Overwhelmed with all of the change. Overwhelmed with the myriad daily work and parenting responsibilities being constantly interrupted. Overwhelmed with the choices about what to do with unstructured time. All of it resulting in a feeling a paralysis that drives readers to spend too much time on social media or watching mindless shows (the Hallmark channel was cited a lot) or nervously reading the news.

It’s interesting to note that parents with children at home who were also newly working from home were the most likely to call their ADHD a disadvantage right now.

“This is a new experience, so it has placed a strain on the techniques I use to manage my ADHD,” wrote one middle-aged woman. “The sheer amount of information has been overwhelming to the point that I am immobilized by the overwhelm.”

“I finally have all this free time to do all the things I have been neglecting around the house, and yet at the same time, there is so much to do that it is overwhelming, so I find myself defaulting each day to reading and other enjoyable tasks so that I do not have to deal with it — not good,” wrote one parent of teens living in a big city.

“I often feel paralyzed and find it difficult to move forward with projects or tasks,” wrote one mother. “I’m able to make sure my 7th and 9th graders get schoolwork done, which typically does not take up more than 2-3 hours of their days… I’m doing more numbing activities, reading or streaming programs. I read too many daily updates.”

Filling unstructured time with productive, healthy tasks is another common challenge among the respondents struggling to manage their ADHD right now. Many told us they find it difficult to structure their days without the anchors of external obligations like meetings, classes, and social events. They recognize the importance and benefits of structure but feel wholly incapable of creating that structure out of the gaping void in front of them.

“Seemingly unlimited, unstructured time means I veer off into too many rabbit holes and before I know it the day is over, and I haven’t completed any of the professional or personal projects on my to-do list!” wrote one reader.

“Home life is totally unstructured, distracting, and overwhelming,” wrote a woman with ADHD, anxiety, and depression in Seattle. “I try to make a to-do list and get going on it, but it’s so long. Prioritizing and managing it is really difficult. It tends to shut my brain down with overwhelm. I go into some kind of procrastination mode… I usually end up bouncing back & forth between many different tasks that I come across in my path. The end of the day always comes too fast. Then I realize that I still hadn’t started on my to-do list.”

Distractions remain a daunting opponent for many ADHD brains trying to work at home. Some readers report being pulled away from work by children and spouses who need their attention during the day. Others struggle to self-regulate their technology use during the day — having social media and YouTube and news just a click away at all times is sucking up a lot of time. Still others report exhaustion from poor sleep and from feeling compelled to work all the time since the office is just down the hallway.

“Distractibility is having a more severe impact, as I can’t change my environment (e.g. by going to the library) and I have to work in the same room with my partner, usually at the same time,” wrote one readers. “Work never seems to end and is “everywhere” — clear starts and ends are very difficult to maintain — and I don’t have less work than before.”

Routine and boundaries are difficult for parents as well, but in a different way. Three-quarters of parents report that their family’s morning and/or evening routine is less stressful than it was before schools closed. But nearly 25% of parents surveyed said they continue to face hardship with the following:

• Getting a child to adhere to a set class schedule on Zoom or other video learning platform, especially when classes begin early in the day
• Getting kids out of bed and organized for a day of learning before leaving the house for work
• Managing pent-up energy and aggravation at the end of the day, which leads to dysregulation and poor sleep
• Children who think they’re on spring or summer break and fight relentless against bedtimes

“It’s impossible to get my child out of bed to sign in for a virtual class – he does not see the point,” wrote one parent. “After signing in, he claims – that’s it for that class and does not do the work. Nighttime is not any easier. My son is reveling in the combo of not having outside activities and unrestrained screen time. If we cut the screen time off, he threatens to leave the house at very late hours (He is a teen). As a result, he is staying up later than he was before.”

“Humbly, I share that the only reason that there is less stress is because I lower the bar, which is not good,” wrote another parent. “As an adult, now understanding that I have ADHD, I know how incredibly important structure and/or routine is to my and my children’s success in developing competence and confidence. I am not currently successful at this with them. The external structure of school was helpful, and I am struggling now.”

So what is helping? Empathy, support, and community.

“I just like to know I’m not alone in my feelings and struggles in our ‘new norm.’”

So thank you for sharing your unfiltered emotions, struggles, and strategies, ADDitude readers. Your voices matter.

[Read This Next: Results from ADDitude’s First Pandemic Survey]

THIS ARTICLE IS PART OF ADDITUDE’S FREE PANDEMIC COVERAGE
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