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

• DECISION 1: What should I consider when developing a comprehensive treatment plan for ADHD?
• DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
• DECISION 3: How can I decide which ADHD medication to prescribe first?
• DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
• DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

NOTE: This resource is for personal use only.

FOLLOW-UP: How should a clinician follow up with a patient being treated for ADHD?

A: Like diabetes or hypertension, ADHD is not an illness for which one can hand the patient a prescription for pills and assume recovery is automatic… | Keep reading on Medscape »

COLLABORATIVE CARE: How can collaborative care models improve care for patients with ADHD?

A: This model – wherein primary care providers, case managers, and psychiatrists work as a team to care for and monitor patients – effectively resolves many common barriers to quality… | Keep reading on ADDitude »

DIVERSION: How can clinicians educate patients about the danger of drug diversion?

A: Doctors can provide printed or video material explaining the legal and health risks associated with sharing or selling stimulants… | Keep reading on ADDitude »

TREATMENT RELUCTANCE: Why might a child resist ADHD treatment, and how can clinicians address medication aversion?

A: When someone refuses to even consider change, your best strategy is to show him empathy and normalize the situation. Instead of driving him into an even more defensive posture… | Keep reading on ADDitude »

POSITIVE PSYCHIATRY: How does positive psychiatry benefit ADHD patients in the long run?

A: Incorporating positive psychiatry is best viewed as the creation of a supplementary toolbox that allows clinicians an expanded set of focus areas to help patients achieve a more robust and sustained response to treatment… | Keep reading on MDedge »

RELATED RESOURCES

How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle

Expert Webinar with Laurie Dupar, PMHNP, RN, PCC | Listen now on ADDitude »

CBT and DBT for ADHD: How Talk Therapies Reduce Symptoms and Boost Confidence

Expert Webinar with John Mitchell, Ph.D. | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
> DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

BEYOND MEDICATION: Which nonpharmacologic treatments are proven to benefit pediatric patients with ADHD?

A: Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them… | Keep reading on MDedge »

LIFESTYLE INTERVENTIONS: How can patients optimize nutrition, sleep, exercise, and other lifestyle factors to improve ADHD symptoms?

A: Regardless of whether a child’s treatment includes medication, maximizing exercise, sleep, and nutrition can effectively transform them into natural remedies for ADHD, and arguably establish the foundation… | Keep reading on ADDitude »

EXERCISE: How much and what type of physical activity will benefit a patient with ADHD, according to research?

A: With regular physical activity, we can raise the baseline levels of dopamine and norepinephrine by spurring the growth of new receptors in certain brain areas… | Keep reading on ADDitude »

SUPPLEMENTS: What supplements and/or vitamins can aid with ADHD symptom control?

A: Usually given in the form of fish oil, omega-3s are probably the best-researched supplement for ADHD. Numerous studies… | Keep reading on ADDitude »

PARENT TRAINING: How can Collaborative & Proactive Solutions parent training benefit an ADHD treatment plan, according to research?

A: CPS has been shown in randomized trials with both parent groups and in home counseling to be as effective as Parent Training in reducing oppositional behavior and reducing… | Keep reading on MDedge »

NEUROFEEDBACK: Is neurofeedback an effective ADHD treatment, according to research?

A: A body of research suggests that neurofeedback is a promising therapy for ADHD, but it should be considered a complement to medication and/or behavior therapy rather than… | Keep reading on ADDitude »

ENVIRONMENTAL CHANGES: Which accommodations and environmental changes have the greatest positive effect on children with ADHD?

A: Encourage parents and teachers to use clear and concise instructions with supplementary visual tools. When providing instructions in classrooms, teachers should look directly at the student… | Keep reading on MDedge »

RELATED RESOURCES

The Exercise Rx for ADHD: How Movement Improves Attention, Working Memory, and Executive Functions

Expert Webinar with John Ratey, M.D. | Listen now on ADDitude »

The Whole-Person Treatment Approach to ADHD

Expert Webinar with Lidia Zylowska, M.D. | Listen now on ADDitude »

How CBT and ADHD Coaching Help Adults Manage Their Symptoms Naturally

Expert Webinar with J. Russell Ramsay, Ph.D., and David Giwerc | Listen now on ADDitude »

New Supplement Strategies: Using Trace Minerals and Plant Extracts to Treat ADHD in Children and Adults

Expert Webinar with James M. Greenblatt, M.D. | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
>DECISION 6:What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

COMPLEX TREATMENT: How should clinicians approach treatment for patients with ADHD and comorbid conditions?

A: As clinicians, we must expect that adults with ADHD will come to us with complex presentations… | Keep reading on ADDitude »

PEDIATRIC COMORBIDITIES: How should clinicians adjust pharmacological treatment for children with ADHD and comorbidities?

A: Though stimulant medication, paired with behavioral therapy, is the first-line treatment for ADHD in children, contraindications and side effects may limit their use. For example, depression and anxiety can worsen… | Keep reading on ADDitude »

ADHD + DEPRESSION: What is the recommended approach for treating ADHD with depression?

A: Options for patients include an array of psychological and psychopharmacological treatments, along with newer, cutting-edge approaches… | Keep reading on ADDitude »

ADHD + EATING DISORDERS: How should clinicians adjust treatment approaches for patients with ADHD and comorbid eating disorders?

A: Treat both ADHD and the eating disorder together and don’t discount the relevance of ADHD symptoms in driving the eating disorder. ADHD has to be treated in order to unlock effective ED treatment… | Keep reading on ADDitude »

ADHD + EFD: How is executive dysfunction related to ADHD, and how should it be treated?

A: The FDA does not allow prescriptions for stimulants to be phoned into a pharmacy or refills to be added to prescriptions — and this adds to the burden of treating patients who take them… | Keep reading on Medscape »

RELATED RESOURCES

Substance Use Disorder and ADHD: Safe, Effective Treatment Options

Expert Webinar with Timothy Wilens, M.D. | Listen now on ADDitude »

Current Guidelines for Treatment and Behavioral Interventions for Tourette Syndrome and Tic Disorders

Expert Webinar with John Piacentini, Ph.D., ABPP | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
> DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

STIMULANT + NON-STIMULANT: How can combination therapy improve symptoms with fewer side effects?

A: 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 when… | Keep reading on ADDitude »

SLEEP: Stimulant use is associated with an elevated risk for sleep problems. How can clinicians address this side effect?

A: Clinicians should titrate while evaluating a patient’s environmental and familial conditions, screen for primary sleep disorders, and… | Keep reading on ADDitude »

MED CHANGES: When should a patient switch to a different medication and/or dosage?

A: If a stimulant is causing excessive irritability, restlessness, or seriousness throughout the day, a dose reduction… | Keep reading on MDedge »

ADHERENCE IN CHILDREN: How can clinicians improve medication adherence in children with ADHD?

A: ADHD medication initiation and adherence are increased when patients have a strong working alliance with their clinician and trust the health care system… | Keep reading on ADDitude »

ADHERENCE IN ADULTS: How can clinicians improve medication adherence in adults and adolescents with ADHD?

A: As clinicians, we must acknowledge how difficult it is take medications every day. And we must be proactive in asking our patients, “How many times did you skip a dose, and what impact did that have… | Keep reading on ADDitude »

RELATED RESOURCES

How to Optimize ADHD Medication: Strategies for Achieving Better Symptom Management

Expert Webinar with William Dodson, M.D., LF-APA | Listen now on ADDitude »

Why Adults with ADHD Abandon Medication — and How to Improve Treatment Outcomes

Expert Webinar with William Dodson, M.D., LF-APA | Listen now on ADDitude »

How to Optimize Stimulant Treatment for Children and Adults: Better Symptom Management Without Side Effects

Expert Webinar with Thomas E. Brown, Ph.D. | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
> DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

MEDICATION CHART: What are the similarities and differences between the most commonly prescribed ADHD medications?

A: This chart presents the most popular and most commonly prescribed medications used to treat ADHD in children and adults… | Keep reading on ADDitude »

METHYLPHENIDATE: How effective is methylphenidate in the treatment of ADHD?

Dosing and uses, interactions, adverse effects, warnings, administration, images, and more. | See medication information on Medscape »

AMPHETAMINE: How effective is amphetamine/dextroamphetamine in the treatment of ADHD?

Dosing and uses, interactions, adverse effects, warnings, administration, images, and more. | See medication information on Medscape »

DEXMETHYLPHENIDATE: How effective is dexmethylphenidate in the treatment of ADHD?

Dosing and uses, interactions, adverse effects, warnings, administration, images, and more. | See medication information on Medscape »

LISDEXAMFETAMINE: How effective is lisdexamfetamine in the treatment of ADHD?

Dosing and uses, interactions, adverse effects, warnings, administration, images, and more. | See medication information on Medscape »

ATOMOXETINE: How effective is atomoxetine in the treatment of ADHD?

Dosing and uses, interactions, adverse effects, warnings, administration, images, and more. | See medication information on Medscape »

RELATED RESOURCES

Pills and Beyond: A Guide to the Formulations and Delivery Options of ADHD Medication

Expert Webinar with Laurie Dupar, PMHNP, RN, PCC | Listen now on ADDitude »

Medication Management: How to Use and Adjust Stimulants Safely

Expert Webinar with William Dodson, M.D., LF-APA | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
> DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

MEDICATION: What classes of medication have been shown to treat ADHD effectively?

A: Methylphenidate is the drug of choice approved by FDA for ADHD in children aged 6 years or older. It is the most commonly used drug… | Keep reading on Medscape »

BEST PRACTICES: How can a clinician determine a patient’s optimal dosage of the stimulant medications used to treat ADHD?

A: Many pediatricians are trained to give a certain number of milligrams per kilogram of a patient’s body mass, but there is no evidence that dose is affected by size, age, gender… | Keep reading on ADDitude »

THE MED DECISION: How should clinicians navigate parental concerns around treating children with ADHD medication?

A: 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… | Keep reading on ADDitude »

HEART HEALTH: Do cardiovascular risks exist for older adults taking ADHD medication?

A: A new meta-analysis concluded that “ADHD medication use was not statistically significantly associated with the risk of any CVD… | Keep reading on ADDitude »

ADHD & SUD: Does ADHD medication increase risk for future substance use problems?

A: No. What’s more, treatment with ADHD stimulant medication prior to age 9 may actually decrease a child’s likelihood of abusing drugs and alcohol later in life, according to research… | Keep reading on ADDitude »

RELATED RESOURCES

ADHD Medication Options and Benefits for Children

Expert Webinar with Walt Karniski, M.D. | Listen now on ADDitude »

Medicating Your Child with ADHD: How to Manage the Feelings of Guilt and Judgment, and Make Peace with Your Decision

Expert Webinar with Roberto Olivardia, Ph.D. | Listen now on ADDitude»

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
> DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

ADHD TREATMENT: What are the recommended first-line treatments?

A: The therapeutic approach to ADHD has been shifting. In some cases, environmental restructuring and behavioral therapy alone has been effective. The medications of choice are stimulants, and… | Keep reading on Medscape »

PEDIATRIC GUIDELINES: What are the AAP guidelines for treating ADHD in children?

A: In 2019, the American Academy of Pediatrics (AAP) released updated guidelines on attention deficit-hyperactivity disorder (ADHD) that… | Keep reading on Medscape »

ADULT GUIDELINES: Do U.S. practice guidelines for adult ADHD exist?

A: APSARD is currently establishing guidelines for ADHD in adults — the first of its kind in the country — set for release in 2023… | Keep reading on ADDitude »

MEDICATION: What are ADHD’s first-line pharmacological treatments?

A: Although stimulants for adult ADHD are associated with the highest treatment response rates, other medications are options… | Keep reading on MDedge »

NON-PHARMACOLOGICAL: What research-validated complementary therapies exist for the treatment of ADHD?

A: Families can positively impact ADHD symptoms by modifying their environments in three simple ways: through sleep, exercise, and food changes. Here’s how… | Keep reading on ADDitude »

RELATED RESOURCES

Integrated Care for Children with ADHD: How to Form a Cross-Functional Care Team

Expert Webinar with Leslie F. Graham, MSW, Douglas Russell, M.D., and Sheryl Morelli, M.D. | Listen now on ADDitude »

Lifestyle Changes with the Biggest Impact on Kids with ADHD

Expert Webinar with Sandy Newmark, M.D. | Listen now on ADDitude »

7-Week Guide to Treating ADHD, from Medscape x MDedge x ADDitude:

> DECISION 1: What should I consider to develop a comprehensive ADHD treatment plan?
DECISION 2: What medications and other approaches should I turn to as first-line treatments for ADHD?
DECISION 3: How can I decide which ADHD medication to prescribe first?
DECISION 4: What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
DECISION 5: How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
DECISION 6: What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
DECISION 7: How should I follow up with patients with ADHD, and what should we discuss during these checkups?

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.

May 1, 2023

A new stimulant medication, Xelstrym (dextroamphetamine), will soon be available for the treatment of attention deficit hyperactivity disorder (ADHD) in children ages 6-17 and adults 18 and older. Xelstrym is the only transdermal amphetamine patch to be approved by the Food and Drug Administration (FDA). It was presented at the annual conference of the American Professional Society of ADHD and Related Disorders (APSARD) by drug manufacturer Noven Pharmaceuticals, Inc., in January.

Xelstrym is a once-daily patch that should be administered two hours before an effect is needed and removed after nine hours. It has a printed backing on one side and a release liner on the other. Medication is absorbed through the skin via application to the hip, upper arm, chest, upper back, or flank areas.

According to a Noven press release distributed on January 10, Xelstrym would be available by the end of March. It is now expected to launch later this year.

Xelstrym is available in the following strengths: 4.5mg, 9mg, 13.5mg, and 18mg. Patients with a known sensitivity to amphetamine products should avoid taking Xelstrym. ^{1, 2}

The FDA approved Xelstrym in March 2022, one year after approving the stimulant Azstarys for the treatment of ADHD in people ages 6 and older.

Dextroamphetamine is approved for the treatment of narcolepsy and ADHD. U.S. brand names for dextroamphetamine, besides Xelstrym, include:

• Dexedrine
• Dexedrine Spansules
• Procentra
• Zenzedi
• Dextrostat
• Liquadd

Adderall Shortage: Could Xelstrym Help Patients?

Xelstrym may help lessen the impact of the lingering Adderall shortage — which began last November and has affected the supplies of other well-known stimulants — however it is also a Schedule II medication subject to regulations by the U.S. Drug Enforcement Administration (DEA). After a $21 billion nationwide opioid settlement, new limits were imposed on controlled drug supplies by the DEA. ADHD stimulant medications are classified as federally controlled substances (CII).

In a recent ADDitude reader panel, patients described the hardships they’ve faced since the shortage began. Ann from Illinois, like many women with ADHD, went undiagnosed for much of her life. She was diagnosed in October 2021 but has struggled to fill her prescription since then.

“All my life, I beat myself up mentally because I thought I was lazy and worthless, but knowing I had ADHD and needed support from medication made me see myself in a new light,” she said.

“It was heartbreaking for me when the Adderall shortage hit my local area. It felt like this new healing journey was cut abruptly when I could no longer find my medication in stock anywhere. I became depressed as I fell back into old habits where I laid around screaming at myself in my mind to get up and do something, anything! Thankfully, my pharmacist worked with me to get on Vyvanse.”

One ADDitude reader said they called seven pharmacies in one day to get their Adderall prescription filled, but instead “went two weeks without medication because there was nothing I could do.”

Tiff, who lives in Kentucky, hasn’t gotten “any dose or type of ADHD medication since late August 2022.”

“Currently, I take Bupropion twice a day. It is not helping with my ADHD at all. We couldn’t get Vyvanse paid for, so that was a no-go. This is affecting every aspect of my life, including work.”

One mom from California relayed the hardship her family experiences due to 30-day refill maximums for her child’s Class II stimulant medication.

“It is a real hardship for my child in college,” she said. “We have to work together as a family to get him his medication during this critical time of his education. And there is little empathy from our health providers. They just expect us to ‘buck up and deal with it.’”

More on Xelstrym

To learn more about Xelstrym, including usage and side effects, visit www.noven.com/xelstrym/. To receive future updates on its release, visit www.xelstrym.com.

Sources

¹Noven Pharmaceuticals, Inc. (n.d.) Xelstrym. https://www.noven.com/xelstrym/

²Daily Med. (2023, March 28). Label: Xelstrym. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0862f02a-72a8-41cc-8845-57cf4974bb6f&audience=consumer

April 17, 2023

High-intensity physical activity greatly improves mental health symptoms in adults across clinical conditions, according to a meta-analysis recently published in the British Journal of Sports Medicine. Vigorous and short-duration exercises were found to be most effective in improving mild-to-moderate symptoms of depression and anxiety, compared to usual care.¹

Higher-intensity workouts were found to be most effective at improving symptoms of depression and anxiety — the comorbid conditions that most commonly occur alongside ADHD. Short-term interventions lasting 12 weeks or less were more effective at improving symptoms than were longer-term exercise programs. Outcomes were measured through self-reports or clinical assessments.

Healthy adults, adults with mental health disorders, and adults with chronic diseases were included across 97 systematic reviews. The study found mental-health benefits associated with all modes of physical activity, including strength-based exercises; mixed mode exercises; stretching, yoga, and mind-body modalities; and aerobic exercise.

Exercise, Depression & Anxiety

While positive effects spanned all groups, the clinical effects of different modes of physical activity varied. Researchers found that resistance or strength training had the largest beneficial impact on depressive symptoms.

“Physical activity improves depression through various neuromolecular mechanisms including increased expression of neurotrophic factors, increased availability of serotonin and norepinephrine, regulation of hypothalamic–pituitary–adrenal axis activity and reduced systemic inflammation,” the researchers wrote.

For symptoms of anxiety, mind-body modalities like yoga had the greatest impact.

“Physical activity (PA) on depression and anxiety are due to a combination of various psychological, neurophysiological, and social mechanisms,” the researchers said. “Different modes of PA stimulate different physiological and psychosocial effects, and this was supported by our findings.”

High-intensity exercise has also been associated with improvements in sleep — thought to be closely connected to mental health.² For middle-aged or older adults, the long-term effects of too much sleep (more than 8 hours) or too little (less than 6 hours) can lead to death by various causes, including cardiovascular disease. Exercise can help to negate those mortality risks. In a recent U.K.-based population cohort, adults who exercised often greatly lowered their sleep-duration-related mortality risk. That risk was nearly non-existent when adults went beyond the WHO’s recommendation of 150 minutes of moderate to intense physical activity per week.³

In the current study, the adults who benefited most from physical activity included generally healthy adults; pregnant or postpartum women; adults with depression; and adults with HIV or kidney disease. Participants included adults aged 18 and older.

Exercise and ADHD

Exercise was rated very highly by people with ADHD in ADDitude’s treatment survey conducted in 2017. More than half of the 1,563 adult respondents rated exercise as “extremely” or “very” effective in managing their ADHD symptoms — which may coexist with and become exacerbated by symptoms of mood disorders like depression.

Exercise was one of the top-rated treatment options among adults in the survey, but only 17% said that exercise came at the recommendation of their doctor. Though it received lower patient ratings, medication was more often used to treat symptoms; patients said they believed medication would have more “immediate” and “consistent” effects. Though exercise promises to lessen some of the commonly reported side effects of ADHD medication — like sleep disturbances and irritability — only 37% of ADDitude survey respondents said physical activity was included in their treatment plan.

The current meta-analysis found that “effect size reductions in symptoms of depression (−0.43) and anxiety (−0.42) are comparable to or slightly greater than the effects observed for psychotherapy and pharmacotherapy.”

Limitations & Future Research

The growing body of research on exercise and mental health is promising, but not without its flaws.

Though researchers from the present analysis “applied stringent criteria regarding the design of the component randomized controlled trials to ensure that effects could be confidently attributed to PA,” AMSTAR 2 ratings were a limitation. Of the 97 systematic reviews, 77 received a clinically low score. Those studies were identified as having more than one critical flaw, and three or more non-critical weaknesses.

A meta-analysis published in Nature found many short trial durations, small sample sizes, variable outcome measures, and other potential biases or inconsistencies in studying exercise and cognition.^{4 5} That’s not to say exercise is without cognitive (or social, or physical) benefits, but the research on mental health and exercise requires more validation.

“Organizations committed to public health, such as the World Health Organization or the National Institutes of Health, currently recommend regular exercise as a means to maintain a healthy cognitive state, which based on our findings cannot be affirmed,” they wrote.

The current study acknowledges this, stating: “Patient resistance, the difficulty of prescribing and monitoring PA in clinical settings, as well as the huge volume of largely incommensurable studies, have probably impeded a wider take-up in practice.”

Future research should reflect these limitations and consider ways to integrate conclusive findings into the clinician-patient setting.

Sources

¹Singh, B., Olds, T., Curtis, R., et al. (2023). Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. British Journal of Sports Medicine. doi: 10.1136/bjsports-2022-106195

²Suni, E., and Dimitriu, A. (2023, March 17). Mental Health and Sleep. The Sleep Foundation. https://www.sleepfoundation.org/mental-health

³Liang, Y. Y., Feng, H., Chen, Y., Jin, X., Xue, H., Zhou, M., Ma, H., Ai, S., Wing, Y., Geng, Q., Zhang, J. (2023). Joint association of physical activity and sleep duration with risk of all-cause and cause-specific mortality: a population-based cohort study using accelerometry. European Journal of Preventive Cardiology, zwad060. https://doi.org/10.1093/eurjpc/zwad060

⁴Pollina, R. (2023, March 28). New research suggests physical exercise has ‘little’ mental benefits. New York Post. https://nypost.com/2023/03/28/new-research-suggests-physical-exercise-has-little-mental-benefits/

⁵Ciria, L.F., Román-Caballero, R., Vadillo, M.A. et al. An umbrella review of randomized control trials on the effects of physical exercise on cognition. Nat Hum Behav (2023). https://doi.org/10.1038/s41562-023-01554-4

April 14, 2023

ADHD increases the likelihood of postpartum depression (PPD) and postpartum anxiety in more significant and impactful ways than do other well-established risks like comorbid psychiatric disorders or sociodemographic factors in women, according to a recent study published in the Journal of Affective Disorders. ¹

The research found that 25% of women with ADHD had postpartum anxiety, compared to 4.61% of women without ADHD. In addition, almost 17% of women with ADHD had PPD, compared to 3.3% without ADHD.

“ADHD is an important risk factor for depression and anxiety disorders postpartum,” the researchers wrote. “Therefore, ADHD needs to be considered in maternal care, regardless of sociodemographic factors and other psychiatric disorders.”

Using population-based registers from Sweden, the researchers identified 773,047 women who gave birth to their first or second child between 2005-2013. Of that number, 3,515 had received an ADHD diagnosis before their pregnancy. They also analyzed data on women’s depression and anxiety diagnoses before pregnancy, maternal age at delivery, highest achieved maternal education at childbirth, cohabitation status with their child’s father, and family history of depression and anxiety disorders.

The study found that the risk of PPD and postpartum anxiety was lower for women diagnosed with a psychiatric disorder before pregnancy and those with a history or family history of depression or anxiety. The researchers suggested that women diagnosed before pregnancy with ADHD and depression or ADHD and anxiety may have received greater support and treatment during and after their pregnancies compared to women diagnosed with ADHD alone.

Women with ADHD Become Pregnant Younger

Women diagnosed with ADHD were more likely to have a lower education level and less likely to live with the father of their child compared to women without ADHD, according to the researchers.

The study also reported that women with ADHD gave birth to their first child at a younger age (15–24 years) than did women without ADHD (25–34 years), supporting previous research. A study published in the Journal of Attention Disorders of more than 7,500 adolescents with ADHD and 30,000 adolescents without ADHD in Taiwan found that participants with ADHD became pregnant younger, more frequently, and had a higher risk of early pregnancy than did their neurotypical peers.² A large Danish study published in the Journal of the American Academy of Child & Adolescent Psychiatry reported that girls with ADHD were more than three and a half times as likely as their peers to become pregnant between the ages of 12 and 15.³

“It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, more sexually transmitted infections, and more unplanned pregnancies in women with ADHD,” said Ellen Littman, Ph.D., in discussing how hormonal fluctuations impact women in the ADDitude webinar titled Why ADHD is Different for Women: Gender Specific Symptoms & Treatments.

In addition, the Swedish study found that 59% of the women diagnosed with ADHD had an additional psychiatric disorder compared to only 5% of the women without ADHD.

“The combination of being diagnosed with ADHD and being pregnant at a young age could increase the vulnerability and therefore the risk of being diagnosed with a psychiatric disorder postpartum, such as depression and anxiety,” researchers wrote. “However, results from the present study also show that women diagnosed with ADHD have an increased risk of depression and anxiety disorders regardless of age. This highlights the importance of health care providers to evaluate women diagnosed with ADHD across the lifespan.”

Postpartum Depression and ADHD

In a recent ADDitude survey of 2,027 women with ADHD, one-third of mothers reported that they experienced PPD, including the following symptoms:

• crying spells: 76%
• feelings of worthlessness, shame, guilt, or inadequacy: 76%
• mood swings: 66%
• irritability: 62%
• lack of concentration: 58%
• sleep problems: 57%
• withdrawing from friends and family 55%
• restlessness 46%
• appetite changes (increase or decrease) 37%
• thoughts of harm to self or others 31%
• other 24%
• extreme mood disorder or psychosis 13%
• self-harm 6%

“My ADHD got significantly worse postpartum,” said a survey respondent. “I felt overwhelmed and was not supported by my husband. He’d say things like, ‘Sarah next door has four children, and she copes. I don’t understand why you can’t even manage to keep things organized when you only have one!’”

“Something in me definitely changed after giving birth,” said an ADDitude reader from Ontario, Canada. “My doctors told me it was ‘anxiety’ and hormones. Although tired and sleep-deprived from the baby, I could not shut down my racing mind. I was constantly irritable, impatient, and a complete space cadet. I did suffer from postpartum depression after the birth of my second child. That is when I looked deeper into the root of my troubles. I have always wondered if I had PPD after my first child, or was my ADHD so out of control that I didn’t even notice?”

ADDitude survey respondents reported that their PPD symptoms lasted:

• 1-3 months 13.14%
• 4-6 months 18.63%
• 7-13 months 21.63%
• 14-24 months 13.63%
• Longer than two years 14.14%

Women Lack Treatment for Postpartum Depression

Almost half of ADDitude survey respondents said their healthcare providers did not offer treatment for their postpartum depression or anxiety.

“The medical community didn’t take baby blues seriously when my children were born,” said one ADDitude reader. “I just ‘needed to exercise, lose the rest of the baby weight, and focus on my family.’ Then I would be all better.”

“No one talked about it, and my doctor never asked how I was doing. So, I assumed I was weak,” said another survey respondent.

One ADDitude reader found the help she needed on her own. “No doctor cared,” she said. “So I self-treated by researching natural treatments and took several supplements that helped.”

According to the ADDitude survey, 41% of respondents received prescriptions for antidepressants, and 20% received therapy for PPD.

“PPD made it hard to get through anything without going into a guilt-depression spiral,” an ADDitude reader said. “It was awful. Antidepressants changed everything so I could function without spiraling or wanting to disappear.”

Postpartum Depression with Undiagnosed ADHD

Many ADDitude readers who experienced postpartum depression or postpartum anxiety were unaware of their ADHD diagnoses at that time.

“I had depression, anxiety, and just went into full paralysis,” an ADDitude reader said. “I didn’t know I had ADHD. I thought I sucked at everything, so I might as well add motherhood to the list.”

“I lost all sense of myself and pretended to cope,” said an ADDitude reader from Edmonton, Canada. “It wasn’t until I was diagnosed and looked back on my pregnancy that I realized how much ADHD and hormones played a role in my lack of coping. I wish I could go back and talk to that frightened, overwhelmed, and so very sad me and let her know there was a reason for it all.”

ADHD and Maternal Care: Next Steps

The Swedish researchers recommended that primary healthcare providers assess women with ADHD for the risk of PPD and postpartum anxiety beginning with the first prenatal visit. In addition, they said, women with ADHD should receive parental education before conception, psychological surveillance during pregnancy, and social support after childbirth.

According to Littman, women should find a doctor who understands the impact of hormones on ADHD and the interplay with medication. “Finding this professional is perhaps the most important and most difficult thing to do,” she said. “Be sure to ask about their experience treating ADHD in women.”

Sources

¹Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

²Hua, M.H., Huang, K.L., Hsu, J.W., Bai, Y.M., Su, T.P., Tsai, S.J., and Chen, M.H. (2020). Early Pregnancy Risk Among Adolescents With ADHD: A Nationwide Longitudinal Study. Journal of Attention Disorders. https://doi.org/10.1177/1087054719900232

³Østergaard, S.D., Dalsgaard, S., Faraone, S., Munk-Olsen, T., and Laursen, T, (2017). Teenage Parenthood and Birth Rates for Individuals with and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study.  Journal of the American Academy of Child and Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2017.05.003

The use of ADHD medication during pregnancy causes no impairment of a child’s neurodevelopment or physical growth, according to research published in Molecular Psychiatry.¹ A large population-based register study found in-utero exposure to medication for ADHD, including stimulants, did not impair a child’s neurodevelopment or growth compared to children whose mothers stopped taking ADHD medication prior to conception.

Research was conducted using data from Danish nationwide registers, including more than one million children born between 1998 and 2015. Of those, 898 children were delivered by mothers who started or continued taking ADHD medication during pregnancy; this became the study’s “exposed” group. The “unexposed” group included 1,270 children whose mothers discontinued — but had previously taken — ADHD medication before conception.

Prenatal & Postnatal Exposure to ADHD Medication

After adjusting for maternal demographic characteristics and psychiatric data, researchers found no difference in long-term neurodevelopmental or growth outcomes between the two groups. In other words, women could stop taking medication before conception or continue during pregnancy without putting their child at greater risk of neurodevelopmental psychiatric disorders (ADHD, ASD); neurodevelopmental impairments (vision, hearing, seizures, epilepsy); or growth impairments.

Though the percentage is small, the number of pregnant women taking ADHD medication has steadily increased over time.^{2, 3} In fact, ADHD medication is one of the most common medications prescribed during pregnancy.^{3, 4}

In a recent survey of ADDitude readers, 2.39% of 1,170 women who had been pregnant reported taking medication for their ADHD following conception. Many of those who did not take medication said they remained undiagnosed and untreated at the time of their pregnancies, and therefore had no prescribed medications. Just 2.58% took ADHD medication while breastfeeding.

If a woman decides to discontinue use while both pregnant and breastfeeding, she may go a year or longer without pharmacological treatment — a first-line treatment for ADHD.

“I stopped [taking] Adderall leading up until delivery, and had been told I couldn’t take it at all during breastfeeding,” wrote one 33-year-old woman in Texas. “I went back to work three months postpartum. I really struggled with symptoms and felt unable to do my job.

“I did some additional research… that suggested a low breastmilk transfer rate for Adderall, and an even lower rate with Ritalin. Five months postpartum, I brought that data to my GP, who agreed to prescribe 5mg of Ritalin twice daily. I continued exclusively breastfeeding for two more months, then did a combination of breastfeeding and formula until weaning completely when my daughter was nine months. At that time, my GP switched me back to Adderall. During this time, my daughter showed no adverse effects, remaining on her growth trajectory in the 90th percentile and sleeping like a champ!”

Impact on Children

The decision to cease or continue treatment for ADHD while pregnant is difficult, in large part because the effects of ADHD medication in utero are not well-documented. Due to the nature of the problem, research is limited to register studies like this most recent one — the second and largest long-term register study to examine the effects of ADHD medication during pregnancy.

In addition, the research is conflicting. A 2015 U.S. population-based study found that ADHD medication use in early pregnancy was associated with three specific, selected birth defects.⁵ Another U.S.-based study, published in 2017, suggested an increased risk of cardiovascular defects from prenatal exposure to methylphenidate — but not amphetamines.⁶

While exposed children faced no increased risks for common neurodevelopmental outcomes in the present study, researchers found that exposed children born to mothers who used other psychotropic medication during pregnancy were more likely to develop ADHD. This was also found when the mother had filled two or more prescriptions for ADHD medication during pregnancy.

Because the increased risk was limited to ADHD only, researchers speculate these results may be “driven by severity of maternal ADHD” through “higher disease liability for ADHD and through referral bias, that is, offspring of mothers with severe ADHD are assessed more carefully for ADHD.”

Impact on Women with ADHD

On average, women in the U.S. have their first child by age 27.⁷ According to the ADDitude survey, it’s around this time that women report a major impact caused by their ADHD symptoms. The majority — 64% to 70% of 2,010 respondents — said the overall impact of ADHD was major or life-altering in their 20s and 30s.

Half of survey respondents who had been pregnant said their ADHD symptoms remained stable during pregnancy. But following delivery, 56.7% of them said they experienced symptoms of postpartum depression. Around more than one-third told ADDitude these symptoms lasted for more than 6 months; for nearly 10%, postpartum depression lasted more than two years.

Similar findings were discovered in a 2020 survey conducted by the MGH Center for Women’s Mental Health. No significant changes in ADHD symptoms were reported by women during pregnancy, but those who chose to discontinue psychostimulant medication experienced a significant increase in postpartum depressive symptoms. Women who elected to adjust their ADHD medication use, or maintained the same prescription schedule, did not experience a significant change in depressive symptoms.

Limitations and Future Research

“Pregnant women who depend on stimulants for daily functioning must weigh the potential of exposing their fetus to unknown developmental risks against potential medical, financial, and other consequences to both mother and child that are associated with exacerbation of ADHD symptoms when stopping the medication, such as inability to maintain employment and unsafe driving,” the researchers stated.

ADHD medication in the present study included stimulants (methylphenidate, amphetamine, dexamphetamine, lisdexamphetamine) and other treatments (modafinil, atomoxetine, clonidine).

“The present study provides reassurance that several essential categories of child outcomes that could reasonably be suspected to be affected by stimulants, including body growth, neurodevelopment, and seizure risk, do not differ based on antenatal stimulant exposure.”

Compared to women without ADHD, the study’s sample population of women with ADHD tended to be younger at the time of childbirth, more likely to smoke during pregnancy, and more likely to have children born preterm or with low birth weight. This finding was consistent regardless of whether the mother took ADHD medication during pregnancy.

Finally, more research is needed to differentiate between the effects of ADHD medication types, dosage, and trimester. This study was limited to diagnoses formally entered into the Danish register. Future research should be expanded to include a larger sample population.

Sources

¹Madsen, K. B., Robakis, T. K., Liu, X., Momen, N., Larsson, H., Dreier, J. W., … Bergink, V. (2023). In utero exposure to ADHD medication and long-term offspring outcomes. Molecular Psychiatry, 1–8. doi: 10.1038/s41380-023-01992-6

²Lemelin, M., Boukhris, T., Zhao, J. P., Sheehy, O., & Bérard, A. (2021). Prevalence and determinants of attention deficit/hyperactivity disorder (ADHD) medication use during pregnancy: Results from the Quebec pregnancy/children cohort. Pharmacology research & perspectives, 9(3), e00781. https://doi.org/10.1002/prp2.781

³Haervig, K. B., Mortensen, L. H., Hansen, A. V., & Strandberg-Larsen, K. (2014). Use of ADHD medication during pregnancy from 1999 to 2010: A Danish register-based study. Pharmacoepidemiology and drug safety, 23(5), 526–533. https://doi.org/10.1002/pds.3600

⁴Louik, C., Kerr, S., Kelley, K. E., & Mitchell, A. A. (2015). Increasing use of ADHD medications in pregnancy. Pharmacoepidemiol Drug Saf, 24, 218– 220, doi: 10.1002/pds.3742.

⁵Anderson, K. N., Dutton, A. C., Broussard, C. S., Farr, S. L., Lind, J. N., Visser, S. N., Ailes, E. C., Shapira, S. K., Reefhuis, J., & Tinker, S. C. (2020). ADHD medication use during pregnancy and risk for selected birth defects: National birth defects prevention study, 1998-2011. Journal of Attention Disorders, 24(3), 479–489. https://doi.org/10.1177/1087054718759753

⁶Huybrechts, K. F., Bröms, G., Christensen, L. B., Einarsdóttir, K., Engeland, A., Furu, K., Gissler, M., Hernandez-Diaz, S., Karlsson, P., Karlstad, Ø., Kieler, H., Lahesmaa-Korpinen, A. M., Mogun, H., Nørgaard, M., Reutfors, J., Sørensen, H. T., Zoega, H., & Bateman, B. T. (2018). Association between methylphenidate and amphetamine use in pregnancy and risk of congenital malformations: A cohort study from the international pregnancy safety study consortium. JAMA psychiatry, 75(2), 167–175. https://doi.org/10.1001/jamapsychiatry.2017.3644

⁷Osterman, M.J.K., Hamilton, B.E., Martin, J.A., Driscoll, A.K., & Valenzuela, C.P. (2023). Births: Final data for 2021. National Vital Statistics Reports; 72(1). DOI: https://dx.doi. org/10.15620/cdc:122047.

Low-income Black families are more likely to seek medication treatment for their children with ADHD following positive experiences and collaborative involvement with healthcare providers and schools, according to a new study published in the Journal of Attention Disorders. ¹

Researchers analyzed datasets from the National Survey of Children’s Health (NSCH) that comprised 450 uninsured or publicly insured Black children with ADHD, ages 6 to 17, who were taking ADHD medication. Researchers analyzed the data to test the validity of seven themes that emerged in their initial-stage interviews with low-income Black caregivers of children with ADHD recruited from an outpatient pediatric behavioral health clinic in New Jersey. The caregivers were interviewed about their views, concerns, and accounts of treatment decisions and treatment experiences for their children; their input helped form the study’s hypotheses.

7 Hypotheses Related to ADHD Medication Decision-Making for Black Children

Researchers identified seven themes from the interviewed caregivers regarding their treatment decisions.

• Child safety and volatility related to the child’s behavior influenced treatment decisions, as did caregiver aggravation tied to the frustrations and burdens of caring for a child with ADHD. Caregivers believed that medication would decrease their children’s ADHD symptoms, such as impulsivity and inattention, and would keep their children and others safe.
• Family-centered care (FCC) and shared decision-making (SDM) were commonly reported among caregivers who felt included in their children’s treatment decisions. Some caregivers felt clinicians involved them in decision-making about their child’s treatment; others felt dismissed and believed clinicians perceived them as uneducated. Caregivers also described positive (appreciation to schools for identifying the need for treatment, administering medications, etc.) and negative (frequently disrupted by school calls, the perception that children had lower intelligence, etc.) experiences with schools.
• Caregiver mental health — caregivers and other family members commonly took medication for a psychiatric diagnosis.
• Sole parent status were associated with self-reported “feelings of being alone in dealing with the challenges of parenting a child with ADHD with a right to independence in making decisions regarding treatment,” researchers wrote.

Analysis of the NSCH data confirmed that SDM and FCC did impact caregivers’ decisions to medicate their children. Researchers reported that children whose caregivers engaged actively in the treatment decision-making process were twice as likely to take ADHD medication as were those who did not. Conversely, feeling dismissed or excluded from decision-making made caregivers apprehensive and unsure regarding medication choices for their children.

Black children who do not receive appropriate treatment can suffer severe consequences for behaviors associated with their ADHD symptoms. “Ample data shows Black students are more likely to be placed in the school-to-prison pipeline than white students,” said Tumaini Rucker Coker, M.D., MBA, Associate Professor of Pediatrics and Chief of General Pediatrics at the University of Washington School of Medicine. “Black students are suspended and expelled three times more often than white students.² And when students are suspended or expelled for behavior, they’re almost three times more likely to be in contact with the juvenile justice system in the following year.” ³

The study also found that Black children who previously received special education services were more than twice as likely to be treated with medication than were those who never received services. However, researchers could not determine “the exact nature of the relationship between receiving special education services and taking medication for ADHD.”

Findings did not confirm a direct causal relationship between taking ADHD medication and caregiver mental health, child safety and volatility, or sole caregiver status. However, the authors wrote that “these topics warrant further discussion.”

Why Shared Decision-Making Matters

Current guidelines for treating ADHD in children focus on behavioral therapy and medication management; however, “Black children are significantly less likely to receive medication than white children due to racially based structural and attitudinal barriers,” researchers wrote. ⁴, ⁵, ⁶

“Sufficiently addressing disparities in care starts with understanding why racial and ethnic imbalances matter, the roots of these inequities, and their consequences for overall health and well-being,” said Coker, who discussed how barriers to ADHD diagnosis and treatment – from the clinical level to systemic factors – disproportionately impact children and adolescents of color in the presentation titled “Equity, Diversity, and ADHD: Achieving Equitable ADHD Care for African American and Latinx Children” at the 2021 APSARD Annual Virtual Meeting.

Next Steps for Clinicians

Sarah Vinson, M.D., Associate Clinical Professor of Psychiatry and Pediatrics at Morehouse School of Medicine, offered several tips for clinicians in the ADDitude article “Evaluating and Treating ADHD in African American Children: Guidance for Clinicians.”

• Clinicians should strive for cultural humility — and embrace the idea that the patient’s family is the expert on the child and their situation. “The patient’s expertise is needed, and cultivating this relationship is a two-way process,” Vinson said. “The clinician educates the patient and family about ADHD, and the caregiver informs the clinician about the child’s realities, challenges, and ideas about ADHD and other neurological and mental health issues.”
• Clinicians should learn how patients and families feel about the child’s ADHD diagnosis, the possibility of medication, and what resources the family can access. “Some families, for example, may bring up the difficulties surrounding being a Black person in a racist society, and having that compounded by mental illness and medication — both of which are still commonly stigmatized,” she said.
• Clinicians must explain what medications do and don’t do to allow patients and families to make informed choices and set realistic expectations.
• Clinicians should understand issues surrounding insurance and family dynamics. “Black children are more likely to be publicly insured, meaning that the medication formulations available are limited,” Vinson said.
• Clinicians should avoid aiming for competency alone. Vinson explained, “Being aware of and continuously learning about historical and current factors (at the local level and beyond) can help clinicians contextualize experiences and issues related to Black communities.
• White clinicians must contend with their ingrained biases and examine any defensiveness and fragility that comes with it to address larger, structural issues.
• Clinicians should know what resources local schools have available and what inequities exist regarding access to school counselors, therapists, and psychoeducational testing to inform treatment planning.
• Clinicians should be guided by an understanding that any intervention which helps the primary caregiver and family unit feel heard and informed is important.

Researchers from the Journal of Attention Disorders study reiterated Vinson’s recommendation in their report. “Clinicians must recognize that applying their expertise in concert with FCC and SDM can ensure that the most vulnerable children receive evidence-based treatment for ADHD,” they wrote. “Interventions should focus on supporting teachers to partner with low-income Black caregivers of children with ADHD and developing partnerships between school districts and medical providers to ensure appropriate referrals for ADHD care and improve access to care for vulnerable populations.”

The study had several limitations, including the lack of specificity regarding medication decision-making over time for low-income Black children with ADHD. Researchers recommended that future research focus on communication between teachers and caregivers from this demographic and the relationship between medication treatment and exit from special education services.

Sources

¹Glasofer, A., Dingley, C., Kim, J., Colosimo, R., & Gordon, H. R. D. (2023). Medication Decision Making in Low-Income Families of Black Children With ADHD: A Mixed Methods Study. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547231158382

²U.S. Department of Education Office for Civil Rights (USDEOCR). (2014). Civil rights data collection, data snapshot: School discipline. Retrieved from https://www2.ed.gov/about/of-fices/list/ocr/docs/crdc-discipline-snapshot.pdf

³Fabelo, T., Thompson, M. D., Plotkin, M., Carmichael, D., Marchbanks, M. P. III, and Booth E. A. (2011). Breaking Schools’ Rules: A Statewide Study of How School Discipline Relates to Students’ Success and Juvenile Justice Involvement. New York , NY; College Station, TX: Council of State Governments Justice Center; Public Policy Research Institute of Texas A&M University. Retrieved from https://www2.ed.gov/about/of-fices/list/ocr/docs/crdc-discipline-snapshot.pdf

⁴Bax, A. C., Bard, D. E., Cuffe, S. P., McKeown, R. E., Wolraich, M. L. (2019). The Association Between Race/Ethnicity and Socioeconomic Factors and the Diagnosis and Treatment of Children with Attention-Deficit Hyperactivity Disorder. Journal of Developmental & Behavioral Pediatrics, 40(2), 81–91. DOI: 10.1097/DBP.0000000000000626

⁵Danielson, M. L., Bitsko R. H., Ghandour R. M., Holbrook J. R., Kogan M. D., Blumberg S. J. (2018a). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents. Journal of Clinical Child & Adolescent Psychology, 47, 199–212. https://doi.org/10.1080/15374416.2017.1417860

⁶Rostain, A. L., Ramsay J. R., Waite R. (2015). Cultural background and barriers to mental health care for African American adults. Journal of Clinical Psychiatry, 76, 279–283. https:0.4088/JCP.13008co5c

Neurofeedback may not be an effective tool for treating ADHD in boys, according to research published in the American Journal of Psychiatry that studied whether functional MRI neurofeedback (NF) was a safe and effective alternative to pharmacological treatment for ADHD. Cognitive and clinical symptoms of ADHD did not significantly improve in subject who received fMRI-NF in this double-blind, sham-controlled randomized, controlled trial. ¹

Neurofeedback: Is It Effective?

The brain’s frontal cortex — responsible for attention, executive function, and organization — is impaired in people with ADHD. In this new trial, researchers studied the activation of the right inferior frontal cortex (rIFC) by neurofeedback training. Medication — a first-line treatment — activates or normalizes the IFC in many patients, but not all. ² Side effects are also commonly reported.

“Functional MRI neurofeedback, which enables self-regulation of brain activation in specific regions or networks by providing feedback of brain activity in real time, could be a novel alternative to pharmacological treatment,” the researchers wrote.

Participants were asked to complete a series of 15 “runs” over multiple visits and four one-hour fMRI-NF scans. Each run presented a video of a rocketeer flying in space. Its speed and direction (up or down) represented brain activity and increased or decreased activation of the rIFC, respectively. Participants in the sham group were shown neurofeedback from the last active participant instead of their own.

Compared to the sham group, the active fMRI-NF group showed improved activation in the rIFC across all sessions. But contrary to the study’s hypothesis, researchers found no improvement in ADHD-RS scores — their primary outcome measure. In other words, parents did not report an improvement in ADHD symptoms among children receiving fMRI-NF.

Additionally, the sham group showed comparatively less irritability and motor inhibition in the post-treatment assessment. Among subjects receiving fMRI-NF, researchers observed neither “progressively increasing upregulation across sessions or runs, nor correlations between changes in rIFC activation and ADHD-RS scores, nor transfer of learning, indicating no progressive training effects.”

“The findings do not suggest that fMRI-NF of rIFC is an effective treatment for ADHD,” the researchers wrote.

Editorial research by ADDitude similarly found neurofeedback ineffective at addressing ADHD symptoms over time, as reported by parents. In a 2017 survey of 2,495 caregivers, less than one-third of those who had tried NF found it effective. They rated it less effective than exercise, medication, behavioral therapy, and ADHD coaching or counseling, but more effective than mindfulness meditation or nutrition changes, at addressing ADHD symptoms.

The cost of treatment was cited as a common reason for neurofeedback’s small adoption rate; 29% of caregivers said they had not tried non-medication ADHD treatment options because of price or lack of insurance coverage.

New Study Limitations

Researchers relied on clinical, cognitive, and fMRI measures during seven participant visits between 2018 and 2020. This included baseline assessments, fMRI interventions, post-treatment assessment, and six-month follow up. Researchers had no direct interaction with participants but were unblinded to administer treatment.

This double-blind study expanded on a single-blind, proof-of-concept study conducted in 2017, which was limited by small sample sizes and no control group. However, the new research was limited by an all-male participant group (between ages 10 to 18), the majority (approximately 65%) of whom were active medication users. The study was ended prematurely due to COVID lockdowns.

“Future studies should investigate whether fMRI-NF of alternative regions of interest or networks implicated in ADHD may be more effective in improving clinical and cognitive problems.”

The results are nonetheless effective in informing parents and clinicians of the most effective treatment options on the market for children with ADHD.

Sources

¹Lam, S. L., Criaud, M., Lukito, S., Westwood, S. J., Agbedjro, D., Kowalczyk, O. S., Curran, S., Barret, N., Abbott, C., Liang, H., Simonoff, E., Barker, G. J., Giampietro, V., & Rubia, K. (2022). Double-Blind, Sham-Controlled Randomized Trial Testing the Efficacy of fMRI Neurofeedback on Clinical and Cognitive Measures in Children With ADHD. The American journal of psychiatry, 179(12), 947–958. https://doi.org/10.1176/appi.ajp.21100999

²Rubia, K., Alegria, A. A., Cubillo, A. I., Smith, A. B., Brammer, M. J., & Radua, J. (2014). Effects of stimulants on brain function in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Biological psychiatry, 76(8), 616–628. https://doi.org/10.1016/j.biopsych.2013.10.016