To successfully address picky eating and related food issues, parents must first recognize possible underlying factors so they can seek the appropriate professional help and treatments.

Picky Eating and Feeding Difficulties: Common Causes and Related Conditions

SPD and Eating Problems

While not an official medical diagnosis, sensory processing disorder is tied to immature neurological development and characterized by faulty processing of sensory information in the brain. With SPD, the brain can misread, under-read, or be overly sensitive to sensory input. Typical symptoms include heightened or deadened sensitivity to sound and light; extreme sensitivity to clothing and fabrics; misreading social cues; and inflexibility. The stress caused by sensory dysregulation can affect attention, behavior, and mood.

Eating is a key SPD problem area, as all aspects of food – from preparation to ingestion – involve reading and organizing data from all of the senses. SPD-related eating issues include:

• Appetite: Sensory overload stimulates the release of stress hormones. Mild to moderate stress increases desire for starches and sweets but chronic or high levels of stress reduces the appetite and interferes with digestion.
• Hunger signals. Young children often miss hunger cues when they are playing. They want to stay at the park for just 10 more minutes when it is obvious that without an immediate influx of food, the afternoon will be shot. When elevated to SPD, children rarely notice they are hungry as the hunger signal is lost amidst a mass of misread and disorganized sensory data. When they do ask for food, they may refuse items that are not to their exact specifications. A small percentage misread satiety, chronically feel hunger and ask continuously for food.
• Food sensory characteristics. How the brain makes sense of smell, taste, temperature, color, texture, and more impacts the eating experience. Because food has so many sensory characteristics, there are many areas where children can get thrown off.

[Read: What’s Causing My Child’s Sensory Integration Problems?]

The most common symptom of SPD is psychological inflexibility. Individuals with SPD attempt to limit sensory discomfort by controlling their external environment in the areas where they are overloaded. With eating, this rigidity can mean only one brand of acceptable chicken nuggets (not the homemade ones),  the same foods repetitively, strict rules about foods not touching,  and random demands about and rejection of core favorites. (e.h. “The apple is bad because of a tiny brown spot,” or suddenly, noodles are on the “don’t like” list.)

Autism

Many people on the autism spectrum identify as having strong or diminished responses to sensory information. If delays in motor planning and oral motor issues are also present, in addition to the sensory aspects of food and eating, children on the spectrum may have trouble chewing and swallowing some foods.

ADHD

ADHD symptoms and behaviors may also contribute to problems with food.

• Impulse control and self-regulation problems can cause overeating and make it difficult to notice and respond to satiety.
• Poor executive functioning can derail meal planning and preparation in adolescents and young adults who prepare their own foods.
• Distractibility and inattention can lead to missed hunger signals or even forgetting to eat.
• Stimulant medications can dull the appetite.
• Mood stabilizers can increase appetite.

[Read: 9 Nutrition Tricks for Picky Eaters]

ARFID

Also known as “extreme picky eating,” ARFID is described in the DSM-5, the guide clinicians use to diagnose health conditions, as an eating or feeding disturbance that can include:

• Lack of interest in eating or food
• Avoiding foods based on sensory characteristics
• Avoiding foods out of concern over aversive experiences like choking or vomiting

These disturbances result in failure to meet appropriate nutritional and/or energy needs, as manifested by one of more of the following:

• Significant weight loss or faltering growth and development
• Significant nutritional deficiency
• Dependence on enteral feeding or oral nutritional supplements
• Marked interference with psychosocial functioning

To merit a diagnosis, the disturbance must not be better explained by a lack of available food or a culturally sanctioned practice, and it must not be associated with body image concerns or a concurrent medical condition/treatment (like chemotherapy).

Children with ARFID may experience certain foods, such as vegetables and fruit, as intensely unpalatable and take great care to avoid them.¹ They may be fearful of trying new foods and rely on highly processed, energy-dense foods for sustenance.¹ Common feeding advice like hiding and disguising vegetables in food, relying on your child to “give in” to avoid starving, or repeating requests to eat does not work with children who have ARFID. This disorder is associated with extreme nutritional and health deficiencies.

Research on the prevalence of ARFID is limited, but findings from studies on patients with eating disorders estimate ARFID rates between 5%² and 23%.³ Notably, ARFID appears to be most common in young males and more strongly associated with co-occurring conditions than are other eating disorders. One study on young patients with ARFID, for example, found that 33% had a mood disorder; 72% had anxiety; and 13% were diagnosed with autism spectrum disorder.³

In my view, the extreme eating behaviors in ARFID are sensory processing disorder symptoms. (Maybe one manifestation of SPD is quietly in the DSM-5 after all.) If you see your child in this description, get professional help. Parents of those with ARFID are usually as frustrated and discouraged as the children they are trying to help.

Picky Eating and Feeding Difficulties: Solutions

Parents can take small daily steps to better fulfill a child’s nutritional needs and reduce stress around meals. Serious feeding difficulties and eating problems warrant professional help.  Occupational therapists, speech therapists, nutritionists, GI specialists, and psychologists are several of the professionals who can help evaluate and treat youngsters that resist your best efforts.

1. Assess the Severity of Sensory and/or Behavioral Challenges

These symptoms may point to challenges that require therapeutic intervention:

• Only eating one type of texture (e.g. crunchy, mushy or foods that require limited chewing, like crackers)
• Avoiding food at certain temperatures (e.g. will only eat cold food)
• Exaggerated reactions to new food experiences. (e.g. vomiting and/or lengthy, explosive temper tantrums)
• Extreme sensitivity to smells
• Brand loyalty, only eating products made by a certain company. (Processed foods may have more sugar and salt to boost flavor, which can exacerbate feeding problems)
• Refusing to eat foods if small changes are made, including in the packaging or presentation
• Refusing to eat or excessive fussing over unpreferred foods on the same plate or table when eating
• Takes 45 minutes or more to finish a meal
• Is losing weight over several months (and is not overweight)

Physical and biological problems can also contribute to feeding difficulties, including:

• Reflux; esophagitis
• Allergies and aversive food reactions
• Poor digestion and gut issues including excessive gas, bloat, constipation, diarrhea, and abdominal pain
• Underdeveloped oral motor skills. Symptoms include frequent gagging, pocketing food, takes forever to get through a meal, difficulty transitioning from baby food to solid food, drooling.
• Chronic nasal congestion.

2. Keep Nutritious Foods at Home

Try not to keep any foods at home that you do not want your child to eat. That includes certain snack foods, which are designed to be extremely appealing to the senses, but often offer paltry nutritional value. (It’s easier to remove these foods than to introduce new ones.) Consider saving leftover lunch or dinner for snacks instead.

It is also better for your child to eat the same healthy meals over and over again than to try to vary meals by filling in with snack foods or different versions of white bread (such as muffins, pancakes, bagels, noodles, rolls and crackers). Find a few good foods that your child enjoys and lean into them.

Rather than make drastic changes at once, focus on one meal or time of day, like breakfast, and start on a weekend so the initial change doesn’t interfere with school and other activities. Breakfast is a good meal to tackle, as most kids are home and this meal sets the tone for the day. These tips can help make the most of the day’s first meal:

• Limit sugary, processed items like cereal, frozen waffles, breakfast pastries, and the like. These foods fuel sudden spikes and drops in your child’s energy levels through the school day. If your child also has ADHD and takes medication for it, it’s important to serve breakfast before the medicine kicks in, as stimulants can dampen appetite.
• Focus on protein. Protein provides long-lasting energy and fullness. A protein-rich breakfast can include eggs, smoothies, paleo waffles, salmon, hummus, beans and nut butters.
• Think outside of the box. Breakfast doesn’t have to look a certain way. Leftover dinner can be an excellent meal to start the day.

3. Consider Supplements

Nutritional deficiency is a common outcome of restricted, picky eating. These deficiencies can impact appetite and mood and, in the severe cases, exact long-term consequences on development and functioning. Vitamins, minerals, and other supplements can close the gap on these deficiencies while you work with your child on eating a more varied diet.

Among the body’s many required nutrients, zinc appears to have the greatest impact on feeding difficulties, as poor appetite is a direct symptom of zinc deficiency. Insufficient zinc intake is also associated with altered taste and smell, which can impact hunger signals and how your child perceives food. Zinc is found in meat, nuts, oysters, crab, lobster, and legumes. “White” foods like milk and rice are not rich in zinc.

4. Stay Calm and Carry On

Family collaboration can play an important role in addressing picky eating and reducing stress around new foods. Even if only one person in the family has feeding difficulties, ensure that everyone is following the same plan for creating and maintaining a positive, cooperative environment at home.

How to Introduce New Foods

• Concentrate on one food at a time to reduce overwhelm. Give your child a limited set of new food options from which to choose. Consider keeping a kid-friendly food chart in the kitchen. If your child won’t choose, pick one for them.
• Introduce one bit of the same food for at least two weeks. Repetition is a sure way to turn a “new” food into a familiar one. Sensory processing issues means new things are bad things, because new means more potentially overwhelming data to read and sort.
• Do not surprise your child – make sure they know what’s coming.
• Offer choices that are similar to foods they already eat. If your child likes French fries, consider introducing sweet potato fries. If they like crunchy foods, consider freeze-dried fruits and vegetables. If they like salty and savory flavors, try preparing foods with this taste in mind.
• Set up natural consequences using when:then to increase buy-in and avoid the perception of punishment. Say, “When you finish this carrot, then you can go back to your video game.” As opposed to, “if you don’t eat your carrot, you can’t play your game.”

No matter the plan or your child’s challenges, stay calm in the process. Losing your temper can cause your child to do the same (especially if they are sensory sensitive) and create undue stress around an already tough situation:

• Start with the assumption that you and your child will be successful
• Explain expectations in simple terms
• It’s OK if your child fusses, gags, and complains about a new food in the beginning
• Give yourself time-outs when needed
• Always keep feedback positive

Picky Eating Problems: Next Steps

• Download: Best Vitamins and Supplements for People with ADHD
• Symptom Test: Sensory Processing Disorder in Children
• Read: The Parent’s Guide to Mealtime with Picky Eaters

The content for this article was derived from the ADDitude Expert Webinar Got a Picky Eater? How to Solve Unhealthy Food Challenges in Children with SPD and ADHD [podcast episode #355] with Kelly Dorfman, M.S., LND, which was broadcast live on May 18, 2021.

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Sources

¹ Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Current pediatrics reports, 6(2), 107–113. https://doi.org/10.1007/s40124-018-0162-y

² Norris, M. L., Robinson, A., Obeid, N., Harrison, M., Spettigue, W., & Henderson, K. (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. The International journal of eating disorders, 47(5), 495–499. https://doi.org/10.1002/eat.22217

³ Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of eating disorders, 2(1), 21. https://doi.org/10.1186/s40337-014-0021-3

Finding the right ADHD nutrition plan can make all the difference.

ADHD and Artificial Food Coloring

As Susan served breakfast for her 6-year-old son with attention deficit hyperactivity disorder (ADHD), little did she know the tasty blueberry muffin, bowl of Fruit Loops, and glass of Sunny D Citrus Punch would worsen his ADHD symptoms all day long, making him more inattentive and fidgety. With some probing, she found the problem wasn’t a food allergy, or even the foods’ too-high sugar content, but rather a common sensitivity to the rainbow of artificial colors in the food. It seemed to be the cause for her son’s distracted mind.

Studies published in The Lancet¹, Pediatrics², and Journal of Pediatrics³ suggest that food additives adversely affect a population of children with ADHD (see “Study Up,” below). Some⁴ even indicate that artificial coloring and flavors, as well as the preservative sodium benzoate, can make even some kids without ADHD hyperactive.

Two studies^{5 6} from the United Kingdom are good examples. In 2004, one studied healthy preschoolers after giving them either a placebo or 20 milligrams of artificial dye mix plus sodium benzoate. They found that, when the children received the actual dye and sodium benzoate, they had a significant increase in hyperactivity.

In the second, in 2007, a research team lead by UK researcher Donna McCann studied a group of 3-year-olds and 8- or 9-year-olds. It found that both hyperactive children and non-hyperactive children experienced increased hyperactivity scores when given artificial food colors and additives, suggesting that the dyes are a general public health concern. Starting in 2010, the European Union required the following warning label for all food that contains artificial dye: “May have adverse effect on activity and attention in children.”

[Free Guide: What to Eat (and Avoid) to Help ADHD Symptoms]

The Center for Science and the Public Interest petitioned the Food and Drug Administration (FDA) to hold a hearing on whether the U.S. should require a similar warning label — or ban artificial colors altogether. In the end, the vote established that labels should not be added, and the food dye was deemed safe.

However, the FDA did admit that a population of children does react adversely to these dyes. The Center for Science and Public Interest has an informative website with more information: Food Dyes: A Rainbow of Risks.

If you consume orange soda in the U.S., you’re consuming red #40 and yellow #5. But in Britain, you’re drinking pumpkin and carrot extract. Strawberry Nutragrain bars have artificial food dyes in the U.S., but natural dyes in Britain. McDonald’s strawberry sundaes are colored with red #40 in the U.S.; British consumers get real strawberries instead.

Things are changing with U.S. food manufacturers. In early 2015, Nestle announced that it will remove all artificial food dyes from its candies. A couple days later, Hershey said its labels would have “simpler ingredients that are easy to understand.” Kraft has committed to removing all yellow dyes from its macaroni and cheese. Taco Bell and Panera have committed to stop using artificial colors or high fructose corn syrup. And General Mills is already removing dyes from some of its cereals.

[Read This: How Balanced Nutrition Harmonizes the ADHD Brain]

How do you know if food additives are compromising your child’s focus? Conduct a quick test at home. For one week, avoid foods and drinks that contain U.S. certified colors Red #40, Blue #2, Yellow #5 (Tartrazine), Yellow #6 (Sunset Yellow), as well as sodium benzoate. Do you find your child less fidgety? Less prone to meltdowns? Less impulsive and hyperactive?

After seven days, reintroduce food additives into his ADHD food plan by squeezing a few drops of artificial food coloring — you know, the McCormick brand in the little plastic bottles — into a glass of water, and have your child drink it. Observe his behavior for two or three hours. If you don’t see a change, have him drink a second glass. Does he become more hyperactive?

Elimination Diets for ADHD

When the British researchers tested food dyes and preservatives, 79 percent of the children tested had a reaction to the food dyes, 73 percent reacted to soy, 64 percent reacted to milk, and 59 percent reacted to chocolate. Additional foods caused problems as well.

When placed on a special elimination diet excluding foods that trigger unwanted behavior, as many as 30 percent of toddlers and preschoolers benefit, says Eugene Arnold, M.D., author of A Family’s Guide to Attention-Deficit Hyperactivity Disorder and professor emeritus of psychiatry at Ohio State University. The benefits for adults with ADHD are less clear.

On an elimination diet, you start by eliminating dairy, chocolate and cocoa, wheat, rye, barley, eggs, processed meats, nuts, and citrus. Instead, your child eats only foods unlikely to cause reactions, including:

• Lamb
• Chicken
• Potatoes
• Rice
• Bananas
• Apples
• Cucumbers
• Celery
• Carrots
• Parsnips
• Cabbage
• Cauliflower
• Broccoli
• Salt
• Pepper
• Vitamin supplements

Then you restore other foods, one at a time, to see whether they cause a reaction.

If nothing happens within two weeks — if you see no difference in your child’s behavior even when he’s eating the restricted diet — stop the experiment. If you notice an improvement, reintroduce one excluded food each day and watch what happens. If the child has a bad response to the food — if he becomes more fidgety or has trouble sleeping, for example — eliminate it again. If it’s a food your child really likes, try reintroducing it again a year or so later. When not repeatedly exposed to a trigger food, children often outgrow sensitivities.

In the 1970s, Benjamin Feingold, M.D., a pediatrician and allergist at Kaiser Permanente Medical Center in San Francisco, introduced an eating plan that he said could help alleviate symptoms of ADHD. The Feingold Diet forbids artificial food colors, flavorings, sweeteners, and preservatives, as well as some salicylates, naturally occurring compounds found in some fruits and vegetables.

Studies failed to uphold Feingold’s claims when he first made them, and most ADHD experts still dismiss the Feingold diet as ineffective. Yet some recent research⁷ suggests that the Feingold diet may, indeed, benefit the small percent of children with ADHD who seem sensitive to chemicals in food.

Any elimination diet is not easy, but it is doable. The results could be very important. It does require careful meal planning, grocery shopping, label reading, and the cooperation of your whole family. Remember, what you don’t look for will probably not be found.

The Sugar Debate and ADHD

Most parents of children with ADHD — 84 percent of 302 parents in one 2003 study⁸ — believe that sugar has a negative effect on their kids’ behavior. And many adults with ADHD are convinced that sugar worsens their symptoms as well.

But medical experts still tend to discount any link between behavior and sugar or artificial sweeteners. As evidence, they point to a pair of decades-old studies^{9 10} that appeared in the New England Journal of Medicine. “Effects of Diets High in Sucrose or Aspartame on the Behavior and Cognitive Performance of Children” (February 3, 1994) found that “even when intake exceeds typical dietary levels, neither dietary sucrose nor aspartame affects children’s behavior or cognitive function.” A similar study, “The Effect of Sugar on Behavior or Cognition in Children” (November 22, 1995), reached much the same conclusion — though the possibility that sugar may have a mild effect on certain children “cannot be ruled out,” according to the study’s authors.

In any case, sugar carries loads of calories and has no real nutritional value. People who eat lots of sweets may be missing out on essential nutrients that might keep them calm and focused. Since ADHD medications tend to blunt the appetite, it’s important to make every calorie healthy and nutritious. Sugar is neither of those things.

One of the more recent review¹¹ of all the studies on diet and ADHD, concluded and published in 2014, found mixed outcomes. The science is still shaky in this area. The studies found that parents often reported behavior changes with consumption of artificial food colorants and additives, but teachers and clinical tests didn’t report the same level of change. The conclusion? Artificial colors do react adversely with ADHD symptoms in some children. The studies on sugar and artificial colors had negligible results as well, thwarting the theory that sugar and artificial sweeteners cause ADHD symptoms. However, all studies on the effect of elimination diets on ADHD symptoms found statistically significant ADHD symptom reduction when children were given a narrow diet of foods unlikely to cause reactions.

It is now known that any sweetener, including artificial sweeteners, disrupts dopamine and dopamine receptors in the brain. This can lead to alterations in behavior, binge eating, and ADHD symptoms.

Every credible agency, including the American Heart Association, recommends that we reduce the amount of sugar in our diets because sugar has been associated with diabetes and heart disease. It’s recommended that preschoolers have no more than four teaspoons of sugar a day. For ages four to eight, three teaspoons, and for pre-teens and teens, five to eight teaspoons.

For context, 12-ounce can of soda contains almost 10 teaspoons of sugar; that is a bad idea for a child of any age. When reading your food labels, remember that four grams of sugar is equal to 1 teaspoon.

Most health-care practitioners recommend greatly reducing sugar for better health and behavior. Try to satisfy sugar cravings with fruits, and avoid all high fructose corn syrup. You can use small amounts of alternative sweeteners like xylitol, monk fruit, and stevia. To test your child for sugar sensitivities, follow the test for the food dyes, above, and substitute sugar as the test material.

What to Do About ADHD and Diet

If you find that your child exhibits food sensitivities, wean him or her off of foods that are artificially dyed or flavored, or that contain sodium benzoate. Here are some helpful tips about what foods to avoid and what to serve instead:

Substitute 100 percent fruit juice for soft drinks, fruit drinks, and fruit punches, all of which are typically artificially colored and flavored. If your child must have a soft drink, try 7-Up, Squirt, or Sprite. These brands are naturally flavored and free of dyes — though they all contain sodium benzoate, except Sierra Mist NATURAL. Even better, buy natural sodas or fruit spritzers sold at health food stores.

If you have time to bake, make muffins, cakes, and cookies from scratch. Cake mixes contain red and yellow coloring. Use pure extracts instead of artificial vanilla (called vanillin), almond, peppermint, lemon, orange, and coconut flavors. Bonus: Pure extracts taste better, although they are more expensive. No time to bake? Try Pepperidge Farm Chessmen cookies, which are free of dyes and low in sugar.

As you would expect, the more colorful the cereal, the more food dyes it usually contains. Cap’n Crunch, Fruit Loops, Lucky Charms, and Apple Jacks are full of food coloring. Look for breakfast cereals that are free of dyes — like Cheerios, which doesn’t contain artificial colors, flavors, or preservatives. As of January 2016, seven of General Mills cereals contain no artificial colors, no colors from artificial sources, and no high fructose corn syrup: Fruity Cheerios, Frosted Cheerios, Chocolate Cheerios, Trix, Reese’s Puffs, Cocoa Puffs, and Golden Grahams.

If your kids love barbecue sauce, or if you use it to spice up everyday dishes, read the label before buying a bottle. Many brands are loaded with Red #40. Hunt’s Original, however, is free of food coloring. Does your child enjoy popsicles? Buy Welch’s Fruit Juice Bars, one of the few brands without dyes or preservatives.

Jell-O and other gelatin mixes are loaded with artificial coloring and flavors. Make your own gelatin salad or desserts by dissolving plain gelatin in 100 percent fruit juice for a pretty, and nutritious, dessert.

Beyond Food for ADHD Symptom Control

Dyes and preservatives can also be found in personal care products, such as toothpaste and mouthwashes, some of which may be swallowed by young children. Again, read the labels carefully before buying any product. Crest toothpaste, for instance, contains blue dye; Colgate’s Original is free of it. Clear, natural mouthwashes are a good substitute for those brightly colored varieties.

Most pediatric medicines are also artificially colored and flavored. Ask your doctor if there is an additive-free substitute that would work just as well. For over-the-counter medicines, choose Motrin or Tylenol, which come in dye-free white tablets. Be sure to adjust the dosage for your child’s age. The liquid form of the over-the-counter antihistamine Benadryl is artificially colored with red dye, but the medication also comes in clear liquid and clear liquid capsules.

Avoiding foods with artificial colors and preservatives has another big benefit: It will raise the nutritional value of your family’s diet, since the “junkiest” foods on supermarket shelves tend to be — you guessed it — the most heavily colored and flavored.

[Why Sugar is Kryptonite for ADHD Brains]

True Colors

Not all food colors have the potential to make your child hyperactive.

Here are some that don’t: annatto; anthocyanin; beta carotene; caramel; carmine; chlorophyll; paprika; red beets; saffron; turmeric.

Study Up

To read article summaries on ADHD and food coloring, go to PubMed:

• Swanson and Kinsbourne (Science), 1980 
• Kaplan (Pediatrics), 1989
• Carter (Archives of Diseases in Childhood), 1993
• Boris (Annals of Allergy), 1994
• Rowe and Rowe (Journal of Pediatrics), 1994
• Weiss (Environmental Health Perspectives), 2012

¹ Mccann, Donna, et al. “Food Additives and Hyperactive Behaviour in 3-Year-Old and 8/9-Year-Old Children in the Community: A Randomised, Double-Blinded, Placebo-Controlled Trial.” The Lancet, vol. 370, no. 9598, 2007, pp. 1560–1567., doi:10.1016/s0140-6736(07)61306-3.
² Kaplan, Bonnie J., Jane Mcnicol, Richard A. Conte, and H. K. Moghadam. “Overall Nutrient Intake of Preschool Hyperactive and Normal Boys.” Pediatrics, vol. 17, no. 2, 1989, pp. 127-32.
³ Rowe, Katherine S., and Kenneth J. Rowe. “Synthetic Food Coloring and Behavior: A Dose Response Effect in a Double-Blind, Placebo-Controlled, Repeated-Measures Study.” The Journal of Pediatrics, vol. 125, no. 5, 1994, pp. 691-98.
⁴ Mccann, Donna, et al. “Food Additives and Hyperactive Behaviour in 3-Year-Old and 8/9-Year-Old Children in the Community: A Randomised, Double-Blinded, Placebo-Controlled Trial.” The Lancet, vol. 370, no. 9598, 2007, pp. 1560–1567., doi:10.1016/s0140-6736(07)61306-3.
⁵ Bateman, B. “The Effects of a Double Blind, Placebo Controlled, Artificial Food Colourings and Benzoate Preservative Challenge on Hyperactivity in a General Population Sample of Preschool Children.” Archives of Disease in Childhood, vol. 89, no. 6, Jan. 2004, pp. 506–511., doi:10.1136/adc.2003.031435.
⁶ Mccann, Donna, et al. “Food Additives and Hyperactive Behaviour in 3-Year-Old and 8/9-Year-Old Children in the Community: A Randomised, Double-Blinded, Placebo-Controlled Trial.” The Lancet, vol. 370, no. 9598, 2007, pp. 1560–1567., doi:10.1016/s0140-6736(07)61306-3.
⁷ Schab, David W., and Nhi-Ha T. Trinh. “Do Artificial Food Colors Promote Hyperactivity in Children with Hyperactive Syndromes? A Meta-Analysis of Double-Blind Placebo-Controlled Trials.” Journal of Developmental & Behavioral Pediatrics, vol. 25, no. 6, 2004, pp. 423-34.
⁸ Dosreis, Susan, et al. “Parental Perceptions and Satisfaction with Stimulant Medication for Attention-Deficit Hyperactivity Disorder.” Journal of Developmental & Behavioral Pediatrics, vol. 24, no. 3, 2003, pp. 155–162., doi:10.1097/00004703-200306000-00004.
⁹ Wolraich, Mark L., et al. “Effects of Diets High in Sucrose or Aspartame on The Behavior and Cognitive Performance of Children.” New England Journal of Medicine, vol. 330, no. 5, Mar. 1994, pp. 301–307., doi:10.1056/nejm199402033300501.
¹⁰ Wolraich, M L, et al. “The Effect of Sugar on Behavior or Cognition in Children.” JAMA, vol. 274, no. 20, Nov. 1995, pp. 1617–1621.
¹¹ Nigg, Joel T., and Kathleen Holton. “Restriction and Elimination Diets in ADHD Treatment.” Child and Adolescent Psychiatric Clinics of North America, vol. 23, no. 4, 2014, pp. 937–953., doi:10.1016/j.chc.2014.05.010.

Feeding Your Emotions with Negative Thoughts

Chronic emotional distress becomes the go-to reaction for those with ADHD. It works something like this:

A person with ADHD does something impulsively under stress. My latest experience of this happened yesterday. As I was driving on a 12-day, once-in-a-lifetime trip with my younger brother, I impulsively passed several cars on an open stretch of road. I was going much faster than I should have been, yet I really wanted to get around those cars. It wasn’t wildly unsafe, but it was enough to set off feelings of shame and embarrassment. This type of impulsivity happens when our brains go down this path again and again. The embarrassment or shame we feel later makes our emotions seem totally out of control.

“Normal” emotions peak and drop off. With Emotional Distress Syndrome, you create higher peaks with negative thoughts. So, after my impulsive driving, I thought: “I am an expert in ADHD, but here I am again.” Such thoughts create waves. You feel frustration, anger, despair, or anxiety. We are building patterns of emotional distress in our brains.

When you learn to maintain balance by re-centering and calming yourself time and time again, you neurologically ingrain the pattern of getting your life back on track. You stop being afraid of screwing up again. Instead of driving people away, you bring them closer. Knowing you can reset, re-center, and re-envision your purpose raises your self-esteem.

[ADHD and Emotional Distress Syndrome: Your Truth and Tactics]

Managing the disruptions of ADHD is a matter of finding and practicing what works for you. I encourage my clients to identify three to five strategies to help them emotionally and mentally rebalance during or after an EDS storm. The following strategies are some of my favorites that work for me:

1. Re-Center Yourself

Learn to calm and re-center your emotions several times a day, whether you feel you need to or not. You can do what I call a micro meditation of one to three minutes: Stop and breathe deeply, taking breaths that push out your stomach. Then push all the air out of your lungs when exhaling so your stomach sinks in. Try it now. Keep going.

Now try taking three, four, five, or even 10 breaths, and on the last one, push all of the air out of your lungs and hold it as long as you can. Then take a full breath in, and hold it until you have to let it out. This technique increases the oxygen level in your body. By training yourself to feel and hold this pressure, you will stay centered during the pressure of the EDS storms of ADHD.

2. Create an Emotionally Safe Place

Link soothing ideas in your imagination to real-world reminders. I pass a majestic oak tree every day while walking my dog. I have uploaded this tree into my mental emotionally safe place of my imagination. Thinking about the tree as I walk by it each day wires my neurological network together. The connection with the tree is strengthened each time I do it.

3. Surround Yourself with Things That Give You a Sense of Purpose

Gaze at these daily, remembering why they are important to you. This will help you connect to yourself and to your purpose, which enhances your feelings of well-being. When I look at and admire the artwork I have placed around my office, I feel a connection to the intentions of the artist and the stories behind the paintings. The peace I experience counterbalances any mental distress from my ADHD.

[Self-Test: Could You Have Emotional Hyperarousal?]

4. Slow Yourself Down by 25 Percent

Pause and reflect. When walking to your car after work, slow your pace by 25 percent, listen to the birds singing or feel the wind blowing through your hair. The neurological patterns of ADHD that create a whirlwind of activity will slow down. This allows your mind and your emotions to stay more at ease. Every day I try to slow down my walking pace. Early this morning, as I was on my way to swim, I noticed I was more hurried than usual. So I slowed down, took a deep breath, and noticed a woman doing yoga in the park. Observing her helped me feel centered and calm. I would have missed this encounter had I not slowed down.

5. Keep Your Chosen Strategies Front and Center

Write down your strategies. Put them in places where you will see them every day, like taped to the middle of your steering wheel. This really works. I keep up with the details of life with a single yellow folder that has sticky notes on the front. Inside there are papers to manage as well as a cut-out heart my son made when he was nine years old.

If I turn the folder over, I will see an inspiring quotation taped to the back. This folder, along with the meaningful items contained in it, restrains the wild emotions that can pop up at any moment and gives me a sense of insulation from them.

Integrating personalized strategies into your life takes time. This is not a skill learned in one day. The tools I suggested will help you build a feeling of safety and counteract EDS, so that your life will become more joyful.

[Restart Your Brain: ADHD-Friendly Tools for Handling Emotional Stress]

James Ochoa, LPC, author of Focused Forward: Navigating the Storms of Adult ADHD (#CommissionsEarned), is founder and director of The Life Empowerment Center in Austin, Texas. 

James M Ochoa, LPC, is a member of ADDitude’s ADHD Medical Review Panel.

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So how can parents and practitioners identify ADHD red flags in this sea of crimson? By honing their focus on a child’s emotional control — or lack thereof.

Early Signs of ADHD in Babies: Poor Sleep, Feeding, Frustration

The American Academy of Pediatrics says children may be diagnosed with ADHD no younger than age 4, but that doesn’t mean ADHD in toddlers isn’t real.¹  There are real differences in the ADHD brain that are present at birth, and waiting too long to intervene may burden a child unnecessarily.

It’s easy to spot children with severely hyperactive or impulsive behaviors — they’re the ones who are extremely active and spontaneous and seem to need less sleep than their peers. Their parents and caregivers are exhausted. But hyperactive behavior is not a hallmark of ADHD for all children; a better predictor for the development of ADHD is actually a child’s ability to regulate their emotions.

Specifically, early negative emotionality (poor response to stress and a tendency to react with unpleasant emotions) is highly predictive of ADHD. The babies who may be at risk for ADHD are the ones who cry constantly and have trouble self-soothing; who are angry, fussy, and difficult to control; who have problems feeding and falling and/or staying asleep; or who are intolerant of frustration.

[Could Your Child Have ADHD? Take This Self-Test]

Early Signs of ADHD in Toddlers: Intense, Uncontrolled Emotions

When negative emotionality persists into toddlerhood, it looks quite different than a few typical toddler tantrums. Children with ADHD show more aggressive and emotionally intense behaviors when a prize is taken away from them. When presented with challenging tasks, such as puzzles with missing pieces, the young children with ADHD show more frustration, negative expressions, emotional outbursts, and anger than do their neurotypical peers. They are also quicker to give up.^2,3,4,5

In short, toddlers and preschoolers with ADHD are overly reactive. Why? Because they feel emotions more deeply and hold on to them longer than do those without ADHD. They overreact with positive emotions, such as excitement, which can mean screaming and jumping for joy over small things (like when my daughter with ADHD ran around the house screaming like a maniac when I told her we were going for ice cream). They also overreact with negative emotions, disappointment, and frustration, which often lead to tantrums or aggressive behaviors.

As neurotypical toddlers reach age 3 or 4 years old, they can begin, for example, to wait until after dinner for ice cream without having a major meltdown (though they may whine a bit if tired or stressed). Preschoolers with ADHD, however, cry or scream regularly over minor situations. “Small deals” are almost always “BIG deals” with these kids, and they show it with their emotional outbursts. Waiting is nearly impossible; they feel extreme pressure to get things now.

Early Signs of ADHD in Toddlers: Emotional Sensitivity and Overwhelm

Toddlers with ADHD tend to be easily frustrated, moody, and even rude. They may worry too much or too long about even the smallest of things and have more difficulty transitioning. They’re also extremely sensitive to corrective feedback – asking them to put on a coat to go outside can result in an angry scream. These children become overwhelmed with their feelings and have a hard time calming down.

[Watch This Video: The Emotionality of ADHD]

Young children with ADHD are also extremely irritable — which can result in whining, demanding, or screaming every request they make — and prone to aggressive and angry outbursts.

In the preschool classroom, students may whine if there are too many kids at the station or center where they want to play. Children without ADHD will generally move to another center. Children with ADHD, however, may drop to the ground screaming or push another child and tell them to leave. And not just once. Instances like these happen over and over. Preschoolers with ADHD tend to be more controlling and react with more hostility, anger, and aggression when upset and are more likely to get calls home than are their non-ADHD peers.

Early Signs of ADHD in Toddlers: Frequent, Severe Tantrums

When upset, young children with ADHD also tend to engage in tantrums that are more frequent, intense, severe, and disruptive than do other children their age. Typically developing toddlers may have weekly tantrums and parents can usually tell why the tantrum is happening (the child is likely tired or doesn’t want to do something).

In toddlers with ADHD, the tantrums occur more frequently, last longer, and seem to come out of nowhere. The child’s reactions are excessive, completely disproportionate to the event, and/or inappropriate to the context. The tantrum can last for 20 minutes or more and the child has trouble calming down on their own and may even retaliate. Many will experience “full-blown” tantrums that they have zero control over — even if promised their most favorite thing in the world, they simply cannot stop.

Typical Toddler Behavior

The table below outlines and compares typical toddler behavior and ADHD toddler behavior.

When children with ADHD become over-stimulated (e.g., busy events or loud environments), their emotional reactions can be even more unpredictable and severe than usual. My daughter had emotional meltdowns at birthday parties and the worst of them always occurred at her own parties. It was just way too over-stimulating for her and resulted in screams, cries, throwing things, and demanding that everyone leave at once. She spent most of her fourth birthday party alone in her room while I led activities for her friends.

Early Signs of ADHD in Toddlers: My Daughter’s Early Symptoms

Unfortunately, these youngsters typically receive a lot of negative feedback for their behaviors, which can contribute to low self-esteem, anxiety, and even depression. My daughter developed significant anxiety by the time she started school. She was the typical active child with ADHD early on. She developed all her motor skills early and was walking with a push car by the time other babies were just learning to crawl. She literally ran circles around the other babies and when she learned to talk, she didn’t stop (until she became a teenager).

Naps ended early and we gave them up completely when she was 14 months, otherwise, she wouldn’t sleep at night. Even then I wondered how much she slept. We had to switch her to a “big girl” bed because she constantly climbed out of her crib. Because we couldn’t keep her contained, we would hear her banging around all night in her room. We removed her toys, but she amused herself by climbing the shelves in her closet. On more than one occasion, I found her in the morning sleeping in the closet.

She was also a terrible eater who somehow grew normally though I was convinced she was starving because she couldn’t stop to nurse for more than two minutes at a time. She was way too impatient and needed to constantly look around the room.

And her emotional meltdowns? Epic.

I remember telling friends and family that the Terrible Twos were way worse than I had ever imagined (or saw based on my friends’ kids). I knew that behavior problems tend to peak at 2 years and then decline as they get older, but I found my daughter’s 3s were worse than her 2s. And, when I thought it just had to get better, the behaviors continued when she turned 4…. When was it going to stop!?

Many parents fall into this trap of waiting for behaviors to improve. Though it was clear my daughter was quite different from other kids, everyone told me to wait. They said she was just an active, imaginative, gifted child. So, we waited.

While we waited for the hyperactive behaviors to go away, we overlooked the fact that she should have started showing more emotional control by the time she was 3. She was just a sensitive girl! More excuses. And then we ended up waiting too long. She continued to lash out emotionally, which interfered with her ability to build friendships and her self-esteem plummeted.

Early Signs of ADHD in Toddlers: Critical Parental Supports

I cannot overstress the importance of early intervention. Children who display emotional dysregulation — less frustration tolerance, more anger — are at great risk. And the more severe their anger outbursts, the more severe their ADHD symptoms tend to be. Similarly, dysregulated happiness is associated with greater inattention.⁶  Worse still, only about 40-50 percent of young children with ADHD receive the early intervention behavioral support they need.

It’s important to know the early warning signs so we can help these kids as quickly as possible. Do not wait to see what happens. Begin logging your observations and concerns as soon as your baby is born. What’s fascinating is that babies actually start to show the ability to regulate their emotions within months of being born. For example, babies learn to look away from things that are upsetting them to self-soothe and control anger, frustration, and upset. Children with ADHD did not do those things as babies.

As they move into preschool and their language capacity grows, typically developing children can better regulate their emotions and begin to respond to situations with flexibility and in socially appropriate ways. Children with ADHD, on the other hand, continue to have trouble managing challenging situations and reducing their distress. They cannot cope with negative emotions effectively and continue to vent (verbally or physically), show aggression, or engage in more avoidance behaviors to try and self-regulate.

Early Signs of ADHD in Toddlers: 5 Complements to Behavior Therapy

Our emotion systems develop earlier than our control systems. What’s more, the emotional brain is much stronger than the thinking brain (the one that helps us keep cool and make good behavioral choices). This means we must start supporting our kids by tapping into their emotional brain very early.

The National Institute of Mental Health (NIMH) funded the Preschool ADHD Treatment Study (PATS) assesses the short- and long-term efficacy and safety of methylphenidate (Ritalin) in preschoolers (ages 3-5.5 years).⁷  Before starting the medication trials, all families completed an intensive 10-week behavioral therapy program, which included counseling supports for parents. One of the most significant findings from this study was that one-third of the children showed a significant reduction of ADHD symptoms after the behavior therapy program and, therefore, did not need to also receive medications. From that study, researchers concluded that behavior interventions designed to reduce symptoms of ADHD in preschoolers should be the first-line treatment for young children.

The parent training component of behavior therapy is critical because parent behaviors influence children’s’ emotion regulation skills from an early age. Here’s how you can get started today.

1. Understand the ADHD brain. The brain continues to develop throughout childhood – a child’s thinking brain is the last to develop in adulthood. Further, when a child is upset, stress hormones are released into the body and all of the blood rushes out of the rational/thinking/calming part of the brain and into the motor cortex, preparing the body to either fight or run away. The emotional brain automatically takes over at this point, so any talking, scolding, punishing, or lecturing is useless because the brain that reads and interprets those messages is offline.

It’s best to avoid engaging kids when they are upset. Get out of the heat! Give them space but stay close by so they don’t feel you are abandoning them.

2. Form strong bonds. As is true of any child, kids with ADHD benefit from strong caregiver relationships. They need to know they are loved and accepted no matter what. When we have strong bonds, we can strengthen positive and prosocial emotions, which helps with emotion regulation. Capitalize on small moments throughout your day where you can connect with your kids. Very important times are first thing in the morning and at bedtime. During these times, give them your full attention. Say something positive like, “I love seeing your sunshiny face first thing in the morning.” And smile! Always be on your child’s team. Teamwork helps build compassion — another strong prosocial emotion that builds the emotional brain.

3. Be warm and responsive. Parents are most effective in supporting their kids’ emotion regulation skills when they are supportive, sensitive, and warmly responsive to their toddlers’ positive and negative emotions. Instead of reacting emotionally, validate their feelings. Saying “Hey, kiddo, I can see that your sister really upset you” is more helpful then demanding that they stop crying. Then create space to let them talk about what happened if they want to. If they don’t add more, or if they aren’t yet talking, create the space for them to cry, give you a hug, or whatever else they need at the moment. (Save learning about appropriate behaviors for a different time.)

When we validate, we do not tell them “It’s no big deal.” It is a big deal to them and so when we say that we minimize how they feel and send the message that we do not want to hear how they feel. It’s important to calmly acknowledge that they are upset and let them know you are there to help.

Kids react emotionally to create safety but also to be heard. When we create that space for our kids, they feel safe, heard, and understood. Showing empathy will help develop their empathy and they’ll learn they don’t need to react in overly emotional ways.

4. Highlight positive behaviors. Though it may not seem like it, your kids keep their cool all the time — we just take those instances for granted. Capitalize on these times by showing appreciation for doing the very things we want them to do, such as using their words for help or saying they are frustrated (vs. screaming and kicking).

5. Create opportunities. Talking to kids about our rules and expectations about keeping calm is not enough. Still, that is often all we do. We tell them what is expected, we send them off to play, and then we are exasperated when they scream 30 seconds later. Remember: they do not have the cognitive controls to keep it together in the heat of the moment. Instead, create opportunities for them to demonstrate how to ask for help when they are upset instead of getting frustrated and melting down.

Create opportunities for independence. Kids who can learn to problem solve on their own learn to regulate behaviors on their own. What are the things they are fighting with you to do by themselves? It is likely time to let them take ownership.

Create opportunities for mindfulness. We are finding more and more that mindfulness is important for emotion regulation and self-control. No child is too young to practice being mindful. Look for simple moments throughout the day — smell the dandelion they picked. Talk about what we feel and taste. Pet the dog and describe how the fur feels.

Create opportunities to be a team. Feeling like they belong is another crucial part of building the emotional brain and there’s no better way to do this than making them feel like they belong on a team. My daughter is my favorite sidekick for just about everything, from going to the grocery store to walking the dogs to cleaning the bathroom. We talk about how we work together to get things done together as a team so we can go and have fun together. She likes to say, “we make a good team.” And we do.

ADHD in Toddlers: Next Steps

• Read This Next: Is Preschool Too Early to Diagnose ADHD?
• Get the eBook: “What Do I Have? The Big Book of Symptom Tests”
• Think Your Preschooler or Toddler Has ADHD? Ask These Four Questions

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What is attention deficit hyperactivity disorder (ADHD)?
• What is the prevalence of ADHD?
• Which regions of the brain are involved in ADHD?
• What causes ADHD?
• What characterizes the inattentive ADHD subtype?
• What do we know about prenatal and environmental risk factors linked to ADHD?
• Free Webinar: How Our Understanding Has Evolved
• Free Webinar: Why Inattentive ADHD is Misdiagnosed
• Free Webinar: How Genes and the Environment Contribute to ADHD in Children
• What do I need to understand about ADHD that is not fully represented in the DSM?
• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• How can I best consider trauma and personality disorders through the lens of ADHD?
• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

Sources

¹Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007‐1022. doi:10.1542/peds.2011-2654

² Martel MM. Research review: a new perspective on attention-deficit/hyperactivity disorder: emotion dysregulation and trait models. J Child Psychol Psychiatry. 2009;50(9):1042‐1051. doi:10.1111/j.1469-7610.2009.02105.x

³Olson SL, Bates JE, Sandy JM, Schilling EM: Early developmental precursors of impulsive and inattentive behavior: from infancy to middle childhood. J Child Psychol Psychiatry 2002; 43:435–447

⁴Shaw, P., Stringaris, A., Nigg., J., Leibenluft, E. (2014). Emotion dysregulation in Attention Deficit Hyperactivity Disorder. The American Journal of Psychiatry, 171, 176-293.

⁵ Steinberg EA, Drabick DA. A Developmental Psychopathology Perspective on ADHD and Comorbid Conditions: The Role of Emotion Regulation. Child Psychiatry Hum Dev. 2015;46(6):951‐966. doi:10.1007/s10578-015-0534-2

⁶O’Neill S, Rajendran K, Mahbubani SM, Halperin JM. Preschool Predictors of ADHD Symptoms and Impairment During Childhood and Adolescence. Current Psychiatry Reports. 2017 Oct;19(12):95. DOI: 10.1007/s11920-017-0853-z.

⁷Riddle MA, Yershova K, Lazzaretto D, et al. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. J Am Acad Child Adolesc Psychiatry. 2013;52(3):264‐278.e2. doi:10.1016/j.jaac.2012.12.007

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Individuals with ADHD face a heightened risk for eating disorders, most notably bulimia nervosa and binge eating disorder, according to a growing body of research. What’s more, eating disorders appear to grow in severity alongside ADHD symptoms.

Several factors – biological, cognitive, behavioral, and emotional – may explain why ADHD predisposes individuals to eating disorders and challenges. Understanding these factors, including the relationship between a patient’s ADHD and eating disorder, is essential when devising an appropriate and effective treatment plan.

Types of Eating Disorders

Roughy 30 million people in the U.S. (20 million women and 10 million men) suffer from eating disorders¹. Eating disorders are thought to be caused by a complex interaction of genetic, biological, behavioral, social, and psychological factors.

Binge Eating Disorder

Binge eating disorder (BED) and bulimia nervosa (below) are both impulsive eating disorders prevalent in individuals with ADHD.

BED is defined by recurrent episodes of binge eating, characterized by both of the following:

• Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
• A sense of lack of control over eating during the episode (e.g., a feeling that you cannot stop eating or control what or how much you are eating).

[Click to Read: ADHD and Impulsive Eating]

In addition, the episodes are associated with at least three of the following to merit a diagnosis:

• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone because of feeling embarrassed by how much you are eating
• Feeling disgusted with yourself, depressed, or guilty afterward

Marked distress regarding binge eating must also be present for a diagnosis. Episodes must also occur, on average, at least once a week for three months.

Bulimia Nervosa

Bulimia is characterized by recurrent episodes of binge eating (as described above) as well as recurrent, inappropriate, compensatory behaviors exercised to prevent weight gain from binging. These behaviors can include self-induced vomiting, laxative misuse, fasting, or excessive exercise.

Binging and inappropriate compensatory behaviors must occur, on average, at least once a week for three months to satisfy a diagnosis. Self-evaluation is also unduly influenced by body shape and weight; often, people with bulimia suffer from negative body image.

[Read: “My Appearance Is the Only Thing I Can Control.”]

Anorexia Nervosa

Anorexia is an obsessive-compulsive eating disorder defined by restriction of energy intake leading to a significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health). The disorder is not as prevalent in people with ADHD as are the impulsive eating disorders.

With anorexia, there is either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain. Anorexia is accompanied by body image distortion – including disturbances in the way one’s body weight or shape is experienced; body weight or shape influence self-evaluation, or there’s a persistent lack of recognition of the seriousness of the low body weight.

Clinicians also specify whether a patient is of the restricting type (no binging; weight loss accomplished through dieting, fasting, and/or excessive exercise) or binge-eating/purging type (i.e. self-induced vomiting, laxative misuse, diuretics, enemas).

Other Eating Disorders

• Avoidant/Restrictive Food Intake Disorder (ARFID): An eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and/or energy needs. It’s often associated with significant weight loss, nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, and marked interference in psychosocial functioning. Absent in this diagnosis is negative body image.
• Other Specific Feeding or Eating Disorder (OSFED): Includes atypical anorexia nervosa (all criteria for anorexia met, but patient’s weight is within or above the normal range); bulimia nervosa of low frequency; BED of low frequency; purging disorder; Night Eating Syndrome; and Chewing and Spitting disorder (chewing but not swallowing food).
• Orthorexia: While not in the DSM-5, orthorexia is characterized by an obsession over healthy, clean eating. It can look like anorexia, but individuals with orthorexia are not motivated by thinness or aesthetic.

Eating Disorders: Medical Consequences

Eating disorders are associated with adverse health consequences including the following:

• Dental problems
• Hair loss
• Dysregulated metabolism
• Sleep problems
• Acute ADHD symptoms (for individuals with existing ADHD)
• Temperature dysregulation
• Problems with concentration
• Cardiovascular problems
• Gastrointestinal problems
• Neurological problems
• Endocrine problems
• Kidney failure

Given these adverse health consequences, eating disorders have high mortality rates². It is estimated that only 10% to 15% of women with eating disorders seek treatment, and an even smaller percentage of men seek treatment.

Eating Habits and ADHD

What Do We Know About ADHD and Eating?

1. Studies show that individuals with ADHD can be quite impulsive with their eating habits. In one study involving a simulated kitchen, children with ADHD consumed more food than children without ADHD. Consumption, furthermore, was not influenced by their mood state, level of hunger, or even their liking of the food³. This means that even for foods the ADHD group didn’t like, they tended to eat more of it simply because it was there.
2. Studies also show that people with ADHD tend to have disruptive eating habits.⁴ In one study, children with ADHD skipped meals more often than did children in the control group, ate fewer fruits and vegetables, and drank more sweetened beverages.³

ADHD and Obesity

These factors may explain why studies have found a high prevalence of ADHD in obese populations.⁵ In a study of 215 bariatric patients, 27% of them had ADD, and the prevalence was highest in patients with extreme obesity (43%).⁶ The same study also found that at all levels, patients with ADHD were less successful at losing weight than their non-ADHD peers. The researchers concluded that, in treatment for obesity and ADHD, outcomes were more closely tied to ADHD symptoms than to level of obesity.

While it is often assumed that individuals with predominantly hyperactive type ADHD are always “on the go” and thus not likely to develop weight issues or eating problems, this is not the case. One study that examined about 100 male patients with ADHD-hyperactive type found that they were significantly more overweight compared to a reference population.⁷

ADHD and Eating Disorders

Numerous studies show that individuals with ADHD are at greater risk (three⁸ to six times⁹ the average) for developing eating disorders compared to non-ADHD individuals.

Research on eating disorders and ADHD has primarily focused on bulimia nervosa and BED. Studies have found that bulimia is more common in adolescent girls with ADHD than it is in their non-ADHD peers¹⁰, and that girls with ADHD are 3.6 times more likely to have bulimia nervosa or BED compared to their peers.¹¹ In a study of patients being treated for bulimia, a quarter of subjects had ADHD.¹²

Few studies have focused on males with eating disorders, but in my clinical practice, where I specialize in the treatment of boys and men with eating disorders, I’ve treated many men with bulimia and binge eating disorder with comorbid ADHD.

ADHD Risk Factors for Eating Disorders

How can having ADHD predispose someone to develop an eating disorder?

Biological and Genetic Factors

• Reward deficiency syndrome. The ADHD brain produces insufficient dopamine, a neurochemical implicated in reward, which may cause individuals to seek satisfaction through food.
• GABA deficit. ADHD brains have lower levels of GABA, a neurochemical implicated in inhibition.
• Purging can be a euphoric, almost addictive form of stimulation that increases dopamine levels.
• Restrictive behaviors can build up reward sensitivity – individuals may purposely restrict food so that when they do eat, it is much more rewarding to them.
• Dopamine receptors could overlap with obesity, binge eating, and ADHD.
• ADHD brains take longer to absorb glucose than non-ADHD brains, which could lead to higher sugar and simple carb consumption.

Cognitive Factors

• Executive function deficits can impact all aspects of eating and preparing foods. Individuals with ADHD, like those with eating disorders, have poor interoceptive awareness, which affects the ability to understand hunger and satiety cues. Planning and decision-making around food can be difficult, which can contribute to impulsive eating or even restriction to avoid the executive task of preparing food.

Behavioral Factors

• Poor impulse control can lead to overeating
• Poor sleep habits can dysregulate metabolism
• Irregular eating schedule can lead to overeating
• Poor self-regulators make it difficult to understand the quantity of food eaten

Emotional Factors and Self-Esteem

• Boredom could be a major predisposing factor to binge eating
• Food can be a relief from anger, sadness, anxiety, and other difficult emotions
• Many individuals with ADHD often struggle with low self-esteem. Food can become a way to cope and feel in control, which could lead to eating disorders

ADHD and Eating Disorders: Treatment

Guiding Principles for Clinicians

• 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.
• Understand the patient’s ADHD-ED link, or how the patient’s ADHD symptoms impact and are impacted by the eating disorder.
• Destigmatize ADHD, especially for girls and women, as many remain undiagnosed.
• Destigmatize eating disorders, especially for boys and men.

Treatments

Treatment for an eating disorder is multimodal, often involving a team of psychiatrists, psychologists, nutritionists, and family therapists. While comparatively few individuals with eating disorders seek treatment, patients who do seek treatment should know that recovery is possible. For patients with ADHD, approaches should be adapted to symptoms and should suit their strengths:

• Executive function skills training can address the cognitive factors that contribute to ED
• Cognitive behavioral therapy (CBT) can help undo negative thought patterns and build self-esteem as well as positive body image
• Dialectical behavior therapy (DBT), which focuses on mindfulness, emotional regulation skills, interpersonal effectiveness skills, and distress tolerance is very helpful for patients with ADHD and eating disorder
• Acceptance and Commitment Therapy (ACT) looks at a patient’s value system and helps line up appropriate behaviors to it
• Nutritional therapy is essential for patients with eating disorders
• Group therapy
• Parent coaching

Psychopharmacological Treatments

Stimulant treatment helps regulate eating in patients with ADHD and an eating disorder.

• Vyvanse is the first FDA-approved medication for BED, and is only the second medication approved for ED
• SSRIs are FDA-approved medications for bulimia nervosa
• Stimulant medication can help patients with ADHD and bulimia, according to research¹³
• There are no approved medications for anorexia (partly because of the difficulty for the starved body to metabolize anything)

Eating Disorders: Next Steps

• Free Download: Guide to Delicious (and ADHD-Friendly!) Eating
• Read: Healthy Eating Habits for Impulsive, Dopamine-Starved ADHD Brains
• Read: Disordered Eating and ADHD: Weight Gain and Loss Understood

The Clinicians’ Guide to Treating Complex ADHD from Medscape, MDedge, and ADDitude

• What should I consider when developing a comprehensive treatment plan for ADHD?
• What medications and other approaches should I turn to as first-line treatments for ADHD?
• How can I decide which ADHD medication to prescribe first?
• What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
  • How should clinicians approach treatment for patients with ADHD and comorbid conditions?
  • How should clinicians adjust pharmacological treatment for children with ADHD and comorbidities?
  • What is the recommended approach for treating ADHD with depression?
  • How should clinicians adjust treatment approaches for patients with ADHD and comorbid eating disorders?
  • How is executive dysfunction related to ADHD, and how should it be treated?
  • Free Webinar: Substance Use Disorder and ADHD: Safe, Effective Treatment Options
  • Free Webinar: Current Guidelines for Treatment and Behavioral Interventions for Tourette Syndrome and Tic Disorders
• What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• How should I follow up with patients with ADHD, and what should we discuss during these checkups?

The content for this article was derived from the ADDitude Expert Webinar Diagnosing and Treating Eating Disorders in Children and Adults with ADHD [podcast episode #358] with Roberto Olivardia, Ph.D., which was broadcast live on June 8, 2021.

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

Sources

¹ Wade, T. D., Keski-Rahkonen A., & Hudson J. (2011).Epidemiology of eating disorders. In M. Tsuang and M. Tohen (Eds.), Textbook inPsychiatric Epidemiology (3rd ed.) (pp. 343-360). New York: Wiley.

² Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry. 2011;68(7):724–731. doi:10.1001/archgenpsychiatry.2011.74

³ Hartmann, A. S., Rief, W., & Hilbert, A. (2012). Laboratory snack food intake, negative mood, and impulsivity in youth with ADHD symptoms and episodes of loss of control eating. Where is the missing link?. Appetite, 58(2), 672–678. https://doi.org/10.1016/j.appet.2012.01.006

⁴ Ptacek, R., Kuzelova, H., Stefano, G. B., Raboch, J., Sadkova, T., Goetz, M., & Kream, R. M. (2014). Disruptive patterns of eating behaviors and associated lifestyles in males with ADHD. Medical science monitor : international medical journal of experimental and clinical research, 20, 608–613. https://doi.org/10.12659/MSM.890495

⁵ Cortese, S., Moreira-Maia, C. R., St Fleur, D., Morcillo-Peñalver, C., Rohde, L. A., & Faraone, S. V. (2016). Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. The American journal of psychiatry, 173(1), 34–43. https://doi.org/10.1176/appi.ajp.2015.15020266

⁶ Altfas J. R. (2002). Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. BMC psychiatry, 2, 9. https://doi.org/10.1186/1471-244x-2-9

⁷ Holtkamp, K., Konrad, K., Müller, B., Heussen, N., Herpertz, S., Herpertz-Dahlmann, B., & Hebebrand, J. (2004). Overweight and obesity in children with Attention-Deficit/Hyperactivity Disorder. International journal of obesity and related metabolic disorders : journal of the International Association for the Study of Obesity, 28(5), 685–689. https://doi.org/10.1038/sj.ijo.0802623

⁸ Nazar, B. P., Bernardes, C., Peachey, G., Sergeant, J., Mattos, P., & Treasure, J. (2016). The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. The International journal of eating disorders, 49(12), 1045–1057. https://doi.org/10.1002/eat.22643

⁹ Curtin, C. , Pagoto, S. and Mick, E. (2013) The association between ADHD and eating disorders/pathology in adolescents: A systematic review. Open Journal of Epidemiology, 3, 193-202. doi: 10.4236/ojepi.2013.34028.

¹⁰ Mikami, A. Y., Hinshaw, S. P., Patterson, K. A., & Lee, J. C. (2008). Eating pathology among adolescent girls with attention-deficit/hyperactivity disorder. Journal of abnormal psychology, 117(1), 225–235. https://doi.org/10.1037/0021-843X.117.1.225

¹¹ Biederman, J., Ball, S. W., Monuteaux, M. C., Surman, C. B., Johnson, J. L., & Zeitlin, S. (2007). Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study. Journal of developmental and behavioral pediatrics : JDBP, 28(4), 302–307. https://doi.org/10.1097/DBP.0b013e3180327917

¹² Seitz, J., Kahraman-Lanzerath, B., Legenbauer, T., Sarrar, L., Herpertz, S., Salbach-Andrae, H., Konrad, K., & Herpertz-Dahlmann, B. (2013). The role of impulsivity, inattention and comorbid ADHD in patients with bulimia nervosa. PloS one, 8(5), e63891. https://doi.org/10.1371/journal.pone.0063891

¹³ Guerdjikova, A. I., & McElroy, S. L. (2013). Adjunctive Methylphenidate in the Treatment of Bulimia Nervosa Co-occurring with Bipolar Disorder and Substance Dependence. Innovations in clinical neuroscience, 10(2), 30–33.

The pandemic has brought with it a troubling surge in eating disorders. The numbers are alarming: National eating disorder hotlines report a 70 percent spike in call volume, and hospitalizations for eating disorders have doubled in the last three years.

Eating disorders have among the highest mortality rate for any mental illness (and yes, they are considered a mental illness and not a behavioral issue), but stigma and shame often keep people from seeking help. Researchers have found that two types of eating disorders in particular, bulimia and binge eating, often co-occur with ADHD. A 2007 study conducted at Harvard Medical School found that girls with ADHD were almost four times more likely to have an eating disorder than were those without ADHD.

Critics blame social media for driving the increase in eating disorders. In fact, nearly a dozen lawsuits have been filed by families against the parent company of Instagram, saying that the platform has harmed the mental health of minors.

Meanwhile, teens and young adults are forming secret online communities to discuss eating disorders, crash diets, looking skinny, and ways to lose weight — and these chats have their own hashtags and phrases on YouTube, Snapchat, TikTok, and Twitter to hide from parents and to evade these platforms’ policies.

In this special Mental Health Out Loud conversation, Dena Cabrera, Psy.D., will answer questions about eating disorders from the ADDitude community. Topics of discussion will include:

• Different types of eating disorders, how these present differently in boys and girls, and how eating disorders differ from disordered eating
• What makes young people with ADHD more prone to eating disorders and body image issues than their peers without ADHD
• How social media’s influence on tweens and teens contributes to disordered eating
• Signs to help parents and others identify an eating disorder in a person when it might not be apparent
• How to identify and best address the underlying self-esteem issues that are common among adolescents with eating disorders. If taking away all social media is not possible, how can caregivers help build up a child who has low self-esteem?
• How to start a conversation with adolescents and young adults about the dangers of eating disorders without judgment or blame
• What are best practices for treating comorbid ADHD and eating disorders? For example, do practitioners hesitate to treat ADHD with stimulant medication, which can suppress appetite?

The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-4357 is a confidential, free, 24-hour-a-day, 365-days-a-year information and referral service.  For anyone experiencing a crisis, immediate help is also available by calling the National Suicide Prevention Lifeline at 1-800-273-TALK.

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Enter your email address in the box above labeled “Video Replay” to listen to the Q&A recording and access related resources.

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Resources and Organizations

• Alliance for Eating Disorders
• National Eating Disorders Association
• Eating Disorder Hope
• Fairplay for Kids
• Eating Disorder Coalition

More on Eating Disorders and Mental Health

• Download: Is It More Than Just ADHD?
• Read: ADHD and Eating Disorders: Research, Diagnosis & Treatment Guidelines
• Read: More Than Picky Eating: ARFID, SPD, and Other Conditions Linked to Feeding Difficulties in Children

Meet the Expert Speaker

Dena Cabrera, Psy.D., CEDS, is a Clinical Psychologist and Certified Eating Disorder Specialist with over 24 years of experience treating psychological and psychiatric disorders. Before opening her own private practice in Anthem, Arizona, she served as the Vice President of Clinical Services for Rosewood Centers for Eating Disorders. Dr. Cabrera is a nationally recognized expert in her field, having authored numerous articles and publications including co-author of the book Mom in the Mirror: Body Image, Beauty and Life After Pregnancy (#CommissionsEarned). She’s also a sought-after speaker and has been featured on numerous news outlets, talk shows, and prominent national and local publications. She previously served as president of the International Association of Eating Disorders Professionals (IAEDP). Learn more by visiting her online at denacabrera.com.

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

Listener Testimonials

“Huge thanks for focusing on this topic. As a high school psychologist, this is becoming a big concern in my school.”

“Excellent presentation and flow.”

“Thank you for your suggestions on comments to make regarding values and integrity versus weight and body shape.”

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My son, William, said this exact phrase to me one morning as I tried to get him to eat an egg for the umpteenth time. He stared at the fried egg I’d carefully prepared, crispy brown edges and all, and gagged as he brought a tiny bite up to his mouth. He was about 9 at the time.

Why did eating have to be so difficult? All I was trying to get him to do was eat something other than bowtie pasta and freshly shaven parmesan cheese. The worst part was that, though William had been a super-picky eater from the time we introduced solid foods, his finicky palate worsened after he started ADHD medication.

Given his weight loss and small size, my husband and I consulted a licensed naturopathic doctor for ways to supplement his diet. Her primary recommendation was to increase William’s protein intake. Each morning, I tried to cook the “perfect” egg in hopes he would finally crack (no pun intended!) and eat the dang thing.

What I didn’t realize, which is mind-boggling given my profession, was that William’s finicky palate was not something he could overcome on his own. I knew that kids with autism suffered from sensory-related food rigidities, but I didn’t realize that many kids with attention deficit hyperactivity disorder (ADHD or ADD) had the same challenges.

The good news is that I forgave myself long ago for my blockheadedness.

The even better news is that, since I’ve raised a child with ADHD and worked as a child psychologist for many years, I’m learned a ton about how to help parents in similar predicaments. Here’s what I would suggest:

[Free Guide to Delicious (and ADHD-Friendly!) Eating]

1. Become a Food Detective

If your child responds to the texture, appearance, and smells of foods in an unusual manner (a.k.a. he or she looks revolted, gags, or cries when encouraged to take a bite), don’t minimize this reaction.

My husband, Bill, got so frustrated with William for crying and refusing to eat when he was a toddler, that Bill actually shoved a bite of oatmeal into his gaping mouth. In Bill’s defense, he thought that if William tried the oatmeal, he would discover that he liked it. It wasn’t until William nearly threw up that Bill backed off.

Sometimes, we’re slow learners.

Instead of getting pushy, which rarely works anyway, why not move into detective mode and try to discover what’s driving your child’s finickiness?

Is it the lumpy texture of the fruit in the yogurt?
The sour smell?
The cold temperature?

Once we identify the problem, we can often find a solution.

[Free Guide to the Best Vitamins and Supplements for Managing ADHD Symptoms]

2. Consult with a Feeding Specialist

Imagine how much better mealtimes could have been if Bill and I had consulted a feeding specialist? We spoke to a handful of pediatricians, but they didn’t have enough training to get to the root of the problem.

Today, given the rise in neurodevelopmental disorders like ADHD and autism, feeding therapy is offered by some clinics, especially those that specialize in treating children with developmental differences.

Organizations, like Feeding Matters Power of Two Program, offer support for families impacted by Pediatric Feeding Disorders (PFD).

Check out the Good Shepherd Rehabilitation, an organization that offers similar support.

3. Stop Buying Off-Limits Foods

This is a big one in my book. I can’t tell you how many parents complain that they literally have to LOCK UP junk foods, like Pop Tarts and Fruity Pebbles cereal, because their kids binge on them.

The question I always ask them is this: Why are you stocking up on junk food in the first place?

Don’t get me wrong. I always have a stash of dark chocolate that I rotate to different hiding spots in the house. But I stopped buying triggering foods, like high-sugar cereal, years ago. It’s not good for anybody, especially a child with poor impulse control.

Plus, high-carb foods are really hard for kids with ADHD to resist.

Check out this article about the ADHD-dopamine Link, which triggers sugar and carb cravings.

Do yourself and your kid a favor and stop buying it!

Once your child knows the junk food is out of the house, he or she will likely be more open to eating healthier foods, too. I know I am.

4. Consider Supplementing Your Child’s Diet

Some research suggests that children with ADHD may be deficient in certain vitamins and minerals, such as zinc and magnesium, and in omega-3 fatty acids.

These mixed findings have made it difficult for many parents to know how to proceed. I encourage parents to consult with their child’s health care provider first before adding supplements to their diet. That way the provider can review your child’s medical history, medication, and general health and then discuss potential benefits and risks.

When my son was little, I snuck omega-3 fatty acid (fish oil) into his bow-tie pasta, with guidance from his pediatrician and licensed naturopathic doctor. He tolerated Nordic Natural’s lemon-flavored fish oil the best.

5. Give Juice the Heave-Ho

Instead of serving juice at meals, switch to water. It’s way better for dental health and it reduces sugar cravings, which often interfere with a child’s appetite. High levels of juice consumption have been associated with weight problems in children, too.

Check out this article 9 Food Rules for ADHD Families: What to Eat, What to Avoid about the benefits of serving your child water, as well as 8 other food rules for ADHD families.

Tips for Parents of Picky Eaters

1. Assume a detective mindset and try to get to the bottom of the problem.
2. If your child’s feeding problems persist, ask your pediatrician for a referral to a feeding specialist.
3. If you don’t want your child to sneak into your bedroom at night in search of gummy worms, stop buying them!
4. Supplement your child’s diet when possible with guidance from a licensed professional, such as a naturopathic doctor.
5. Offer water instead of juice at meals.

[Free Guide: What to Eat (and Avoid) for Improved ADHD Symptoms]

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

ODD is characterized by persistent hostility, aggression, and defiance. What’s more, it often co-occurs with ADHD. So, how can parents manage their kids’ ODD symptoms and not exacerbate negative behaviors?

Here, ADDitude readers share their tips for managing oppositional defiance. Read about their experiences below and share yours in the Comments section below.

“My son’s ODD tends to flare when he becomes frustrated by seeing something as ‘wrong.’ The infraction could be serious, or something as small as a different pronunciation of a word. He becomes so disturbed and obsessed with that ‘wrong’ that he tries to right it whatever the cost. But, often, his solution becomes a much bigger ‘wrong’ than the original issue. It could mean interrupting an event, shaming someone, or just discouraging them. It can really hurt others he cares about. My main strategy for dealing with this opposition and negativity is a light-hearted, humorous distraction. When I’m feeling patient and light-hearted, it’s easier to do. And when my rapport with my son is pretty good, it’s easier for him to receive it.” — Nathan

“My 10-year-old son with ADHD exhibits ODD symptoms only at home. He questions everything he is told to do, argues for the sake of argument, and responds aggressively if told to do something he doesn’t like. We try to give him room to share his feelings with us, good or bad, but we often intervene when the aggression is aimed at his younger sister, who is neurotypical. We send him to his room, not as a traditional timeout, but as a physical pause button to stop the aggression. We usually talk through the scenario after he calms down, and we have sought outside counseling to help our family deal with the conflict.” — Anonymous

[Get This Free Download: Why Is My Child So Defiant?]

“My son exhibits characteristics of ODD, however, it is more prevalent when he deals with adults who are inflexible in their own thinking.” — Anonymous

“Both of my teens have ADHD, which manifests in different ways. The defiance increases with parental demands to pick up dirty dishes or do homework, etc. This is not only frustrating for me as a parent, but it causes my overwhelmed ADHD brain to fixate on them completing the task. My daughter ignores the request, and my son burrows into his blanket or becomes overwhelmed and yells at me to leave him alone.” — Anonymous

“I’ve learned not to push them. It only results in a battle of wills, which I know I won’t win. Instead, I try to lead them to make good decisions. I give them options or offer information to get them thinking on the right track.” — Dee

“A very aggressive ‘No!’ is my daughter’s first response to most requests. I calmly repeat whatever it is I expect her to do or stop doing and then walk away to give her the space to calm down and digest what she needs to do.” — Anonymous

[Read This: Why Is My Child So Angry and Defiant? An Overview of ODD]

“I see ODD in my 7-year-old son when he’s unmedicated. If I ask him to do something, the answer is immediately ‘No!’ or ‘Never!’ It seems like an automatic reaction. I just wait and give him a chance to think about what he’s said. He then toddles off to do what he’s told (with all the usual distractions along the way). He’s not like that when he’s medicated. It took me a long time to work out that he can’t help it, and I need to deal with it calmly.” — Nikki

“I never tell them directly what to do, except in an emergency. I make them think that it’s their idea, give choices, or I even tell them to do the opposite. I don’t react if they do something odd. I just raise an eyebrow and carry on. I am never angry with tantrums or oppositional verbal naysaying. It’s best to laugh it off as it’s often funny. Most of these things take the sting out.” — Paul

“Mine are still young (6-year-old twins). One twin has ADHD and ODD, and I’m sure they feed off each other. I make corrections using redirection. We are trying behavioral charts with short-term and long-term rewards.” — LC

“My son has both ADHD and ODD. The ODD is only directed at home to us. Other authority figures like teachers or doctors are questioned but not defied. We are constantly re-establishing order in the house. It’s exhausting to plan for him to defy a new boundary. We are consistent and very careful with our words. We maintain control by repeating and disengaging. It’s isn’t pretty, but we are doing our best.” — Anonymous

“My teenage son has ADHD with ODD with symptoms of CD (conduct disorder). Anybody with authority is treated with disdain. It makes it difficult for him to get an education, keep a job, hold on to his driver’s license, the list goes on. In between bouts of lawlessness, he is a fantastic kid. We all have professional support; it helps us more than him. He will be 18 soon, and we worry about his future.” — Chris

“There is nothing we can ask our 10-year-old to do that is not met with some level of resistance. Initially he gets angry. Then he complains. Often, he cries. Depending on how tired or overwhelmed he is, he may go into full meltdown mode. We are finally learning to pick our battles, but it’s never easy when so much of his behavior requires correction. He figured out that reading calms him and hugs help (once he’s over his meltdown). I know he doesn’t want to make our lives difficult on purpose and he wishes he could be different. It inspires me to show empathy and continue to educate myself about ADHD and ODD to do better for him.” — Anonymous

ODD Parenting Advice: Next Steps

• Self-Test: Oppositional Defiant Disorder (ODD) in Children
• Read This: How to Discipline a Child with Oppositional Defiant Disorder (ODD)
• Learn: Oppositional Defiant Disorder Strategies — 8 Discipline Rules

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

I’ve written two books on women with attention deficit disorder (ADHD or ADD), and I am considered an expert in the field.

And I have ADHD.

People say, “How can that be? You seem so together! Even your socks match.”

I was diagnosed with inattentive ADD almost 25 years ago. And though I’ve dedicated my professional life to helping other women with ADD, I, too, struggle with the condition.

ADHD doesn’t go away after you use the pretty polka dot planner or the calendar with the cute stickers and matching pen. It doesn’t go away with medication, meditation, or magical gadgets to keep you on track. ADHD is generally a life-long condition that can affect anyone: a bus driver, teacher, surgeon, writer, or rock star. And it affects each of us in different ways.

[Could You Have Inattentive-Type ADHD? Take This Symptoms Test]

My ADHD: Anxiety Over Being Late, Lost, Left Behind

I’m never late because I’m so anxious about being late. I arrive with lots of time to spare to alleviate a sense of panic, a panic driven by ADHD. I keep my eyes on the clock so that I’m not embarrassed by lateness. The fear of being judged keeps me on my toes, but what a price I pay for that.

As I said, I never lose my keys. If I do lose something, though, I can recall where I misplaced it. I’ve learned to visualize where I last had the object in my hands.

I remember the name of the clerk who filled my script yesterday at CVS, but I don’t remember the name of the woman who sat next to me for two hours, making fascinating conversation at a recent party. My word retrieval is worsening with age: “You know, that thing you boil water in? Oh, yes, a teapot. Thanks.”

I did well in school until I hit sixth grade and moved to another district, where I could not keep up academically or socially. It got worse from there. With the help of a kind adult who cared about my future, I was provisionally accepted into college. That’s when I took off. My secret (I did not know I had ADHD or even know what it was) was to take courses I had an interest in. I learned to sidestep classes I knew I’d struggle with or fail. I’m sure many of you have done that dance. Instead of going into psychology and earning a Ph.D., where I’d have to take statistics (my math skills are nil), I turned to social work. My love of people and wanting to help the less fortunate made me a good candidate for that kind of degree.

Not to say I didn’t struggle. There was still a required statistics class that almost did me in. My husband got me through it. I’m not proud to admit how much he had to help me.

[Download This Free Resource: Get Control of Your Life and Schedule]

What Is Your Flavor of ADHD? Mine Is Inattentive

My flavor of ADHD means that I shut down easily. If someone asks me to bring food to an upcoming gathering, I nearly pass out. What does that mean? How much food? What kind of food? I’ve passed on many invitations, out of fear of not knowing what to bring.

This leads me to clothes, the other reason for declining many social activities. Deciding what to wear (unless I’m home and out of view of anyone besides my family) is excruciating. Many people might laugh at this, but it’s true. Packing for a trip takes me a week. It involves making lists, trying on outfits, checking the weather daily to determine what to bring. Then I forget what I packed, only to have to start over.

Planning daily meals when my children were young made me feel like the worst parent in the world. I couldn’t figure it out. A meal isn’t typically one thing. It usually involves three things: a main dish and two sides. To me, that was like making three meals each night. My failure at meal prep took a toll on my self-esteem. I’d talk to my sister-in-law on the phone. She is also a mother of two, and she could talk me through cooking things. If that isn’t a magic trick, I don’t know what is.

To make matters worse, my kids were picky eaters and nothing was acceptable to both of them on any given night. Feeding involves nurturing and love, yet I fell short and felt like a terrible mother. I remember one child fussing because I had put butter on her pasta, while the other beamed over her butter-covered plate of penne.

My ADHD Doesn’t Define Me

We each have our own ADHD profile. Some of us lose things. Some of us say things out of turn. Some of us are so inattentive that we could sit for hours watching clouds go by. That’s what I did as a 10-year-old. The world slipped by while I made cloud pictures in the sky, lying on the cool green grass, enjoying the breeze blowing through my hair.

I won’t forget my 6 p.m. meeting tomorrow night. I’ll be there early and ready to go. But I won’t be able to concentrate because, more than likely, my clothes will make me feel uncomfortable. I may have a headache because the weather is changing. I won’t be able to hear what people are saying, because I can’t filter out other sounds and will be terribly distracted.

As I’ve gotten older and wiser, I’ve learned an important lesson: ADHD doesn’t define me. I am a woman, a wife, a mother, a daughter, a sister, and now a grandmother with an ADHD brain. I can choose to focus on my challenges, or I can celebrate my strengths. I raised two wonderful daughters who care more about people’s feelings and well-being than what I cooked for them when they were kids.

I make paintings that are shown in galleries. I play five instruments, all self-taught. I write. I am, I think, a good friend. I have a good marriage (yes, that takes work, but most things do). I like to think that I help other people, like you, like me.

And I have ADHD.

[Watch This Free Webinar Replay: The Happiness Project for Women with ADHD]

Shine: Using Brain Science to Get the Best from Your People

Are you in the right job? You can figure that out by answering the 18 questions below. Your answers will help you think clearly about your career choices, skills and preferences, where you fit best in the organization, and under what circumstances you feel most comfortable and motivated.

What do you do best? You should be spending the majority of your workday doing what you do best. Many people spend too much time trying to get good at what they’re bad at, instead of getting better at what they’re good at.

What do you like to do the most? This does not always have the same answer as #1. Ideally, you can make your favorite activities your career.

What do you wish you were better at? Your answer may suggest that you need a mentor, need to delegate, or need to get training. Many adults with ADHD have difficulty figuring out office politics — a mentor or a coworker could help. Others have difficulty organizing, in which case an ADHD coach can work with you on tidy-up strategies.

[Quit It! The 10 Worst Jobs for Restless Minds and Creative Spirits]

What do others say are your greatest strengths? Friends, coworkers, and performance reviews can identify skills you have but may not value because they seem easy to you.

What are you most proud of in your work life? The answer could be another tip off about what you should be doing.

What have you gotten better at? This will give you an idea of where applying additional effort will pay off.

What are you not getting better at, no matter how hard you try? It’s good to know where not to expend effort.

[Free Download: 8 Dream Jobs for Adults with ADHD]

What do you most dislike doing? You might be good enough at something, but still hate it. I know a lawyer with ADHD who hated to do billing. He would procrastinate and then feel guilty because he was always behind. By admitting his dislike of billing, and hiring an assistant to do it, he improved his cash flow and decreased his stress.

Which skills prevent you from excelling in your job? If you lack a skill required for your job and can’t delegate it, consider taking a course, finding a mentor, reading a book, or working with a coach.

What regrets do you have about your career? Could you make changes based on those regrets?

What one lesson would you want to pass along to your children about how to manage their careers? Another way to get at your most important views about work.

What was the most important lesson you learned from your mother and father (one each) relating to work? Reflecting on this helps you understand attitudes that have been passed along and how your mind works.

What lesson did your best boss teach you about yourself? Tapping into the insight of others is helpful. Others often know us better than we do.

In what way(s) do you think your time could be better used in your current job to add value to your organization? This may provide valuable insight to your manager and your own perspective about your job.

What sort of people do you work best/worst with? Do you hate to work with highly organized, analytic types, or do you love it? Do creative types drive you crazy, or do you work well with them? Make up your own categories.

What kind of company culture brings out the best in you? Chances are, you will get excited about your job if you feel connected to the company’s culture. Are you a top-down person, who thrives with a specific hierarchy, or do you work best in a “no walls allowed” atmosphere?

What are your hopes for the future, in terms of your career? Knowing that fear is the only true learning disability, what stands in your way of reaching those hopes?

What were you doing when you were happiest in your work life? Can you do something like that again? Perhaps you enjoyed the excitement and deadlines in sales work, but are unhappy in the management position you were promoted to. Is it time to move back into sales? That could be the key to career happiness.

[Finding a Career That Works For You]

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

There is no single African-American experience. Consider three different eight-year-old African-American boys, one each from the Mississippi delta, Chicago’s inner city, and the affluent suburbs of Prince George’s County. Their cultures will have significant differences, and a cookbook cultural competency model would not serve them well. While consideration of cultural differences regarding ADHD in African Americans is helpful, cultural humility is a must within each individual patient encounter. Cultural competency implies an endpoint; however, cultural humility embraces a lifelong process that includes self-reflection, introspection, advocacy, and co-learning.

ADHD is a common and treatable disorder that can have significant implications for social, educational, and occupational trajectories. Diagnosis rates have increased over time. This webinar will explore some of the cultural considerations that do and/or should impact diagnosis and treatment of this disorder in African-American children and families. Listen to Sarah Y Vinson, M.D., about:

• Potential causes for over-diagnosis of ADHD in African-American children
• Potential causes for under-diagnosis of ADHD in African-American children
• Structural barriers to ADHD diagnosis and treatment that disproportionately impact African-American families
• The importance of trauma’s consideration in diagnosis and treatment in this population.

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More On Treating ADHD in African American Children from Dr. Vinson

• Evaluating and Treating ADHD in African American Children: Guidance for Clinicians

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Meet the Expert Speaker

Dr. Sarah Y. Vinson is a physician who specializes in adult, child and adolescent, and forensic psychiatry. She is an Associate Clinical Professor of Psychiatry and Pediatrics at Morehouse School of Medicine, where she is the creator and rotation director of Psychiatry Mini-Rotation for pediatric interns. She is also the co-editor of Pediatric Mental Health for Primary Care Providers – A Clinician Guide. During her tenure on the board of the Georgia Council on Child and Adolescent Psychiatry, she strengthened connections with the local pediatric community. She has planned CME events and spoken at multiple conferences with pediatric audiences. Additionally, she has experience being co-located with and providing integrated care services and consultation to pediatric providers.

Dr. Vinson is the founder of the Lorio Psych Group, an Atlanta, Georgia-based mental health practice providing expert care and consultation. Dr. Vinson graduated Summa Cum Laude from Florida A & M University. After graduating from medical school at the University of Florida with Research Honors and as an Inductee in the Chapman Humanism Honors Society, she completed her general psychiatry training at Cambridge Health Alliance/Harvard Medical School. While there, she also received specialized training in trauma through the Victims of Violence Program. She then returned to the South to complete fellowships in both child and adolescent and forensic psychiatry at Emory University School of Medicine.

Dr. Vinson has received numerous awards in recognition of her service and leadership. Just two years after joining the faculty she was honored as Psychiatry and Faculty of the Year in 2015. In 2018, she was selected as the Outstanding Young Alumni for the University of Florida College of Medicine. She has been elected and/or appointed to national and statewide office by her professional peers. She is the immediate past President of the Georgia Council on Child and Adolescent Psychiatry, and is the current Secretary of the Georgia Psychiatric Physicians Association Board. Additionally, she serves on the Communications Council of the American Psychiatric Association and is the Southern Regional Rep. for the American Association of Community Psychiatrists. She has been a speaker at national conferences including the National School-Based Health Conference, the American Academy of Child and Adolescent Psychiatry Annual Meeting and the American Psychiatric Association Annual Meeting. She is also Adjunct Faculty at Emory University School of Medicine. | See expert’s full bio »

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Listener Testimonials

• “Excellent! All teachers, social workers, and mental health clinicians should listen to this webinar.”
• “Great webinar. I appreciated the balance between history and context, and concrete examples of treatment options.”
• “Dr. Vinson’s presentation was exceptional. I regularly follow ADDitudemag.com and share this resource with EVERYBODY. I really valued seeing representation of the black community, and hope to see more black physicians and clinicians in the future.”
• “One of the best speakers I have heard through ADDitude webinars. Clear, concise, helpful information.”

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Attention deficit hyperactivity disorder (ADHD) and depression are conditions that can and often co-occur. 

Depression is estimated to be 2.7 times more prevalent among adults with ADHD than among the general adult population. Studies also show that about 30 percent of people with ADHD will experience a depressive episode or have a mood disorder in their lifetimes. 

What’s more, individuals with ADHD and depression experience symptoms for each condition more acutely than what would be present if they only had one condition. It’s very important for anyone with ADHD and depression to make sure that both conditions are properly managed, and especially for ADHD to be identified and treated — as it can have a significant impact on how depression manifests. 

Does ADHD Cause Depression? Can Untreated ADHD Cause Depression?

Having ADHD puts you at four times the risk of depression. The risk is even greater for hyperactive/impulsive types, who are also at a higher risk of suicide.

The nature of ADHD itself, especially if untreated, can sometimes cause depression. This type of “secondary depression” arises as a direct consequence of the chronic frustration and disappointment that many individuals with ADHD experience. 

[Take This Test: Depression Symptoms in Adults]

All the struggles that ADHD symptoms can bring, like troubles with school, relationships, work, executive functions, and the demands of everyday life can lead people with the condition to often feel not good about themselves, making them prone to low self-esteem and negative self-concept. 

Making sure that ADHD is properly managed and treated, in these cases, can be key to lifting depression. But by some estimates, 25 percent of adults with the disorder haven’t gotten appropriate ADHD treatment.

“I frequently see depression in adults whose ADHD wasn’t recognized and treated in their younger years,” says Yvonne Pennington, Ph.D., an Atlanta-based psychologist who specializes in adult ADHD. “Having endured so many blows to their self-esteem, they’ve accepted the idea that they’re lazy and stupid-or not good enough to succeed socially or professionally.

Other components of ADHD that can create the conditions for depression include: 

[Get This Free Expert Resource: How to Recognize and Treat Depression]

Dopamine

ADHD brains have a dysregulation of dopamine, a neurochemical responsible for motivation and implicated in reward systems and moods. People with ADHD are not accessing the levels of dopamine that their neurotypical peers are because of this dysregulation, making motivation and reward harder to realize, and putting them at risk for not feeling their best.

Emotional Dysregulation

People with ADHD are more prone to emotional dysregulation — they can and often experience emotions more intensely than non-ADHD counterparts. Individuals with ADHD can take longer to soothe from difficult emotions, and can have a harder time transitioning out of and distracting themselves out of them, all which can contribute to depression.

ADHD Comorbidities

ADHD rarely travels alone. A significant number of people with ADHD have a comorbid or associated disorder, whether that’s depression, bipolar disorder, obsessive-compulsive disorder, binge eating disorder, a substance abuse disorder, or a learning disability. Certainly, ADHD plus something else can also set someone at more risk for depression. An individual with ADHD and OCD, for example, has to work through a tough combination of conditions — they may be constantly feeling tormented in their heads and ruminating about many different things that can lead them to shut down and feel helpless.

How Do You Treat ADHD and Depression?

ADHD and depression are typically treated through psychotherapies, medications, or a combination of the two. Cognitive behavioral therapy (CBT), for instance, has proven to be highly effective against depression. The first goal of CBT is to enable the patient to identify and reduce frequent, intense negative thoughts — “This is too hard to do,” for example. 

Depending on the case, treatments can also range from electroconvulsive therapy to ketamine infusions.

Whether depression is a result of ADHD or not, it doesn’t take away the fact that the individual is still experiencing depression. While there are some factors medical providers consider when treating both conditions, like how ADHD medications and antidepressants may interact with one another, depression is usually treated as its own condition.

“Work first on the condition that causes the greater impairment,” says Lenard Adler, M.D., director of the adult ADHD program at the NYU Langone Medical Center in New York City.  “Problems raised by ADHD are real, but depression can be life-threatening.”

Antidepressants that aim to boost levels of the neurotransmitters serotonin and/or norepinephrine are the primary treatment for severe depression. Doctors may also prescribe an antidepressant if mild to moderate depression persists, despite lifestyle changes and treatment of ADHD. 

Most antidepressants work well alongside ADHD stimulant meds, as well as with the nonstimulant Strattera (atomoxetine), though minor adjustments may need to be made. Wellbutrin (bupropion) is an antidepressant that can also be useful for ADHD.

Most of the time, depression improves substantially with the first antidepressant tried. If it doesn’t work, a second one probably will. About half of those who take antidepressants achieve complete relief of depressive symptoms.

Minor medication or lifestyle adjustments may make a tremendous difference, too. Aerobic exercise “has a profound effect on the mood level of people with ADHD,” says William Dodson, M.D., a Denver-based psychiatrist. “If you can’t motivate yourself, exercise can normalize your mood.”

Many individuals with ADHD find that their mood darkens when they have nothing to do. “The ADHD nervous system feeds on interest and challenge,” says Dodson. To guard against idleness, he recommends setting up an “interest closet”: Whenever you come across something interesting – a good book, for instance, or a craft project – stash it in a closet. The next time you find yourself looking for something to do, there will be something waiting for you.

Meditation also has its place in treating depression. Sit quietly, with your eyes closed, and focus on your breathing. Each time you exhale, silently repeat a one-syllable word — “one” or “peace” or “om.” Do this for a minute or so, or try it for 10 to 20 seconds whenever you have trouble moving from one activity to another.

The goal is to reduce the frequency and intensity of depressive symptoms. Don’t expect to eliminate them. But you can manage symptoms of depression that once got in the way of living a happy life.

[Read This Next: “I Live With Both ADHD and Depression”]

Dyspraxia is a neurological disorder that affects a child’s ability to plan and process motor tasks. Children with dyspraxia appear awkward when moving their whole body, or use too much or too little force. When a child has dyspraxia, he can’t imitate others, often mixes up the steps in a sequence, and can’t come up with new ideas during play. Dyspraxia is sometimes called “clumsy child syndrome” and is often considered ubiquitous with Developmental Coordination Disorder (DCD), a unique but very similar diagnosis also associated with poor eye-hand coordination, posture, and balance.

Up to 50 percent of children with DCD, which is more common in boys than it is in girls, meet the diagnostic criteria for attention deficit hyperactivity disorder (ADHD or ADD).¹

Dyspraxia-related coordination difficulties affect all aspects of daily life — for example, brushing teeth, getting dressed, and doing laundry. Though dyspraxia research is growing, the condition is often misunderstood or diagnosed improperly. Well-intentioned professionals dismiss symptoms of dyspraxia by saying, “Oh, he’s just an active boy” or “She will come around eventually.” But an overdue diagnosis of dyspraxia can greatly affect the self-confidence and achievement of a child, even if he or she has an average or above-average IQ.

Symptoms of Dyspraxia

The following dyspraxia symptoms correspond to each stage of development in children:

0-3 Years Old

• Delayed early motor development
• Delayed language development
• Repetitive behaviors and frequent motor activity
• Highly emotional
• Feeding difficulties
• Sleeping difficulties
• Toilet training may be delayed

[Self-Test: Dyspraxia Symptoms in Children]

3-5 Years Old

• Can’t stay in one place for longer than 5 minutes, constantly tapping feet or hands
• Speaks too loud, easily distressed
• No sense of danger
• Clumsy, constantly bumping into things
• Associated mirror movements (hands flap when running or jumping)
• Trouble with fine motor skills — when handwriting, using scissors and eating utensils, tying shoes, buttoning clothes
• Limited response to verbal instructions
• Sensitive to sensory stimulation
• Difficulty with speech, concentration and memory

Many of the signs listed above are similar to ADHD symptoms, and they persist through a child’s development. Additionally, a child with dyspraxia may learn well in a one-on-one setting, but struggle in a class with other children around. He or she may also avoid physical sports and particularly struggle with math and writing homework.

Diagnosing Dyspraxia: What To Do

Talk to your child’s doctor about your concerns. If you’re worried that your child might have dyspraxia, voice your concerns with her doctor. Pediatricians can diagnose dyspraxia, or they might refer you to a clinical or educational psychologist. Occupational therapists assist in the evaluation and treatment of dyspraxia but cannot make a diagnosis on their own. Any of these professionals will assess your child’s developmental history, intellectual ability, gross motor skills (use of the large muscles that coordinate body movement), and fine motor skills (use of smaller muscles for actions like writing or tying shoes). A norm-referenced assessment of these skills will allow the evaluating professional to compare your child’s results to the normal range of scores for a child his or her age.

A dyspraxia diagnosis is warranted if

• Motor skills are significantly below the age-expected level
• Lack of motor skill persistently affects your child’s daily activities and success at school
• Symptoms arose during early stages of development
• Lack of motor skills is not better explained by a general learning disability or rare medical condition

[Free Resource: Overcoming Common Learning Challenges]

Tell the school about your child’s dyspraxia. If you haven’t already, reach out to the administration at your child’s school regarding available and appropriate accommodations. You can also formally request an evaluation for special education services. Make a list of tasks that frustrate your child. Ask his teacher to look for school tasks that cause stress or irritability. Teacher observations assist caregivers and therapists in determining how to help.

Treatment Options for Dyspraxia

• Occupational Therapy: An occupational therapist helps children with dyspraxia develop skills specific to the daily tasks that challenge them most.
• Speech and Language Therapy: A pathologist will administer a speech assessment used to develop a treatment plan to help your child communicate more effectively.
• Perceptual Motor Training focuses on language, visual, auditory, and movement skills. Children with dyspraxia are given a set of tasks that gradually become more advanced, challenging the child but not so much that become stressed.
• Active Play: Anything that involves physical activity, inside or outside the home, helps improve motor play.

How to Help a Child with Dyspraxia

ADDitude’s “Explaining Dyspraxia” article provides six helpful tips for parents to when building motor skills in children who have dyspraxia:

1. Break complicated tasks into smaller steps. Master one before moving on to the next one. For example, when teaching shoe tying, make sure your child can independently complete the first step of making the knot.
2. Use pictures or video modeling to illustrate the sequence of steps in doing a difficult task.
3. Use multi-sensory teaching. Add songs, movements, scents, and textures to learning a new task. Use a song or rhyme when learning to tie shoes. When learning how to form letters, trace a letter onto sandpaper, paint it, or form it with scented dough.
4. Create an obstacle course in or outside your home. Have your child try to complete the course without shoes to stimulate sensory receptors in the feet. Add beanbags, soft mats, swings, and cut pool noodles in half to make balance beams. Purchase a scooter board. The obstacle course builds motor skills in a fun way. Let your child plan the course and give her different commands, such as, “Now crawl like a puppy.” Imitating animals is fun and builds creativity and muscle strength.
5. Allow children to use pencil grips, scissors with self-opening handles, and other therapeutic tools that hone fine motor skills. Begin with verbal and physical cues, then ask your child to name the next step.
6. Look into Cognitive Orientation to daily Occupational Performance (CO-OP), an active treatment approach that uses mutual goal-setting, analysis of a child’s performance, and high-level cognitive (thinking) strategies to improve motor-based skills.

[What Learning Disabilities Look Like In the Classroom]

Footnotes

¹ Keen, Daphne, and Irene Hadjikoumi. “Attention deficit hyperactivity disorder in children and adolescents.” BMJ Clinical Evidence (Aug. 2015) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4551107/

Can this stigma be avoided? How can children and adults with ADHD avoid being the victims of ridicule, contempt, or discrimination? ADDitude‘s Carl Sherman, Ph.D., posed these and other questions to Stephen Hinshaw, Ph.D., the author of The Mark of Shame: Stigma of Mental Illness and an Agenda for Change (#CommissionsEarned) (Oxford). Dr. Hinshaw, who chairs the psychology department at the University of California, Berkeley, has done pioneering research on ADHD and the ways it affects children and adolescents.

Why does ADHD carry a stigma?

Despite evidence to the contrary, many people still don’t believe that ADHD is a bona fide medical condition. They see it as an excuse for sloppiness or laziness. The fact that ADHD symptoms appear to come and go, depending on the situation, only feeds the doubters’ contempt. They say, or think, things like, “Why can’t you pull it together? You’re fine with certain friends — how come you can’t sit down and do your homework?”

Another factor is the widespread negative feeling about the use of psychiatric drugs. In recent years, there’s been a surge in the number of people taking ADHD medication. Some wonder if this increase is justified.

Finally, the fact that ADHD can undermine academic performance worsens the stigma. Our society seems to think, “If your grades are poor, you’re not worth much.” This is especially true if the cause of poor performance is hidden, as it is with ADHD.

[Click to Download: Your Free Guide to Debunking Annoying ADHD Myths]

What harm does ADHD stigmatization cause?

There are obvious things, like social problems and workplace discrimination. But the greatest harm often comes from self-stigmatization — that is, when people with ADHD internalize negative stereotypes.

In the course of my research, I’ve gotten to know hundreds of children who have ADHD, and I’ve heard many say things like, “I just can’t make it,” or “I’m just not cut out for school.” The stigma has so corrupted their motivation that they’ve given up even trying to be successful.

The flip side of self-stigmatization is denial. You consider the stereotypes of ADHD and think, “That’s not me.” You want nothing to do with such a shameful identity.

People with ADHD tend to have trouble seeing themselves realistically, and the desire to avoid discrimination makes it even harder. For example, if you believe that needing medication proves there’s something wrong with you, then not taking your medication “proves” there is nothing wrong with you.

[Free Webinar Replay: From Shame and Stigma to Pride and Truth: It’s Time to Celebrate ADHD Differences]

Who is affected most by stigmatization?

Stigmatization can be difficult for anyone who has ADHD, but the burden falls more heavily on girls and young women. People continue to think of ADHD as an exclusively male problem. According to this stereotype, if a girl exhibits common ADHD traits, there must really be something wrong with her.

Something similar may be operating with adults. Since ADHD is commonly thought of as a childhood disorder, adults who have it, or claim to have it, come under suspicion. The thinking seems to be, “Either you made it up to compensate for the failures in your life, or there’s something very wrong with you.”

What should you do if you hear a hurtful comment about ADHD?

A firm, but gentle, discussion with the person making the remark goes a long way toward raising awareness.

“I have ADHD,” you might say, “and it’s just as real as other medical conditions.” Or you might say, “I work hard, and I bet that you have no idea how demoralizing it is to hear a comment like that.”

What else can people with ADHD do to counteract the effects of stereotyping?

The more aware you are of stereotyping, the easier it is to recognize when it is affecting you.

Of course, it’s also important to recognize that negative feedback about oneself is occasionally valid — and valuable. If you believe that all criticism leveled at you is the result of stereotyping, you’ll be less motivated to seek appropriate treatment.

Taking positive action is another way to avoid the negative effects of stereotyping. Joining others in the struggle to do away with discrimination is empowering. So, when you encounter biased, belittling portrayals of people with ADHD in the media, write a letter to the people responsible for those portrayals.

If you’re not already involved with advocacy groups, like CHADD and ADDA, consider getting involved. Or contact your elected representatives to ask them to consider needed policy changes, such as parity. This means putting insurance coverage for mental health problems, like ADHD, on an equal footing with coverage for physical illnesses.

What can parents do to help protect their children with ADHD?

If you’re the parent of a child with ADHD, make sure that he or she understands what that means. ADHD should never be used as an excuse, but it probably explains why your child has trouble doing certain things, and why she or he might have to work a little harder than other kids to get the same results.

Make sure your child’s school understands that ADHD is a legitimate disorder — and that it may be legally obligated to provide accommodations.

How or when should you reveal a diagnosis of ADHD?

It’s a dilemma. If you conceal the fact that you have ADHD, you avoid the ADHD label and the discrimination that can lead to. However, you risk a kind of indirect discrimination. People who notice you being disorganized, impulsive, or forgetful might assume that you are simply rude or lazy.

When is the right time to talk to your boss about your ADHD? When to tell a new friend? It’s a judgment call, and timing is crucial. If your employer has a reputation of being good about providing accommodations, for example, you might broach the subject. Otherwise, it might be better to keep it quiet, at least until you get established in your job. Advice from a therapist or consultant can be helpful.

There’s no need to tell everyone that you or a loved one has ADHD. But if you feel you shouldn’t tell anyone, you’re wasting energy — and reducing the likelihood that you will get treatment.

Secrecy fuels feelings of shame. Better to seek out people and places that make secrecy unnecessary, and open up.

[Read This Next: Life Is Too Short for Shame]

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