April 17, 2023

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

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

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

Exercise, Depression & Anxiety

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

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

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

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

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

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

Exercise and ADHD

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

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

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

Limitations & Future Research

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

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

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

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

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

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

Sources

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

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

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

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

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

“Reading the book, I diagnose you with ADD,” Maté said, referring to the Duke of Sussex’s autobiography, Spare. “I see it as a normal response to normal stress, not a disease.”

Maté, author of Scattered Minds: The Origin and Healing of Attention Deficit Disorder and The Myth of Normal, also diagnosed the prince with anxiety, panic disorder, depression, post-traumatic stress disorder (PTSD), and substance abuse issues during the 90-minute, live-streamed event, which has been described as both unorthodox and reckless.

Maté made his diagnosis before meeting the prince and, admittedly, based his evaluation solely on stories of grief, trauma, and substance abuse from Spare. In his past work, Maté has called ADHD a “normal response to normal stress,” which he says may be healed without medication. In last week’s conversation, he suggested Prince Harry’s ADHD stemmed from his childhood, especially the death of his mother, Princess Diana, when he was just 12.

There is a lot to unpack here and so much ADHD misinformation to correct. Here, leading ADHD experts address Maté’s claims regarding ADHD and trauma, respond to his spontaneous diagnosis, and fact-check his treatment advice.

[Download This Free Guide to Debunking ADHD Myths]

Can Clinicians Diagnose ADHD Based on a Patient’s Life Story?

In short, no.

“An accurate and well-rounded ADHD diagnosis is a complex, multi-step process including a clinical interview, a medical history review, and the completion of normed rating scales by loved ones, educators, and/or colleagues,” says Thomas E. Brown, Ph.D., a clinical psychologist who served on the clinical faculty of the Yale School of Medicine for 21 years and has published six books on ADHD.

Only a medical professional, such as a pediatrician, a psychologist, a psychiatrist, or an advanced practice registered nurse (APRN), should diagnose ADHD. An in-depth, well-rounded ADHD evaluation comprises several components, explains Brown, the director of the Brown Clinic for Attention and Related Disorders in California.

First, Brown says, a clinician will determine whether the patient has the ADHD symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V). (A patient must have shown at least six of the nine symptoms of inattention and/or hyperactivity and impulsivity before age 12.) Next, the clinician will conduct an interview with the individual (and, if possible, with one or two people who know that person well) or refer the patient to a medical or mental health clinician who is familiar with ADHD and with the other medical or psychological disorders that produce similar symptoms, Brown explains.

“A good clinical interview may take two to three hours, including time explaining to the patient what we now understand about ADHD and what it means for them,” he said in the ADDitude article, “The Building Blocks of a Good ADHD Diagnosis.”

[Self-Test: Common ADHD Symptoms in Adults ]

The clinician should use normed ADHD rating scales, such as the Barkley, BASC, Brown, Conners, or BRIEF scales, to gather self-reported information from the patient and observer information from parents, teachers, partners, or others who have seen how this individual has functioned over recent months and previously in various aspects of daily life.

“A clinician should also conduct a complete physical exam to rule out medical problems, such as thyroid conditions or pinworms,” Brown says. A physical exam can also assess whether an individual can safely take ADHD medication.

A complete assessment may take several visits and/or visits with an ADHD specialist.

Does Trauma Cause ADHD?

Not exactly. Studies show that experiencing trauma increases a patient’s chances of being diagnosed with ADHD. However, research does not support the idea that trauma causes ADHD.¹

“Research does tell us that ADHD is a condition that’s largely genetic and inherited and that it causes specific areas of the brain to be underdeveloped or otherwise impacted,” says Nicole M. Brown, M.D., MPH, MHS, a general pediatrician and health services researcher and Chief Health Officer of Strong Children Wellness Medical Group in New York.

“Because trauma affects those same areas of the brain, it exacerbates ADHD symptoms,” she said in the ADDitude webinar titled How Stress and Trauma Affect ADHD in Children of All Colors — and How to Heal the Wounds. Her research on the topic was published in Academic Pediatrics, the official journal of the Academic Pediatric Association.

“ADHD is a brain-based disorder often diagnosed after a child struggles in school, or even later in life,” adds Kerry J Heckman, LICSW, a Seattle-based licensed therapist specializing in somatic therapy for the treatment of trauma. “Trauma is the result of exposure to stressful events or experiences that can occur anytime during a person’s life. Childhood trauma that occurs when the brain develops may lead to cognitive and emotional changes resembling ADHD.”

Epigenetics, which the Centers for Disease Control and Prevention (CDC) defines as “the study of how your behaviors and environment can cause changes that affect the way your genes work,” sheds some light on how environmental factors and experiences, such as trauma, may impact brain development. However, ADHD is not solely a result of trauma.

“It starts with genes,” says Joel Nigg, Ph.D., a clinical psychologist, and professor in the departments of psychiatry and behavioral sciences at Oregon Health & Science University. “But everyone is exposed to different environmental toxins and advantages beginning at conception — and after we’re born, psychological inputs like stress, adversity, and even trauma begin to factor in. Epigenetics uses this input to change how genes are expressed — meaning a gene’s output isn’t fully known until environmental and personal histories are factored in.” Nigg further explained how epigenetics affects ADHD in the ADDitude webinar titled Genes and the Environment: How Biology and Exposures Contribute to ADHD in Children.

Can ADHD Be “Healed?”

No silver-bullet solution or magic elixir exists for ADHD; it is a lifelong condition that persists well into adulthood for most people who have it.

The best treatment for managing the core symptoms of ADHD in children is a combination of behavioral parent training and medication. Stimulants (methylphenidate and/or amphetamine) are considered a first-line pharmacological treatment for adult ADHD.² Several types of non-stimulants (considered second-line treatments) can address ADHD symptoms as well.

Even medication can’t “cure” ADHD. “There is no ‘cure’ that we know of,” said Larry Silver, M.D., a psychiatrist, and former Clinical Professor of Psychiatry at Georgetown University Medical Center in Washington, D.C. “Think about a person with diabetes on insulin. Insulin corrects a chemical deficiency and allows a person to metabolize sugar. Once it wears off, however, the person can no longer do this. At this time, we can’t correct the problem, only compensate for it, and medication is an effective approach.” Silver was the former Acting Director and Deputy Director of the National Institute of Mental Health (NIMH).

Laurie Dupar, PMHNP, RN, PCC, a senior certified ADHD coach, trained psychiatric nurse, and founder of the International ADHD Coach Training Center, agrees with Silver. “We know from years of research that ADHD medications work — in fact, studies show they work up to 80% of the time,” she says.

Adults should expect to work closely with their physicians to adjust medication and dosage and to find the right ADHD treatment combination to alleviate symptoms.

For those individuals with ADHD who cannot or prefer not to take medication, cognitive behavioral therapy, nutrition, meditation, exercise, lifestyle changes, and/or brain training, among other natural treatments, may help alleviate or lesson some ADHD symptoms like poor focus and memory.

Can Individuals with ADHD Effectively Self-Medicate with Marijuana and Psychedelic Drugs?

The Duke of Sussex and Maté talked candidly about the benefits of drinking ayahuasca, a plant-based psychedelic from South America.

“I would say it [taking ayahuasca] is one of the fundamental parts of my life that changed me and helped me deal with the traumas and pains of the past,” Prince Harry said. He also described his experiences using cocaine, smoking marijuana, and trying magic mushrooms (Psilocybin).

While some individuals with ADHD seek alternatives to first-line treatments, research does not support the idea that illegal substances assuage ADHD symptoms. According to Roberto Olivardia, Ph.D., a Clinical Psychologist and Clinical Instructor of Psychology at Harvard Medical School, the risk of developing cannabis use disorder (CUD), a problematic pattern of cannabis use linked to clinically significant impairment, is twice as high in people with ADHD.³

“Contrary to popular belief, individuals can be mentally and chemically dependent on and addicted to cannabis. Contemporary marijuana has concentrations of THC higher than historically reported, exacerbating this. What’s more, the adverse effects of cannabis are especially amplified in people with ADHD,” he says.

Cannabis use may also exacerbate paranoia, panic, and mood disorders, explains Olivardia. Further, the increased risk of suicide associated with cannabis use further complicates marijuana among individuals with ADHD, who already face an elevated risk for suicide compared to neurotypical individuals.⁴

“The substance’s negative effects are most harmful to developing brains,” Olivardia says. “Many studies show that usage earlier in life, particularly before age 25, predicts worse outcomes. One study found that heavy marijuana use in adolescence was associated with a loss of 8 IQ points, on average, in adulthood.⁵ Another study found that people under 18 are four to seven times more at risk for CUD than adults.⁶  Olivardia discussed marijuana and the ADHD brain in the ADDitude webinars titled Marijuana and the ADHD Brain: How to Identify and Treat Cannabis Use Disorder in Teens and Young Adults and Marijuana and the ADHD Brain, Part 2.

The use of very low (micro) doses of psychedelics, such as LSD and psilocybin, appears promising for treating symptoms of obsessive-compulsive disorder, cluster headaches, and ADHD; however, additional research is required and these treatments are not without risks, cautions psychologist Ari Tuckman, Psy.D., and Stephanie Moulton Sarkis, Ph.D., NCC, LMHC, an AMHCA Diplomate and Clinical Specialist in Child and Adolescent Counseling. They stressed that psychedelics can potentially worsen symptoms of bipolar disorder or lead to psychosis and said that “these drugs are illegal unless they are administered in medical or research settings.”

Why Is a Public ADHD “Diagnosis” Like Prince Harry’s So Dangerous?

Doctor-patient confidentiality prohibits doctors from sharing patients’ medical information with others. It appears Maté disregarded this by diagnosing Prince Harry with ADHD in a public — and profit-generating — setting. Access to the interview required purchasing a $25 ticket (ticket holders received a hardcover copy of Spare.).

According to the American Academy of Family Physicians website, “a confidential relationship between physician and patient is essential for the free flow of information necessary for sound medical care. Only in a setting of trust can a patient share the private feelings and personal history that enable the physician to comprehend fully, to diagnose logically, and to treat properly.”

ADHD is not globally understood. Myths and misinformation abound, leading to systematic barriers to helping and supporting adults and children with ADHD. Some people falsely believe ADHD is a fake disorder, an excuse for bad behavior, or a pharmacological fairy tale. None of these things is true, but that doesn’t change the fact that enduring stigma impacts how and whether adults with ADHD choose to share their diagnosis.

The UK did not recognize ADHD until the publication of the NICE (National Institute of Clinical Excellence) Clinical guideline CG72 in 2008.⁷ According to a 2022 study published in BMC Psychiatry, before that time, there was an enormous amount of skepticism about ADHD and virtually no recognition of it in the UK.⁸

“While the last two decades have seen a stepped change and increase in the provision of adult ADHD clinical services in the UK and elsewhere, demand currently outstrips provision by a long way in many regions and countries,” the study’s authors wrote.

ADHD is treated as more of a “niche problem,” they wrote, “with diagnosis, treatment initiation and monitoring frequently constrained to scarce specialist services with limited capacity.”

By offhandedly diagnosing a public figure, Maté diminishes the experience of many people with ADHD in Europe who already struggle to access care.

The ADHD Foundation, UK’s leading neurodiversity charity, tweeted: “Gabor Maté — it is neither ethical nor appropriate to tell someone for the first time, — in a public interview, that they have ADHD. It is for the individual to decide whether to disclose their neurodiversity.”

Debunking Prince Harry’s ADHD “Diagnosis:” Next Steps

• Download: 31 ADHD Myths in 31 Days —Debunked
• Learn: The Brain Circuits that Link ADHD and PTSD
• Read: 21 Ignorant Comments (and Lies) About ADHD 
• Q: Who Can Diagnose ADHD? 
• eBook: Secrets of the ADHD Brain 

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Sources

¹Brown, N.M., Brown, S.N., Briggs, R.D., Germán, M., Belamarich, P.F., Oyeku, S.O. (2017) Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity. Acad Pediatr.https://doi.org/10.1016/j.acap.2016.08.013

²Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of Adults with Attention-Deficit/Hyperactivity Disorder. Neuropsychiatric Disease and Treatment. 4(2), 389–403.https://doi.org/10.2147/ndt.s6985

³Lee, S. et. al. (2011). Prospective Association of Childhood Attention-Deficit/Hyperactivity Disorder (ADHD) and Substance Use and Abuse/Dependence: A Meta-Analytic Review. Clinical Psychology Review. 31(3), 328–341. https://doi.org/10.1016/j.cpr.2011.01.006

⁴Balazs, J., & Kereszteny, A. (2017). Attention-Deficit/Hyperactivity Disorder and Suicide: A Systematic Review. World Journal of Psychiatry. 7(1), 44–59. https://doi.org/10.5498/wjp.v7.i1.44

⁵Meier, M, et. al. (2012). Persistent Cannabis Users Show Neuropsychological Decline from Childhood to Midlife. Proceedings of the National Academy of Sciences. 109 (40) E2657-E2664; https://doi.org/10.1073/pnas.1206820109

⁶Winters, K. C., & Lee, C. Y. (2008). Likelihood of Developing an Alcohol and Cannabis Use Disorder During Youth: Association with Recent Use and Age. Drug and Alcohol Dependence. 92(1-3), 239–247. https://doi.org/10.1016/j.drugalcdep.2007.08.005

⁷NICE. Attention Deficit Hyperactivity Disorder: The NICE Guideline on Diagnosis and Management of ADHD in Children, Young People and Adults: The British Psychological Society and The Royal College of Psychiatrists; 2008.

⁸Asherson, P., Leaver, L., Adamou, M., et al. (2022) Mainstreaming Adult ADHD into Primary Care in the UK: Guidance, Practice, and Best Practice Recommendations. BMC Psychiatry. 22, 640 https://doi.org/10.1186/s12888-022-04290-7</a?

Here, we examine the effectiveness of three of these:

Lion’s Mane

Lion’s mane is a mushroom marketed as delivering “brain-boosting benefits.” As with many proposed alternative treatments, it claims to treat many symptoms and conditions, including anxiety, depression, Alzheimer’s, Parkinson’s disease, heart disease, and multiple sclerosis. Given the vastly different causes of these conditions, it is highly improbable that one intervention could provide universal benefit.

The websites we reviewed, which touted the shaggy white mushroom, acknowledged the dearth of published research studies examining the use of lion’s mane for ADHD. No research shows that it impacts the production or transmission of dopamine, the primary neurotransmitter involved in ADHD. Instead, the product’s marketers cite research done on animals or in test tubes that suggest the potential for general cognitive or health benefits and propose that it could benefit ADHD — without citing any clinical studies on humans for support.

More research is needed on humans to determine if lion’s mane has therapeutic effects.

Micro-Dosing Psychedelics

The use of very low (micro) doses of psychedelics, such as LSD and psilocybin, is gaining renewed interest for treating anxiety and depression. Some experts say these psychedelics might also show promise for treating symptoms of obsessive-compulsive disorder, cluster headaches, and ADHD. These treatments are not without risks, however, at least at higher doses. It is important to know that psychedelics can potentially exacerbate symptoms of bipolar disorder or lead to psychosis. These drugs are illegal unless they are administered in medical or research settings.

[Download: Best Natural Remedies for Managing ADHD Symptoms]

Some studies have examined micro-dosing psychedelics for ADHD, but the results involved self-reported benefits; there was no control group. A clinical trial is underway in Europe using a randomized, double-blind, placebo-controlled design, the gold standard for medication research. Results are expected in late 2023 and will offer much more helpful conclusions. The use of psychedelics over an extended period of time would also need to be studied, both for ongoing effectiveness (assuming short-term effectiveness is found) and also for safety.

Mega-Dosing Caffeine

Caffeine is the most popular brain-altering chemical that improves alertness, attention, and focus, at least briefly, for many people. Caffeine may improve memory, learning, complex problem-solving, mental stamina, and more. If you are sleep-deprived, mentally fatigued, or experiencing a mid-day dip in energy, caffeine may provide a temporary boost.

But the faster you consume caffeine, and the more concentrated it is, the quicker your blood levels of caffeine rise. Generally, caffeine has a six-hour half-life, meaning half of the blood levels are metabolized every six hours. Drinking more coffee than your system can tolerate may cause irritability, higher heart rate, jitteriness, headaches, anxiety, insomnia, or restless sleep. The combination of caffeine and prescription stimulants can worsen these side effects.

There is no research-supported evidence that caffeine is a valid treatment for ADHD. While it provides general cognitive benefits, caffeine doesn’t activate the parts of the brain that improve executive functioning, as prescription stimulants do.

[eBook: The ADDitude Guide to Treating ADHD Naturally]

Lion’s Mane, Psychedelics, & Caffeine: Next Steps

• Download: 5 All-Natural ADHD Supplements
• Readers Share: Favorite Non-Medical Therapies for ADHD
• Read: 10 Foods (and Supplements and Vitamins!) to Boost Your ADHD Brain

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.

Which is why I started a series of Facebook Live events, in partnership with ADDitude magazine, called Ask Ned. This free, interactive Q&A session takes place every other Thursday at 1 p.m. ET. To register for these events, go to www.facebook.com/DrHallowell/

During each event, I talk briefly about a topic related to attention deficit hyperactivity disorder (ADHD) and then take participants’ questions for nearly an hour. Below are a few questions from our talks to give you a sense of the topics and concerns we tackle. We hope to see you at the next session!

Too Old for Stimulant Medication?

Q: “I’m 74 and have been taking a stimulant for ADHD for 20 years. My family is afraid that I’m too old to still be taking a stimulant. What do you think?”

What matters when taking stimulants is not a person’s chronological age but their physiology. ADHD medications should always be given under medical supervision — at any age. If you’ve been taking a stimulant for 20 years, then there’s no reason to stop simply because you’re now 74, or older for that matter.

[Get This Free Download: Comparison Chart of Stimulants & Non-Stimulants]

As long as you continue to have a normal EKG, your heart rate and blood pressure are stable on the meds, you’re getting good sleep, you don’t feel agitated or “loopy,” and your weight is stable, then you’re fine to take stimulant medication and reap the benefits they can provide.

Solving ADHD Sleep Problems

Q: “I take stimulants for my ADHD during the day and at night, but I have a lot of trouble getting to sleep. Do you have suggestions that could help?”

Regardless of treatment plan, it is common for people with ADHD to experience sleep problems — and this symptom can be made worse by stimulants.¹ To remedy the problem, first make sure you practice good “sleep hygiene.” This means:

• Don’t bring your cell phone or other devices with a screen to bed with you.
• Don’t eat a meal just before bedtime.
• Make sure your bed and room temperature are comfortable.
• Have an agreement with your bed partner, if you have one, about what is or isn’t okay for each of you to be doing while the other is trying to fall asleep.

[Read: How to Fall Asleep with a Rowdy, Racing ADHD Brain]

Second, time the dosing of your medication so that it wears off before you try to sleep. This is a process of trial and error. While we can estimate how long a given stimulant will last in your system, there’s tremendous individual variation. To assess this, take the medication at different hours to try to time your dose so that it wears off when you want to sleep.

Third, if your medication still prevents you from sleeping no matter when you take it, or it’s worse than if you had not taken the medication at all, then talk with your doctor about trying a different remedy. Getting adequate sleep is very important to your overall health.

CBT for ADHD?

Q: “Will cognitive behavioral therapy (CBT) help my child with self-regulatory challenges, such as impulsiveness and anger-control problems associated with ADHD?”

There’s a good chance that it will. CBT has been shown in studies to help a variety of problems, including many of the associated challenges of ADHD. ^{2 3} But it should never be the only intervention — education, coaching, structure, exercise, proper nutrition, good sleep, and regular doses of positive human interaction should all be included, or at least considered, in every treatment plan. But CBT is an excellent adjunct for many people of all ages.

Questions About ADHD: Next Steps

• Free Download: The Ages & Stages of ADHD — Key Solutions from Childhood to Adulthood
• Read: Answers to the ADHD Questions You Didn’t Know You Had
• Read: Expert Answers to Common Questions About ADHD

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

Sources

¹ Hvolby A. (2015). Associations of sleep disturbance with ADHD: implications for treatment. Attention Deficit and Hyperactivity Disorders, 7(1), 1–18. https://doi.org/10.1007/s12402-014-0151-0

² Young, Z., Moghaddam, N., & Tickle, A. (2020). The Efficacy of Cognitive Behavioral Therapy for Adults With ADHD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Attention Disorders, 24(6), 875–888. https://doi.org/10.1177/1087054716664413

³ Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current Concepts and Treatments in Children and Adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658

Q1: “Where can I find a provider who specializes in the diagnosis and treatment of ADHD in adults?”

Use ADDitude’s Online Directory to find professionals who can diagnose ADHD and recommend treatment plans. Find even more professionals in the directories linked below, and determine what kind of professional might best suit your needs here: How to Find the Best ADHD Treatment Professional

• The CHADD Professional Directory
• Psychology Today Therapy Directory

Q2: “How do you advocate for a full ADHD assessment as a woman? I feel like providers shrug off ADHD symptoms as hormonal or stress-related, especially if the woman apparently functions well in daily life.”

Outdated assumptions regarding symptom presentations (namely, that ADHD shows up as hyperactivity only in young males) and a lack of research on women contribute to severe underdiagnosis of ADHD in women. To help combat this issue, ADDitude created an ADHD symptom test specifically for women: Female ADHD Test: Symptoms in Women and Girls. Be sure to share the completed test with your doctor when requesting an evaluation and share the resources below.

Next Steps:

• Understand: Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately
• Read: “ADHD Is Too Often Overlooked in Women. This Needs to Change.”
• Subscribe to The ADDitude Newsletter for Women with ADHD

Q3: “How do comorbid conditions affect the process of obtaining an ADHD diagnosis?”

Comorbid conditions are almost always found alongside ADHD, complicating the evaluation and diagnosis process. In cases of “complex ADHD,” treatment strategies typically aim to first address the condition causing the most daily problems. To ensure effective and coordinated care, disparate doctors must share patient medication information and collaborate on care. The responsibility for smoothing this communication ultimately falls on the patient or caregiver.

Next Steps:

• ADHD Comorbidity: An Overview of Dual Diagnoses
• Read: What Is Complex ADHD?
• Download: Is It More Than Just ADHD?

Q4: “Is telehealth available for children and teens?”

Virtual care options are available to everyone, including children and teens. Though direct interactions are limited, online sessions allow children to engage in their own environment as opposed to in-office visits. According to Ari Tuckman, Psy.D., this can be beneficial to providers:

“It’s been helpful to see some kids at home — they are more themselves than they are in some new guy’s office. It gives me a more accurate sense of who they really are.”

Q5: “What kind of services are offered via telehealth?”

Obtaining a proper ADHD diagnosis is a multi-step process that includes a clinical interview, a medical history review, and the completion of normed rating scales by loved ones, educators, and/or colleagues. While much of this can be done online, limitations such as medication fulfillment, physical exams, and cognitive or educational testing may need to be completed in an office setting. Medication prescription, medication titration, and teletherapy may also be delivered in the virtual care space.

Next Steps:

• Special Report: Cerebral, ADHD Telehealth Patients Report Rushed Diagnoses, Medication Prescriptions
• Read: Your Complete ADHD Diagnosis and Testing Guide
• Read: How Online Therapy Helps Soothe the ADHD Mind and Soul During This Pandemic

The content for this article was based on questions submitted by live attendees during the ADDitude ADHD Experts webinar titled, “Virtual Mental Health Providers: How to Get Quality ADHD Care Online” [Video Replay & Podcast #406] with Maggie Sibley, Ph.D., which was broadcast live on June 22, 2022.

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.

This helps to explain why ADHD is linked to chronic stress, burnout, anxiety, mood disorder, sleep problems, substance use, and other conditions and issues. The reverse is also true: chronic stress and anxiety can worsen ADHD symptoms.

ADHD impacts the whole self, so is treatments must likewise target more than inattention and impulsivity. Integrative medicine is growing in popularity because it’s a treatment approach that addresses symptoms and promotes general health and wellness.

Integrative Medicine for People with ADHD: Index of Topics

• Stress management (therapy, mindfulness, lifestyle habits)
• Mind-body alignment (exercise, breathwork, acupuncture)
• Nutrition (gut-brain axis, micronutrients, herbal supplements, adaptogens)
• Working with an integrative health provider

What Is Integrative Medicine?

Integrative medicine considers the whole person and leverages all options — holistic thinking, complementary therapies, and conventional treatments — in devising a patient’s care plan.

Studies exploring the effectiveness of integrative approaches for ADHD specifically are limited. Moreover, the most common treatments for ADHD are the conventional – medication and psychotherapy. The American Academy of Pediatrics (AAP) recommends treating ADHD in children and adolescents aged 6 to 18 with FDA-approved medications, plus parent training in behavior modification and behavioral classroom interventions. Research studies have found that “stimulant medications are most effective, and combined medication and psychosocial treatment is the most beneficial treatment option for most adult patients with ADHD.”

Still, just as ADHD affects many aspects of wellbeing, a variety of treatments and approaches can do the same.

[Get This Free Download: Natural ADHD Treatment Options]

As an integrative practitioner, my approach for treating patients with ADHD is this: If the ADHD symptoms are significantly impairing, I start with medication, and then phase in other strategies, often outside of conventional care. If the ADHD symptoms are mild to moderate, the non-medication and lifestyle approaches can be tried first.

Over time, as the other skills and strategies are employed, the need for medication can be re-evaluated and the dose reduced.

An example of an integrative medicine plan for ADHD may combine psychotherapy (a conventional strategy), stress-management skills (holistic thinking), and omega-3 fatty acids (a complementary supplement). All ADHD treatment decisions should be made in consultation and coordination with a licensed medical provider.

Conventional Treatments for ADHD

• Parent training
• Executive function or ADHD coaching
• ADHD medication
• Psychotherapy (CBT, DBT, and others)

Holistic Wellness and Lifestyle Approaches for ADHD

• Mindfulness and self-compassion exercises
• Movement and exercise
• Sleep hygiene
• Self-care

Complementary and Alternative Medicine (CAM)

• Brain-gut health
• Supplements and herbs
• Acupuncture

[Read: How Nutrition, Exercise & Sleep Curb ADHD]

Integrative Medicine for ADHD: Combining Holistic & Conventional Care

Most of the following approaches address ADHD’s secondary symptoms — namely stress, anxiety, mood, low self-esteem, and emotional dysregulation. Treating these factors can help decrease the severity and impairment of ADHD’s core symptoms.

Stress Management and Executive Function

Psychotherapy

Cognitive behavioral therapy (CBT) helps patients develop a greater understanding of their ADHD symptoms and teaches skills that help with executive dysfunction.

CBT aims to improve patients’ problem-solving and stress-management skills by setting realistic goals and teaching organizational and time-management skills to achieve them. This type of psychotherapy can also improve balanced thinking and communication skills by focusing on one’s unique challenges (e.g., history of trauma or other comorbid mental health conditions).

ADHD coaching

Like CBT, coaching helps individuals meet their goals and develop skills to address ADHD-related barriers along the way.

Mindfulness

Mindfulness — a practice that includes meditation as well as awareness shifts in daily activities — has been shown to improve both inattentive and hyperactive/impulsive symptoms, as well as selected measures of attention, emotion regulation, and executive functions¹.

By analysis of automatic habits, the practice allows you to change them in the moment. For example, mindful awareness may help you realize that you are procrastinating, and help you tune in to the emotions that are driving the procrastination.

Self-Compassion

A facet of mindfulness, practicing self-compassion is particularly important for mental health. Offering yourself some validation and kindness — “This is hard. I’m stressed. I’m struggling” — will make a difference in how stress is experienced.

As you observe your reaction and create inner pause, you can ask: “What can I do to help this situation?” and find possibilities to do so. The answer may be “I need to take a few deep breaths” or “I need to prioritize my tasks.”

Sometimes one can reframe the situation or focus on the positive (e.g., gratitude) to see what is working versus what is not. By making such shifts in awareness and response, you can begin to self-regulate and enhance your resilience.

Neurodiversity Perspective

Seeing ADHD symptoms as neurobiologically driven ways of responding versus the idea that you are defective in some way fosters self-acceptance. The important thing is to see ADHD as a biological difference and condition that needs extra support or accommodation.

Lifestyle Habits

Regular sleep, adequate hydration, prioritized self-care, and avoidance of excessive alcohol and other substances can help manage ADHD symptoms. At the same time, the ability to keep up with these practices is often compromised by ADHD itself. It is best for patients and clinicians to identify and target the most problematic areas first.

Exercise

Exercise has wide-ranging health benefits (physical, cognitive, and emotional) both acutely and when done regularly over time. In particular, aerobic exercise has been shown to improve executive functions, attention, and behavioral symptoms in ADHD². Other types of mind-body movement, such as yoga or tai chi, can also be helpful for ADHD symptoms.

Breathwork

Stress and anxiety typically make breathing faster and shallower (i.e., chest breathing). Slower and deeper breathing (i.e., belly breathing) is the ideal. Breathing regulates the sympathetic-parasympathetic nervous system balance, so breathwork can counteract stress and change your body state.

Examples of breathing exercises:

• 2-to-1 breathing (exhale for twice as long as you inhale)
• Square breathing (inhale to a count of 4, pause to a count of 4, exhale to the count of 4, and pause to a count of 4)

Acupuncture

Acupuncture, derived from Chinese medicine, aims to treat a variety of conditions by stimulating diverse points on the body (acupoints). This approach focuses on regulating the body organ system to lower inattention and hyperactivity. Some research supporting the use of acupuncture for ADHD is available from Asian countries³. But this approach to ADHD has not been studied widely in Western cultures.

For general wellness, acupuncture is often used to treat pain and stress-related conditions. There is also some evidence supporting it as an adjunctive treatment for anxiety. I have found it helpful for those who struggle with chronic stress and pain.

Nutrition

Poor nutrition and lifestyle habits can increase the level of impairment from ADHD. While specific nutritional approaches for ADHD symptoms don’t have strong research evidence, we do know that processed foods, refined grains, excessive sugar, and high fat worsen mental health.

Eat the foods that support health and mood. Foods like whole grains, fruits, vegetables, lean proteins, fish, and nuts has been shown to improve depressive symptoms⁴. Colorful fruit and vegetables (high in flavonoids and antioxidants) appear to protect against cognitive decline⁵, and may support modulation of neurotransmitters, such as dopamine⁶. Eating protein at each meal and low-glycemic foods (which don’t spike blood sugar quickly) enhance steady blood glucose and cognitive function.

Gut-Brain Axis

The gut-brain axis refers to the two-way link between these parts of the body (i.e. the emotional and cognitive centers of the brain with intestinal functions). Research tells us that the foods we eat affect the microbiome in the gut, which influences this connection⁷. Healthy gut flora, for example, can reduce anxiety and serum cortisol levels⁸. Prebiotic and probiotic foods, like kimchi and sauerkraut, can support gut health.

Herbal Supplements

A variety of supplements and herbs have been studied for their use in treating ADHD. In using supplements, two paths can be taken:

• Using supplements specifically for ADHD symptoms
• Using supplements to support general mental and physical health (mood, sleep, stress and cognition to indirectly modulate ADHD symptoms)

The thinking in using a combination of supplements for ADHD is that multiple nutrients will be involved in the important processes in the brain, such as modulation of key neurotransmitters. Since ADHD symptoms exist on a spectrum from mild to severe, supplementation can be individualized and used with or without medications. When using supplements, practical considerations, like cost or the number of pills needed per day, should be considered.

1. Micronutrients & Vitamins. For ADHD symptoms, there is evidence that a specific broad-spectrum micronutrient formula (Daily Essential Nutrients) can improve aspects of ADHD^9 10, such as inattention, hyperactivity/impulsivity, and emotional regulation. Some studies found higher risk of low zinc¹¹, ferritin¹² (marker of iron status), and magnesium¹³ in those with ADHD. Talk with your clinician or a registered dietitian about incorporating these supplements into your health plan.
2. Omega-3 fatty acids have been shown to improve ADHD symptoms¹⁴ and are among the most common supplements used to manage the condition.
3. Melatonin has been shown to improve sleep. L-theanine, inositol, and magnesium may also be used for sleep and/or anxiety.
4. Adaptogens (supplements that help your body withstand stress) support cognitive function as well¹⁵. Two well-known adaptogens are rhodiola rosea and ashwagandha. Rhodiola tends to be stimulating, and ashwagandha calming.
5. One small study suggests that passionflower extract may help treat some ADHD symptoms¹⁶. Korean red ginseng, ginkgo biloba, marine bark (pycnogenol), and bacopa monnieri have all shown some evidence of improving inattentive and hyperactive/impulsive symptoms^{17 18 19 20 21}. Botanical preparations vary in quality, and may have interactions with medications or come with medical contraindications. Guidance from a clinician, herbalist, or pharmacist can be helpful.

How to Work with an Integrative Provider

There are many kinds of integrative providers, with different training backgrounds and attitudes about treating ADHD. A good integrative provider will understand conventional mental health and won’t sell only one approach. They should be willing to work collaboratively with you and your other clinicians.

I recommend beginning your search for integrative providers with these national organizations.

• The Academy of Integrative Health & Medicine
• The American Association of Naturopathic Physicians
• The Institute for Functional Medicine

Talk with the provider before making an appointment to understand their approach and to see if they are a good fit for your needs. Many of the providers found here have knowledge of integrative approaches, and are willing to collaborate with other integrative clinicians on a holistic treatment plan.

Keep in mind that medication is a very helpful tool to support the brain processing differences due to ADHD. It is important to collaborate with your doctor to find the most effective medication and dosage for you. There may be times when more medication is needed, and times when it can be decreased or eliminated. We know that the level of impairment that comes with ADHD can fluctuate over a lifespan. The change can happen because one’s environment (school or job tasks) changes, if lifestyle habits are optimized, or if treatment tools are used successfully.

The whole-person approach looks at how ADHD affects all of one’s health and lifestyle, and vice versa. It is important to start treatment gradually and to have support — family, ADHD community, nutritionist, coach, or clinician — along the way to better wellbeing.

Integrative Medicine: Next Steps

• Free Download: Everyday Foods Filled with Omega-3s
• Read: Somatic Therapy: Understanding the ADHD Brain, Body & Trauma
• Read: ADHD Therapy Overview: The 9 Best Treatments for Children and Adults

How to Treat ADHD in Children: Next Questions

1. What ADHD medications are used to treat children?
2. Is ADHD medication right for my child?
3. What are common side effects associated with ADHD medication?
4. What natural treatments help kids with ADHD?
   • What are the most effective natural ADHD treatments for kids?
   • What foods can help control ADHD symptoms?
   • What vitamins and supplements should my child take?
   • Does brain training help with ADHD?
   • How much and what type of exercise helps kids with ADHD?
   • What types of therapy help patients with ADHD?
5. What if the medication stops working?
6. How can I find an ADHD specialist near me?

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Sources

¹ Zylowska, L., Ackerman, D. L., Yang, M. H., Futrell, J. L., Horton, N. L., Hale, T. S., Pataki, C., & Smalley, S. L. (2008). Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study. Journal of attention disorders, 11(6), 737–746. https://doi.org/10.1177/1087054707308502

² Mehren, A., Özyurt, J., Lam, A. P., Brandes, M., Müller, H., Thiel, C. M., & Philipsen, A. (2019). Acute Effects of Aerobic Exercise on Executive Function and Attention in Adult Patients With ADHD. Frontiers in psychiatry, 10, 132. https://doi.org/10.3389/fpsyt.2019.00132

³ Hong, S. S., & Cho, S. H. (2011). Acupuncture for attention deficit hyperactivity disorder (ADHD): study protocol for a randomised controlled trial. Trials, 12, 173. https://doi.org/10.1186/1745-6215-12-173

⁴ Ventriglio, A., Sancassiani, F., Contu, M. P., Latorre, M., Di Slavatore, M., Fornaro, M., & Bhugra, D. (2020). Mediterranean Diet and its Benefits on Health and Mental Health: A Literature Review. Clinical practice and epidemiology in mental health : CP & EMH, 16(Suppl-1), 156–164. https://doi.org/10.2174/1745017902016010156

⁵ Yeh, TS, Yuan, C., et. al. (July 28, 2021). Long-term dietary flavonoid intake and subjective cognitive decline in US Men and Women. Neurology, 97(10). https://doi.org/10.1212/WNL.0000000000012454

⁶ Meireles, M., Moura, E., Vieira-Coelho, M. A., Santos-Buelga, C., Gonzalez-Manzano, S., Dueñas, M., Mateus, N., Faria, A., & Calhau, C. (2016). Flavonoids as dopaminergic neuromodulators. Molecular nutrition & food research, 60(3), 495–501. https://doi.org/10.1002/mnfr.201500557

⁷ Carabotti, M., Scirocco, A., Maselli, M. A., & Severi, C. (2015). The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Annals of gastroenterology, 28(2), 203–209.

⁸ Foster, J. A., Rinaman, L., & Cryan, J. F. (2017). Stress & the gut-brain axis: Regulation by the microbiome. Neurobiology of stress, 7, 124–136. https://doi.org/10.1016/j.ynstr.2017.03.001

⁹ Darling, K. A., Eggleston, M., Retallick-Brown, H., & Rucklidge, J. J. (2019). Mineral-Vitamin Treatment Associated with Remission in Attention-Deficit/Hyperactivity Disorder Symptoms and Related Problems: 1-Year Naturalistic Outcomes of a 10-Week Randomized Placebo-Controlled Trial. Journal of child and adolescent psychopharmacology, 29(9), 688–704. https://doi.org/10.1089/cap.2019.0036

¹⁰ Johnstone JM, Hatsu I, Tost G, et al. Micronutrients for Attention-Deficit/Hyperactivity Disorder in Youths: A Placebo-Controlled Randomized Clinical Trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2021 Jul. DOI: 10.1016/j.jaac.2021.07.005. PMID: 34303786.

¹¹ Ghoreishy, S.M., Ebrahimi Mousavi, S., Asoudeh, F. et al. Zinc status in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis of observational studies. Sci Rep 11, 14612 (2021).

¹² Bener, A., Kamal, M., Bener, H., & Bhugra, D. (2014). Higher prevalence of iron deficiency as strong predictor of attention deficit hyperactivity disorder in children. Annals of medical and health sciences research, 4(Suppl 3), S291–S297. https://doi.org/10.4103/2141-9248.141974

¹³ Effatpanah, M., Rezaei, M., Effatpanah, H., Effatpanah, Z., Varkaneh, H. K., Mousavi, S. M., Fatahi, S., Rinaldi, G., & Hashemi, R. (2019). Magnesium status and attention deficit hyperactivity disorder (ADHD): A meta-analysis. Psychiatry research, 274, 228–234. https://doi.org/10.1016/j.psychres.2019.02.043

¹⁴ Derbyshire E. (2017). Do Omega-3/6 Fatty Acids Have a Therapeutic Role in Children and Young People with ADHD?. Journal of lipids, 2017, 6285218. https://doi.org/10.1155/2017/6285218

¹⁵ Dimpfel, W., Schombert, L., Keplinger-Dimpfel, I. K., & Panossian, A. (2020). Effects of an Adaptogenic Extract on Electrical Activity of the Brain in Elderly Subjects with Mild Cognitive Impairment: A Randomized, Double-Blind, Placebo-Controlled, Two-Armed Cross-Over Study. Pharmaceuticals (Basel, Switzerland), 13(3), 45. https://doi.org/10.3390/ph13030045

¹⁶ Akhondzadeh, S. et.al. (2005). Passiflora incarnata in the treatment of attention-deficit hyperactivity disorder in children and adolescents. Therapy 2(4);609-614. 10.1586/14750708.2.4.609

¹⁷ Lee, S. H., Park, W. S., & Lim, M. H. (2011). Clinical effects of korean red ginseng on attention deficit hyperactivity disorder in children: an observational study. Journal of ginseng research, 35(2), 226–234. https://doi.org/10.5142/jgr.2011.35.2.226

¹⁸ Shakibaei, Fereshteh, et al. “Ginkgo Biloba in the Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. A Randomized, Placebo-Controlled, Trial.” Complementary Therapies in Clinical Practice, vol. 21, no. 2, Apr. 2015, pp. 61–67., doi:10.1016/j.ctcp.2015.04.001.

¹⁹ Trebatická, J., Kopasová, S., Hradecná, Z., Cinovský, K., Skodácek, I., Suba, J., Muchová, J., Zitnanová, I., Waczulíková, I., Rohdewald, P., & Duracková, Z. (2006). Treatment of ADHD with French maritime pine bark extract, Pycnogenol. European child & adolescent psychiatry, 15(6), 329–335. https://doi.org/10.1007/s00787-006-0538-3

²⁰ Dave, U. P., Dingankar, S. R., Saxena, V. S., Joseph, J. A., Bethapudi, B., Agarwal, A., & Kudiganti, V. (2014). An open-label study to elucidate the effects of standardized Bacopa monnieri extract in the management of symptoms of attention-deficit hyperactivity disorder in children. Advances in mind-body medicine, 28(2), 10–15.

²¹ Katz, M., Levine, A. A., Kol-Degani, H., & Kav-Venaki, L. (2010). A compound herbal preparation (CHP) in the treatment of children with ADHD: a randomized controlled trial. Journal of attention disorders, 14(3), 281–291. https://doi.org/10.1177/1087054709356388

These are some of the statements I hear from clients diagnosed with ADHD. To help them see themselves the way I see them — and to notice all the ways in which they are successful — I use a therapy technique called cognitive restructuring.

What is Cognitive Restructuring?

Cognitive restructuring is one of the primary techniques used in cognitive behavioral therapy (CBT). The premise of CBT is that our thoughts and beliefs influence our feelings, which in turn influence our behavior. So if we think crappy things about ourselves, we will feel crappy and be less able to do the things necessary to live well with ADHD. Cognitive restructuring is a fancy way of saying, “Change the way you think.”

How do you change the way you think? You can try choosing to believe the opposite of your negative thoughts: I am successful. I can do anything I set my mind to. I am normal. Affirmations like these have their place in your positive-thinking repertoire, but there’s likely to be a part of you that says, “Yeah, right.”

Cognitive Restructuring Tip #1: Seek Out a Different Perspective

One way to change the way you think is to actively seek out a different perspective. What is another way of looking at it? A guy I met at a party said to me, “Everyone has issues. Everyone.” Of course, I argued with him (we with ADHD are pretty good at arguing any point). But I couldn’t meet his challenge to name one person who is without issues. This is now one of my mantras when I’m feeling down on myself. I feel less alone, less of a victim.

[Read This Next: How Cognitive Behavioral Therapy Works]

You can also use evidence gathering, another staple of CBT. Think about all those times when you were successful, when you didn’t fail. The more examples you come up with, the more you will be able to start to believe that it isn’t true that you fail at everything. You can believe you are successful some of the time.

Cognitive Restructuring Tip #2: Use Metaphor

Using metaphor in cognitive behavioral therapy is an approach I’m especially fond of — and it is effective for my clients. CBT founder Aaron T. Beck, M.D., championed the use of metaphor early on. He saw it as a powerful way to generate alternative ways of thinking. A metaphor applies a concept we understand to something harder to grasp, in a vivid, catchy way. A good metaphor is paradigm altering; you can’t un-see it once you’ve seen it.

To be therapeutically effective, you want the metaphor to be strength-based. You could equate ADHD to quicksand, but that’s likely to keep you stuck. You want the metaphor to suggest a new, positive way of thinking about the situation.

Edward Hallowell, M.D., a leading authority on ADHD and co-author of the best-selling Driven to Distraction, likens ADHD to having a race-car brain and bicycle brakes. He explains to his newly diagnosed patients that their brain is very powerful and capable of winning races (doing well in life). But they have bicycle brakes, so they can’t slow down very well; they are impulsive on many fronts. He describes himself as a brake specialist.

[Click to Read: The Success Mindset for ADHD Procrastinators, Dreamers & Survivors]

Cognitive Restructuring Tip #3: Reframe Distractions

I like to share the “paperweight metaphor” with my clients. Imagine you and a colleague decide to go to the park and get some work done. You each go to a picnic table and spread out your papers (there are no electronics in this metaphor). You arrange them in neat stacks. You look over and notice that your colleague has done the same. But she puts a paperweight on each of her stacks.

Paperweights, brilliant! But you don’t have any paperweights. The wind blows and your papers fly away. Your colleague looks up for a moment, smiles at the breeze, and gets right back to work, her papers safely secured. You have to track down your papers. You finally gather them up, lay them out, and start to work again. And the wind blows again and you’re back to chasing papers, because you don’t have any paperweights.

You and your colleague are equally smart, equally talented, equally capable. She gets more done because she isn’t affected by the wind (distractions). You are not “less than” just because you weren’t given paperweights at birth like 95 percent of the population.

Cognitive Restructuring Tip #4: Make Sure Your “On” Switch Isn’t Turned “Off”

Another metaphor I like to use with clients with ADHD is the circuit and the switch. Everyone, neurotypical or not, can be compared to a simple electrical circuit. Current runs through the circuit and powers equipment such as a light bulb. Everyone’s circuit has a switch in this metaphor. Turn on the switch and the light comes on. Turn off the switch and the light goes out. The current in people with ADHD is just as strong as anyone’s, and our light just as bright. But our switch is not reliable. It turns itself off when we get distracted or overwhelmed and our light goes out.

We have to keep an eye on the switch and be ready to turn it back on. That means we have to use our coping strategies without fail. Structure, good sleep, diet, exercise — those are the things that keep the switch on. It seems unfair that some people have more reliable switches. But it’s just the switch. There’s nothing wrong with our basic circuitry. That’s the point I want my clients to get.

With metaphor, we can move from “It’s a given that I’m (insert negative belief here)” to the ability to challenge that assumption and generate hope. We can make sense of the problem. We come out of that dark place of feeling alone and misunderstood. There’s a sense of “Ah, that’s a thing.”

[Relax! It’s Part of Your Treatment Plan]

Another good thing about metaphors in therapy is that they help clients remember what was said in the session. Information is more likely to be remembered if it’s accompanied by vivid imagery.

Some clients use metaphors to help the therapist fully understand their experience. They can be used to describe a feeling, a thought, or a belief that may be too complex to describe in simple sentences. This shared understanding leads to improved rapport and therapeutic alliance. Metaphors that come from the client are more likely to resonate with them, so I encourage them to do it.

Sometimes in sessions I find the client and I will pass a metaphor back and forth, each expanding on it as we gain clarity. We use it as shorthand: “What happened to your switch?” “What do you want to use as a paperweight?” or “Yeah, there go my bicycle brakes again.” The ADHD community feels misunderstood. Shared metaphor lets them know they are understood, accepted, and valued.

Cognitive Restructuring and ADHD: Next Steps

• Download: Everything You Need to Know About CBT
• Learn: How CBT Dismantles ADHD Negativity
• Read: Putting a Stop to Negative Thoughts

Beth Main, LCPC, BCC, is an ADHD coach, therapist, and founder of ADHDSolutions.net. She specializes in using a cognitive-behavioral approach to helping people with ADHD overcome their challenges and achieve success.

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The Emotional Symptoms of ADHD

The prefrontal cortex is a busy intersection through which attention, behavior, and emotions zoom. In ADHD brains, this intersection is unregulated, causing runaway emotions to barrel right through, slamming into the other cars on the road. This dysregulated emotion could look like rejection sensitive dysphoria, extreme anger, frustration, or any other strong feeling of the moment.

How Inflow Helps

Inflow is the #1 app to help you better manage ADHD. It is based on the principles of cognitive behavioral therapy (CBT) and combines psychoeducation, habit development as well as community support.

Enter to Win a One-Year Inflow Subscription

To win a one of two one-year subscriptions to Inflow (a $95.99 value each), use the Comments section below to tell us: What kind of emotional dysregulation most impacts your life and how do you deal with it?

Deadline

Saturday, July 31, 2021, at 11:59 pm EST.

Rules

One entry per household. The editors of ADDitude will select one winner at random and notify them via email on Monday, August 2, 2021. (Full official rules)

This lack of awareness and training extends beyond diagnosis and into effective treatments for this demographic. Learn more about the importance of screening for attention deficit hyperactivity disorder (ADHD or ADD) in older adults, along with proven treatment and lifestyle intervention, in this Q&A session with Kathleen Nadeau, Ph.D., director of the Chesapeake ADHD Center in Bethesda, Maryland.

Q: What is the best way to find a doctor who specializes in ADHD in older adults?

It’s not easy. Major metropolitan areas tend to be home to strong ADHD specialty clinics. If you’re located outside a city, it’s a good idea to get a formal assessment in such a place to bring back to your primary care physician for ongoing care, especially if they don’t feel qualified to evaluate you, or are reluctant to do so. These forms outline the diagnostic procedure and the recommended treatment course for the individual.

It’s also important to note that anyone who is truly an expert in diagnosing ADHD in older adults will not limit themselves to the DSM-V for diagnosis because the ADHD symptoms listed therein apply largely to children and do not reflect the adult experience with attention deficit for most people.

As a patient, I’d question clinicians who rely too much on understanding your ADHD symptoms in childhood. If others, like siblings, can speak to this, then it is helpful information. But, for the most part, interviews about the distant past will likely yield inaccurate responses. Whose memory is accurate 60 years later? Beyond that, symptom presentation can differ over the years, and lifestyle factors can do a great deal in “concealing” ADHD symptoms.

[ADHD in Older Adults — Symptom Overview]

Q: Speaking of symptoms – for women, can diagnosis be complicated later in life by menopause?

What we know is that the brain is a target organ for estrogen. What that means is that, when estrogen levels fluctuate, our dopamine and serotonin receptors — which are linked to attention, self-management, anxiety, and mood disorder — are less sensitive. We also know that estrogen levels start declining on average at around 40, and that decline over many years can greatly exacerbate ADHD symptoms. Overall, there is ample evidence to suggest an estrogen-ADHD symptom connection, and we need more research on the link.

Q: What treatments and interventions are best for older adults with ADHD?

One of the first things I talk about with older patients after diagnosis is instilling brain-friendly daily habits that improve health and cognition. This includes:

• Sleep: Recent research shows that during certain phases of deep sleep, our brains are cleansed of the toxins that can become the beginning of Alzheimer’s, for example. Adequate sleep is critical to overall health and functioning.
• Nutrition: I always counsel patients to consume low-glycemic foods, to limit starch and sugar, and to have protein at every meal. This combination makes for a level supply of glucose, which is what our brains run on.
• Stress management
• Exercise

Structure and social interaction are crucial for older adults with ADHD as well. It’s important to remain connected to others, as healthy relationships boost our mood and focus. I encourage my patients to take active steps toward social interaction in activities and meeting others. One way to do so is through senior living communities, where social life and activities are built in. Some older adults may also benefit from working in retirement.

[Read This: Older Adults with ADHD are Staying Safe – but Really Lonely]

Executive function coaching is also a great way to promote structure by working on everyday issues with problem-solving, habit development, time management, organization, money management, and so on.

Q: What about stimulants? Are they safe to prescribe to older adults to treat ADHD?

In my experience, a great many adults can tolerate stimulant medication and benefit from them. For individuals with cardiovascular problems, approval from a primary care physician or cardiologist is needed prior to prescribing stimulants (this goes for a patient with ADHD of any age). We also start prescribing at very low doses.

Overall, many psychiatrists and primary care providers are reluctant to prescribe stimulants, and often for no good reason. They’re usually worried about the interaction between stimulants and other medications, as older adults are more likely to be taking several medications, or about the impact of stimulants on the heart. I find this ironic because in geriatric medicine it’s not uncommon at all to prescribe stimulants to wake up the brain and provide energy.

Often, guidance and documentation from an outside ADHD clinic (as mentioned above) is enough to get the primary care provider to prescribe stimulants. If stimulants don’t work, older adults may also benefit from non-stimulants.

Q: Is there a significant benefit to a late-life ADHD diagnosis?

There are tremendous benefits to getting a diagnosis at any point in life, but certainly this is true in later years. I do hear people make ageist statements sometimes, like, “Why does it matter if you have ADHD? You’re 72.” But it does matter; having a diagnosis and proper treatment hugely impacts quality of life.

Living with undiagnosed ADHD makes life more stressful, and makes individuals feel badly about themselves. The diagnosis alone is therapeutic, and it allows us to help older adults restructure their lives. My advice to older adults who think they have ADHD is to stop dismissing yourself.

The content for this article was derived from the ADDitude Expert Webinar “ADHD in Older Adults: From Late Diagnosis to Treatment Strategies” by Kathleen Nadeau, Ph.D., (podcast episode #331), which was broadcast live on November 5, 2020.

Older Adults with ADHD: Next Steps

• Read: Inside the Aging ADHD Brain
• Guide: How to Retire with ADHD – Structure, Stimulation, Purpose
• Resource: When I’m 64 – Why ADHD Treatment Gets Tougher with Age

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.

It’s a common and understandable question, especially for those newly diagnosed with attention deficit hyperactivity disorder (ADHD or ADD). Gauging whether a medication is working as well as it should, or whether it’s the right medication at all, requires consistent self-appraisal and ongoing communication with your clinician regarding symptom control — or lack thereof. It also requires patience as the clinician works to potentially adjust or switch medications before settling on the right combination for you.

How to Tell If Your ADHD Medication is Working: Targets and Adjustments

The following two questions will help you and your clinician determine whether the current ADHD medication and/or dose is ideal and effective:

1. What are you expecting from ADHD medication?

Any medication should work to decrease ADHD symptoms at the lowest optimal dose. To know for sure if the medicine is accomplishing this, first work with your clinician to come up with a list of four or five target symptoms that can actually be measured before starting on medication.

Choose target symptoms that are already known to respond well to medication. They include (but are not limited to):

• Distractibility
• Procrastination, difficulty getting started on boring tasks
• Restlessness, fidgeting
• Mood lability
• Emotional overreactions
• Impulsivity, acting or speaking without thinking
• Temper flashes and outbursts
• Poor reading speed, comprehension, and retention
• Difficult to stick with boring activities to the pay-off
• Scattered, misplace things

ADHD symptoms that are known to not be influenced as much by medication include:

• Organization
• Sense of time
• Forgetfulness
• Argumentativeness; disobeying rules

[Click to Download Our Free ADHD Medication & Symptom Tracking Log]

2. Are you seeing improvement in your target ADHD symptoms?

Your doctor will likely start you on a stimulant – the first line treatment for ADHD – at a low dose, and increase it periodically in the smallest increments manufactured. Stimulant medications are completely effective the first time you take them as soon as they reach the brain. You will see all of the benefits and all of the side effects of that medication and dose right from the very first day.

This means that late adolescents and adults can adjust their dose every day if they want to. Children, however, who lack self-perception and lack the words to describe what they are experiencing, need more time at each dosage level in order to accurately assess the effects of the ADHD medication. Elementary-aged children should see their doctors regarding a dose change no more often than every 5-7 days so that the observations of both parents and another observer (like a school teacher) can be incorporated in the decision to raise or lower the dose.

The patient can keep increasing the medications so long as each time they do, they get a clear improvement in all of their target symptoms and only minimal side effects. If the patient increases the dose and does not see further improvement, then the previous lower dose is that person’s “sweet spot” dose. It is the lowest dose that provides optimal level of benefits without significant side effects. But how can you tell if you’re improving?

How to Tell If Your ADHD Medication is Working: Scales and Tests

On a Scale of 1 to 10…

Without overthinking it, rank or score your current ADHD medication on a scale of 1 to 10: 1 being just awful – nothing but side effects – and 10 being the best you can imagine a medication ever working.

Many clinicians ask some version of this question to patients and require other self-appraisals to determine how well the medication is reducing symptoms. Generally, they’re looking for scores of 8 through 10. Nine is a very good response to medication. For most people, the lowest acceptable score is a 7.

ADHD stimulant medications are not subtle – they are some of the most effective medications in all of medicine. Most clinicians have found that people who respond with a 6 or lower, therefore, can do much better on a different medication or a difference dose. So, if you think that you have fine-tuned this particular medication but you are not experiencing a life-changing level of improvement, continue to work with your clinician to find the right medication and dose for you.

Standardized Medication Scales

There is only one scale that is research validated to be able to monitor progress in medication response trials – the Conner Global Index Scale, designed for children ages 3 to 17. It is filled out by the teacher and a parent, which asks for ratings across several areas including restless-impulsive behaviors and emotional lability. The scale is administered prior to medication so as to come up with a baseline for comparison while a child is on medication.

[How Does ADHD Medication Work? Your First Questions Answered.]

Performance Testing

Some clinicians test symptom improvement by conducting computerized continuous performance testing (for example, the TOVA, the Quadrant, the Conner’s etc.). This is a single measurement in time of two major areas of impairment from any cause of 1) vigilance, attention, distractibility, and 2) impulse control. As with standardized scales, testing has to start prior to treatment to create a baseline to which subsequent tests on various doses of medication can be compared. The cost is about $100 per test. However, it’s worth noting that some individuals who effectively hyperfocus can achieve high or “normal” scores on these tests on or off medication. In such cases these tests are not useful or informative.

No matter the method, your doctor will work to arrive at an optimal dose by increasing the dosage until it no longer results in further improvement (or until worsened symptoms and side effects appear) – the previous dose, therefore, was the lowest to achieve optimal performance.

How to Tell If ADHD Medication is Working: Treatment Troubleshooting

Not everyone responds well to stimulant medications. In fact, about 15 percent of individuals who have tried both of the usual stimulant class medications (methylphenidate and amphetamine) either do not see any benefit or cannot tolerate the side effects even at the lowest doses.

If all signs indicate that a given stimulant medication is not working, the treatment troubleshooting process typically goes like this:

1. Check the diagnosis. Evaluation and diagnosis mistakes do happen. Go back to the drawing board to be sure that you have the right diagnosis and all of the diagnoses that are present.
2. Check absorption. If a patient shows no benefits and no side effects, this may indicate that the medication isn’t being properly absorbed. It’s best to avoid organic acids (citric acid or ascorbic acid, like fruit juices, soft drinks, daily multivitamins) about one hour before and after taking the dose. (Note: Vyvanse and Daytrana are the only stimulants not affected by organic acid intake). Transdermal delivery (via a skin patch) can also be tested.
3. Try non-stimulants. Non-stimulant medications (clonidine, guanfacine) are the second-line treatment for ADHD. While research shows that stimulants are more effective, many individuals can see positive responses from non-stimulants. The next most effective class of medications are the alpha agonist drugs clonidine (Kapvay) and guanfacine (Intuniv). The non-stimulants are most effective with symptoms of hyperactivity and impulsiveness (i.e. excess energy, insomnia, multiple simultaneous thoughts).
4. Try atomoxetine. Strattera is a good third line medication. It is a noradrenaline reuptake inhibitor, and so it has a sizable response rate (about 50%), and can be added to other medications. Unfortunately, Strattera also has a high side effect burden especially in adults.
5. Consider methamphetamine. Sold under the brand name Desoxyn, this drug is approved for ADHD treatment. And yet, it still carries negative connotations among many patients and clinicians. Many individuals with ADHD, however, who did not get a good response from any of the alternatives above will get a very good response to methamphetamine with few side effects and at very low doses. The negative connotations to just the name of “methamphetamine” makes it extremely difficult to find a patient willing to take it, a clinician willing to prescribe it, and a pharmacy willing to carry it in stack.

How to Tell If ADHD Medication is Working: Next Steps

• Download: The Ultimate Guide to ADHD Medication
• Read: How Does ADHD Medication Work? With Lots of Monitoring
• Learn: 10 Things Your Doctor May Not Have Told You About ADHD Medications

How to Treat ADHD in Children: Next Questions

1. What ADHD medications are used to treat children?
2. Is ADHD medication right for my child?
3. What are common side effects associated with ADHD medication?
4. What natural treatments help kids with ADHD?
5. What if the medication stops working?
   • How long will it take to get the medication and dosage right?
   • How do we know the medication is working?
   • When is it time to switch medications?
   • How can we safely treat ADHD alongside its comorbid conditions?
   • What should I do if my child stops taking their medication?
   • How can we solve medication rebound problems?
6. How can I find an ADHD specialist near me?

The content for this article was derived from the ADDitude Expert Webinar “Optimizing ADHD Medication: Strategies for Achieving Better Symptom Management” by William Dodson, M.D. (available as ADDitude ADHD Experts Podcast episode #277), which was broadcast live on November 13, 2019.

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Cognitive behavioral therapy (CBT) and ADHD coaching are typically the first non-medical treatments recommended to adults with attention deficit disorder. The two therapies share many similarities — and important differences in their approaches to improving functioning and well-being in adults with ADHD, their delivery methods, and the professionals trained and qualified to deliver each treatment.

Listen and learn from David Giwerc, a Master Certified Coach, and Dr. Russ Ramsay, who specializes in CBT for adult ADHD, about:

• How ADHD coaching and CBT treat ADHD in adults
• The respective training and credentialing of ADHD coaches and CBT therapists
• Similarities and differences in how the therapies promote ADHD symptom management
• How CBT and ADHD coaching complement each other

*Please note: The Q&A portion of this webinar was cut short, so the experts answered questions from attendees in a separate article: ADHD Therapy Comparison: CBT vs. ADHD Coaching.

Watch the Video Replay

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Read More on CBT and ADHD Coaching

• “ADHD Therapy Comparison: CBT vs. ADHD Coaching”
• “What Is An ADHD Coach?”
• “Cognitive Behavioral Therapy Overview”

Obtain a Certificate of Attendance

If you attended the live webinar on October 8, 2020, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speakers:

David Giwerc is a Master Certified ADHD Coach (MCAC), with the Professional Association of ADHD Coaches (PAAC) and a Master Certified Coach, MCC, with the International Coach Federation (ICF). He is also the Founder and President of the ADD Coach Academy (ADDCA), the first and largest comprehensive ADHD coach training program fully accredited by the ICF and PAAC, the governing bodies of the Life Coaching and ADHD Coaching Professions.| See expert’s full bio »

Dr. J. Russell (“Russ”) Ramsay is co-founder and co-director of the University of Pennsylvania’s Adult ADHD Treatment and Research Program and an associate professor of clinical psychology in psychiatry in the University of Pennsylvania Perelman School of Medicine. He has authored five books and numerous peer-reviewed professional and scientific articles, research abstracts, as well as many book chapters on issues related to adult ADHD. He is a member of the CHADD Hall of Fame, serves on the editorial board of the Journal of Attention Disorders, and has served on the Professional Advisory Boards of ADDA, CHADD, Totally ADD, on the Board of Directors of APSARD, and on the Scientific Advisory Board of ADDitude. | See expert’s full bio »

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The transition to digital technology is good news for existing patients stuck at home and for those new to therapy and eager to find help, especially as heightened anxiety, stress, and fear clash with existing conditions like attention deficit hyperactivity disorder (ADHD). Here’s what online therapy looks like, how it can help, and what factors to consider as the treatment landscape changes for adults and children with ADHD.

What is Online Therapy?

Online therapy refers to mental health services provided outside of a traditional office, usually over the Internet using video conferencing on a HIPAA-secure platform. But it doesn’t stop there. Therapists also work with patients on phone calls, e-mails, texts, and newly expanded websites and apps designed to connect users to mental health care providers.

Prior to the pandemic, some mental health professionals used teletherapy to supplement in-person visits, while some worked almost entirely online. Now, the latter is the temporary norm.

Therapy, whether in person or via teletherapy, can help treat neurological and psychological disorders like panic disorder, anxiety, and obsessive compulsive disorder (OCD). Therapists can help their patients better manage stress and cope with life’s many hurdles, including the unique challenges brought about by conditions like ADHD.

[Click to Read: ADHD Catastrophizing in Times of Crisis]

Dr. Maria Zimmitti, president of Georgetown Psychology, a practice with offices in Washington D.C., Maryland, and Virginia, has spent more than 20 years evaluating and treating children, adolescents, and adults with ADHD.

“ADHD treatment is comprehensive,” she said, noting that treatment can and often does extend beyond medication. For many people with ADHD, symptoms like impulsivity, executive dysfunction, and poor focus trigger further problems ranging from low self-esteem, behavioral and interpersonal problems, and mood disorders. Therapy can effectively address many of these problems, making it an important component of ADHD treatment.

Many parents of children with ADHD also benefit from therapy designed to help them better manage their child’s behavior and symptoms. The American Academy of Pediatrics recommends combining medication treatment with behavior therapy for children with ADHD.¹

Teletherapy is a convenient and effective option for many patients — and providers. Zimmitti’s practice, which began offering online therapy years ago, shifted entirely online in a matter of days in response to the outbreak, and continues to provide support for patients who are sheltering in place.

[Pandemic Anxiety Getting to You? 10 Expert Coping Strategies]

“Telehealth is now the primary mode that most therapists are working in, which is a drastic change from a couple of weeks ago,” Zimmitti said, noting a recent uptick in anxiety symptoms like stomach aches, worries, and fears about germs among many patients.

“Families are under unexpected, unplanned, and never-before-experienced stress because of this pandemic,” she said.

How Can Online Therapy Help Now?

Though face-to-face therapy is unsafe now, mental health professionals today are largely keeping their “doors” open online, not just to continue caring for existing patients, but to work with first-time patients and parents who need new and timely support.

“Teletherapy support for parents, including parents of children with ADHD, is helpful and can be offered in the form of virtual support groups and online resources,” she said. “Research has shown that training parents in interventions to deal with a child’s ADHD symptoms can be done effectively with teletherapy.”

For patients experiencing extreme stress over the outbreak, Zimmitti said she is focusing on teaching strategies that emphasize social connection and good health habits, and promote self-regulation.

“The first thing we want to do is normalize anxiety,” she said. “Anxiety in and of itself is not a bad thing, and they certainly are in good company; the world is feeling anxious right now.”

Helping children feel in control, especially under uncertain circumstances, is important. Having kids wash their hands frequently and stay at home to promote health is one way to help ease anxiousness. Devising and maintaining a reliable schedule — including adequate sleep, exercise, meal times, and recreation — helps as well.

The social distancing measures widely in effect should not be conflated with social isolation, which can increase the risk for mood disorder, poor sleep quality, and other adverse effects.² Some ideas include:

• Organizing virtual playdates
• Meeting up for coffee over Zoom
• Signing up for online classes in art, yoga, anything
• Video calls with grandparents and other family members

What Does Online Therapy Look Like?

Online therapy retains the structure and goals of in-person sessions. Sessions are conducted from home or another convenient location that is secure, quiet, and private — both for the therapist and the patient. Protecting a patient’s privacy means ensuring that no one else is in the room, and insisting that everyone wear headphones during the session, which may take place using any Internet-enabled device including desktop computer, laptop, tablet, or smartphone.

Most therapists use HIPAA-compliant platforms and technologies for services. Typically, penalties would exist for failing to do so, however enforcement has been temporarily relaxed in light of the public health emergency.³ Non-compliant technologies like FaceTime and Skype, therefore, can be used without risk of penalty with patient consent.

“The biggest issue, I think, is making sure the technology is working,” Zimmitti said. “If it’s not, then that certainly can be frustrating for patients, but typically, once you work out the kinks, it runs very smoothly.”

Online therapy is a convenient, easily accessible way to continue essential care. Some facets of in-person sessions, however, are lost online. “The sessions tend to be more waist-up in terms of how you’re seeing people,” she said. “You’re going to miss some of the non-verbal pieces that you might get otherwise.” That includes knowing when a patient might be looking at their phone during an online session or reading full body language.

Still, the benefits outweigh the minimal downsides. “People show up for appointments more consistently with teletherapy because they don’t have the hassle of all the things that can get in the way,” she said. “It opens up therapy for a lot of people who would struggle to get it otherwise.”

Is Online Therapy Right for You?

Online therapy is effective ⁴ for many patients and practitioners, but it’s not right for everyone. Meanwhile, the pandemic is driving up demand for online therapy and forcing mental health professionals into unchartered territory.

Online therapy is generally not appropriate for someone in crisis, who would benefit more from in-person sessions and other targeted resources. Still, if teletherapy is deemed appropriate for a patient, therapists will develop a crisis plan to use in the event that an emergency arises.

Therapists largely prefer to see new, potential patients in person first and conduct evaluations face-to-face, which is often not possible during the pandemic.

“In-person intakes are optimal,” Zimmitti said. “But given the current situation, initial sessions are being done via videoconferencing, which is why therapists must be especially detailed and include rating scales and structured interviews to assess a client’s symptoms.”

Those interested in teletherapy should reach out to their insurance company to see if the service is covered, or if co-pays have been waived in response to the pandemic; many health insurance providers have temporarily done this ⁵. Fees vary depending on the practice, but rates may be the same for in-person and teletherapy sessions.

Though some states have temporarily lifted their licensing restrictions, allowing out-of-state therapists and clinicians to treat residents, it is recommended that individuals new to therapy look for professionals licensed in their state to ensure continuity of care once the crisis settles.

To find a therapist who specialize in ADHD, these resources may help:

• The ADDitude Directory
• The CHADD Professional Directory
• Psychology Today Therapist Directory

“If you’re having trouble, reach out for help,” Zimmitti said. “Teletherapy is an effective and an appropriate treatment during COVID and beyond.”

[Read This Next: Now Is the Time for Realistic Expectations (and More ADHD Advice for a Pandemic)]

Sources

¹ Wolraich,M., Hagan, J., et. al. (2019, Oct.) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144 (4) e20192528; DOI: https://doi.org/10.1542/peds.2019-2528

² Novotney, A. (2019, May). The risks of social isolation. Monitor on Psychology. Vol. 50. No. 5. Retrieved from https://www.apa.org/monitor/2019/05/ce-corner-isolation

³ Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. Retrieved March 30, 2020 via https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

⁴ Andrews, G. et. al. (2018, April). Computer therapy for the anxiety and mood disorders is effective, acceptable and practical health care: an updated meta-analysis. Journal of Anxiety Disorders. 55. 70-78. https://doi.org/10.1016/j.janxdis.2018.01.001

⁵ Health Insurance Providers Respond to Coronavirus (COVID-19). (2020, March 6). Retrieved from https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

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My obstacles appeared early. When I was 7, I started disturbing the other children in my class. I clearly couldn’t concentrate and for the life of me, I couldn’t sit still. Not long after that, I was diagnosed with attention deficit hyperactivity disorder (ADHD), Tourette’s Syndrome, and dyslexia. Medication was prescribed to help me perform better in school; another pill stopped the twitching.

Taking the medication always made me feel anxious. It made my heart beat faster and pump louder. It brought my eyes into a strange tunnel vision but also helped me concentrate enough to get through the school day.

It’s true I performed better at school with the help of the medication, but the quality of my life decreased significantly in other areas. When I was medicated, I never felt like my normal self. I felt more like a zombie, going through the motions but never really experiencing them.

Getting pulled out of class to join a small group of other kids with learning disabilities destroyed what little confidence I had. I felt like an outcast and I painfully remember my friends snickering and laughing every time I left. I hated being the dumb kid in the class — the one who needed extra help, extra attention. I bottled up my emotions and never shared my feelings with my parents or anyone else.

[Read This Next: “The Day I Was Shamed at School”]

This soul-sucking pattern — medication, feeling like a zombie, special education humiliation, followed by the post-medicine crash at the end of the day — continued for years. I worked hard to stay under the radar. I prayed no one would talk to me or notice me, which is not a healthy way to live and grow.

Looking back, I can see that’s when the seeds of self-hatred started taking root. Late in the day, when the meds were out of my system, I remember feeling really angry. Thankfully this was followed each day by one hour of sheer bliss — from 5 to 6 p.m. I was happy.

On the squeaky floor of the indoor basketball court, I got relief. Basketball was my saving grace. I loved the fast movements, the sweaty camaraderie, and the thrilling rush of endorphins. At basketball practice, I was calm and content. It was the only place I felt like me and it was where my love of exercise, fitness, and nutrition was born.

The End of ADHD Medication

By the time I got to high school, I was still taking prescription medication and hating it. One day, during geometry class, everything changed…

Math never came easily for me, so my anxiety was always through the roof during that class. But this day was different. I started sweating profusely and noticed that my heart was pounding, racing faster and louder in my ears. Then my vision got blurry and I felt dizzy. When I got up out of my seat, I fell to my knees. Another student helped me to the nurse. From there I was sent to the hospital where — after multiple tests and symptom checks — I was told I had suffered a panic attack.

[You Might Also Like: The Exercise Solution for ADHD]

I was a 14-year-old freshman and already feeling pressure to excel. I knew good grades and participating in extra-curricular activities were important for college admissions, but I didn’t think my current path would lead me there. I wanted to make a change and started to wonder if there was another way to deal with my symptoms of ADHD and anxiety.

The day after my hospital trip, I stayed home from school and told my mom I was done with meds. She was understandably concerned. What parent wouldn’t be? Stopping ADHD medication might have negative consequences, but I was determined to find a different way.

From my earliest days, I never wanted extra time for tests, smaller classrooms, or additional help. I just wanted to be like everyone else. I wanted to work hard and rise to the occasion because I knew I could. I was raised to believe that you shouldn’t shy away from your battles. You should embrace them, feel the pain, and work harder because you can.

Learning to Conquer and Cope with ADHD

I idolized elite athletes and was inspired by bodybuilders. I wanted to learn how they transformed their bodies and disciplined their minds, so I started researching fitness and nutrition. I adopted a basic nutrition plan and created workout routines from free programs I found online.

Going to the gym for the first time was an unforgettable experience. I was nervous and intimidated and didn’t have a clue about how to use any of the equipment. I hopped on a stationary bike because it didn’t require any special knowledge and from there I keenly observed seasoned gym-goers move through their exercises. Eager to learn, I absorbed all of this new information like a sponge.

Workout after workout, I learned. The familiar rush of endorphins I recognized from basketball practice came back every time I lifted heavy loads. My mindset began to change. I dug deeper and deeper into my memories and allowed the pain to surface. I knew that if I could stop my medication cold turkey, I could accomplish anything.

I drove myself to work harder and harder. I focused on the task at hand and my persistence eventually paid off. From 8 reps to 10, to 12 and eventually to 15. To this day, that awesome post-workout feeling keeps me motivated and committed.

I hope my story inspires anyone who is having a tough time and doesn’t know where to turn or how to start. Adopt a workout routine or other daily exercise habits. Give yourself the self-care and self-love you need. It will give you confidence and change your life.

Whatever you face, face it head-on. Nothing is impossible as long as you remember, “What’s possible for one is possible for me!”

[Want to learn more about how exercise impacts the ADHD brain? Read this next: The Neuroscience of Movement]

A study published in The New England Journal of Medicine¹ finds that young patients with attention deficit disorder (ADHD or ADD) beginning a first-time amphetamine, like Adderall or Vyvanse, are more likely to develop psychosis than are similar patients starting methylphenidate, like Ritalin or Concerta. Though the chance of developing psychosis — including depressive disorder or bipolar disorder with psychotic features, schizophrenia spectrum disorders, delusional disorder, hallucinations, and unspecified psychosis — is low overall, patients taking amphetamine are twice as likely as patients taking methylphenidate to merit a diagnosis.

The studied population included 221,846 adolescents and young adults ages 13-25 who received a stimulant prescription for ADHD. The participants were evenly split between those who had started taking amphetamine and those who took methylphenidate for the first time between January 1, 2004, and September 30, 2015.

Among this population, there were 343 new diagnoses of psychosis that merited a prescription for an antipsychotic medication within the first four to five months of stimulant-medication treatment. Among those, 237 psychosis diagnoses came from the group taking amphetamine and 106 came from the group taking methylphenidate. In other words, psychosis occurred in 1 out of every 660 patients, and the risk for psychosis was nearly twice as high among patients taking amphetamine for the first time compared to those taking methylphenidate for the first time.

“This study reminds us that we need to keep a close watch on our patients and follow up on any suspicious changes in mood, thinking or behavior,” says Dr. Anthony Rostain, professor of psychiatry and pediatrics at the Perelman School of Medicine at the University of Pennsylvania, and attending and supervising psychiatrist at the Children’s Hospital of Pennsylvania and the University of Pennsylvania Health System. “Additionally, we should always educate patients about the potential risks of side effects. One possible contributor to the onset of psychosis is misuse/abuse of stimulant medication including snorting and IV use; immediate release preparations are more likely to be misused.”

Researchers stressed that these new findings do not apply to those who have taken either ADHD stimulant and tolerated it well — only to those who have recently began treatment with an amphetamine. This study was not a randomized, controlled trial.

Researchers also stressed that physicians must exercise an abundance of caution when prescribing a stimulant medication for the first time to a patient, particularly an adolescent or young adult. Specifically, doctors should screen for potential risk factors including:

• History of a mood disorder or other psychiatric disorder
• Family history of psychiatric illness
• Use of cannabis or other non-prescription drug

In August 2018, researchers from the UK undertook a systemic review and network meta-analysis of 133 double-blind, randomized, controlled trials designed to compare the drug effectiveness and tolerability of amphetamines and methylphenidate — plus atomoxetine, bupropion, clonidine, guanfacine, and modafinil. For children and adolescents, the research found that methylphenidate and modafinil produced the best results.

For children diagnosed with ADHD before age 6, the American Academy of Pediatrics (AAP) recommends methylphenidate if the first-line treatment of behavior therapy alone does not produce significant results. For children ages 6 to 11, the AAP recommends stimulant medication paired with behavior therapy but it does not stipulate a preference for methylphenidate or amphetamine. The same is true for teen-aged patients. Still, amphetamines are prescribed more often — and at a faster growing rate — than are methylphenidates in the United States today.

In 2007, the Food and Drug Administration mandated that ADHD medication labels warn about potential psychiatric risks. To date, the risk of psychosis among adolescents taking a new amphetamine vs. methylphenidate has not been rigorously studied.

Footnote

¹ Lauren V. Moran, M.D., Dost Ongur, M.D., Ph.D., John Hsu, M.D., M.S.C.E., Victor M. Castro, M.S., Roy H. Perlis, M.D., Sebastian Schneeweiss, M.D., Sc.D. Psychosis with Methylphenidate or Amphetamine in Patients with ADHD. The New England Journal of Medicine (Mar. 2019). https://www.nejm.org/doi/full/10.1056/NEJMoa1813751