In other words, it’s critical for college students and others who recently moved out on their own to develop reliable medication management routines without parental scaffolding — and to advocate for their own health care needs at the doctor’s office.

[Free Resource: 2024 Scorecard of ADHD Treatments]

Here is the advice I give to my young adult patients:

• Incorporate medication administration into your daily routine. Use alarms or reminders on your phone, or associate medication with specific daily activities (e.g., breakfast or brushing teeth). Use a pill organizer to keep track of doses.
• Understand the expected effects and potential side effects of ADHD medication, and the likelihood that ADHD symptoms will return if doses are skipped. Also know that ADHD medication reduces the risk of substance use and improves productivity at work and in school.
• With your provider, brainstorm ways to adjust your routine to better support medication maintenance. Discuss different medication options, such as long-acting versus short-acting formulations.
• Regularly monitor medication effectiveness and side effects. Keep track of changes in symptoms or adverse reactions. Talk to your doctor about these and any other challenges with your medication regimen, concerns about mixing your ADHD medication with other medications or substances, difficulties adhering to the prescribed schedule, or struggles with getting timely refills from your pharmacy.
• If you experience significant side effects, worsening symptoms, or recognize a change or deterioration in your work performance, relationships, sleep, exercise routines, task management, or overall executive functioning skills, it’s important to tell your health care provider.

ADHD Medication Management: Next Steps

• Download: Get Control of Your Life and Schedule
• Q&A: ADHD Medication — Side Effects, Dosages, Precautions & More
• Read: How to Treat a Teen Self-Medicating ADHD

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.

Health Insurance Plans: High-Deductible vs. Low-Deductible

Employer-sponsored health plans generally include high-deductible plans and low-deductible plans. With the former, you pay less in premiums but more out-of-pocket for medical care and prescriptions before your insurance kicks in to cover eligible costs.

In traditional low-deductible plans, you pay higher premiums, but the carrier covers a copay or coinsurance on your office visits and certain prescriptions. Your deductible is tapped only for services like surgery, emergency room visits, MRIs, and so on. Under these plans, you typically copay for medication and therapy sessions.

[Free Download: What to Ask Before Starting ADHD Medication]

Drawbacks of High-Deductible Plans for ADHD Patients

The higher your deductible, the lower your premiums. For people with ADHD, this is usually not the best option. (However, if you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA), a high-deductible plan may be worthwhile because it will let you set aside pre-tax dollars for certain health care costs. More on that below.) Generally, high-deductible plans are not advised for these reasons:

• You’re unlikely to put the money saved from lower premiums toward your health care. Also, many folks with ADHD are reluctant to seek routine health care. If they must pay out-of-pocket to see a provider, their motivation won’t improve.
• You may avoid preventive care and end up spending more in the long run. A copay-based system generally helps you to spend less on medical care and keeps you healthier.

HSA vs. FSA

Many employer-based insurance plans offer these options. HSAs are attached to high-deductible plans. If you contribute more than you spend on health care costs in a year, you can roll those funds over year after year and build a sizable nest egg.

FSAs, on the other hand, do not typically roll over to the next year; you must spend the funds during the policy year or lose them. But if you have a sudden expense early in the year, you can typically pay for it with an FSA because these accounts are usually fully funded at the beginning of the policy year (then paid back over the next 12 months through an employee’s pre-tax payroll deduction). By contrast, the HSA can pay only what has been saved.

[Free Resource: Treatment Strategies You Haven’t Tried]

Prescription Discount Programs and Medication Discount Cards

Before you start any brand name medication for ADHD (or anything else), go to the manufacturer’s website and see if they offer a discount program (find a list at additu.de/medsavings). This is not the same as an after-market coupon, like GoodRx. Those can be helpful too, but typically only for generics.

How Does Health Insurance Work: Next Steps

• Free Webinar: How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle
• <Read: Doing Battle with Your Insurance Company
• Read: Can Insurance Companies Discriminate Because of ADHD?
• Find: ADDitude Directory — Affordable Care Near You

Wes Crenshaw, Ph.D., is a licensed psychologist in Kansas and co-author of ADD and Zombies: Fearless Medication Management for ADD and ADHD.

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.

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

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

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

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

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

Associations Urge Government to Address ADHD Medication Shortage

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

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

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

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

FTC, HHS Seeks Public Input on ADHD Medication Shortage

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

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

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

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

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

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

How Do Psychedelics Work?

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

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

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

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

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

A Brand-New Framework

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

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

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

Or so we thought.

Psychedelics Restore Child-Like Learning

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

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

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

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

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

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

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

Psychedelics Therapy and Mental Health: Next Steps

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

Nicole C. Kear is Consumer Health Editor at ADDitude.

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

Sources

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

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

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

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

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

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Despite highly esteemed and plentiful literature on the use of stimulant and nonstimulant medication to treat ADHD, relatively little information is available on the treatment of complex ADHD — that is, attention deficit disorder plus at least one comorbid condition like anxiety, depression, or an eating disorder. Few studies address the treatment of comorbid conditions, the order of treatment, or the treatment of cognitive deficits and/or hard-to-treat ADHD symptoms.

This presentation will integrate data from controlled and open trials to highlight strategies for illustrative cases of complex ADHD. Participants will learn:

• About new medications approved for ADHD and their use for complex and hard-to-treat ADHD
• About strategies to manage ADHD comorbidities
• About approaches for treating cognitive executive function deficits in ADHD

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

Meet the Expert Speaker

Timothy E. Wilens, M.D., is the Chief of Child and Adolescent Psychiatry, and (Co) Director of the Center for Addiction Medicine at the Massachusetts General Hospital. He is a Professor of Psychiatry at Harvard Medical School. Dr. Wilens specializes in the diagnosis and treatment of ADHD, substance use disorders, and bipolar disorder. Widely published, Dr. Wilens has more than 350 original articles, reviews, chapters, books and editorials to his credit. Dr. Wilens is a consultant to the National Football League, Major/Minor League Baseball, Bay Cove Human Services and Phoenix/Gavin House and is consistently named one of the Best Doctors in Boston and in America for psychiatry.

Treating Complex ADHD: More Resources

• Download: 2024 Scorecard of ADHD Treatments
• Sign Up: The Clinicians’ Guide to Treating Complex ADHD
• Read: Treatment Troubleshooting Guide for Patients
• Replay: Substance Use Disorder and ADHD: Safe, Effective Treatment Options with Dr. Timothy Wilens

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ADDitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

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But if you’ve tried some of these ADHD interventions with limited success and ended up feeling like you “failed” at treatment, rest assured that you did not -— and you’re not alone in feeling this way.

In ADDitude’s recent treatment survey, we asked 11,000 readers about their experiences with 10 different kinds of treatments for ADHD, from medication to meditation. Readers shared what worked and what didn’t, plus stories of how painful the process of finding effective treatment can be, especially for those with rejection sensitive dysphoria (RSD), perfectionism, or feelings of shame.

“I felt as though I flunked mindfulness because I couldn’t pay attention for that long!” said one ADDitude reader. Another shared: “I felt like I was failing in talk therapy when I couldn’t talk in straight lines or remember what I had just said.”

Robyn, an ADDitude reader in Canada, simply said, “I always feel like I’m failing.”

[Read: ADHD and the Epidemic of Shame]

Feelings of Failure, Easily Triggered and Intense

Many people are quick to blame themselves when supplemental therapies don’t work as rapidly or as well as they’d hoped. This instinct has everything to do with the wiring of the ADHD brain, explains Tamar Rosier, Ph.D., in the ADDitude article, “Silence Your Harshest Critic — Yourself.”

“Neurotypical people have prefrontal cortexes that act like a butler. ‘Sir,’ the butler calmly says, ‘your keys are on the table.’ Or ‘Madam, you must leave now if you want to be on time,’” Rosier explains. “Instead of a tranquil butler, individuals with ADHD have an angry neighbor threatening them with his shoe. ‘If you lose your keys again,’ he yells, ‘I’ll throw this at you!’”

Zak, an ADDitude reader in Florida has experienced this first-hand: “My doctor is still working with me to get the meds correct and I feel at times it’s my fault; that I am the one whose body is not adjusting.”

[Download: 2024 Scorecard of ADHD Treatments]

For many, these feelings of falling short or failing to meet expectations are amplified by RSD, which triggers intense emotional sensitivity and pain, explains William Dodson, M.D., LF-APA in “How ADHD Ignites Rejection Sensitive Dysphoria.” “For people with RSD, these universal life experiences are much more severe than for neurotypical individuals. They are unbearable, restricting, and highly impairing.”

This description resonates with ADDitude reader Calvin in Florida. “When I have tried things like mindfulness, exercise, or therapy, I have not had success and I just felt awful,” Calvin says. “I thought mindfulness might help to end the snow-piercer-like train that lives in my head, but instead I felt like a child unable to do a simple concept.”

In addition to the neuroscientific factors that play a role in triggering feelings of failure, a long history of negative experiences exerts a powerful force, says J. Russell Ramsay, Ph.D., ABPP, clinical psychologist.

“Adults with ADHD are often more susceptible to feelings of failure and defeatism when undertaking new endeavors,” Ramsay explains. “This is likely due to past experiences with setbacks, which often result in criticisms. This, in turn, makes adults with ADHD sensitive to the first signs that something seems to not be going well.”

Clinical psychologist Sharon Saline, Psy.D., agrees, adding: “These past struggles resemble a thousand paper cuts per day and accumulate over time into larger wounds which leave sensitive scars. Feelings of shame and not measuring up haunt folks and make it tougher to try new things.”

How to Reframe Feelings of Failure

Experts agree that to optimize treatment for ADHD, trial-and-error is essential. The “error” part of that process can be demoralizing, but it is critical. To discover interventions that work, you’ll have to try ones that don’t — and knowing that from the get-go can be helpful.

“It is important to normalize setbacks as a part of the process of establishing new habits. It is rarely, if ever, a straight line,” Ramsay says. “Reframing a new habit as a challenge or as an experiment is important, as is setting up realistic expectations.”

“I have a hard time planning and sticking to a good regular habit, like exercise and mindfulness meditation. I used to get so aggravated with myself, and feel helpless,” says an ADDitude reader. “My therapist has taught me to not make a big deal of it and simply get back on track.”

Fine-tuning the therapies, lifestyle changes, and medications that best address your particular constellation of symptoms — and dealing with the emotional fallout of that process — is hard work, make no mistake. You can make that hard work a little easier by being kind to yourself, says Saline.

“Treat yourself with compassion, understanding that change usually involves forward motion along with some backsliding,” Saline urges. “Stumbling, regrouping and trying again is part of living for everybody—ADHD or not.”

 Fear of Failure & Treatment: Next Steps

• Read: You Are Worthy of Self-Compassion – How to Break the Habit of Internalized Criticism
• Read: “My Fear of Failure Becomes Paralyzing Perfectionism”
• Free Resource: Understanding Rejection Sensitive Dysphoria

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.

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

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

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

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

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

Psychedelic Therapy: A Blast from the Past

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

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

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

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

“Monumental Results”

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

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

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

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

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

Psychedelic Therapy: Investigating Risks

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

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

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

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

Important Questions Remain

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

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

Patient Suitability

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

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

Psychedelics Research Timeline

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

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

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

1960: Harvard psychologist Timothy Leary begins experiments with psilocybin.

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

1965: Sandoz stops manufacturing LSD and psilocybin.

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

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

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

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

Psychedelic Therapy & Mental Health: Next Steps

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

Nicole C. Kear is Consumer Health Editor at ADDitude.

Sources

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

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

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

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

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

Small studies suggest that an individual with trauma may be predisposed to ADHD, just as anyone with a history of trauma is predisposed to depression, anxiety, and post-traumatic stress disorder (PTSD).

The task of a good diagnostician is to identify a patient’s current diagnoses and treat them, focusing particularly on the most pressing and problematic symptoms. If all of those appear to be symptoms of PTSD, we treat that with a different kind of therapy called trauma-focused cognitive behavioral therapy (TF-CBT). If we find that ADHD symptoms linger even after the trauma is addressed, then we add in ADHD treatment as well. The general rule is to treat the most pressing problem first, then determine whether there are other problems, such as ADHD, that also require treatment.

Q: What do you think about genetic or blood testing, and using those results to choose a prescribed medicine?

These blood tests look at the enzymes in the liver and some of the blood cells to learn how antidepressants, in particular, metabolize in an individual. Enzymes come in different variants, some of which may metabolize an antidepressant very quickly. Other variants of the same general enzymes metabolize medication very slowly.

[Read: What to Expect When You Start Depression Medication]

If someone metabolizes an antidepressant quickly, they’re going to need a higher dose. A slow metabolizer given a doctor’s standard dose will be more likely to have higher blood levels of the medication and more likely to experience side effects.

Q: Can taking certain medications during pregnancy cause ADHD in the child?

The medications people most commonly worry about during pregnancy are SSRIs taken for depression or anxiety. However, there is no evidence that taking SSRIs poses a risk. On the other hand, we do know that taking opioids or heavily abusing stimulants, such as methamphetamine or cocaine, can have a negative effect. Opioids, the top concern on my own list, have been linked to birth defects. Federal and state health agencies provide resources online about reducing the risk of birth defects through behavioral and environmental exposures.

[Read: Treating for Two – ADHD Meds in Pregnancy]

Q: What do researchers think will be different about ADHD treatment in, say, 10 years?

ADHD is a final common pathway of external symptoms. Like a bad cough, it can have many different causes. A cough might occur because of allergies, an infection such as pneumonia, or even cancer. We can find many causes using physical examinations, X-rays, blood tests, and so on.

We don’t yet have precise tools to do that for ADHD. But there is reasonable hope that advances in research will help us develop testing to identify an individual’s specific ADHD causes. And when we figure that out, we can begin to think about preventing and treating ADHD in a very person-specific way. But this is 10 to 20 years away.

PTSD Symptoms and ADHD: Next Steps

• Read: The Science of Fear – Probing the Brain Circuits That Link ADHD and PTSD
• Learn: A Playbook for Post-Traumatic Growth
• Read: Getting Meds Right – Is It in the Genes?
• Learn: The Future of ADHD Research Looks Like This

The comments below are a true testament to the difference a trained provider can make in your ADHD journey. These ADDitude readers recall interactions with clinicians who made them feel seen and understood… and offer hope to those adults and caregivers who are struggling to get their needs met.

Patient-Provider Relationship: Positive Interactions

“As soon as I met my current psychiatrist, we clicked. I felt like she understood my symptoms and my struggles right from the beginning. It has made it easier to trust her with details about how my meds are helping or not helping — knowing that she will believe me.” — Jenna

“We had a really great mental health/psych evaluation years ago. The provider wrote a very wonderful story for my child to help him understand his diagnosis. It was based on the animal character to which my son related best. My son, sadly, picked a Sasquatch, which just about broke my heart. He said it was because he liked to just be left alone. The provider wrote a story about how the Sasquatch elders would help him to not be so alone.” — Katie, Oregon

“When talking with my new gynecologist about hormone replacement therapy, I advised her I may need a higher dose of Estradiol due to ADHD. She was unfamiliar with the ADHD-estrogen relationship but said she was always interested in learning more. I sent her a few links to studies (the scant few available so far), and we were able to develop a few options for treatment in conjunction with my ADHD meds.” — Paulette

[Free Class: ADHD Treatment Guide for Adults]

“…My son’s psychiatrist turned to me and said, ‘Your son has a neurodivergent brain. It’s like his brain processes information in a different language.’ We had recently been in a foreign country, so it was easy to compare. That wonderful psychiatrist was the start of our journey to understanding and providing appropriate support for our burnt-out teenager.” — Karen, New Zealand

“When we connected with our new psychiatrist, it was the first time we felt ‘seen’ and understood by someone. With a complex diagnosis of ADHD and autism in an extremely bright child, it was difficult to get someone to see [my son’s] difficulties. Once we realized she got it, it was such a relief. She said, ‘We have a lot of work to do…but we’ll get there. Don’t worry.’” — Leslie, Pennsylvania

“When talking to a psychologist for stress management, he just tossed out that I had ADHD. I had suspected it for a long time, but I felt like someone had finally noticed why things were so stressful.” — Ann, California

“When I finally got to see a psychiatrist, who confirmed my suspicion that I had ADHD (at age 35), I felt very validated. My family doctor had just put me on antidepressants, which didn’t work for me at all. It was great to know I wasn’t actually crazy.” — Claire, Canada

[Read: “Here’s How I Found an ADHD Specialist Near Me.”]

“We hired an occupational therapist to help our son with self-regulation. She saw all the good things in our son that we didn’t see due to the impulsivity issues he was having at school, summer camps, etc. She really helped us to see him for the amazing child he is and opened our eyes to the curiosity behind behavior that got him into trouble.” — Tiffany, Canada

“When my son was in elementary school, the school counselor had a wonderful relationship and bond with him. During a meeting at school, she told me: “Everyone focuses on his behavior challenges, but I want to acknowledge his personality and what a bright and caring kid he is. Yes, he has lots of challenges, but he’s also a great kid. Don’t forget that.” This was after a serious incident involving my son. I felt that she was really on our side and truly cared about him. The others in the meeting were talking negatively about him; she stood up for him.” — An ADDitude reader

“For me, it was a counselor at a crisis center. This was before my ADHD diagnosis, and I was in a depression/anxiety crisis in which my significant other had called 911. The police response took me to this center, and the counselor on duty (it was after midnight and she was the only one there) happened to be the most amazing fit for me. I usually would resist speaking to counselors in these settings, but something about her had me feeling comfortable enough to be honest. She said things that ‘clicked’ and got my wheels turning, which propelled me to seek out a diagnosis. Two months later, I was finally getting the correct diagnosis of ADHD, and my life changed forever.” — Laura, Oregon

The Patient-Provider Relationship: Next Steps

• ADDitude Directory: Find an ADHD Specialist Near You
• Free Guide: 25 Things to Love About ADHD
• Deep Dive: ADHD’s Pediatrician Problem

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.

Amphetamine and methylphenidate have been used to treat ADHD for at least 80 years, and their safety and efficacy have been studied relentlessly. But according to a recent ADDitude survey, less than half (42%) of parents opt to medicate their children in the months after a diagnosis, largely due to the risk of side effects like appetite suppression or sleep disruption — both possible impediments to growth.

In the end, 85%  of all people with ADHD end up taking medication and they rate its efficacy higher than any other treatment included in the survey, ADDitude’s largest to date. More than 11,000 adults with ADHD and caregivers of children with the condition participated in the survey from July to December 2023.

“We hesitated for a long time and tried diet changes first in an attempt to avoid medication,” said one respondent. “Although diet is very important, medication has given our child the opportunity to enjoy life by having more emotional control, better friendships, and the ability to complete work and think things through. Greater self-confidence flows from all of this.”

Most Popular ADHD Medications

To be clear, ADHD medication is not a quick fix. On average, children try 2.75 different medications and adults try 2.56 prescriptions before finding one that works for them. Even still, survey respondents said that 17% of children and 14% of adults cease treatment with medication for one reason or another — cessation rates lower than reported in other studies.

Biggest Impediments to ADHD Treatment

Access to treatment professionals with experience in ADHD is the biggest impediment to effective treatment, according to both caregivers and adults. Other barriers include side effects, long wait times, poor access to diagnosing clinicians, and comorbid conditions that complicate evaluation and treatment (82% of children and 92% of adults with ADHD report comorbid diagnoses).

ADHD’s Most Common Comorbid Conditions

The average age of ADHD diagnosis in children is 8 for boys and 9 for girls, according to survey respondents. On average, adults not diagnosed as children learn of their ADHD around age 39. Most of these late diagnoses are among women, who report years of struggle preceding their diagnosis.

“I wish I had been diagnosed and treated sooner,” wrote one survey respondent. “The struggle is so profound and deep. And the longer you go through it without help or knowing what you’re really struggling with, the harder it feels to get others to hear and see you. You feel alone.”

Persistence, flexibility, and self-advocacy are vitally important when working to find the right medication. Though the trial-and-error phase was described as frustrating by most survey respondents, research tells us the benefits of ADHD medication use — reduced risks of automobile accidents, substance abuse, unwanted pregnancy, sexually transmitted diseases, and self harm in teens — are worthwhile and meaningful.

“I wish I had known that ADHD medication helps prevent addictions to dangerous substances,” wrote one survey respondent, “and car accidents for people with ADHD.”

ADHD Medication Formulation, Duration & Satisfaction

Barely half of patients taking a long-acting medication are satisfied with its duration of coverage, which is 9.5 hours for children and 10 hours for adults, on average. This is a flunking grade, but it’s far superior to the satisfaction ratings for short-acting formulations. So why do up to 23 percent of children and 30 percent of adults take short-acting stimulants? Perhaps because clinicians are more likely to prescribe them, and some adults like the medications’ relative flexibility.

“Sometimes, in a social setting, I quite like taking only 5 mg of short-release (rather than my prescribed 10 mg),” wrote one survey respondent. “Other times, when working on something that I find really dull, I often take 15 mg (3 x 5 mg tablets).”

In the end, adults are more likely than children to take short-acting formulations, to be dissatisfied with their medications, and to be considering a switch.

ADHD Medication Side Effects

Caregivers are likely to try fish oil, eliminate food dyes, and sign up for karate before considering a prescription for their child. Once they decide to try medication, caregivers prioritize finding the one with the fewest side effects.

At the same time, 53% of children who end up taking medication try methylphenidate, 36% take amphetamine, and just 11% take a non-stimulant. So given its popularity, methylphenidate must deliver the fewest side effects, right?

No. According to caregiver reports, slightly more children reported side effects from methylphenidate than amphetamine, and those side effects were nearly identical, with appetite suppression being the most common by far; it impacted 61% of children taking any stimulant.

Adults use amphetamine for what they cite as their top priority in choosing a medication — symptom control. Yet they gave it an efficacy rating that was only slightly better than methylphenidate, which is associated with fewer side effects.

So should more adults consider trying Concerta, Ritalin, or a newcomer like Azstarys? One-quarter to one-third of adults said they are now considering some kind of medication switch.

ADHD Treatments Scorecard

Most Highly Recommended ADHD Treatments

ADHD Treatments with Highest Efficacy Ratings

Rated According to Effectiveness on ADHD Symptoms, Specifically

What Readers Say vs. What They Do

The most highly recommended ADHD treatment (exercise) has been used by less than half of ADDitude survey respondents. The second most recommended treatment among adults (ADHD coaching) has been adopted by only 17 percent of people. And the vitamins, minerals, and supplements used by 49 percent of people don’t even earn a passing grade. All of this hints at problems with availability, cost, and medical advice in the world of ADHD treatment.

Diet and Nutrition for ADHD Symptoms

What dietary changes move the needle?

At least half of caregivers and adults agree that the following dietary changes improve ADHD symptoms:

• Decreasing or eliminating artificial colors/preservatives/sweeteners
• Decreasing or eliminating sugar
• Increasing protein

Research supports these observations and reader efficacy ratings are high. So why are fewer than 30% of caregivers and adults making dietary changes to address ADHD? For one, 61% of children using stimulant medication to treat their ADHD experience appetite suppression as a side effect, according to their caregivers. Dietitians generally advise that children should focus on eating first and eating heathy second.

“We struggle to get enough calories into our child due to decreased appetite,” wrote one parent. “We are happy to have her eat, regardless of what or when, to keep energy levels up.”

Psychotherapy More Prevalent Than ADHD Coaching

Though the recommendation rates are nearly identical, far more people engage in psychotherapy than work with an ADHD coach. Therapy generally helps clients work through comorbid conditions like anxiety and depression, and negative beliefs or self-defeating behaviors. Coaching helps to strengthen skills to mitigate ADHD deficits and reach goals, but its benefits are short-lived, readers say.

“ADHD coaching helped me to narrow down my biggest challenges and work on practical solutions for the day-to-day things I struggle with,” said one survey respondent.

Parent Training or Behavioral Therapy for ADHD

This first-line treatment is used by less than 6 out of 10 study participants.

The American Academy of Pediatrics recommends parent training in behavior management as a first-line ADHD treatment for children diagnosed before age 7, and a complementary treatment thereafter. Despite this recommendation, and a high rate of reported satisfaction, just more than half of parents say they’ve ever used it. Possible reasons for this: Clinicians aren’t recommending parent training nearly enough; behavioral therapists versed in ADHD are difficult to find; and/or therapy is expensive and time-consuming. Likely, all of these reasons are true.

“Changing the way we parented was a game changer,” wrote one survey respondent. “It brought the stress in the house down significantly and meant we could focus on the lagging skills and promoting the behaviors we wanted to see versus punishing behaviors we didn’t want to see.”

Exercise for ADHD: Invaluable and Infrequent

Does exercise eradicate ADHD symptoms? Hardly. Readers rated its efficacy on ADHD just 2.4 out of 5, but they also called it invaluable — especially vigorous cardiovascular morning exercise. It aids sleep, mood, and hyperactivity, our readers say. So why isn’t exercise a universal component of treatment plans? As we know, the ADHD brain is easily bored and resists routine.

“When I get into a good stride with routine exercise, it almost always goes hand-in-hand with better eating habits, better focus, energy levels, mental clarity, and stronger relationships and productivity,” said one adult with ADHD. “Exercise is undoubtedly a crucial piece of the (treatment) puzzle.”

Most Impairing Symptoms of ADHD

ADHD Treatment Options: Next Steps

• Download: Share This Report with Your Doctor
• Read: ADHD Medication Reviews
• Get: The ADHD Treatment Guide for Adults

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

The impact of rising and falling hormone levels on ADHD symptoms is compounded for females beginning in puberty, according to a review article published in Hormones and Behavior. ¹

Menstrual Cycle

ADHD symptoms correlate with hormonal fluctuations, especially declines in estrogen, argue the review authors, who present a new two-phase theory of hormonal sensitivity that asserts ADHD impairments spike during two points in the menstrual cycle:

• Periovulatory (mid-cycle)
• Perimenstrual (end-of-cycle)

Per the theory, females may be more likely to engage in risk-taking and reward-seeking behaviors in the days leading up to ovulation. These behaviors coincide with a steady rise in estrogen levels that drops off during ovulation. In contrast, withdrawal and/or depletion of estrogen at a cycle’s end may be characterized by increased negative affect, avoidant behaviors, and reduced executive functioning.

The effects of estrogen withdrawal may potentially exacerbate ADHD symptoms based on inherent individual differences in affect and impulsivity. The theory also points to luteal-bound increases in hyperactivity driven by fluctuations in progesterone metabolites.

“In the follicular phase, which is the period when estrogen levels are steadily increasing, ADHD symptoms are at their lowest,” said Jeanette Wasserstein, Ph.D., in an ADDitude webinar on hormones and ADHD. “That’s the period when estrogen and progesterone are jointly protected. They work together.”

A preliminary pilot study conducted by the authors in 2018 published similar conclusions.² Among young adult females aged 18 to 25, declines in estradiol (a type of estrogen) led to an increase in ADHD symptoms. Specifically, the study showed a two-fold increase in ADHD symptoms of inattention and hyperactivity-impulsivity, which were moderated by positive and negative urgency and by levels of progesterone.

Reproductive Periods

Adolescents are particularly vulnerable to the impact of hormones as they develop. ADHD or not, adolescent females undergoing hormonal changes experience an increase in impairments, including comorbidity, suicidality, and unplanned pregnancy, the authors said. They are also faced with unique environmental stressors including delinquent peers, strained family functioning, and psychosocial stressors. However, limited research exists on how sex hormones impact ADHD symptoms specifically across the lifespan.

Rises in estrogen and progesterone at the onset of puberty may trigger neurobiological sensitivity to hormonal changes, per the theory, and lead to structural and functional changes in the brain. “If those networks are particularly those in the executive brain, the prefrontal cortex, and its linkages throughout the brain, we could see a rise in ADHD symptoms,” said Russell Barkley, Ph.D., in a YouTube video summarizing the review article.

The authors said that the combination of transient activational effects and long-lasting organizational effects during puberty acts as a “double whammy” that is mirrored during later reproductive events, including pregnancy and menopausal periods.

“We’ve had instances where we’ve seen a rise of referrals in women to clinics that is coincidence with the onset of perimenopause or menopause,” Barkley said. “Women who weren’t necessarily ADHD previously — or were able to cope with elevated symptoms that may not have been in the clinical range — now found themselves fully, clinically ADHD as they approach mid- to late life.”

Multiple hormone sensitivity theory may help explain why rates of ADHD differ between males and females during development. As many as three males to one female are diagnosed with ADHD during childhood; by adulthood, the rates even out. While ADHD risk appears to be highest for males during the prenatal period, females experience heightened risk during multiple reproductive periods, as cited by the authors.

Treatment Implications

Timed interventions may make treatment plans more effective for females with ADHD. This might include adjusting medication dosage and type to the menstrual cycle and reproductive period. For example, the authors cited research showing heightened sensitivity to stimulants during the follicular phase of a woman’s cycle — when estrogen is high, and progesterone is low. “Changes in response to ADHD medications likely reflect the point in the menstrual cycle that a woman is and where all these different hormones are,” Wasserstein said. And “there might be different reactions depending on which presentation of ADHD the person has.”

Barkley says that some doctors are already using these practices. “Clinicians who have worked with young women have often told me that they adjust medication, and even add additional medication, at different stages of the month to help women manage their ADHD and period-related exacerbations.”

Additionally, ADHD assessments should provide a lower threshold for women and account for these behavioral changes.

Future Research

To test their theory, the authors suggest assessing for circulating hormone levels and ovulation. Future research should focus “on the hormonal impacts on females with ADHD, not just the impact of stimulant medications on fetuses.”

“This work is vitally important because knowledge of what ADHD looks like and the public health impacts of ADHD in females is limited, particularly in adolescents and young adults, which are understudied developmental periods in their own right in the ADHD field,” the authors wrote.

This review article was made available online on November 30, 2023, and will be published in Volume 158 of Hormones and Behavior in February 2024.

Sources

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

²Roberts, B., Eisenlohr-Moul, T., & Martel, M.M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed type of antidepressant. But we shouldn’t confuse their popularity with ease of access, as clinicians take great care when initially prescribing these medications and determining their efficacy for individual patients, especially due to their side effects.

“Side effects of these medications are important to consider,” said Nelson Handal, M.D., in a webinar for ADDitude, adding, “You have to look at every little detail before you give an antidepressant.”

A full family history of psychological disorders is considered when clinicians decide whether to prescribe an SSRI. “I have to know from the family history if there is bipolar disorder,” Handal offers as an example. For individuals with bipolar disorder, SSRIs are thought to increase risk for mania.

Increase in suicidal thoughts is another concerning side effect of SSRIs, especially in younger patients. To avert these and other side effects, the gold standard is to adopt a conservative approach when starting a patient on an SSRI and to establish checks along the way.

“There are two goals with treatment: One is efficacy, and the other is tolerance,” said Handal. “I tell every parent… we will go low and slow because of tolerance and possible side effects.”

“Low and slow” helps build a patient’s tolerance to the new medication, and it is an effective method to minimize the more serious side effects of SSRIs. Handal, who encourages clinicians to communicate openly with patients, especially with parents of younger patients, also recommends seeing young patients about three weeks after they start on an SSRI to review their experiences and adjust if necessary.

To learn more about treating depression, watch the full replay of Dr. Handal’s free ADDitude webinar, “New Insights Into and Treatments for Comorbid Depression.”

SSRI Side Effects: Next Steps

• Free Class: Living with Depression — a 5-Week Guide to Building Healthier Habits
• Parenting Resource: A Guide to Depression in Teens
• Read: What to Expect When You Start Depression Medication
• Read: Safely Treating Depression and ADHD

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

“I have two kids with ADD,” said an ADDitude reader. “One takes medicine and sees its value. The other has stopped. I worry for both and feel like I’m not sure what the best route is.”

Many parents find themselves in this position. The decision to start or stop medication involves not just you and the doctor, but also your teen, who is seeking increased independence and control in their life. You know that sticking to a consistent medication regimen can make your child’s life easier… but they might need to come to this realization on their own.

“They’re teens, and I have to trust that this part of life is for figuring out hard things,” the reader continued. “We are working together to build skills that will support their growth, regardless of whether they take medication. I’m also working really hard to let them know that even as an adult, I continue to try to improve my habits and figure out what works for me.”

If you have a teen with ADHD who takes medication, have they ever asked to stop taking it? Refused to take it? Or lied about taking it? How did you handle it? Read on to see how these readers broached the topic of medication with their teens.

[Sign Up: The Caregiver’s Guide to ADHD Treatment]

When Teens Refuse ADHD Medication

“My 15-year-old… has always opted not to take her medication on the weekends, and that’s a battle I choose not to engage in. When she stopped taking it on school days, I pointed out that there was no point in seeing a pediatrician if she didn’t follow the treatment plan. That strategy works. However, some mornings her ADHD is the barrier. I try to be available to subtly assess if my independent daughter needs help. If she hasn’t had breakfast, I offer to make it, and place the capsule beside it; if she refuses breakfast, I place the capsule in her hand.”

“We let her get away with [not taking medication] during the shortage. Incentives didn’t work because there was nothing she cared about, and she couldn’t keep her interest long enough to actually earn anything. We finally had to resort to threats of taking away the only thing she cared about: sports.”

“[My son] has said he doesn’t need it, specifically on the weekends. I don’t force it on him.”

“My child has refused to take medication for ADHD for the last two years. I don’t force her. I explain that it’s going to take a more concentrated effort to get things done. We also work with a therapist to consistently learn and implement coping techniques and focus strategies.”

[eBook: The Parents’ Guide to Raising Teens with ADHD (Part One)]

“I was the teen who wanted to stop medication. I felt so overwhelmed in high school by medication; I didn’t think I was the same person on and off my meds. My parents didn’t allow me to stop because we agreed that I would not put other supports in place (like an ADHD diet) to manage my symptoms. I’m glad we were able to have an open and honest conversation about it, and that I did not stop taking medication. I learned how to feel like myself both off and on medication, and I think it is now essential to managing my symptoms and being in control of myself.”

“My 13-year-old is on a variety of medications. Some help her focus, and one helps her sleep at night. She takes them willingly because she knows they help her. She has a check-in with her psychiatrist once a month to make sure they’re working. Every time there’s a medication change, we watch her carefully to make sure there are no side effects. Her psychiatrist is very careful with medications. ‘Go low and go slow’ is her motto.”

“I let [my teens] go off of [medication] for a bit to see how they would function without it… they went back on it after a few weeks.”

“I have a daughter who is 14 and has refused to take her medication for about a year and a half now. She says she doesn’t like the way it makes her feel, which is anxious. Unfortunately, I have tried multiple times unsuccessfully to convince her how much she needs it. Her ADHD symptoms have gotten worse and she doesn’t care about school or her grades. It is very frustrating. I have tried to convince her to try for a week or two so that her body adjusts, and the symptoms improve. I don’t have much advice, but maybe it will help someone to know they are not alone.”

Parenting Teens Who Refuse ADHD Medication: Next Steps

• Download: Questions to Get Your Child Talking
• Read: Make Your Teen the CEO of Her Treatment Plan
• Read: 10 Supplements and Vitamins for ADHD Symptom Control

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.

The head of the Food and Drug Administration (FDA) blames the persistent ADHD medication shortage, in part, on a surge in stimulant use by people with ADHD, who he suggests may not all truly need the drugs. In a new interview with WebMD’s John Whyte, M.D., FDA commissioner Robert M. Califf, M.D., claims that telehealth providers are largely responsible for driving a “tremendous” increase in ADHD diagnoses and stimulant prescriptions over the last few years and, in his words, not all of them are warranted.

“If only the people that needed these drugs got them, there probably wouldn’t be a [stimulant medication] shortage,” Califf says. “There’s a large amount of use which is on the margins. And this is why we need better clinical standards.”

Califf’s call for “better clinical standards,” purportedly to determine whether a patient with ADHD warrants treatment with stimulant medication, echoes lingering misconceptions about the real and important ways that ADHD symptoms impact the lives of adult patients, in particular. “Adult patients with ADHD deserve high-quality care, and providers likewise deserve authoritative resources that outline effective, evidence-based practices for adult ADHD,” said Maggie Sibley, Ph.D., and Ann Childress, M.D., who are working with the American Professional Society of ADHD and Related Disorders (APSARD) to develop the first-ever guidelines for diagnosing and treating ADHD in adults, set for release later this year.

In addition, Califf’s suggestion that ADHD medication use may be unnecessary and inadvisable for some population of diagnosed individuals contradicts decades of research verifying the necessity and safety of short- and long-term ADHD medication use — and its profound ability to help children and adults focus, control impulsivity, perform better at work and in school, and more. In short, stimulants are considered effective and safe for the vast majority of children and adults. “Moderate to severe ADHD absolutely warrants medication,” said Russell Barkley, Ph.D., a pre-eminent expert in ADHD. “This is the most effective treatment available – bar none.”

William Dodson, M.D., a frequent ADDitude contributor, often cites decades of research affirming the safety of ADHD medication use and the dangers associated with untreated ADHD. “The risk comes from not taking ADHD stimulants,” he said, citing extensive research on the subject.^{1 2 3 4 5} “People with ADHD who didn’t use stimulants had a four-fold increase in severe accidents and substance-use disorders (SUDs), seven times the rate of incarceration, and 10 times the rate of unplanned conceptions compared to people with ADHD who took stimulants.”

ADHD Treatment Rates Still Low

Califf’s suggestion that “a large amount” of individuals are unnecessarily or irresponsibly using stimulant medication is at odds with a study published last month by JAMA Network, which shows that treatment rates for children with ADHD are generally low. It found that only 12.9% of 9- and 10-year-olds with reported ADHD symptoms had taken ADHD medication during the preceding two weeks.⁶

Treatment rates in adults with diagnosed ADHD are also low; only about 4.1% of adults take a stimulant medication.⁷ Evidence of medication misuse among adults is scarce and isolated to reports of over-prescription by certain telehealth providers.

For older children, a different story has been shaping up. The National Institute on Drug Abuse reported a 36% increase in ADHD medication use among 12th graders in 2022 compared to 2021.⁸ It attributed the uptick to “more stress” and to attention issues that were amplified by the pandemic’s lockdowns and remote learning. A recent study from the University of Michigan found that up to one in four middle and high school students reported abusing prescription stimulant medications used to treat ADHD.⁹

Still, stimulant misuse among adolescents is not likely significant enough to explain the rampant, ongoing Adderall shortage that has dramatically affected ADDitude readers’ lives for nearly a year.

ADHD and Telehealth Controversies

In March 2020, the Drug Enforcement Agency (DEA) lifted in-person requirements and allowed practitioners to conduct evaluations and prescribe Schedule-II controlled substance like Adderall (a stimulant) in virtual appointments. The move led to a surge of new ADHD diagnoses in patients seeking telehealth care from 2020 to 2021, especially among women, according to the U.S. Centers for Disease Control and Prevention (CDC). The most common ADHD stimulant prescribed by one telehealth provider, Cerebral, was Adderall.

In 2022, Cerebral, along with other telehealth companies, came under federal investigation after multiple news reports revealed that these companies engaged in “aggressive” and questionable prescribing practices. ADHD specialists, too, have expressed fears that stimulants have been overprescribed of late, partly due to these telehealth companies.

“There’s been a tremendous increase in prescribing, some of it related to virtual prescribing, and that’s caused a number of problems,” Califf says in the interview.

However, no research yet exists to confirm or deny the validity of ADHD diagnoses made by telehealth providers during the pandemic. It’s unclear whether telehealth providers over-diagnosed ADHD and over-prescribed stimulants, or simply caught up to pent-up demand from a population of adult patients who had struggled to access in-person health care prior to the pandemic. Women, as a population, have been notoriously under-diagnosed due to outdated ADHD stereotypes, societal stigma, and provider bias. In addition, many reported to ADDitude that telehealth helped them unlock life-changing diagnoses and care, including stimulant medications for ADHD.

Calls for Reform

Patient advocates and legislators dedicated to solving the Adderall shortage are taking a different tack. Rep. Abigail Spanberger (D-Va.) has called on the FDA to coordinate a response with the DEA that addresses artificially low production quotas for stimulant medication, among other roadblocks to accessing care. Twenty other members of Congress likewise wrote a letter to the DEA, urging it to formulate new telemedicine and prescription rules, to take seriously increases in demand when setting production quotas, and to better map supply chains. And Maia Szalavitz, a leading commentator on substance abuse issues, suggested in a column published in The New York Times that oversight of ADHD medication should be shifted from the DEA, to the Food and Drug Administration.

“We wish that we could fix all these things,” Califf said in the interview with Whyte. “But we don’t make the medicines and we can’t tell someone they must make medicines. There are some things that are out of our control.”

Califf also blames the drug shortage on market disincentives for generic drug manufacturers, saying, “A number of generic drugs are in shortage at any given time because there’s not enough profit for a company to… go into the business of making that drug.’” He notes that quality problems in manufacturing may contribute to distribution challenges but calls the Adderall shortage a “special case.”

The Bottom Line

Califf’s statements regarding the ongoing ADHD medication shortage, and efforts to mitigate it, are disappointing. His statements purporting rampant stimulant over-prescription and overuse are troubling. While the FDA can’t act alone to solve the shortage, Califf, who has used his “bully pulpit” to raise public awareness on other health issues, has missed an opportunity to assure millions of Americans with ADHD – many of whom had a diagnosis and were undergoing treatment well before shortages (and before the proliferation of telehealth) began – that the agency takes ADHD and ADHD treatment seriously.

Sources

¹ Chang, Z., Quinn, P. D., Hur, K., Gibbons, R. D., Sjölander, A., Larsson, H., & D’Onofrio, B. M. (2017). Association Between Medication Use for Attention-Deficit/Hyperactivity Disorder and Risk of Motor Vehicle Crashes. JAMA psychiatry, 74(6), 597–603. https://doi.org/10.1001/jamapsychiatry.2017.0659

² Wilens, T. E., Adamson, J., Monuteaux, M. C., Faraone, S. V., Schillinger, M., Westerberg, D., & Biederman, J. (2008). Effect of prior stimulant treatment for attention-deficit/hyperactivity disorder on subsequent risk for cigarette smoking and alcohol and drug use disorders in adolescents. Archives of pediatrics & adolescent medicine, 162(10), 916–921. https://doi.org/10.1001/archpedi.162.10.916

³ Kahveci Öncü, B., & Tutarel Kişlak, Ş. (2022). Marital Adjustment and Marital Conflict in Individuals Diagnosed with ADHD and Their Spouses. Noro psikiyatri arsivi, 59(2), 127–132. https://doi.org/10.29399/npa.27502

⁴ Lichtenstein, P., Halldner, L., Zetterqvist, J., Sjölander, A., Serlachius, E., Fazel, S., Långström, N., & Larsson, H. (2012). Medication for attention deficit-hyperactivity disorder and criminality. The New England journal of medicine, 367(21), 2006–2014. https://doi.org/10.1056/NEJMoa1203241

⁵ Ginsberg, Y., Quintero, J., Anand, E., Casillas, M., & Upadhyaya, H. P. (2014). Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. The primary care companion for CNS disorders, 16(3), PCC.13r01600. https://doi.org/10.4088/PCC.13r01600

⁶ Olfson, M., Wall, M. M., Wang, S., Laje, G., & Blanco, C. (2023). Treatment of US Children With Attention-Deficit/Hyperactivity Disorder in the Adolescent Brain Cognitive Development Study. JAMA network open, 6(4), e2310999. https://doi.org/10.1001/jamanetworkopen.2023.10999

⁷ Danielson, M.L., Bohm, M.K., Newsome, K., et al. Trends in Stimulant Prescription Fills Among Commercially Insured Children and Adults — United States, 2016–2021. MMWR Morb Mortal Wkly Rep 2023;72:327–332. https://doi.org/10.15585/mmwr.mm7213a1

⁸ Miech, R. A., Johnston, L. D., Patrick, M.E., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E., (2023). Monitoring the Future national survey results on drug use, 1975–2022: Secondary school students. Monitoring the Future Monograph Series. Ann Arbor, MI: Institute for Social Research, University of Michigan. Available at https://monitoringthefuture.org/results/publications/monographs/

⁹ McCabe, S.E., Schulenberg, J.E., Wilens, T.E., Schepis, T.S., McCabe, V.V., and Veliz, P.T. (2023). Prescription Stimulant Medical and Nonmedical Use Among US Secondary School Students, 2005 to 2020. JAMA Netw Open. (4):e238707. doi:10.1001/jamanetworkopen.2023.8707

COMPLEX TREATMENT: How do I treat ADHD alongside a comorbid condition in my child?

A: Contraindications — some of them common comorbidities — and side effects may limit the use of stimulant medication in… | Keep reading on ADDitude »

ANXIETY: How should we treat comorbid ADHD and anxiety in my child?

A: It’s important to talk to your child’s doctor if you believe they may have ADHD, anxiety, or both. If left untreated, either condition can get worse, making it harder for your child at school, home, and… | Keep reading on WebMD »

DEPRESSION: How should we treat comorbid ADHD and depression in my child?

A: ADHD is usually treated with medicines known as stimulants. Antidepressants might also help some symptoms of ADHD and ADHD that’s combined with depression. Studies suggest… | Keep reading on WebMD »

ODD: How should we treat comorbid ADHD and ODD in my child?

A: If your child has been diagnosed with both ADHD and ODD, the doctor may recommend treatment as early as possible and… | Keep reading on WebMD »

OCD: How should we treat comorbid ADHD and OCD in my child?

A: Both conditions respond well to cognitive behavioral therapy and medications. If your child has ADHD and OCD, the doctor may combine the treatments… | Keep reading on WebMD »

AUTISM: How should we treat ADHD in my autistic child?

A: Work with your child’s care team to find a treatment plan that’s right for your little one. It might include both behavior therapy for autism and medication for ADHD… | Keep reading on WebMD »

FIRST-PERSON: “The Nightmare of ‘Back to Baseline’”

“For those who may not know, ‘baseline’ is the process of weaning a child from any medication he may be taking. This is usually suggested before a major med change or to reassess how your child is doing. Our boy has been taking the same prescriptions for ADHD and ODD for nearly a year, and the doctors thought it might be time for a change.” | Keep reading on ADDitude »

RELATED RESOURCES

FREE DOWNLOAD: 9 Conditions Often Linked to ADHD

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SYMPTOM TEST: The ADDitude Symptom Checker

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

DECISION 1: How should I approach my child’s ADHD treatment plan?
DECISION 2: Is ADHD medication right for my child?
DECISION 3: How can I address side effects associated with my child’s ADHD medication?
DECISION 4: How can I integrate nutrition & supplements into my child’s ADHD treatment?
DECISION 5: How can I integrate exercise & mindfulness into my child’s ADHD treatment?
DECISION 6: What therapies should I integrate into my child’s ADHD treatment plan?
DECISION 7: How should I adjust and optimize my child’s ADHD treatment plan over time?
> DECISION 8: How can my child’s treatment plan safely address comorbid conditions?