The concept of the midlife crisis began a century ago with Sigmund Freud and Carl Jung, who argued that greater self-awareness and self-actualization in midlife leads to a fear of impending death. Critics challenge whether mortality-related anxiety is actually to blame for the drastic life changes so commonly associated with midlife crisis: divorce, job loss, and convertible acquisition.

Research suggests that 10% to 20% of adults will experience a midlife crisis.¹ Among adults with ADHD, that number is considerably higher: 59% of men aged 40 and older, and 51% of women aged 40 and older said they have experienced a “period of emotional turmoil in middle age frequently characterized by a strong desire for change,” according to a recent ADDitude survey of 1,829 adults with ADHD.

The 690 women and 228 men who responded in the affirmative shared stories of career upheaval, infidelity, divorce, money problems, substance abuse, and burnout. For some, the change was more like a “midlife catharsis” that was long overdue; for others, it was traumatic.

“I divorced my narcissistic ex, started graduate school to become an educator, met the best man I’ve ever known, fell in love (for real this time), and earned two black belts during about an 18-month span of time,” wrote one 49-year-old mother in Washington.

[Take This Self-Test: Do I Have ADHD?]

“I didn’t feel I was able to function in the world,” wrote a 49-year-old male who rated his ADHD symptoms as “life-altering” in his 40s. “I left a seven-year relationship with my partner and stepdaughter, quit my job with no other job to go to, and went to live at a Buddhist monastery.”

These may seem like extreme examples, but the root causes of these crises — namely, ADHD traits like impulsivity, emotional dysregulation, and restlessness — form a ribbon snaking through many of the ADDitude survey respondents’ answers. Indeed, 81% of men and 71% of women who said they have experienced a midlife crisis attributed it to ADHD symptoms and attributes.

“I believe my midlife crisis was a perfect storm of life-stage dissatisfaction, perimenopause, a poor relationship, and the upsurge of previously well-masked ADHD symptoms due to stress, hormonal deficiency, and increased emotional dysregulation (oh, and lockdown!),” wrote a 53-year-old mother who quit her job and divorced her husband of 28 years. “I experienced a peak in my impulsivity, libido, mood changes, and interests in new and varied topics, which I pursued in ways that my husband saw as distractions from the marriage. I needed new stimulation and to get out of old situations that were no longer serving me.”

Here are more stories of ADHD’s impact at midlife, from ADDitude readers reflecting on their experiences:

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Source

¹Lachman, Margie E. (2003). Development in Midlife. Annual Review of Psychology. Vol. 55:305-331. https://doi.org/10.1146/annurev.psych.55.090902.141521

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 25, 2023

New York – ADDitude magazine, the world’s most trusted resource on ADHD, is honoring Women’s Health Month with the publication of groundbreaking research on the impact of hormonal fluctuations on female ADHD symptoms during each life stage, from puberty and pregnancy to menopause. The upshot: Wild swings in estrogen levels dramatically worsen ADHD symptoms, and the severity grows more pronounced with age, according to more than 2,000 women surveyed aged 18 to 82.

ADDitude’s new survey also found that men with ADHD were equally affected by the rise and fall of testosterone levels during distinct life stages, and that andropause (often called male menopause) seemed to incite the most dramatic life changes. The survey included more than 2,711 men and women with ADHD between the ages of 18 and 82.

Women and men alike reported the greatest symptom severity from ages 50 to 59 — during menopause and andropause, respectively. Women reported that plummeting estrogen levels during menopause magnified the effects of ADHD, echoing the results of a 2022 ADDitude survey of 3,930 women that found hormonal changes exerted an outsized impact on ADHD functioning during this life stage.

How did the ebb and flow of hormones affect other life stages?

ADHD Link to PMS, PMDD

A staggering two-thirds of women surveyed said they experienced premenstrual syndrome (PMS) and/or premenstrual dysphoria disorder (PMDD) — well over national rates of PMS and PMDD. The overwhelming majority of women surveyed cited irritability, mood swings, cramps or discomfort, anxiety, and lack of concentration as the most impairing symptoms.

“For me, PMDD meant suicidal ideation, increased meltdowns and shutdowns, a decrease in emotional regulation, extreme sensitivity to rejection, and intrusive thoughts,” a woman, 39, who was diagnosed with ADHD, anxiety, and autism, told ADDitude.

Postpartum Depression and ADHD

The hormonal drop associated with postpartum depression, cited by 61 percent of women surveyed, was debilitating and, for many, lasted about one year. Worse, many women said they were not forewarned by their healthcare providers of the potentially debilitating effects of plummeting hormone levels after birth — and almost half said they were offered no treatment options, such as antidepressants or recommendations for therapy.

“The nurses I spoke to did not recognize my postpartum depression and told me it was probably a normal hormonal drop, but things never improved,” a 36-year-old mother in Pennsylvania told ADDitude.

Another woman, now age 50, said she thought she was a “bad mom” for feeling as she did, “so I masked my issues.”

ADHD in Puberty

During the hormonal swings of puberty, men were more likely to report illegal drug use, hypersexuality, and anger-management problems than were women, according to the ADDitude survey. Testosterone levels typically reach their peak around age 20, when challenges shift to procrastination, emotional dysregulation, and relationship problems, the men reported in the survey.

ADDitude will be publishing and promoting insights from its research, as well as other content chronicling the female experience with ADHD and its comorbid conditions, during the month of May at ADHD in Women: In Women We Trust.

For more information on ADDitude’s proprietary surveys of women and men with ADHD and possible interviews with patients, medical review board members, and/or ADHD experts, please contact Carole Fleck at carol@additude.com.

About ADDitude magazine:

Since 1998, tens of millions of readers have trusted ADDitude to deliver expert advice and caring support, making us the leading media network for clinicians, educators, parents, and adults living with attention deficit hyperactivity disorder (ADHD). ADDitude is the world’s most trusted source of strategies and information about ADHD and related conditions, such as learning disabilities, anxiety, depression, and oppositional defiant disorder. In 2021, ADDitude, the voice of and advocate for the ADHD community, joined the WebMD family of health brands.

April 24, 2023

One in four middle and high school students has reported abusing prescription stimulant medications used to treat ADHD, according to a cross-sectional study recently published in the journal JAMA Network Open. ¹ Non-medical use of prescription stimulants among teens remains more prevalent than misuse of other prescription drugs, including opioids and benzodiazepines, the research found.

According to researchers at the University of Michigan, students who used marijuana in the past 30 days were four times more likely to abuse ADHD medications than teens who did not use cannabis. In addition, stimulant drug abuse was 36% more likely to occur in schools with a large population of students with stimulant medication prescriptions to treat ADHD than it was in schools with fewer students using prescription stimulants like Adderall or Ritalin. (Studies have shown that one in every nine high school seniors reported taking prescribed stimulants for ADHD.) (², ³)

According to the research, other factors associated with increased rates of stimulant drug abuse included:

• Schools located in suburban, non-Northeastern regions of the U.S.
• Schools with a high proportion of parents with a college degree
• Schools with a higher proportion of white students
• Schools with a medium amount of binge drinking among students (10%-19% of the total student body)

Prolonged stimulant abuse, researchers said, can lead to several detrimental health effects, including cardiovascular conditions, depression, anxiety, seizures, overdoses, psychosis, and stimulant use disorder.

“The key takeaway here is not that we need to lessen prescribing stimulants for students who need them, but that we need better ways to store, monitor, and screen for stimulant access and use among youth to prevent misuse,” said study author Sean Esteban McCabe, Ph.D.

For the study, the University of Michigan research team analyzed data collected between 2005 and 2020 by Monitoring the Future, a National Institute of Drug Abuse (NIDA) multi-cohort survey that measures drug and alcohol use among adolescents nationwide. More than 230,000 teens in grades 8, 10, and 12 from 3,284 secondary schools participated in the survey.

Dangers of Stimulant Misuse

Counterfeit Medication

Demand for prescribed stimulants to treat ADHD symptoms increased substantially from 2020 to 2021, a recent U.S. Centers for Disease Control and Prevention (CDC) report found. According to the CDC report, prescription stimulant fills were highest among males and females aged 5–19 and 15–24 years, respectively. ⁴

Previous studies have reported that more than half of adolescents who misuse prescription stimulants get the medication for free from friends or relatives. ⁵ However, illicit medications are increasingly obtained via online drug markets and social media referrals, making it harder to differentiate real and counterfeit medications. ⁶

“The drug supply has rapidly changed,” said National Institute on Drug Abuse Director Nora Volkow in a press release about the study. “What looks like medications — bought online or shared among friends or family members — can contain fentanyl or other potent illicit substances that can result in overdoses. It’s important to raise awareness of these new risks for teens.”

Students who use counterfeit medications often believe they are obtaining the actual medication as dispensed by a pharmacist, explained Kevin Antshel, Ph.D., professor of psychology at Syracuse University. “However, students obtaining counterfeit medications may purchase a product that is laced with potentially lethal amounts of drugs, usually fentanyl or methamphetamine,” Antshel said. “Fentanyl is especially concerning. A lethal dose of fentanyl is roughly the size of a few grains of salt.”

In May 2022, two Ohio State students died from suspected use of counterfeit stimulant medication laced with a synthetic opioid.

Drug Diversion

The University of Michigan researchers recommended that caregivers educate teens about the consequences of drug diversion (selling or sharing prescribed medications). “Nearly a quarter of adolescents who are prescribed stimulant therapy will be approached to divert their stimulant medications by their peers before the completion of high school (and more than half [54%] during college),” they wrote. ⁷, ⁸

Theresa E. Laurie Maitland, Ph.D., coordinator of the Academic Success Program for Students with learning differences and ADHD at the University of North Carolina, Chapel Hill, learned first-hand how widespread medication diversion is on college campuses.

“I asked a graduating senior if he had any advice for me. He said, ‘There’s one topic I wish you’d talk about with all students taking ADHD medication: How to handle the demand they will face to give away or sell their pills!’

“I was shocked but hid my reaction and listened attentively,” she said. “The student had been open about stimulant use, and the news spread quickly among his peers and classmates. He was often approached to sell or hand over ‘just one pill.’”

The FDA classifies stimulants as Schedule II controlled substances. Most state laws follow federal laws, with criminal penalties for possession without a prescription.

“Even if no money is exchanged, sharing your medication is, technically, ‘dealing drugs,’ and anyone who expects you to do it isn’t a true friend,” said Susan Yellin, Esq., Director of Advocacy and Transition Services at The Yellin Center for Mind, Brain, and Education in New York.

How Parents Can Help Teens

“The diversion of stimulant medication has serious legal and health risks for undiagnosed students and major personal, legal, and financial consequences for teens diagnosed with ADHD,” Maitland said. “We must inform those with ADHD about this important issue.”

Maitland offered the following suggestions to caregivers and teens:

1. Talk to Family Physicians
“For middle and high school students, doctors can provide printed or video material explaining the legal and health risks associated with sharing or selling stimulants,” she said.

2. Value Your ADHD Diagnosis
It’s important that adolescents understand and accept their ADHD diagnosis, and that parents include them in healthcare decisions. “When students accept their diagnoses and value their medication, they have no desire to give or sell their pills to others,” Maitland said.

3. Use Discretion
Teens must store their ADHD medications in a lockbox or other secure device. They should also use discretion when sharing information about their stimulant use. “Many students have told me it is best not to discuss one’s stimulant use until they make friends (or maybe not at all),” Maitland said.

4. Foster Open Dialogue
Parents should talk with their children about the health and legal risks of misusing, sharing, or selling medication and potential scenarios they may encounter.

Teens can even role-play what to say if a family member, friend, or stranger asks them for pills. “Have teenagers rehearse several scripts to prepare them to say ‘no’ and to deal with pressure,” Maitland said.

Most importantly, Maitland continued, “Young people need to know they can turn to us in awkward situations and talk with us about something they regret having done.”

Sources

¹McCabe, 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

²Garfield, C.F., Dorsey, E.R., Zhu, S., et al. (2012) Trends in Attention Deficit Hyperactivity Disorder Ambulatory Diagnosis and Medical Treatment in the United States, 2000-2010. Acad Pediatr. 12(2):110-116. https://pubmed.ncbi.nlm.nih.gov/22326727/

³Xu, G., Strathearn, L., Liu, B., Yang, B., and Bao, W. (2018) Twenty-Year Trends in Diagnosed Attention-Deficit/Hyperactivity Disorder Among US Children and Adolescents, 1997-2016. JAMA Netw Open. 1(4):e181471. https://10.1001/jamanetworkopen.2018.1471

⁴Danielson, M.L., Bohm, M.K., Newsome, K., et al. (2023). 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

⁵Compton, W.M., Han, B., Blanco, C., Johnson, K., Jones, C.M. (2018) Prevalence and Correlates of Prescription Stimulant Use, Misuse, Use Disorders, and Motivations for Misuse Among Adults in the United States. Am J Psychiatry. 175(8):741-755. https://doi.org/10.1176/appi.ajp.2018.17091048

⁶Moyle, L., Childs, A., Coomber, R., and Barratt, M.J. (2019). #Drugsforsale: An Exploration of the Use of Social Media and Encrypted Messaging Apps to Supply and Access Drugs. Int J Drug Policy. 63:101-110. https://doi.org/10.1016/j.drugpo.2018.08.005

⁷McCabe, S.E., Teter, C.J., and Boyd C.J. (2006). Medical Use, Illicit Use, and Diversion of Abusable Prescription Drugs. J Am Coll Health. 54(5):269-278. https://doi.org/10.3200/JACH.54.5.269-278

⁸McCabe, S.E., West, B.T., Teter, C.J., Ross-Durow, P., Young, A., and Boyd, C.J. (2011). Characteristics Associated with the Diversion of Controlled Medications Among Adolescents. Drug Alcohol Depend. 118(2-3):452-458. https://doi.org/10.1016/j.drugalcdep.2011.05.004

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

April 2, 2023

Demand for prescribed stimulants to treat ADHD symptoms increased substantially from 2020 to 2021, especially among women, a new U.S. Centers for Disease Control and Prevention (CDC) report found. Stimulant medication use among women in their 20s and 30s rose 17.5% with the biggest jump among women aged 20-24, 6.2% of whom now take a stimulant medication for ADHD, the CDC said. Notably, stimulant use also rose 16% among women aged 50-54, 2.9% of whom now take medication for ADHD — up from 2.1% in 2016.¹

According to the CDC report, more than 10% of all females aged 15–44 and males aged 25–44 filled prescriptions for stimulants commonly used in ADHD treatment in 2020-2021. The CDC arrived at these numbers by analyzing data from the Merative MarketScan Commercial Database, a national convenience sample of deidentified healthcare claims from enrollees in employer-sponsored insurance plans from 2016–2021. The percentage of enrollees with prescription stimulant fills rose from 3.6% in 2016 to 4.1% in 2021.

Rise in Women Diagnosed with ADHD

A spike in ADHD diagnoses among women likely contributes to the jump in stimulant medication prescriptions. The number of women aged 23 to 49 who were diagnosed with ADHD nearly doubled from 2020 to 2022, according to a new study from Epic Research. The health analytics firm reported that, though males are more likely to be diagnosed with ADHD than are females, the gender gap has decreased during the past 12 years. In 2010, males were 133% more likely to be diagnosed with ADHD than were females; in 2022, men were 28% more likely to receive an ADHD diagnosis. The study analyzed data from 3,389,383 patients diagnosed with ADHD between 2010 and 2022.²

The increase in adult diagnoses and stimulant medication prescriptions aligns with findings from a 2021 ADDitude survey of 2,365 adults, 26.5% of whom said they had received a formal ADHD diagnosis within the last year. What’s more, nearly 22% of adult survey respondents said they began taking ADHD medication for the first time during the pandemic — among newly diagnosed adults, this number was 64%. Only 5.5% of adults said they stopped taking medication and only 4.5% decreased dosage during the pandemic.

Pandemic Influences Demand for Stimulants

Policies enacted during the pandemic, which expanded access to prescription stimulants via telehealth providers, contributed to the increase in stimulant prescriptions. Overall, 56% of adults surveyed by ADDitude reported changes in their treatment team during the pandemic with nearly a quarter using telehealth appointments for the first time. Among newly diagnosed adults, 57% began seeing an ADHD professional for the first time during the pandemic.

According to U.S. Census data from 2022, 22% of Americans have used telehealth services. In a survey of 484 adult ADDitude readers conducted in April 2022, 57% reported using telehealth services and/or mental health apps during the preceding two years. A staggering 97% of the Cerebral users diagnosed with ADHD reported receiving a new prescription, according to the survey. Roughly 59% of those respondents said they were prescribed Adderall; 34% were prescribed Wellbutrin; and less than 10% were prescribed Vyvanse, Strattera, or Ritalin.

This upswing in demand undoubtedly contributed to the ongoing, nationwide Adderall shortage, which began in August 2022 and continues to impact as many as 75% of ADHD patients, according to ADDitude surveys of clinicians and patients conducted late last year and early this year.

Source

¹Danielson, 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

²Russell, J., Franklin, B., Piff, A., Allen, S., and Barkley, E. (2023, March 30). Number of ADHD Patients Rising, Especially Among Women Epic Research. Epic Research. https://epicresearch.org/articles/stimulant-prescribing-rates-remain-steady-for-patients-with-adhd

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

Early childhood sleep problems, including irregular sleep routines, short nighttime sleep duration, and frequent night awakenings, correlate with subsequent ADHD diagnoses, according to research published in the Journal of Child Psychology and Psychiatry. ¹

Researchers conducted an observational review of the Avon Longitudinal Study of Parents and Children (a U.K. birth cohort study), which included 7,769 10-year-old children (49.6% girls; 50.4% boys). Participants’ parents assessed their children’s sleep habits at age 3.5, answering questions such as ‘Does your child have regular sleep routines?’ ‘How long does your child sleep during the day?’ and ‘How often during the night does your child usually wake?’ Researchers calculated nighttime sleep durations from questions asking what time (to the nearest minute) the child ‘normally’ went to sleep in the evening and woke up in the morning. Findings showed that short nighttime sleep durations, frequently waking up in the middle of the night, and irregular sleep routines increased the toddler’s risk of receiving an ADHD diagnosis at age 10. (Researchers used the Development and Wellbeing Assessment to identify children with ADHD.)

Prior studies have identified sleep disturbances as a common comorbid condition with ADHD ² and found that 70% to 85% of children with ADHD experience sleep problems.³ However, researchers said this is the first longitudinal study that “specifically investigated the prospective association between inflammation, sleep, and ADHD.”

“These results highlight the potential of future preventative interventions in ADHD, with the novel target of sleep and inflammation,” they said.

Sleep Problems Comorbid with ADHD

The study’s findings mirror those of a recent ADDitude poll, which found that 66% of participants noticed sleep problems in their children with ADHD at age 3 or younger.

“As an infant, my daughter was a horrible sleeper,” said a reader from Colorado. “She almost never napped for more than 20 to 30 minutes. She woke up several times throughout the night until she was 18 months old. She’s 7 now and still has trouble falling asleep without melatonin. Even with melatonin, she’ll wake up after a couple of hours.”

Said another respondent, “Our son has fought sleep since infancy. He has always tried to stay awake as long as possible. He often has disrupted sleep and does not want to return to sleep, even at midnight.”

“She would wake up every two hours and then be ready to party for two hours,” said a panelist from Maryland. “It was absolutely exhausting. At age 1, she finally started to sleep more consistently but continued to wake up very early (before 5 a.m.).”

Sleep Problems in Early Childhood

Reader panelists indicated the following early childhood sleep problems in their children who were later diagnosed with ADHD:

• Shorter nighttime sleep due to difficulty falling asleep: 71.63%
• Frequent waking during the night: 60.58%
• Shorter nighttime sleep due to waking up very early: 44.71%
• Inconsistent bedtime routine: 25.96%

Sleep problems persisted for some panelists’ children as they aged. “Both of my kids took forever to fall asleep,” said a panelist from Wisconsin. “By the time my son started daycare at four months old, I could not get him to nap. One of us still lies with our kids at night; we usually fall asleep and spend the night in their beds. They are now ages 8 and 5 (both have ASD along with ADHD), and there is no end in sight.”

“My child seemed to need less sleep from the beginning,” said another parent. “As an infant, she often woke up in the middle of the night and was wide awake for quite some time. She took very short naps and gave up napping very early on. As she got older, we had to put an alarm on her door because she would go out in the garage during the winter or climb on kitchen counters looking for candy in the middle of the night.”

ADHD Sleep Solutions

Creative thinking, natural supplements, and medication helped some ADDitude readers’ children get to sleep. “There were a lot of ‘midnight snack’ escapades and much wandering around the house,” said a panelist from Georgia. “We made an approved snack drawer for her and gave her a flashlight, books, coloring books, etc., so she could do what she needed and stay in her room.”

A Michigan panelist said, “We were militant about sleep hygiene, diet, screens, etc., and it did not make a difference. Even lots of exercise wasn’t the answer. We finally had to use clonidine. It was like a miracle. My now 13-year-old is off clonidine with a ‘normal’ sleep routine.”

“My child began having difficulty falling asleep at six months,” a panelist from Virginia said. “Melatonin is a staple in our household. Just like you know, if you forgot your child’s ADHD medication on a Saturday morning, you also know when they haven’t had their melatonin!”

A North Carolina parent turned her son’s insomnia into a positive. “My oldest had a terrible time going to sleep,” she said. “Early on, I found ‘go to sleep’ meant nothing, so switched to ‘Lie down and be still and quiet;’ that was something he could do (even if it didn’t lead to immediate sleep). I read to him at length at night — and through middle school. It became a close sharing time and a chance to read some really good books.”

Sources

¹Morales-Muñoz, I., Upthegrove, R., Lawrence, K., et al. (2023). The Role of Inflammation in the Prospective Associations Between Early Childhood Sleep Problems and ADHD at 10 years: Findings from a UK Birth Cohort Study. J Child Psychol Psychiatry. https://doi.org/10.1111/jcpp.13755

²Bondopadhyay, U., Diaz-Orueta, U., and Coogan, A.N. (2022). A Systematic Review of Sleep and Circadian Rhythms in Children with Attention Deficit Hyperactivity Disorder. Journal of Attention Disorders. https://doi.org/10.1177/1087054720978556

³Yürümez, E., and Kılıç, B.G. (2013). Relationship Between Sleep Problems and Quality of Life in Children with ADHD. Journal of Attention Disorders. https://doi.org/10.1177/1087054713479666

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

Children with migraines are more likely to experience symptoms of anxiety and depression than are children without migraines, according to a recent systematic review and meta-analysis of 80 studies recently published in JAMA Pediatrics. ¹

Researchers found an association between migraine and both anxiety and depressive symptoms, and they concluded that children aged 18 and younger with migraines are significantly more likely to develop anxiety and depressive disorders than are children without migraines. However, they wrote, “it is unclear whether having anxiety and depressive symptoms or disorders affects migraine outcomes or incidence.”

WebMD defines migraine as a “neurologic disorder that often causes a strong headache. The headache comes in episodes and sometimes comes with nausea, vomiting, and sensitivity to light.” According to the website, one in five children and teens are prone to having headaches, and roughly 5% struggle with migraine headaches — some as early as four years old.

The Migraine-ADHD Connection

While researchers did not collect information regarding other co-existing conditions, such as ADHD, a 2020 population-based study published in the Journal of Attention Disorders found that children with ADHD are at greater risk for migraines than children without ADHD. Further, the risk of ADHD may directly link to the frequency of migraine headaches. ²

“Headaches, including migraine headaches, do seem to be triggered by ADHD,” said Sarah Cheyette, M.D., a pediatric neurologist at the Palo Alto Medical Foundation in Northern California. “For one, researchers theorize that headaches may be biologically linked to ADHD and that their co-occurrence stems, in part, from shared pathophysiological mechanisms potentially related to dopaminergic dysfunction.” ³,⁴ Cheyette discussed the link between migraine headaches and ADHD in a recent ADDitude webinar.

“Though the underlying connections between ADHD and headaches are not fully understood, headaches cause undue pain and stress in patients as they attempt to manage existing ADHD symptoms and challenges,” she said.

When asked if their children with ADHD experience migraines, 16% of ADDitude’s reader panel members responded in the affirmative. Migraine was found in 26% of ADHD patients between the ages of 6 and 18 and 10% of healthy controls, according to a 2018 study published in Brain and Development.⁵

One reader panel member from Indiana said: “My child sometimes gets auras but always gets nausea and dizziness. It’s terrible to see her in pain.”

“This has been horrible,” wrote a parent from California. “A pediatrician first suggested he had migraines when he was five. In third grade, he missed 35 days of school. Now in 4th grade, he does a reduced school schedule because of his migraines. He now has POTS [Postural orthostatic tachycardia syndrome], too. Seeing him in pain is horrible, and we don’t have an effective treatment plan yet.”

“She has missed so much school due to migraines,” said another parent. “She has headaches, nausea, fatigue, irritability, sensitivity to light and sound, and sometimes vomiting. Her migraines started around age 11 or 12.”

Treatment for ADHD and Migraine in Tandem

While migraines and ADHD are comorbid, few clinicians consider the headache connection when evaluating and treating patients. “The medical community largely overlooks or dismisses the association, to the disservice of patients,” Cheyette said. “When healthcare providers recognize that these conditions are connected — and approach treatment holistically — the quality of care improves, and patients function better.”

“Our 15-year-old son began getting migraines about a year into puberty,” said a parent from South Carolina. “He has nausea, stomach pain, and irritability. His pediatric neurologist started him on magnesium and vitamin B2, which have helped tremendously.”

“We noticed them [migraines] very early on (at age 6 or 7) as stomachaches, which the doctor finally deduced were ‘abdominal migraines.’ It all just fit,” said a parent from Pennsylvania. “Today, at age 14, the primary symptoms are still nausea as much as headache and brief, impaired vision when they move.”

The researchers behind the new meta-analysis recommend that clinicians routinely screen children and adolescents with migraines for anxiety and depression. In a 2022 survey of 1,187 caregivers, ADDitude found high comorbidity rates between ADHD and both anxiety (67% of teens with ADHD) and depression (46% of teens with ADHD).

“These results have critical implications for clinical practice, underscoring the need to screen all children and adolescents with migraine for anxiety and depression,” researchers wrote. “Future work should address these questions and aim to determine whether trauma- and stressor-related symptoms and disorders are associated with migraine in children and adolescents.”

Migraines and ADHD: Next Steps

• Free Download: 9 Conditions Often Linked to ADHD
• Read: The 5 Most Common ADHD Medication Side Effects — and Their Fixes
• Read: What Is Complex ADHD?
• Learn: Study Reveals Significant Comorbid Link Between ADHD and Migraines

Sources

¹Falla, K., Kuziek, J., Mahnaz, S.R., Noel, M., Ronksley, P.E., Orr, S.L. (2022) Anxiety and Depressive Symptoms and Disorders in Children and Adolescents with Migraine: A Systematic Review and Meta-analysis. JAMA Pediatr. 176(12):1176–1187. doi:10.1001/jamapediatrics.2022.3940

²Arruda, M. A., Arruda, R., Guidetti, V., & Bigal, M. E. (2020). ADHD Is Comorbid to Migraine in Childhood: A Population-Based Study. Journal of Attention Disorders. 24(7), 990–1001. doi.org/10.1177/1087054717710767

³Pan, P. Y., Jonsson, U., Şahpazoğlu Çakmak, S. S., Häge, A., Hohmann, S., Nobel Norrman, H., Buitelaar, J. K., Banaschewski, T., Cortese, S., Coghill, D., & Bölte, S. (2021). Headache in ADHD as Comorbidity and a Side Effect of Medications: A Systematic Review and Meta-Analysis. Psychological Medicine. 52(1), 1–12. doi.org/10.1017/S0033291721004141

⁴Hansen, T. F., Hoeffding, L. K., Kogelman, L., Haspang, T. M., Ullum, H., Sørensen, E., Erikstrup, C., Pedersen, O. B., Nielsen, K. R., Hjalgrim, H., Paarup, H. M., Werge, T., & Burgdorf, K. (2018). Comorbidity of Migraine with ADHD in Adults.  BMC Neurology  18(1), 147. doi.org/10.1186/s12883-018-1149-6

⁵Kutuk, M.O., Tufan, A.E., Guler, G., Yalin, O.O., Altintas, E., Bag, H.G., Uluduz, D., Toros, F., Aytan, N., Kutuk, O., Ozge, A. (2018). Migraine and Associated Comorbidities are Three Times More Frequent in Children with ADHD and Their Mothers. Brain Dev. 40(10):857-864. doi.org/10.1016/j.braindev.2018.06.001

Researchers have “refined the genetic architecture of ADHD” after identifying 27 variations in genetic code that are most present in people with the attention deficit hyperactivity disorder. A Danish-led international genome-wide association study (GWAS) published in Nature highlighted these and 76 probable risk genes — including “brain-expressed genes” involved in development and genes known to influence other psychiatric disorders. ¹

The study identified 27 ADHD risk loci, or locations of a gene or mutation on a chromosome. Researchers then linked these loci to 76 ADHD risk genes. They found that many of the genes thought to influence ADHD also influence early embryonic brain development.

“This emphasizes that ADHD should be seen as a brain developmental disorder, and that [ADHD] is most likely influenced by genes that have a major impact on the brain’s early development,” said Ditte Demontis, one of the study’s authors and a professor at Aarhus University.

Researchers estimated that up to 7,300 common genetic variants influence ADHD, highlighting its polygenicity. They observed that common variants were often found in genes expressed in the frontal cortex, which is responsible for attention and working memory, and in genes expressed in midbrain dopaminergic neurons that control voluntary movement and reward processing.

“There was a time about 30 years ago when many scientists — and the general public — thought that… we would find the [one] gene for ADHD, bipolar disorder, autism, and so on,” said Joel Nigg, Ph.D., in a recent ADDitude webinar. “That is clearly wrong. We now know after 25 to 30 years of extensive genetic research that lots of genes are involved in these conditions; there’s lots of overlap and genetic correlations. And [we know] that genes don’t explain the whole story for any of these conditions, despite some fairly substantial genetic influence in all of them.”

According to the study, 84% to 98% of common variants tied to ADHD seemed to influence other psychiatric disorders including autism spectrum disorder, depression, and schizophrenia. This correlates with the high rate of comorbidity seen among ADHD patients.

“As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder, while approximately 60% of children with ADHD have at least one co-occurring condition,” wrote Theresa Cerulli, M.D., in an ADDitude article about complex ADHD.

The considerable genetic overlap found in the current study helps to explain the frequency of ADHD comorbidities.

“The presence of co-occurring conditions almost always muddles the diagnosis, treatment, and prognosis of ADHD,” Cerulli wrote. “ADHD and comorbidities may also influence the presentation and severity of one another, which can complicate the detection and treatment of symptoms.

This GWAS meta-analysis of ADHD is the largest to date. Researchers analyzed twice as many ADHD cases and identified more than double the number of ADHD-associated loci compared to a 2019 GWAS. ² That study helped establish the role of common variants in ADHD; the current study is an updated GWAS meta-analysis.

“The results advance our understanding of the underlying biology of ADHD and reveal new aspects of the polygenic architecture of ADHD, its relationship with other phenotypes and its impact on cognitive domains,” wrote the researchers.

The study sampled 186,843 people with ADHD, 38,691 controls, and analyzed data on over 6 million variants.

Sources

¹Demontis, D., Walters, G. B., Athanasiadis, G., Walters, R., Therrien, K., Nielsen, T. T., … Børglum, A. D. (2023). Genome-wide analyses of ADHD identify 27 risk loci, refine the genetic architecture and implicate several cognitive domains. Nature Genetics, 55(2), 198–208. doi: 10.1038/s41588-022-01285-8

²  Demontis, D., Walters, R.K., Martin, J. et al. (2019). Discovery of the first genome-wide significant risk loci for attention deficit/hyperactivity disorder. Nat Genet 51, 63–75. https://doi.org/10.1038/s41588-018-0269-7

ADHD is a stronger predictor of depression and anxiety in adults than is autism spectrum disorder, according to a new study that suggests patients with attention deficit hyperactive disorder are more likely that autistic patients to experience “internalizing problems” like mood disorder. The study, led by researchers at the University of Bath and published in Scientific Reports, underscores the importance of screening for comorbid conditions in adults with ADHD. ¹

As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder.² According to a recent ADDitude survey of 1,500 readers, anxiety and depression are the two most common comorbid conditions diagnosed alongside ADHD in adults, with co-diagnosis rates of 72% and 70%, respectively.

Despite this high rate of comorbidity, researchers said, “ASD has often been prioritized over ADHD in both research on internalizing problems and clinical practice, particularly for anxiety.”³

Notably, approximately 28% of autistic individuals have ADHD, making it difficult to determine which disorder — ASD or ADHD — more significantly impacts mental health outcomes.² (The ADDitude reader survey found that 9% of adults with ADHD have ASD.)

Researchers aimed to clarify the associations between self-reported ASD traits and ADHD traits with mental health conditions like anxiety and depression using a general population sample, which included 504 adults from the U.K. (49% male, 51% female) aged 18–79 years.

While the results linked both ASD and ADHD with anxiety and depression, ADHD was a stronger statistical predictor of both mental-health conditions than was ASD. Further analysis confirmed that ADHD traits were associated with more severe anxiety and depression symptoms in adults than were ASD traits.

Researchers “speculate that response inhibition difficulties, which appear to be a cognitive feature of ADHD, may also potentially underpin the stronger association between ADHD traits and internalizing problems.”

To the researchers’ knowledge, this is the first study showing ADHD more strongly predicts mental health outcomes in adults than do other neurodevelopmental conditions, like ASD.

“Our finding that ADHD traits dominated ASD traits in predicting internalizing disorder symptoms could inform strategies to identify individuals who are at an increased risk of internalizing problems,” researchers said. “This might allow preventative measures and interventions to be implemented at an earlier age, which, for example, could focus on managing ADHD symptoms for a greater impact on ameliorating internalizing problems and improving mental wellbeing in adults.”

Recognizing complex ADHD (attention deficit plus one or more co-occurring conditions) is of “high clinical importance,” said Theresa Cerulli, M.D., of Beth Israel Deaconess Medical Center and the Neuroscience Education Institute, in the ADDitude webinar titled, “Complex ADHD: The New Approach to Understanding, Diagnosing, and Treating Comorbidities in Concert.”

“The presence of co-occurring conditions almost always muddles the diagnosis, treatment, and prognosis of ADHD,” she said. “ADHD and comorbidities may also influence the presentation and severity of one another, which can complicate the detection and treatment of symptoms, and impair overall quality of life.”

Researchers hope the study’s findings will encourage more research probing whether genetics help explain why ADHD traits are more strongly associated with internalizing problems than are autistic traits.

Sources

¹Hargitai, L.D., Livingston, L.A., Waldren, L.H. et al. (2023). Attention-Deficit Hyperactivity Disorder Traits Are a More Important Predictor of Internalising Problems Than Autistic Traits. Sci Rep. 13, 31. https://doi.org/10.1038/s41598-022-26350-4

²Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC psychiatry. 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

³Bishop, D. V. M. (2010). Which Neurodevelopmental Disorders Get Researched and Why? PLoS ONE 5, e15112/

⁴Young, S. et al. (2021). Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement. Front. Psychiatry 12, 324.

ADHD prescriptions and medication use among 12^th grade patients hit an all-time high last year, according to a new study that found 15% of high school seniors reported stimulant or non-stimulant ADHD medication use in 2022 compared to 11% in 2021. The annual Monitoring the Future (MTF) survey published by the National Institute on Drug Abuse (NIDA) attributed this 36% increase in ADHD medication use to “more stress” or attention issues made “more salient to their parents” during the pandemic’s lockdowns and remote learning.¹

The legal, or medically supervised, use of ADHD medication was “one of the few substances with increasing prevalence during the pandemic,” according to the report, which found that lifetime use had increased for 8^th, 10^th, and 12^th graders in 2022. The 30-day use of stimulant and non-stimulant medication by 12th graders in 2022 was the highest ever recorded by NIDA’s survey. Notably, 11.2% of 12th graders had used a stimulant for ADHD in their lifetime and 5.6% in the past 30 days, according to 2022 data collected from 31,438 students across 308 schools.

The MTF survey is conducted annually by researchers at the University of Michigan. The use of ADHD medication was first recorded in 2001 (nonmedical) and 2005 (medical). Researchers collect data on self-reported use of various drugs over 30 days, 12 months, and lifetime from hundreds of schools across the U.S. It also measures attitudes and beliefs surrounding substance use.

Examining the Rise in ADHD Medication Use

Prior to the pandemic, legal use of ADHD medication had been trending downward for patients in the 8th, 10th, and 12th grades. Levels were at the lowest or near-lowest ever recorded by NIDA’s survey.

“It is possible that the need for treatment of ADHD increased during the pandemic due to adolescents experiencing more stress during the pandemic,” the researchers proposed.

That theory accurately reflects the experience of many caregivers surveyed by ADDitude in early 2023; 60% of the 370 parents surveyed reported a change in their child’s ADHD medication treatment plan during the pandemic. A 2021 survey of ADDitude readers found that 22% of adults and 17% of children had started ADHD medication for the first time since pandemic lockdowns began in March 2020.

“The emotional regulation piece made it very hard to create meaningful change,” said Jessie from Michigan, who first attempted to address her child’s ADHD symptoms with “elimination diets and nutritional supplements.”

“Our hope is that medication will bring equilibrium and allow us to address root causes long term.”

MTF researchers also posit that “sheltering at home during the pandemic may have made any attention issues of adolescents more salient to their parents, who then sought out medical care for their children.”

This reflects the experience of Catherine, whose three children were diagnosed with ADHD in 2022 after a lengthy wait for evaluations.

“They all started medications, and we immediately saw improvement in their schoolwork and home life,” she said. “One child went from a 2nd grade reading level to 4th grade within months.”

Illicit Drug Use Among Adolescents

NIDA’s study found that 11% percent of 8th graders, 21.5% of 10th graders, and 32.6% of 12th graders reported illicit drug use in the past year. It concluded that “adolescents and adults in their 20s fall into the age groups at highest risk” for illicit drug use. For teens and young adults with ADHD, the use of medically supervised stimulant medication may prevent illicit drug use, according to Walt Karniski, M.D., in a recent ADDitude webinar.

“ADHD affects substance abuse in both children and adults,” Karniski said. “Children with ADHD are more likely to smoke and to begin smoking at younger ages. They’re more likely to use alcohol at younger ages and more likely to abuse alcohol as adults. Adults with ADHD are two to three times more likely to abuse drugs, but less likely to abuse drugs if they’re taking medication for their ADHD… Multiple research studies have indicated that, when children and adults are treated with stimulant medication, they are less likely to abuse drugs in the future.”

Nonmedical use of ADHD medication also rose in 2022, according to the NIDA survey, which found the use of Ritalin without a doctor’s orders rose to 1.1% for 12th graders. Unprescribed Adderall use returned to near-2020 levels following a decrease in 2021. In contrast, the nonmedical use of amphetamines by 12th graders declined, and no significant changes were found for Ritalin use by 8th and 10th graders.

“As these varied patterns of use show, the overall proportion of U.S. adolescents using any substance in their lifetime has changed over the years, and the mix of drugs they use has changed even more.”

Research published by MTF has and continues to inform decisions regarding public debate and policy making. To learn more about NIDA’s survey results, visit monitoringthefuture.org.

Sources

¹https://monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022.pdf

²https://nida.nih.gov/news-events/news-releases/2022/12/most-reported-substance-use-among-adolescents-held-steady-in-2022