What is the relationship between ADHD and emotional regulation?

During the first 170+ years of its medical history, attention deficit hyperactivity disorder (ADHD) and its precursor disorders were believed to involve deficits in emotional inhibition and self-regulation along with the core problems with attention and hyperactive-impulsive behavior. Yet, beginning in the 1960s, especially with the second edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-II: APA, 1968), the symptoms of emotional impulsiveness (EI) and deficient emotional self-regulation (DESR) were divorced from the core deficits of ADHD, being treated as merely associated problems that may arise in some cases, if these problems were acknowledged at all. This led to most people, clinicians included, excluding emotional self-regulation from their understanding of and theories about the nature of ADHD.

Infographic emotional regulation

Emotional impulsiveness refers to the expression of provoked emotional reactions to events more quickly than is the case in typical people. Being impatient, having a low frustration tolerance, being easily excitable or emotionally aroused, expressing more forceful primary emotions when provoked, quickness to anger, and other impulsive emotional reactions illustrate this deficit in emotion regulation. DESR refers to the inability or difficulty with gaining control over strong emotions that have been provoked by events so as to inhibit their public expression, down regulate or reduce their severity, more quickly engage in efforts at self-calming, and even substitute more moderate emotional reactions that are more conducive to one’s immediate and longer term welfare.

Yet none of the above is to suggest that all of the emotional difficulties seen in a patient with ADHD can be written off to this emotional dysregulation component. ADHD is certainly associated with an elevated risk for various mood and anxiety disorders beyond just impulsive emotions.

What distinguishes affective disturbances of ADHD from comorbid affective disorder

First, consider that the emotional disturbances in ADHD are just that – emotions, and not moods. Emotions are short duration, provoked, and often situation specific to the setting of the provocation. They are also largely rational which is to say understandable to others given that typical people would have had the same subjective reaction to the provocation. But the difference is that the typical person would have acted to suppress the voluntary aspects of the emotion over which they have some volitional control rather than express it publicly. They would then have engaged in the self-regulatory steps to down-regulate or otherwise alter the emotion to make it more compatible with the situation, others, and the person’s longer-term goals and welfare. Recovery from such a provoked change in emotional state can be relatively quick compared to moods, though perhaps not as easily as is seen in typical people given that those with ADHD have more difficulties down-regulating strong emotions using executive self-control.

In contrast, a mood is just that – a long duration change in emotional state that is often cross-situational and may arise without provocation or from trivial events that would often not have led others to react in this fashion. It can be described as capricious as well as extreme. Consequently, it is not rational in the sense that other people would have the same emotional state under these circumstances over such an extended period of time and across settings. Admittedly, the dividing line between an emotion and mood is not as crisp as is portrayed here. But the above guidelines seem sensible at this time to guide clinicians in sorting out what affective symptoms of a patient with ADHD belong to that disorder and its EI-DESR problems and what symptoms are likely to be attributable to a comorbid disorder.

Compelling evidence has arisen over the past decade that clearly shows that many if not most cases of ADHD involve problems with EI and DESR. It also shows that these problems are correlated with the severity of more traditional ADHD symptoms, and that they share the same genetic influences that are well-documented in research on ADHD. The abundant evidence argues for the return of EI-DESR to the status of a key associated feature if not a core component of ADHD in its conceptualization and diagnostic criteria.

The argument is based on various lines of reasoning and evidence:

  1. EI-DESR has a long history of being a central feature of ADHD in its clinical conceptualization well before the 1960s.
  2. Current neuropsychological theories of ADHD consider EI-DESR to be just such a central component.
  3. The neuroanatomical findings associated with ADHD would have to give rise to symptoms of EI-DESR because the brain structures and networks involved in ADHD are also involved in emotion generation, expression, and self-regulation.
  4. Ample evidence now exists that children and adults with ADHD are highly likely to manifest EI-DESR (low frustration tolerance, impatience, quickness to anger, and being easily excited to emotional reactions more generally).
  5. Returning EI-DESR to a central place in ADHD would more clearly show the basis for its high comorbidity with oppositional defiant disorder and probably several related disorders, such as future risk for anxiety and depression.
  6. Promoting EI-DESR as a core component of ADHD would also clarify one basis for the frequent social interaction problems and impairments in several other domains of major life activities (work, driving, marriage/cohabiting, managing finances, and parenting) seen in ADHD.
  7. Understanding the role of EI/DESR in ADHD would greatly assist with differential diagnosis of ADHD from mood disorders and reduce misdiagnosing emotional problems in ADHD as entirely arising from comorbidity.
  8. ADHD medications appear to reduce the EI/DESR evident in ADHD as much as they do the traditional ADHD symptom dimensions, yet each may do so through different neural mechanisms and networks.
  9. Psychosocial interventions for ADHD should include programs targeted at helping patients with EI/DESR specifically rather than just traditional ADHD symptom dimensions.
  10. Doing so is likely to reduce the various impairments that are specifically associated with the emotional component of ADHD that are largely going unaddressed in current therapies.

Regardless of what the next DSM may do, clinicians need to be aware of the EI-DESR symptoms inherent in ADHD and evaluate them as much as they evaluate the traditional ADHD symptoms during their initial assessment of a patient for ADHD. Doing so can provide not just a clearer and more comprehensive account of the patient’s current status, but also a richer understanding of the basis for many of the impairments the patient may be experiencing that are partly or largely a consequence of this emotional component of ADHD. That ADHD includes such a component likewise needs to be explained by clinicians to their ADHD patients and families so they, too, gain such a better, more complete understanding of the condition and why the patient may emote as they do. Interventions also need to be targeted at this component of ADHD besides the ongoing efforts to develop both psychosocial and medical interventions that focus on the traditional symptom complex of ADHD and its related “cold” cognitive executive deficits. Treatment should also focus on how best to help family members cope with and assist the patient with ADHD in the effective management of their emotional dysregulation.

In sum

It is time to return EI-DESR to its rightful place in the core or central components of ADHD and to investigate better ways to treat or manage it if the well-being of those with ADHD is to be improved.

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About the Author

russell barkley

Dr. Barkley is a Clinical professor of Psychiatry at the Virginia Commonwealth University Medical Center in Richmond, Virginia, USA.  He has published more than 27 books, rating scales, and clinical manuals and more than 300 scientific papers and book chapters on ADHD, and has presented more than 800 invited lectures in more than 30 countries.  His latest books are Taking Charge of ADHD: The Complete, Authoritative Guide for Parents (4th ed., June 2020, Guilford press) and The 12 Principles for Raising and Child with ADHD (October 2020, Guilford Press).  His website is www.RussellBarkley.org.

Supportive Scientific References

  • Barkley, R. A. (2015).  Emotional dysregulation is a core component of ADHD. In R. A. Barkley (ed.). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.) (pp. 81-115). New York: Guilford Press.
  • Barkley, R. A. & Fischer, M.  (2010). The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults.  Journal of the American Academy of Child and Adolescent Psychiatry, 49, 503-513.
  • Barkley, R. A. & Murphy, K. R. (2011).  Deficient emotional self-regulation in adults with ADHD: The relative contributions of emotional impulsiveness and ADHD symptoms to adaptive impairments in major life activities.  Journal of ADHD and Related Disorders, 1(4), 5-28.
  • Braaten, E. B., & Rosen, L. A. (2000).  Self-regulation of affect in attention deficit-hyperactivity disorder (ADHD) and non-ADHD bys: differences in empathic responding.  Journal of Consulting and Clinical Psychology, 68, 315-321.
  • Ciuluvica, C., Mitrofan, N., & Grilli, A. (2013).  Aspects of emotion regulation difficulties and cognitive deficit in executive functions related to ADHD symptomatology in children.  Social and Behavioral Sciences, 78,  390-394.
  • Dowson, J. H., & Blackwell, A. D. (2010).  Impulsive aggression in adults with attention-deficit/hyperactivity disorder.  Acta Psychiatrica Scandinnavica, 121, 103-110.
  • Harty, S. C., Miller, C. J., Newcorn, J. H., & Halperin, J. M. (2009).  Adolescents with childhood ADHD and comorbid disruptive behavior disorders: Aggression, anger, and hostility.  Child Psychiatry and Human Development, 40, 85-97.
  • Hinshaw, S. P. (2003).  Impulsivity, emotion regulation, and developmental psychopathology: specific versus generality of linkages.  Annals of the New York Academy of Sciences, 1008, 149-159.
  • Hulvershorn, L., Mennes, M., Castellanos, F. X., Martino, A.D., Milham, A. P., Hummer, T. A., Roy, A. K. (2013).  Abnormal amygdala functional connectivity associated with emotional lability in children with Attention-Deficit/Hyperactivity Disorder.  Journal of the American Academy of Child & Adolescent Psychiatry, 53(3), 351-361.
  • Jensen, S. A., & Rosén, L. A. (2004). Emotional reactivity in children with attention-deficit/hyperactivity disorder. Journal of Attention Disorders, 8, 53-61.
  • Maedgen, J. W., & Carlson, C. L. (2000).  Social functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes.  Journal of Clinical Child Psychology, 29, 30-42.
  • Martel, M. M. (2009).  Research review: A new perspective on attention-deficit/hyperactivity disorder: emotion dysregulation and trait models.  Journal of Child Psychology and Psychiatry, 50, 1042-1051.
  • Melnick, S. M., & Hinshaw, S. P. (2000). Emotion regulation and parenting in AD/HD and comparison boys: linkages with social behaviors and peer preference.  Journal of Abnormal Child Psychology, 28, 73-86.
  • Merwood, A., Chen, W., Rijsdijk, F., Skirrow, C., Larsson, H., Thapar, A., Kuntsi, J., & Asherson, P. (2013).  Genetic association between the symptoms of attention-deficit/hyperactivity disorder and emotional lability in child and adolescent twins.  Journal of the American Academy of Child and Adolescent Psychiatry, 53(2), 209-220.
  • Musser, E. D., Backs, R. W., Schmidtt, C. F., Ablow, J. C., Measelle, J. R., & Nigg, J. T. (2011).  Emotion regulation via the autonomic nervous system in children with attention-deficit/hyperactivity disorder (ADHD).  Journal of Abnormal Child Psychology, 39, 841-852.
  • Ryckaert, C., Kuntsi, J., & Asherson, P. (2018).  Emotional dysregulation and ADHD.  In Banaschewski, T., Coghill, D., & Zuddas, A. (Eds.).  Oxford Textbook of Attention Deficit Hyperactivity Disorder (pp. 103-117).  London: Oxford University Press.
  • Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014).  Emotion dysregulation in attention deficit hyperactivity disorder.  American Journal of Psychiatry, 171 (3), 276-293.
  • Sobanski, E., Banaschewski, T., Asherson, P., Buitelaar, J., Che, W., Franke, B., Holtman, M. et al. (2010).  Emotional lability in children and adolescents with attention deficit/hyperactivity disorder (ADHD): clinical correlates and familial prevalence.  Journal of Child Psychology and Psychiatry, 51, 915-923.
  • Surman, C. B. H., Biederman, J., Spencer, T., Miller, C. A., McDermott, K. M., & Faraone, S. V. (2013).  Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: A controlled study.  ADHD: Attention Deficit Hyperactivity Disorder, 5, 273-281.
  • Walcott, C. M., & Landau, S. (2004).  The relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder.  Journal of Clinical Child and Adolescent Psychology, 33, 772-782.

What other diagnoses are seen with ADHD?

ADHD usually starts early in life, typically between ages six and 12. Besides the core symptoms of hyperactivity, impulsivity, inattention and also emotional instability, many affected people suffer from other mental disorders that are found more frequently than expected by chance – so called comorbid disorders. The pattern of comorbid disorders however changes considerably over the life span. In childhood, oppositional defiant disorder (ODD) or conduct disorder (CD) are the most frequent comorbid disorders. However, ADHD can also occur together with autism spectrum disorders and learning disorders.

What other diagnosis are seen with adhd

When people get older, ADHD may persist into adulthood and around two thirds of people continue to experience impairing symptoms. ODD and CD may develop further into antisocial personality disorder, and substance use disorders (for both legal substances like alcohol and illicit drugs such as cannabis or cocaine) may become a problematic comorbidity with respective overall health consequences. Most frequently however, adults with ADHD suffer from anxiety or mood disorders; up to 50% of people suffering from adult ADHD also experience at least once in their life an episode of major depression. Furthermore, overall mortality rate is increased due to higher risks of suicide and unintentional injuries.

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About the Author

Andreas Reif

Prof. Andreas Reif, MD is head of the Department of Psychiatry, Psychosomatic Medicine and Psychotherapy of the University Hospital Frankfurt, Germany. His clinical and research interests comprise ADHD and mood disorder, with focus on mechanisms to enable new treatments. He coordinates the large EU consortium CoCA on comorbid conditions of ADHD.


Further reading

Franke B, Michelini G, Asherson P, Banaschewski T, Bilbow A, Buitelaar JK, Cormand B, Faraone SV, Ginsberg Y, Haavik J, Kuntsi J, Larsson H, Lesch KP, Ramos-Quiroga JA, Réthelyi JM, Ribases M, Reif A. Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. Eur Neuropsychopharmacol. 2018 Oct;28(10):1059-1088. doi: 10.1016/j.euroneuro.2018.08.001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379245/

Chen, Q., Hartman, C. A., Haavik, J., Harro, J., Klungsøyr, K., Hegvik, T. A., Wanders, R., Ottosen, C., Dalsgaard, S., Faraone, S. V., & Larsson, H. (2018). Common psychiatric and metabolic comorbidity of adult attention-deficit/hyperactivity disorder: A population-based cross-sectional study. PloS one13(9), e0204516. https://doi.org/10.1371/journal.pone.0204516 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157884/

Solberg, B. S., Halmøy, A., Engeland, A., Igland, J., Haavik, J., & Klungsøyr, K. (2018). Gender differences in psychiatric comorbidity: a population-based study of 40 000 adults with attention deficit hyperactivity disorder. Acta psychiatrica Scandinavica137(3), 176–186.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5838558/

What is the connection between ADHD and sleep problems?

Is ADHD a sleep disorder?

ADHD and sleep problems are intimately intertwined in the majority of children as well as adults. The sleep problems usually also start in early childhood. Most people have difficulty falling asleep on time, in children described as ‘bedtime resistance’ and adults are called ‘evening types’ or ‘night owls’. This circadian rhythm disorder, or Delayed Sleep Phase Syndrome is associated with a delayed onset of the sleep hormone melatonin, as was objectively measured in saliva (van Veen 2010). ADHD itself is associated with a dysregulation of the neurotransmitter dopamine, which is typically produced during daytime. So disturbances in the rhythm of day and night seem implicated in ADHD. Which leads to the question: could ADHD (also) be a sleep disorder?? (Bijlenga 2019). We are testing this hypothesis in our research. If this is true,  treatment of the delayed rhythm may improve ADHD symptoms, leading to a new perspective in the treatment of ADHD.

infographic connection between ADHD and sleep problems

Besides the delayed sleep rhythm, there are several other sleep disorders associated with ADHD: Restless Legs (restlessness before falling asleep)/Periodic Limp Movement Disorder (restlessness during sleep), Insomnia (arousal, worrying in bed) and Sleep Apnea (sleep breathing disorder) (Vogel 2017; Wynchank 2016, 2017). Some people with ADHD even have several sleep disorders. If disturbed sleep is not treated, the treatment of ADHD will be suboptimal due to sleep loss, that induces memory & attention problems and irritability.

Treatment of sleep and ADHD

Every sleep disorder has its own specified treatment:

Delayed sleep is treated by ‘Chronotherapy’ consisting of

  1. sleep hygiene measures (no screens at night, or wearing orange goggles to protect the eyes from the blue light, no caffeine at night, shower before bedtime, and many more)
  2. Melatonin in the evening, and
  3. Light therapy in the early morning (7-8 am). This combination is an effective way to reset the late sleep rhythm in a few weeks. Only sleep hygiene is usually insufficient.

Insomnia is effectively treated by a special Cognitive Behavior therapy for Insomnia (CGT-I).

Restless legs by supplementing ferritin levels if too low, and medication.

Sleep apnea by diet (often in obese people), prevention of supine position, devices in the mouth to advance the jaw or tongue, and CPAP (Continuous Positive Airway Pressure).

Knowledge about sleep disorders is increasing, but treatment is not always available in psychiatry or at the GP. When ADHD is treated with medication and coaching or CBT, and the sleep disorder according to the guidelines, the rhythm of night and day, memory, attention and mood improve, as well as control over appetite and weight. In the long term, this may prevent the development of chronic diseases.

Sleep is our natural medicine.

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About the Author

Sandra Kooij

Prof. Dr. J.J. Sandra Kooij is a psychiatrist and researcher specialized in ADHD and sleep in adults. She is affiliated with Amsterdam University Medical Center/VUmc and PsyQ, psycho-medical programs in the Hague, the Netherlands.

References

A clarifying easy read is the book Why We Sleep by Matthew Walker.


What does a comprehensive treatment plan for adults with ADHD look like/include?

ADHD is a neurological condition that makes it harder for some people to stay focused, manage time, and get things done. This can affect how they interact with others and how they feel about themselves. Therefore, a comprehensive treatment program begins with effective medication to help the person with ADHD better manage the demands of life at work/school and home. Extended release stimulants are very effective and safe. It is also really important that the adult with ADHD (and also their romantic partner) educate themselves about ADHD, to better understand why they have had the struggles that they do and also to learn new strategies to get organized, prioritize tasks, pay attention, and manage time. These ADHD-friendly strategies tend to work better than the general good advice that they have been given all their lives.

infographic Treatment Plan for adults with ADHD

ADHD is not caused by psychological problems or bad parenting, and talking to a therapist won’t change the brain wiring that causes ADHD. But living with the additional struggles that come with ADHD, especially if it wasn’t diagnosed until adulthood, can affect how someone sees themselves, interacts with others, and handles the demands in their life. This is why it can be helpful to work with a therapist or coach who can help you understand your past struggles in a different way and help you manage your life better today. Therapy can also be helpful in addressing the anxiety, depression, substance abuse, and relationship problems that untreated ADHD can cause. Managing ADHD takes effort, but a comprehensive treatment program can reduce many of the symptoms and make your life much happier.

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About the Author

Ari Tuckman

Ari Tuckman, PsyD, CST is a psychologist, author, and international speaker specializing in ADHD, particularly how it impacts relationships.

Further Reading

Safren SA. Cognitive-behavioral approaches to ADHD treatment in adulthood. The Journal of Clinical Psychiatry. 2006 ;67 Suppl 8:46-50.(https://europepmc.org/article/med/16961430)

Wilens, T, et al. ADHD Treatment With Once-Daily OROS Methylphenidate: Interim 12-Month Results From a Long-Term Open-Label Study. Journal of the American Academy of Child & Adolescent Psychiatry. Volume 42, Issue 4, April 2003, Pages 424-433 )

Weiss, M., Murray, C., Wasdell, M. et al. A randomized controlled trial of CBT therapy for adults with ADHD with and without medication. BMC Psychiatry 12, 30 (2012). https://doi.org/10.1186/1471-244X-12-30

https://link.springer.com/article/10.1186/1471-244X-12-30

How common is ADHD in children and adults?

The behaviors that characterize ADHD were described a long time ago, but in clinical practice the diagnosis of ADHD has been used for only 40 years. This was also when ADHD became important in scientific research. Since then many studies have been done around the world to estimate how often ADHD is present in children. Averaged across these studies it has been estimated that around 5.6%, i.e., roughly one in every twenty children, has ADHD. Around the age of 12 years old and further on during adolescence, some of the children with ADHD start to experience fewer symptoms of ADHD. Research findings indicate that by young adulthood, roughly 22% of children have no ADHD symptoms anymore, 43% still have symptoms and impairments in daily life although not as severe as before, and another 35% still have the symptoms and impairments as they had these during childhood.

How common is ADHD in children and adults

For a long time, only children received a diagnosis of ADHD. When it became clear that only a minority of the children ‘lost’ their symptoms and impairments when they reached adulthood, researchers started to investigate how often it was the case that symptoms and impairments remained so severe that the ADHD diagnosis applies. The current best estimate is that ADHD is present between 2.8% to 4.4% of adults. Especially when persisting in adulthood, persons with ADHD may develop additional psychiatric or somatic conditions that have their onset in adulthood, like depression or diabetes. These conditions are more frequent in adults with ADHD compared to adults without ADHD and could potentially be prevented if ADHD could be successfully treated. However, the latter is speculative; this has not yet been fully established by sound scientific research. In addition, there are still very few longitudinal studies examining how ADHD develops during adulthood.

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About the Author

Catharina Hartman

Catharina Hartman is an associate professor of psychiatric epidemiology in the Netherlands. Her research is focused on improving our understanding of childhood-onset psychiatric disorders and their course across the lifespan, in particular ADHD and autism.

Further Reading

Lange KW, Reichl S, Lange KM, Tucha L, Tucha O. The history of attention deficit hyperactivity disorder. Atten Defic Hyperact Disord. 2010; 2(4):241–55. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000907/

Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007; 164(6):942-948. doi:10.1176/ajp.2007.164.6.942 https://ajp.psychiatryonline.org/doi/10.1176/ajp.2007.164.6.942

Fayyad J, Sampson NA, Hwang I, et al. The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord. 2017; 9(1):47-65. doi:10.1007/s12402-016-0208-3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5325787/

Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006; 163:716–23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859678/

Franke B, Michelini G, Asherson P, Banaschewski T, Bilbow A, Buitelaar JK, Cormand B, Faraone SV, Ginsberg Y, Haavik J, Kuntsi J, Larsson H, Lesch KP, Ramos-Quiroga JA, Réthelyi JM, Ribases M, Reif A. Live fast, die young? A review on the developmental trajectories of ADHD across the lifespan. Eur Neuropsychopharmacol. 2018 Oct;28(10):1059-1088. doi: 10.1016/j.euroneuro.2018.08.001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379245/

What is the relationship between ADHD and obesity / eating habits?

Individuals with ADHD have a higher body mass index (BMI) and a higher prevalence of obesity, with the odds ratio increasing with age. Indeed, the pooled prevalence increase by about 70% in adults and 40% in children. Additionally, individuals with ADHD suffer more from eating disorders (OR=3.82*), especially binge eating (OR=4.13).

Infographic - Relationship between ADHD and eating habits

Several mechanisms have been suggested to account for this association including shared genetic transmission, dysregulation of dopamine, mood lability, psychiatric comorbidities, and low participation in physical activity, impulsivity, inattention, and poor eating habits. It was found that both children and adults with ADHD consume less healthy foods (such as vegetables, fruits, and dairy products) and more unhealthy foods (fatty, sweet and processed foods, such as snacks, candies, “fast food” and “junk food.”)

*OR=3.82 means 3.82 times more likely

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About the Author

Shirley Hershko

Shirley Hershko is the director of the diagnostic and support center, a senior teacher, and a researcher at the Hebrew University in Israel. Her study won an award at the World Congress on ADHD.


References

What are the advantages and disadvantages of taking ADHD medication?

The medications used to treat ADHD have many advantages. By reducing symptoms of hyperactivity, impulsivity and inattention, they help patients with ADHD to do better at school and work. They also improve interactions with family members and friends. Treatment with ADHD improves motor vehicle driving skills and decreases accidents of all kinds. From large medical registry studies of stimulant medications, we know that consistent medication use reduces delinquency, substance abuse, criminality and suicidality. 

infographic Advantages and disadvantages of ADHD medication

There are two types of disadvantages of the mediations used to treat ADHD. The first type of problem is that these medications can cause unwanted side effects such as insomnia, appetite loss or nausea. But for most patients, these side effects can be controlled by reducing the dose or changing medications. 

The second type of problem applies to the stimulant medications, which are addictive substances. Although taking stimulant medications as prescribed will not lead to addiction, they can be misused in a way that leads to addiction. They can also be diverted to others for either substance abuse or performance enhancement. This is especially problematic for immediate release stimulants.

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About the Author

Stephen Faraone, PhD,

Professor. Faraone is Distinguished Professor and Vice Chair for Research in the Department of Psychiatry at SUNY Upstate Medical University. He is also Senior Scientific Advisor to the Research Program Pediatric Psychopharmacology at the Massachusetts General Hospital.  Prof. Faraone studies the nature and causes of mental disorders in childhood and has ongoing research in psychiatric genetics, psychopharmacology, with a current focus on machine learning approaches to these areas. An author on over 1000 journal articles, editorials, chapters and books, in 2005, the Institute for Scientific Information determined him to be the second highest cited author in the area of Attention Deficit Hyperactivity Disorder and the fourth most highly cited researcher in psychiatry for the preceding decade.  From 2014 to 2019 he has been listed as a highly cited researcher by Thomson Reuters/Clarivate Analytics.  In 2019, his citation metrics placed him in the top 0.01% of scientists across all fields .  His lifetime H-Index as of March 2020 was 208. Prof. Faraone is Editor for the journal Neuropsychiatric Genetics.  He heads the educational website www.adhdinadults.com. He is President of the World Federation for ADHD and a Board member for the American Professional Society of ADHD and Related Disorders. In 2002, Professor Faraone was inducted into the CHADD Hall of Fame in recognition of outstanding achievement in medicine and education research on attention disorders.  In 2010 he received the Chancellor’s Award for Excellence in Scholarship and Creative Activities from the State University of New York.  In 2018 he received the Lifetime Achievement Award from the International Society of Psychiatric Genetics and in 2019 he received the Paul Hoch Award from the American Psychopathological Association.


References

  • Cortese, S., N. Adamo, C. Del Giovane, C. Mohr-Jensen, A. J. Hayes, S. Carucci, L. Z. Atkinson, L. Tessari, T. Banaschewski, D. Coghill, C. Hollis, E. Simonoff, A. Zuddas, C. Barbui, M. Purgato, H. C. Steinhausen, F. Shokraneh, J. Xia and A. Cipriani (2018). “Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis.” Lancet Psychiatry 5(9): 727-738.
  • Faraone, S. V., P. Asherson, T. Banaschewski, J. Biederman, J. K. Buitelaar, J. A. Ramos-Quiroga, L. A. Rohde, E. J. Sonuga-Barke, R. Tannock and B. Franke (2015). “Attention-deficit/hyperactivity disorder.” Nat Rev Dis Primers 1: 15020.
  • Chang, Z., L. Ghirardi, P. D. Quinn, P. Asherson, B. M. D’Onofrio and H. Larsson (2019). “Risks and Benefits of Attention-Deficit/Hyperactivity Disorder Medication on Behavioral and Neuropsychiatric Outcomes: A Qualitative Review of Pharmacoepidemiology Studies Using Linked Prescription Databases.” Biol Psychiatry.

What causes ADHD?

In most people having the diagnosis, ADHD is likely to be the result of their genetic make-up (i.e. their DNA) and events that happen to them throughout (early) life (which we call environmental factors).

ADHD has a high heritability of around 70-80%. What this means is that in an average person with ADHD, 70-80% of the inattention and/or hyperactivity can be explained by contributions of genes. Sometimes I hear people talk about ‘having the ADHD gene’. This is not correct: the average person with ADHD probably has tens to hundreds small variations in different genes. The more of those gene variants a person has, the higher their risk to develop ADHD.

While 70-80% heritability sounds like a lot, genetic factors are certainly not the only factors that are important in developing ADHD. Also environmental factors, in particular events occurring before or during birth, but also stress during childhood, play an important role. Thus, not everybody with a high load of gene variants will actually go on to develop ADHD.

In most cases, a combination of many gene variants and environmental factors is likely involved. There are probably many environmental factors involved in ADHD, which we do not yet know. In addition to those that increase risk for ADHD, there may be also factors that reduce the risk.

The genetic factors (together with environmental factors) involved in ADHD are thought to alter brain development very early in life, probably starting already before birth. However, much research is still needed to

  1. identify all the specific factors involved (e.g., we expect that variants in more than 1000 genes are involved, and we need to get more insight into the environmental factors that increase and reduce ADHD risk) and
  2. to understand, how these factors alter the structure, function, and development of the brain.

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About the Author

Barbara Frank

Barbara Franke is a Professor of Molecular Psychiatry at the Radboud University Medical Center in Nijmegen, The Netherlands. She studies the genetic factors involved in psychiatric disorders, especially ADHD, and investigates the biological pathways that lead from variants in genes to alterations in the brain and to symptoms.


Read more:

About genetic studies in ADHD and heritability:
Faraone SV, Larsson H. Genetics of attention deficit hyperactivity disorder. Mol Psychiatry. 2019 Apr;24(4):562-575. doi: 10.1038/s41380-018-0070-0. Epub 2018 Jun 11. PMID: 29892054; PMCID: PMC6477889. https://www.nature.com/articles/s41380-018-0070-0

About the factors that contribute to ADHD:
Larsson, H. et al. Genetic and environmental influences on adult attention deficit hyperactivity disorder symptoms: a large Swedish population- based study of twins. Psychol. Med. 43, 197–207 (2013).
https://bit.ly/3laz7Yi

About ADHD across the lifespan:
Franke B, Michelini G, Asherson P, Banaschewski T, Bilbow A, Buitelaar JK, Cormand B, Faraone SV, Ginsberg Y, Haavik J, Kuntsi J, Larsson H, Lesch KP, Ramos-Quiroga JA, Réthelyi JM, Ribases M, Reif A. Live fast, die young? A review on the developmental trajectories of ADHD. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379245/

What are the risk factors for people with ADHD during the coronavirus pandemic?

Emerging studies from the COVID-19 pandemic show that ADHD symptom severity appears to be increasing during this global event. Several factors may be to blame. First, students with ADHD must adjust to low-structure, online learning platforms. These school environments demand more self-discipline than regular school, which can make concentration and motivation very challenging. For older high school and college students with ADHD, disengaging from virtual school may pave a slippery path towards formal dropout. Warning signs include a build-up of missing work, avoiding virtual class meetings, and slipping grades.

Risk factors for people with ADHD in coronavirus time

Second, social isolation is a known consequence of COVID-19 and is a risk factor for depression and suicide. During COVID-19, social isolation may be particularly severe for people with ADHD, who often have few close friends or may have trouble getting motivated to set-up social activities. On top of this concern, increased ADHD symptoms can be triggered by high stress situations. COVID-19 brings stressors that include safety concerns, economic hardship, and increased family conflict during confinement. In addition to worsening ADHD symptoms, ongoing stress exposure can also create risks for depression. To prevent these concerns, individuals with ADHD and their family members can:

  1. ensure that proper academic supports are in place at school,
  2. prioritize social interaction (even if it means getting creative) during COVID-19,
  3. practice stress reduction behaviors such as outdoor and physical activity, spending positive time with loved ones, and practicing favorite hobbie, and
  4. reach out to mental health providers early on if you notice signs of emerging school disengagement or depression.

Both mental health therapy and medication can support children, adolescents, and adults with ADHD through these challenging times.

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About the Author

Margaret H. Sibley, Ph.D. is Associate Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine and a Licensed Clinical Psychologist at Seattle Children’s Hospital. Her research is focused on ADHD in adolescence and young adulthood.


References

  • Behar‐Zusman, V., Chavez, J. V., & Gattamorta, K. (2020). Developing a measure of the impact of COVID-19 social distancing on household conflict and cohesion. Family Process, 59(3), 1045–1059.
  • Becker, S. P., Breaux, R., Cusick, C. N., Dvorsky, M. R., Marsh, N. P., Sciberras, E., & Langberg, J. M. (in press). Remote learning during COVID-19: Examining school practices, service continuation, and difficulties for adolescents with and without ADHD. Journal of Adolescent Health.
  • Bobo, E., Lin, L., Acquaviva, E., Caci, H., Franc, N., Gamon, L., … & Purper-Ouakil, D. (2020). How do children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) experience lockdown during the COVID-19 outbreak?. L’encephale.
  • Cortese, S., Asherson, P., Sonuga-Barke, E., Banaschewski, T., Brandeis, D., Buitelaar, J., Coghill, D., Daley, D., Danckaerts, M., Dittmann, R. W., Doepfner, M., Ferrin, M., Hollis, C., Holtmann, M., Konofal, E., Lecendreux, M., Santosh, P., Rothenberger, A., Soutullo, C., … Simonoff, E. (2020). ADHD management during the COVID-19 pandemic: Guidance from the European ADHD Guidelines Group. The Lancet Child & Adolescent Health, 4(6), 412–414. https://doi.org/10.1016/S2352-4642(20)30110-3
  • Courtet, P., Olié, E., Debien, C., & Vaiva, G. (2020). Keep socially (but not physically) connected and carry on: Preventing suicide in the age of COVID-19. Journal of clinical psychiatry, 81(3), e20com13370-e20com13370.
  • Eadeh, H.-M., Bourchtein, E., Langberg, J. M., Eddy, L. D., Oddo, L., Molitor, S. J., & Evans, S. W. (2017). Longitudinal evaluation of the role of academic and social impairment and parent-adolescent conflict in the development of depression in adolescents with ADHD. Journal of Child and Family Studies, 26(9), 2374–2385. https://doi.org/10.1007/s10826-017-0768-7
  • Ellis, W. E., Dumas, T. M., & Forbes, L. M. (2020). Physically isolated but socially connected: Psychological adjustment and stress among adolescents during the initial COVID-19 crisis. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 52(3), 177.
  • Hall-Lande, J. A., Eisenberg, M. E., Christenson, S. L., & Neumark-Sztainer, D. (2007). Social isolation, psychological health, and protective factors in adolescence. Adolescence, 42(166), 265-. Gale Academic OneFile.
  • Hartman, C. A., Rommelse, N., van der Klugt, C. L., Wanders, R. B. K., & Timmerman, M. E. (2019). Stress exposure and the course of ADHD from childhood to young adulthood: Comorbid severe emotion dysregulation or mood and anxiety problems. Journal of Clinical Medicine, 8(11), 1824. https://doi.org/10.3390/jcm8111824
  • Horesh, D., & Brown, A. D. (2020). Traumatic stress in the age of COVID-19: A call to close critical gaps and adapt to new realities. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 331.

Zhang, J., Shuai, L., Yu, H., Wang, Z., Qiu, M., Lu, L., … & Chen, R. (2020). Acute stress, behavioural symptoms and mood states among school-age children with attention-deficit/hyperactive disorder during the COVID-19 outbreak. Asian journal of psychiatry, 51, 102077.

What are some ways to reduce stress with ADHD?

Infographic What are sme ways to reduce stress with ADHD

Having ADHD often means living with an increased stress or processing stress in unique ways.  The ADHD symptoms, such as trouble focusing, disorganization, forgetfulness, impulsive actions and other executive function problems, can get in the way of effective problem-solving, managing emotions, or feeling in control of one’s life.  The difficulties can set up a stage for feeling overwhelmed or discouraged. Research shows high rates of family or marital conflict and stress, academic or job underachievement, financial difficulties and increased burden of other mental and physical disorders in ADHD (1). Overall, ADHD is a risk factor for chronic stress, and chronic stress often makes having ADHD more challenging. 

Strategies to manage stress

If you have ADHD and are feeling a great deal of stress because of it, there are ways to manage it. 

Medication can minimize core ADHD symptoms of inattention or restlessness, and ADHD-focused psychotherapy or coaching can help identify and tackle your main triggers for stress.  If you are feeling unfocused, overwhelmed and getting in your own way, starting or optimizing these ADHD treatments can help you feel more in control of your day and relieve a great deal of stress.  At the same time, it is important to have a healthy lifestyle and learn some strategies for stress resilience. 

If your daily routine is irregular or not so healthy, the stress can be addressed by setting up a work and break schedule, having adequate sleep, and exercising.  Eating a Mediterranean style diet rich in fruits, vegetables and healthy protein and fats may also help offset ADHD symptoms and support overall mental health (2, 3). 

Exposure to nature or green spaces has also been found helpful with ADHD symptoms (4) and is known to support stress coping.  Lifestyle changes should be tackled one at a time so they are not overwhelming.

Mindful awareness or mindfulness training is also proving helpful for the core ADHD symptoms as well as associated difficulties of anxiety, depression or stress (5).  This training uses meditation practice and brief awareness exercises in daily life to train attention, balance negative emotions and increase experience of positive emotions such as self-compassion.  The mindful practice of pausing to check in and look inward, can help you recognize signs of stress such as tight shoulders, or thoughts of overwhelm, and address it before the tipping point.  Breathing exercises and mind-body movement often encourage relaxation response and can mitigate the in-the-moment feeling of overwhelm or stress. 

Last but not least, effective communication, such as good listening, being assertive and clear about your needs, setting self-boundaries or navigating conflict can relieve relationship stress in families.

Bottom line:

Identify your sources of stress and prioritize which one you want to tackle first.  If unsure or stuck, ask a friend/partner for help or engage with an ADHD professional.  Acknowledge with self-compassion that tackling stress may not be easy but even a small first step can create an upward spiral.

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About the Author

Lidia Zylowska

Lidia Zylowska MD is an Associate Professor at the University of Minnesota Department of Psychiatry and Behavioral Sciences.   She led the development of the Mindful Awareness Practices (MAPs) for ADHD program and is an author of Mindfulness Prescription for Adult ADHD.


References

1 Kooij SJ, Bejerot S, Blackwell A, et al.  European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry. 2010 Sep 3;10:67. doi: 10.1186/1471-244X-10-67. PMID: 20815868; PMCID: PMC2942810.

2.Ismael San Mauro Martín, Javier Andrés Blumenfeld Olivares, Elena Garicano Vilar, et al (2018) Nutritional and environmental factors in attention-deficit hyperactivity disorder (ADHD): A cross-sectional study, Nutritional Neuroscience, 21:9, 641-647, DOI: 10.1080/1028415X.2017.1331952

3Camille Lassale et al. Healthy dietary indices and risk of depressive outcomes: a systematic review and meta-analysis of observational studies, Molecular Psychiatry (2018). DOI: 10.1038/s41380-018-0237-8

4 Kuo FE, Taylor AF. A potential natural treatment for attention-deficit/hyperactivity disorder: evidence from a national study. Am J Public Health. 2004;94(9):1580-1586. doi:10.2105/ajph.94.9.1580

5Mitchell, J. T., Zylowska, L., & Kollins, S. H. (2015). Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: Current empirical support, treatment overview, and future directions. Cognitive and Behavioral Practice, 22(2), 172–191.