On April 29, the Trump administration announced it was cutting $1 billion in funding for federal grants used to hire and train 14,000 mental health professionals in 260 public school districts across 49 states.

The grants originated in 2022’s Bipartisan Safer Communities Act, a bill that passed the Senate with unanimous consent following the school shooting in Uvalde, Texas, where 22 people died, including 19 elementary school children. The bill was largely seen as important recognition of and support for an escalating mental health crisis among American youth.

In April, the Trump administration eliminated all funding for these grants, blaming Diversity, Equity and Inclusion (DEI) initiatives associated with them. Specifically, the administration objected to grant money being used to train and recruit diverse mental health counselors who reflect the demographic make-up of the students they serve.

Meanwhile, research shows that BIPOC students benefit from access to a diverse cohort of mental health professionals¹, and the inverse is true as well.

“We see studies that show a bias in the way that Black children, in particular, are treated in the health care system compared to white children,” said Tumaini Rucker Coker, M.D., during the ADDitude webinar “Equity in ADHD Care.” “It is directly related to racial bias. Black families are less likely than white families to have concordance or a shared lived experience with their healthcare providers, and studies have shown that Black adults are more likely than white adults to report lower levels of trust in their providers as well.”

[Read: “As Inclusion Disappears, My Mask Reappears”]

Furthermore, “studies show that Black families tend to have worse outcomes with white doctors,” said Napoleon B. Higgins, Jr., M.D., during his ADDitude webinar “Health Equity in ADHD.” “That is that is a sad thing to hear, but if we can educate more providers, maybe we could change that.”

Recently, ADDitude invited its readers’ reflections on news of the $1 billion in cuts to youth mental health services. Nearly 200 people responded, and many of them expressed concern that all students’ mental health may suffer because of the cuts, but especially those with autism, ADHD, and learning differences, who may benefit from seeing school counselors with similar lived experiences.

[Read: “DEI – and Neurodivergence – Are Under Attack”]

ADDitude Readers React to Mental Health Funding Cuts

“As a school social worker and the parent of a child who has an IEP, I consider Trump’s cuts to funding for public school mental health to be gross negligence. I think that it highlights his ignorance on the issues plaguing our youth. I also find it irresponsible. Our kids still are not okay ever since COVID. I believe that it will impact the services that my son receives.”

“Students need to feel safe and be OK within themselves before they can take in the knowledge to learn anything. Cutting access to mental health services means that students who are at-risk learners due to factors outside a school’s or educator’s control may become disengaged learners. This leads to more problematic and potentially anti-social behavior.”

“As a former teacher of students with disabilities, I am concerned. Students need safe places to go and get mental health support. Parents are doing their best but don’t always have the resources to support their children.”

“All three of my children are neurodiverse, and this can take a toll on their mental health. Having supports like counselors, DEI programs, and other accessibility programs is vital. I now have two children in college and one entering high school.”

“I am a school counselor and my son has ADHD. We’re already incredibly behind on providing mental health services to students. These cuts are only going to significantly increase the percentage of students whose health needs are hardly or never addressed.”

“Every child should have the support they need to excel in school. School mental health services are critical for this.”

“I don’t understand why we are defunding mental health awareness, advocacy, and resources. It really doesn’t make any sense to me. It seems like we had made such strides forward in mental health, but now we’re going backward for some reason. I understand cutting expenses to cut spending and improve the national deficit, but it seems like we are cutting very vital and necessary things. It’s like trying to cut back on your own budget by deciding to not buy groceries anymore.”

Understanding Trump’s Funding Freeze: Next Steps

• Read: Generation AnXiety — Findings on ADHD & the Mental Health Crisis
• Learn:Youth Mental Health Care Is Vital. And Hard to Access.
• Watch: Mental Health Out Loud Webinar

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
McGuire, TG., Miranda, J. (March-April 2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs.https://doi.org/10.1377/hlthaff.27.2.393

In my clinical experience as a music therapist, I’ve seen how music and other sensory experiences help individuals improve their focus, impulse control, and emotional regulation. Try these fun (and whimsical!) activities, designed to stimulate the sensory pathways (sight, sound, touch, taste, and smell) to relax the body and mind.

The Scarf’s Serenade

Grab a light scarf. Put on some instrumental, relaxing music of your choice. Glide the scarf over your body. The calming and repetitive action works well to regulate hyperactivity, racing thoughts, and impulses, as your attention will be drawn to the sensory experience of the scarf over your skin to the tune of soothing music.

A Symphony of Mist

Put on a relaxing, instrumental music track. (Not sure what to select? Try “Raindrops Keep Falling on My Head” by B.J. Thomas. You’ll see why.) Grab a spray bottle and fill it with water. Spray it over your head and let the mist fall onto your face. The light touch of the mist paired with familiar, rhythmic music activates the parasympathetic nervous system, which is responsible for the body’s calming response. This helps shift the brain and body from a hyper-aroused to a more regulated and calm state.

The Balloon’s Dance

Put on some music and bounce a balloon to the beat. Music adds a predictable auditory rhythm, to which you can naturally sync your movements. Meanwhile, repetitive bouncing will provide a target for your focus and give your body an outlet for restless movement, without being overly stimulating.

Sticks and Sounds

Turn on your favorite music and grab two pencils or chopsticks. Then, tap along to the beat on any surface you can find! If you’re already in the habit of drumming along, keep at it. Tapping is a controlled, safe outlet for movement — you may not realize how it has probably helped you manage restlessness and reduce impulsive behaviors! Moving and grooving to a beat supports body regulation and coordination, promoting a sense of internal calm.

Music Therapy and ADHD: Next Steps

• Read: Music Therapy — Sound Medicine for ADHD
• Read: Rhythm Notion — 10 Benefits of Music for ADHD Brains
• Read: Music Is Magic — 9 Hacks to “Beat” ADHD Symptoms

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

Yes, I could be seeing patients inside a clinical office to discuss suppressing or ignoring old behaviors while allowing a deeper self to arise. Or I could just remind them to bring an umbrella to our session today as we delve into these issues.

Three months into the COVID-19 pandemic, I moved across the country with my three young children to Palo Alto, California, for the University and College Mental Health Fellowship in psychiatry at Stanford University. But instead of joining a vibrant academic community, I worked from my apartment. Alone. A few months later, forest fires made the air quality so bad that we couldn’t even go outside.

[Free Download: How to Choose the Right ADHD Treatment Profesional]

As the pandemic began to lift, we wore masks when we treated patients in person. But in doing this emotional work, revisiting the difficult moments of a patient’s childhood, it is so important to see kindness on a psychiatrist’s face. So I made a decision: Whenever possible, I met with patients outside in nature, where masks weren’t required.

Benefits of Nature Therapy

After the pandemic ended, even as we sat in coats under umbrellas during the rainy season, I repeatedly asked my patients, “Do you want to do this in an office?” The answer was always the same: “Absolutely not.”

When patients are diving deeply into old pain, desperately hoping for connection while also fearing it, I can simply say: “What do you see, right now? What do you hear?” They look around at the grass and the trees, hear the birds, feel the sun on their skin, or hear the rain drumming on their umbrella. They discover that their fear is about the past, not the present. Try as they might, they can’t force their fear away any more than they can stop the rain. But they can notice it. They can choose to ignore the narrative it generates in their inner monologue. They can breathe and let the tears fall so that something new can grow.

The rainy season of change can be hard. But it doesn’t last forever. Eventually, spring comes. And the grass grows. To allow growth to change us for the better, we need to trust this deeply in our bodies. For my patients, I’ve found there is great power in learning from the change of the seasons. So we do the work. Outside. And sometimes it rains.

[Read: Go Take a Hike! (No, Really, It Helps.)]

Nature Therapy for ADHD: Next Steps

• Free Download: Everything You Need to Know About Cognitive Behavioral Therapy (CBT)?
• Read: How Green Time Promotes Better Focus
• Read: Never Underestimate the Healing Power of Mother Nature

Aaron Winkler, M.D., is a board-certified psychiatrist in California. He founded and directed the Adult ADHD Clinic at Stanford University before deciding to pursue private practice.

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.

The anticipated MAHA Commission report released yesterday misrepresents ADHD causes and care in the U.S., misinterpreting studies and disregarding compelling new research and patient voices to suggest that ADHD is contributing to a “crisis of overdiagnosis and treatment” in American children.

The MAHA Report, spearheaded by Health and Human Service (HHS) Secretary Robert F. Kennedy, Jr., equates ADHD with obesity, heart disease, and diabetes in calling these harmful contributors to the “childhood chronic disease crisis” in the U.S. It disregards the genetic underpinnings of ADHD to suggest it is solely caused by environmental factors and foods, twists data to stoke fear over rising diagnosis rates, and excludes a wealth of studies that link stimulant medication use to improved health outcomes.

It assumes ADHD is a disease caused and cured by environmental factors. And it suggests that curing ADHD will “make America healthy again.” We disagree, and so does the research.

Should the U.S. government take a long, hard look at the impact of ultra-processed foods, environmental chemicals, and declining physical activity on American children? Absolutely. Should it invest in programs to provide healthy foods, affordable health care, and screen-free activities for all children, regardless of socioeconomic status or means? Yes. Do we support efforts to eliminate toxins from our kids’ food, water, and air? To protect them from unhealthy screen use? To help them live longer, healthier lives? 100%.

Will any of these efforts “cure” ADHD, as the MAHA Report suggests? No, the research does not support that notion. But these efforts, if undertaken by Kennedy, do stand to improve quality of life for many children, and so they should be seriously considered by HHS through investment in the FDA, CDC, and NIH.

Do you know what else improves quality of life for kids? Less stigma and shame, and more investment and solutions. The MAHA Report, sadly, increases ADHD stigma by claiming the condition is overdiagnosed and disparaging its treatment as ineffective without any credible evidence to support these claims. On the flipside, it makes no mention of the proven, life-saving benefits of ADHD treatment or the risks associated with undiagnosed, untreated ADHD. It makes no mention of behavioral parent training, cognitive behavioral therapy, dialectical behavior therapy, or classroom interventions for ADHD, all of which are shown to improve outcomes for individuals with ADHD. Instead, the report’s “solutions” for ADHD suggest more scrutiny of and restricted access to stimulant medication.

Finally, it is notable that the commission included few scientists or experts in pediatric health care. The commission conducted no new research and it apparently did not seek comment or insight from the American Professional Society of ADHD and Related Disorders (APSARD), the American Academy of Pediatrics (AAP), or the World Federation of ADHD regarding the established science on ADHD causes and treatments. No patients were interviewed for or quoted in the report.

The next steps outlined in the report are vague and we expect the commission to propose more detailed strategies in August, but here are three takeaways from the May 22 MAHA Report that may impact the ADHD community.

#1: The Report Misrepresents the Causes of ADHD

ADHD is a highly genetic condition, as confirmed by brand-new research that identified measurable genetic traits that essentially act as biomarkers for ADHD. Lifestyle factors such as nutrition, exercise, and sleep exert epigenetic changes on DNA that influence how strongly or weakly ADHD genes are expressed. However, diet, physical activity, sleep, or screen use alone do not cause — and have not been shown to “cure” — ADHD.

Scientific research has established no causal link between consumption of sugar, food additives, or food dyes and ADHD, though some studies show a heightened sensitivity among children with ADHD to these foods, which may exacerbate existing symptoms. Likewise, scientific research has established no causal link between excessive screen time, video game play, or social media use and ADHD.

Despite clear evidence to the contrary, the MAHA Report claims that ADHD is caused by all of the following, but it never mentions genetic factors:

• Antibiotics: The report cited as evidence a study that “could not disentangle the effects of antibiotics from those of the underlying conditions” and “could not verify adherence to antibiotic prescriptions.” Other recent studies have found gut microbiome alterations in children with ADHD but no causal link between antibiotic use and ADHD in humans.
• Food additives: Research shows that food dyes may worsen symptoms of inattention or hyperactivity in children with ADHD, however there is no evidence of a causal relationship.
• Environmental toxins: This article by Joel Nigg, Ph.D., contains a thorough overview of all existing research on environmental toxins and ADHD, but the bottom line is this: “Genes and environments work together to shape development of the brain and behavior throughout life, but especially — and most dramatically — in very early life. ADHD, like other complex conditions, doesn’t have a single cause. Both nature and nurture influence its development.”

#2: The Report Casts Doubt on the Validity of an ADHD Diagnosis

The MAHA Report claims that “research shows ADHD has the strongest evidence of overdiagnosis,” however no such research is cited in the report. Perhaps that is because there is no definitive evidence that ADHD is overdiagnosed in America today. ADHD diagnosis rates have increased over the last few decades, however this may be a result of any of the following, and other factors:

• The high diagnosis rate cited in the report comes from a problematic and misleading CDC study that is “terribly designed to assess the prevalence of the disorder,” says Russell Barkley, Ph.D., a leading authority on ADHD. “In this survey, there is one question about ADHD: ‘Has a doctor or other healthcare provider ever told you that this child has ADD or ADHD?’ That could be anybody associated with the healthcare profession who has no training in ADHD… and there is no effort in this study to follow up to see if these children were, in fact, diagnosed.” Barkley goes on to say that meta-analyses of better-conducted studies that apply diagnostic criteria to their research populations find that the prevalence of ADHD among children ranges from 5 to 8 percent, not 10 to 11 percent.
• Revised diagnostic criteria published in the DSM-5 changed the age of onset from 7 to 12 and added the first-ever qualifier symptoms for ADHD in adulthood
• With ongoing research and clinician training on ADHD, education and symptom recognition have improved
• Twenty years ago, ADHD was viewed as a disorder that affected young males. As research on females began to take hold, girls and women were able to secure ADHD evaluations for the first time
• Likewise, as mental health stigma dissipates within time, historically underserved populations are seeking care for the first time

The report further suggests that “the harms associated with an ADHD diagnosis may often outweigh the benefits” without naming those supposed harms or acknowledging the many health risks associated with undiagnosed ADHD. Research shows that undiagnosed and untreated individuals face a higher risk for fatal car accidents, unwanted pregnancies, serious injury and hospitalizations, job loss, academic interruptions, self-harm, anxiety, depression, eating disorders, and more. The harms associated with undiagnosed ADHD are too severe to ignore, yet the MAHA Commission does just that.

#3: The Report Misrepresents the Efficacy and Risks of ADHD Medication

The MAHA Report draws faulty conclusions from the ​​Multimodal Treatment of Attention-Deficit/Hyperactivity Disorder (MTA) study to argue that ADHD medication use offers no benefits “in grades, relationships, achievement, behavior, or any other measure” after 14 months of use. This is untrue.

In reality, the MTA study ended after 14 months, so the control group members with ADHD who did not initially receive medication were free to seek it out after 14 months. As many of the controls began treating their ADHD symptoms with medication, the differences between the control and treatment groups faded because the control group members began to improve on medication, not because the treatment group began to do worse. It is wrong and irresponsible to suggest that no patients experienced benefits from ADHD medication use after 14 months.

“The groups became very contaminated after that 14-month follow-up,” Barkley says in a video on his YouTube channel. “Therefore, we can’t make comparisons at years 2, 3, or 4 between or among the treatment groups and draw any conclusions about them because the treatments were mixed up among all the groups.”

The report claims that stimulants, “when stopped, often lead to disabling and prolonged physical dependence and withdrawal symptoms.” This is untrue. The research cited in the report was a study of antidepressants, not stimulants. There is no evidence to support this assertion regarding stimulant medication. In addition, we know that half of teens and adults with ADHD stop taking stimulant medication within one year of starting it, often due to stigma or access problems. This suggests that it is not addictive. In fact, stimulant medication has been used safely and effectively for nearly 100 years — more than enough time for long-term adverse outcomes to come to light, yet none has.

Finally, the report’s claim that stimulant medication use does “not improve outcomes long-term” is also false.

Research dating back more than 40 years has documented the positive impact of ADHD treatment on specific symptoms like inattention and hyperactivity, and on life expectancy overall. Recently, a Swedish study, published in JAMA Network Open, documented these findings:

• ADHD medication use reduced overall risk of death by 19%. Among people with ADHD who did not receive medication, there were 48 deaths for every 10,000 people, contrasted with 39 deaths per 10,000 people within the medicated cohort.
• ADHD medication use reduced the risk of overdose by 50%. Medication use also reduced the risk of death from other unnatural causes, including accidental injuries, accidental poisoning such as drug overdoses, and suicide.
• ADHD medication use reduced the risk of death from natural causes, such as medical conditions, for women.

People with childhood ADHD are nearly twice as likely to develop a substance use disorder as are individuals without childhood ADHD. However, research suggests that patients with ADHD treated with stimulant medications experience a 60% reduction in substance use disorders compared to those who are not treated with stimulant medication. Considerable evidence also suggests that children taking ADHD medication experience improvements in academic and social functioning, which translates to improved self-esteem, lower rates of self-medication with drugs or alcohol, and decreased risk of substance abuse.

Given all of the above, it’s difficult to view the increase in stimulant medication use flagged by the MAHA Report as anything but positive. “Why isn’t that evidence of improvement in good public mental health?” Barkley asks. “The fact that there is a rise in the occurrence of a particular treatment does not provide prima facie evidence that there is something bad, wicked, evil, wrong going on here; it simply means that, over time, we are getting closer and closer to identifying conditions that produce harm in individuals, and that we try to alleviate that harm and suffering.”

The Threat to ADHD Care Access

The MAHA Commission plans to release its recommended strategies in August, but it’s easy to see the writing on the wall now. The arguments presented in Thursday’s MAHA Report, based largely on outdated or poorly interpreted research, suggest that Kennedy may seek to restrict access to ADHD care and that he’s building a foundation of doubt and misinformation now to support that action.

We fear efforts to dissuade physicians from diagnosing and treating ADHD may be forthcoming from the Drug Enforcement Administration (DEA) with support from the CDC, which Kennedy oversees. Of course, we hope we are proven wrong. We hope that, instead, HHS chooses to fully restore funding for ADHD research efforts through the National Institutes of Mental Health, for mental healthcare initiatives through the CDC, and for nationwide nutrition assistance programs through the FDA.

ADDitude supports an investment in unbiased research into the root causes of and effective treatments for ADHD to support, not ‘cure,’ individuals living with neurodivergent brains. We welcome the opportunity to engage in transparent dialog with the MAHA Commission and to introduce the voices and viewpoints of individuals and families living with ADHD, which were excluded from this report. And we hope that this administration will fund initiatives to improve food quality and access, eliminate harmful food additives, provide mental health services to all children, and crack down on the industries and companies contributing toxins to our environment.

We also stand ready to defend the legitimacy of the robust library of credible, science-backed research studies that confirm ADHD’s genetic underpinnings, that validate its diagnostic tools, and that confirm the benefits of its uninterrupted treatment.

Reactions from the ADHD Community

Mark Bertin, M.D., PLLC, of Developmental Pediatrics

“Lifestyle changes that promote child health are a wonderful idea. However, the MAHA paper ignores the reality of ADHD, a common medical disorder with genetics nearly as strong as the inherited trait of height. Undertreated ADHD is a public health concern that affects school performance, relationships, and driving; increases the risk of substance abuse; and shortens lifespans. Research and clinical experience show clear benefits to ADHD medication, which has been used for a century without evidence of chronic side effects. Supporting individuals with ADHD requires more understanding, not less, while making medical, educational, psychological, and health-related supports affordable and easily available. The MAHA document completely misrepresents ADHD in ways that are judgmental, demeaning, and will be harmful to individuals, our health care system, and society.”

Russell Barkley, Ph.D.

The ADHD Evidence Project, Founded by Stephen Faraone, Ph.D.

“ADHD is one of the most discussed neurodevelopmental disorders in the MAHA Report, but many of its claims about ADHD are misleading, oversimplified, or inconsistent with decades of scientific evidence, much of which is described in the International Consensus Statement on ADHD, and other references given here.”

A complex condition requires a thoughtful treatment approach, and multiple diagnoses often require treatment with more than one medication. Unraveling the answers takes time, plus trial and error. Thanks to years of research, however, clinicians are now equipped with highly effective options for addressing tough-to-treat cases of ADHD plus comorbidities.

Use this evidence-based information to begin a conversation with your doctor about treating complex ADHD with combination therapy.

Is Combination Therapy Safe?

The stimulants used to treat ADHD generally have no major drug-to-drug interactions, so they don’t increase the levels of other medications you may be taking, and vice versa. They are safe to use in combination with other medications, including non-stimulants, antidepressants, and antipsychotics. However, some of the non-stimulants, such as atomoxetine (brand name Strattera) or viloxazine (brand name Qelbree), may affect the blood levels of other medications.

Which Condition Do I Treat First?

We generally recommend treating the more sever condition first. If untreated, the symptoms of severe conditions like bipolar or panic disorder can undermine or hijack ADHD treatment. If a patient has mild anxiety, for example, it makes sense to address the ADHD first and then assess any remaining anxiety. Sometimes, anxiety improves when the ADHD is addressed.

Even the most optimized treatment regimen may need to be adjusted over time. After feeling quite stable, a person with ADHD and depression, for example, may feel as though their ADHD is suddenly worse. Worsening depression may worsen the ADHD response. Treating the depression may enhanced the effectiveness of ADHD treatment. Clinicians must take time to sort out such issues when dealing with multiple diagnoses.

[Free Course: The Adult’s Guide to ADHD Treatment]

Anxiety and ADHD

Generally, stimulants don’t worsen anxiety, but they may for some patients. If ADHD symptoms are causing anxiety, stimulants may lessen the anxiety. If the anxiety is unrelated to ADHD, if won’t be improved by stimulants and may, in fact, be exacerbated. A meta-analysis of studies concluded that, in the aggregate, treatment with stimulants significantly reduced the risk of anxiety compared to a placebo.³ The first-line treatment for anxiety is a selective serotonin reuptake inhibitor (SSRI), such as Lexapro, Prozac, or Zoloft.

Atomoxetine is a selective norepinephrine reuptake inhibitor (SNRI) that can effectively treat both anxiety and ADHD with a single medication. There is a caveat: For reasons we don’t yet understand, atomoxetine is not as effective in patients who have already tried a stimulant. If you’re a new patient, talk with your doctor about trying atomoxetine first to treat both the ADHD and the anxiety.

Autism and ADHD

Addressing ADHD in autistic patients may improve functioning dramatically. However, studies show that ADHD medications may cause more side effects and be less effective for autistic people, particularly those with lower intellectual functioning.⁴ Research has found that autistic patients taking ADHD medication experienced a 50% response rate for symptoms including hyperactivity and emotional regulation, which is lower than the 70 to 80% response rate found in children with ADHD who do not have autism.⁵

Begin slowly and monitor closely when increasing the dosage of ADHD medications in autistic patients. It is not uncommon to see an autistic child or adult have a good response to a particular dose of medication, whereas a slightly higher dose may cause many side effects and lessens response. Rather than seeking the “best” ADHD treatment, doctors may aim for good treatment with manageable side effects.

[Read: Interventions for Adult Autism and ADHD]

When severe irritability, aggression, and acute outbursts occur, it may be necessary to stabilize these episodes before addressing ADHD symptoms. Second-generation antipsychotics, such as risperidone or aripiprazole, can work very well to create a calm and controlled context before introducing stimulants or non-stimulants.

OCD and ADHD

Untreated OCD can significantly impede treatment of ADHD, so most practitioners initially prescribe medication and/or psychotherapies like exposure response prevention for OCD, and then tackle the ADHD with stimulant or non-stimulant medication. Both SSRIs and SNRIs are indicated for the treatment of OCD, though SSRIs appear to be more effective. Most medications for ADHD can be used safely in combination with SSRIs/SNRIs.

Depression and ADHD

For children with depression and ADHD, treatment options are limited to an SSRI plus a stimulant or non-stimulant. Adults may benefit from bupropion (brand name Wellbutrin), an antidepressant that is used off-label for ADHD. While depression in adults is commonly treated with SSRIs/SNRIs, some patients report that tricyclic antidepressants help with symptoms of depression and are also quite effective for ADHD.

Eating Disorders and ADHD

Clinicians sometimes hesitate to prescribe ADHD medications to patients with eating disorders due to the common side effect of appetite suppression. These patients’ weight and eating patterns should be monitored closely during treatment, but fear of the side effects should not preclude ADHD treatment, which is shown to improve overall health outcomes.

Though non-stimulants like atomoxetine or viloxazine may be tried first, stimulants need not be ruled out. In fact, the stimulant lisdexamfetamine (brand name Vyvanse) is FDA-approved for the treatment of binge eating disorder as well as ADHD.

Executive Dysfunction and ADHD

The executive function deficits that come with ADHD – difficulties with organization, time management, and sequential thinking – are often burdensome and impairing. For these patients, non-stimulants such as atomoxetine or viloxazine may be used in combination with a stimulant for treating both ADHD and executive function deficits.

Adding an extended-release form of an alpha agonist, like guanfacine or clonidine, to a stimulant is another option that can be useful for executive dysfunction. These medication combinations (e.g., clonidine or guanfacine plus a stimulant) are FDA-approved for treating ADHD in children under 17. They are sometimes used off-label in adults with ADHD.

Research suggests that the Alzheimer’s medication memantine added to the stimulant methylphenidate may improve executive functioning and social cognition, or the capacity to read verbal cues.⁶ This can be especially helpful for autistic children with ADHD.

Comorbid Conditions with ADHD: Next Steps

• Free Tool: The ADDitude Symptom Checker
• Read: What Is Complex ADHD?
• Read: Stimulant, Non-Stimulant, or Both? Combination Therapy for ADHD

Timothy E. Wilens, M.D., is a professor of psychiatry at Harvard Medical School.

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

¹Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

²Danielson, M. L., Claussen, A. H., Bitsko, R. H., Katz, S. M., Newsome, K., Blumberg, S. J., Kogan, M. D., & Ghandour, R. (2024). ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 53(3), 343–360. https://doi.org/10.1080/15374416.2024.2335625

³Coughlin, C. G., Cohen, S. C., Mulqueen, J. M., Ferracioli-Oda, E., Stuckelman, Z. D., & Bloch, M. H. (2015). Meta-Analysis: Reduced Risk of Anxiety with Psychostimulant Treatment in Children with Attention-Deficit/Hyperactivity Disorder. Journal of child and adolescent psychopharmacology, 25(8), 611–617. https://doi.org/10.1089/cap.2015.0075

⁴Joshi, G., & Wilens, T. E. (2022). Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder in Individuals with Autism Spectrum Disorder. Child and adolescent psychiatric clinics of North America, 31(3), 449–468. https://doi.org/10.1016/j.chc.2022.03.012

⁵Joshi, G., Wilens, T., Firmin, E. S., Hoskova, B., & Biederman, J. (2021). Pharmacotherapy of attention deficit/hyperactivity disorder in individuals with autism spectrum disorder: A systematic review of the literature. Journal of psychopharmacology (Oxford, England), 35(3), 203–210. https://doi.org/10.1177/0269881120972336

⁶Biederman, J., Fried, R., Tarko, L., Surman, C., Spencer, T., Pope, A., Grossman, R., McDermott, K., Woodworth, K. Y., & Faraone, S. V. (2017). Memantine in the Treatment of Executive Function Deficits in Adults With ADHD. Journal of attention disorders, 21(4), 343–352. https://doi.org/10.1177/1087054714538656

ADHD and schizophrenia are distinct neurodevelopmental disorders with some overlapping symptoms, such as inattention, impulsivity, weak working memory, and emotional dysregulation. Symptoms of schizophrenia may also include hallucinations, delusions, and paranoia. Understanding how ADHD fits into this diagnostic picture, and untangling overlapping symptoms, leads to better treatment approaches and outcomes.

While most people with ADHD will never develop schizophrenia, these factors increase risk: family history of schizophrenia, adverse childhood experiences or trauma, and abuse of psychoactive substances, such as marijuana that contains elevated levels of THC.

Schizophrenia typically emerges in the late teens through early thirties. ADHD can be diagnosed at any age, though it usually emerges in the early grade school years.

[Watch: “Understand How ADHD and Schizophrenia Overlap”]

ADHD and Schizophrenia: Treatment Options

When treating comorbid schizophrenia and ADHD, a priority must be to treat any psychosis with first-generation antipsychotics such as Haldol and Trilafon, or second-generation antipsychotics such as Abilify and Risperdal. Antipsychotics can be taken orally in the form of daily pills or as injectables. Recent innovations have yielded exciting new medications, such as injectables effective for as long as three months, and other promising new interventions are on the horizon. Antidepressants, mood stabilizers, or anti-anxiety drugs may also help in treating associated symptoms of schizophrenia, as do adjunctive therapies such as cognitive behavioral therapy and family therapy.

Only after the psychosis is under control can clinicians clearly identify symptoms associated with ADHD and prescribe treatment. ADHD is associated with low dopamine levels in the brain, and most ADHD medications are intended to increase these. Patients with schizophrenia tend to have high dopamine levels, so doctors must exercise caution when prescribing stimulants to them. If medication increases dopamine levels further, this may exacerbate schizophrenia by worsening psychosis.

[Read: Why ADHD Brains Crave Stimulation]

Under the consistent care of a clinician, patients with schizophrenia who adhere to their medication regimen tend to do very well. No matter a condition’s treatment challenges, I understand a patient and their symptoms more fully every time I see them. I learn from what we’ve tried, bringing us closer to getting a medication combination just right. This kind of treatment takes trial and error, thoughtfulness, and time spent with a doctor.

ADHD and Schizophrenia: Next Steps

• Read: When It’s Not Just ADHD – Symptoms of Comorbid Conditions
• Read: ADHD Comorbidity – An Overview of Dual Diagnoses
• Read: A Clinician’s Guide to Impulsive Aggression

Napoleon B. Higgins, Jr., M.D., is a child, adolescent, and adult psychiatrist in Houston, Texas. He is the owner of Bay Pointe Behavioral Health Services and Kaleidoscope Clinical Research.

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Misdiagnosis is a significant barrier to care. Black children and adolescents with ADHD are more likely to be labeled with oppositional defiant disorder and to have their ADHD symptoms misunderstood as defiance. Also, cultural stigma surrounding mental health can prevent Black families from seeking care and from using ADHD medication when it is prescribed. Black parents report a preference for interventions like parent training and executive function skills training, to which their access is often limited.

One possible solution: integrated primary care, in which behavioral health services are embedded within primary care practices. When children go to a pediatrician appointment, they may also see a behavioral health care specialist for common concerns like depression, anxiety, and a range of disruptive behaviors from failing to follow caregivers’ directions to disrupting the classroom.

[Read: ADHD Clinicians Must Consider Racial Bias in Evaluation and Treatment of Black Children]

Integrated primary care can address the treatment disparities in Black youth by enabling more personalized, collaborative treatment for ADHD and its co-occurring difficulties. Parents should ask their pediatrician whether an in-office behavioral health specialist is available. Additionally, many primary care practices affiliated with academic medical centers or children’s hospitals have integrated primary care clinics.

Mental Health Stigma in ADHD Care: Next Steps

• Learn: Why We Need Clinicians of Color to Normalize ADHD in BIPOC Communities
• Read: Evaluating and Treating ADHD in African American Children: Guidance for Clinicians
• Watch: “Health Equity in ADHD: Addressing Racial Disparities in Diagnosis and Treatment” [Video Replay & Podcast #495]

Heather A. Jones, Ph.D., is an associate professor of psychology at Virginia Commonwealth University.
Alfonso L. Floyd, Ph.D., is a postdoctoral fellow in the Department of Child & Adolescent Psychiatry and Behavioral Sciences at The Children’s Hospital of Philadelphia.

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.

Listening to music while practicing mindfulness exercises may improve focus, mood, and emotional wellbeing in people with symptoms of ADHD, anxiety, and depression, according to two new studies.

A systematic review examining the relationship between music and ADHD found that music listening activates brain regions involved in sensory processing, motor control, and motivation — networks that are often dysregulated in individuals with attention deficit.¹

Traditional thinking suggests that quiet environments help sustain attention; however, the opposite may be true. The review, published in Behavioral Science, indicated that music, especially calm music with or without lyrics, can improve focus and performance in individuals with ADHD, especially when it is heard before or during tasks. Listening to music can also help filter out distractions, leading to improved learning and mood.

“People with ADHD benefit from ‘rhythmic entrainment,’ using strong, steady rhythms to imprint structure and consistency. This assists with regulation of attention and behavior,” said Roberto Olivardia, Ph.D., Clinical Instructor of Psychology at Harvard Medical School, during his presentation titled, “We Got the Beat: The Impact of Music on ADHD,” at the 2024 Annual International Conference on ADHD.

Listening to music could become counterproductive if it causes overstimulation or if the listener is doing a challenging task that requires significant cognitive resources, the researchers noted.

Music Therapy Boosts Emotional, Social Skills

Music listening may be self-directed or facilitated by a trained music therapist, as part of music therapy. Music therapy sessions often incorporate active music listening, playing instruments, songwriting, or singing, as well as passive music listening.

The review made a compelling case for using music therapy to complement ADHD medications and other recommended therapies, citing evidence for the efficacy of music therapy in reducing symptoms of ADHD. For example, active music-making can enhance working memory and social skills while decreasing aggression. Conversely, passive music listening may improve learning and reduce disruptive behaviors.

“These insights highlight the potential for music to contribute to more holistic, non-pharmacological approaches, offering individuals with ADHD new avenues for enhancing cognitive functioning and overall wellbeing,” the study’s authors wrote.

The systematic review included 20 studies published between 1981 and 2023, reflecting data from 1,170 participants aged 2 to 56 years. Several limitations exist: The studies primarily focused on children and adolescents, rather than adults. Variations in study methods and design also resulted in some inconsistent findings.

“Despite these limitations, this review provides a valuable foundation for future research on the interaction between ADHD and music,” the study’s authors wrote.

Mindfulness Paired with Music Reduces Stress, Improves Mood

Another recent, smaller study, published in Frontiers in Neuroscience, suggests that listening to music while performing mindfulness exercises activates areas of the brain and body related to stress and emotional regulation that could reduce moderate symptoms of anxiety and depression in adults.sup>2

The study, led by a team of researchers from the Yale School of Medicine, assessed the physiological impact of music mindfulness by recording heart rates and EEGs from 38 participants, aged 18 to 65, as they engaged in a bilingual, two-week mindfulness program centered on “focus” and “mindfulness.”

“Anxiety and depression reduce autonomic system activity, as measured by Heart Rate Variability (HRV), and exacerbate cardiac morbidity, while both music and mindfulness have been shown to increase HRV,” wrote the researchers.

They found that music mindfulness quickly improved HRV — a sign of better stress regulation — and changed brain wave patterns (measured by EEG) in areas of the brain linked to emotion, awareness, and decision-making.

Both virtual and in-person sessions incorporated similar guided mindfulness exercises, accompanied by live improvised music, music listening, or no music at all. In addition to wearing mobile heart rate and EEG monitors during each session, participants completed surveys regarding their stress levels, degree of mindfulness, state of consciousness, and level of social connection before and after each session.

The virtual group exhibited a significant decrease in stress and a significant increase in altered states of consciousness during the “focus” sessions, but not the “motivation” sessions. This contrasted with the in-person sessions, where stress decreased and mindfulness and altered state of consciousness increased during both Focus and Motivation sessions.

The researchers said that the differences in music composition features (tempo, key, mode) between “focus” and “motivation” sessions may explain the physiological differences observed in heart rate variability.

In-person sessions with music boosted feelings of social connection more than the virtual sessions did, underscoring the value of live, shared experiences in therapeutic settings.

“Our results imply that, while virtual sessions reduce stress, they do not have as extensive an effect on psychological states as in-person sessions do,” the researchers wrote. “Important aspects of live social interaction may drive feelings of social connection and serve as a key differentiator between live and virtual sessions.”

The researchers also observed gender-specific effects via HRV; women appeared to benefit more physiologically from music mindfulness than men.

While the findings from the Behavioral Science and Frontiers in Neuroscience studies contribute to a growing body of evidence supporting the use of music as a viable adjunct treatment for ADHD and mood disorders, both research teams emphasize the need for further investigation. Future studies would include randomized controlled trials, long-term outcome assessments, and greater representation of adult populations.

Sources

¹Saville, P., Kinney, C., Heiderscheit, A., Himmerich, H. (2025). Exploring the intersection of ADHD and music: A systematic review. Behav. Sci. https://doi.org/10.3390/bs15010065

²Ramirez, C., Alayine, G.A., Akafia, C., Selase, K., Adichie, K. et al. (2025). Music mindfulness acutely modulates autonomic activity and improves psychological state in anxiety and depression. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2025.1554156

Reserve your spot in this free webinar, and get the event replay link plus a 15% discount to ADDitude magazine

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ADHD brings with it intense emotions, impatience, and stress — and our inability to regulate these feelings affects everyday life as well as our most important relationships. We overreact to situations and feel angry or dejected due to real or perceived criticism. We have trouble calming down and sometimes react in ways that we later regret.

Mindfulness and related contemplative practices offer a powerful counterbalance to these feelings. They are valuable tools that aid in stress reduction, self-awareness, cognitive flexibility, self-compassion, habit change, and more. And here’s the good news: Contrary to popular belief, these practices do not require a still mind and body. When these practices are integrated with a proactive approach to physical health, they can create a stable emotional foundation that supports comprehensive, evidence-based ADHD care.

In this webinar, you will learn:

• How ADHD impairs executive function and contributes to emotional dysregulation
• About the clinical importance of addressing emotional health as a foundational step in ADHD treatment planning
• How unmanaged emotional reactivity disrupts adherence to evidence-based ADHD interventions
• How to evaluate the role of mindfulness and contemplative practices in promoting emotional self-regulation and cognitive flexibility
• How to apply specific mindfulness-based strategies to support comprehensive, individualized ADHD care across clinical settings.

Have a question for our expert? There will be an opportunity to post questions for the presenter during the live webinar.

Meditation for Emotional Regulation: Resources

• Free Download: Make Mindfulness Work for You
• Read: Meditation for the Bored & Restless: How to Practice Mindfulness with ADHD
• Read: The Key to ADHD Emotional Regulation? Cultivating Gratitude, Pride & Compassion
• Read: The Ultimate List of Mindfulness Exercises
• eBook: Mindfulness & Meditation for ADHD Symptoms

Meet the Expert Speaker

Mark Bertin, M.D., is a developmental pediatrician and author of How Children Thrive, Mindful Parenting for ADHD (#CommissionsEarned), Mindfulness and Self-Compassion for Teen ADHD (#CommissionsEarned), all of which integrate mindfulness into evidence-based pediatric care. Dr. Bertin is a faculty member at New York Medical College and the Windward Teacher Training Institute, and has served on advisory boards for APSARD, ADDitude Magazine, The Screen Time Action Network, Common Sense Media, and Reach Out and Read. His blog is available through Psychology Today and elsewhere.

In addition to his clinical and writing work, Dr. Bertin leads workshops and retreats that combine mindfulness and practical support for families and professionals. Join him for Held and Whole: A Restorative ADHD Retreat Rooted in Nature, October 10–12, 2025, in the Catskills. For more information, please visit www.developmentaldoctor.com.

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

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Living with ADHD can feel like an emotional rollercoaster – Inflow gets it. Their science-backed program, developed by ADHD experts, teaches mindfulness techniques tailored for ADHD brains so you can learn to pause, process, and respond instead of reacting. Build emotional regulation skills, create calmer routines, and take back control. Take the free ADHD traits quiz to get started.

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Vitamin D insufficiency worsens sleep problems in children with ADHD, but it does not directly affect the condition’s symptoms or functional impairments, a recent study published in Frontiers in Psychology found.¹

Children with ADHD are more likely to experience vitamin D deficiencies than are children without ADHD, according to previous research.² However, this study found no causal relationship or direct link between ADHD symptoms and vitamin D insufficiency.

Scientists did find that low vitamin D levels (below 30 ng/mL) can worsen sleep difficulties, impairing sleep quality and worsening sleep disordered breathing, in children with ADHD.

The researchers wrote that sleep difficulties “increased daytime sleepiness, inattention, and oppositional defiant disorder symptoms in children.” Additionally, it was found that sleep disordered breathing can affect a child’s attention, focus, hyperactivity, memory, and executive functioning, essentially exacerbating ADHD symptoms.

Nearly three-quarters of children with ADHD experience a sleep problem or disorder.³ Additionally, up to half of children with ADHD have sleep problems, such as difficulty sleeping, insomnia, night waking, and hypersomnia.⁴, ⁵

This is the first study, to the researchers’ knowledge, that examines whether vitamin D insufficiency exacerbates sleep problems and symptoms in children with ADHD. Exploring the impact of vitamin D on sleep in children with ADHD is an important area of study since sleep problems in childhood may last into adolescence and adulthood.

“Poor sleep is a self-fulfilling prophecy,” says Joel Nigg, Ph.D., a clinical psychologist and a professor in the departments of psychiatry and behavioral sciences at Oregon Health & Science University. “Just one night of bad sleep can make a child’s inattention and opposition even worse the next day, in turn making it even more difficult to get ready and settled for sleep the next night. The pattern repeats indefinitely if not arrested.”

The case-control study examined data collected from 260 children with ADHD aged 6 to 14 years, 95 with vitamin D sufficiency and 165 with vitamin D insufficiency, from the Department of Child Health at Dalian Municipal Women and Children’s Medical Center in China.

The researchers noted several study limitations. Sleep information was obtained through subjective reports from the subjects’ parents, and researchers noted differences between these and objective sleep measures. Additionally, the study participants were limited to a group of children from Northeastern China. The sample size of 220 children is also too small to extrapolate the findings to other populations. Furthermore, since all participants had ADHD, there was no control group in this study.

The scientists hope to use the data collected from this study to further explore the relationship between ADHD symptom severity, sleep, and vitamin D levels in future studies with a more representative sample and a control group.

Vitamin D, which is mainly sourced from sunlight, can help with sleep difficulties commonly found in people with ADHD, like sleeping late, waking up throughout the night, or waking up very early. In the past few decades, researchers have found that locations with greater sunlight report lower-than-average ADHD prevalence, suggesting a possible connection between ADHD and vitamin D.⁶

Sources

¹ Zhang, P., Liu, Y., Yan, M. et al. (2025). Vitamin D insufficiency and sleep disturbances in children with ADHD: a case-control study. Frontiers in Psychology. https://doi.org/10.3389/fpsyt.2025.1546692

²Kotsi, E., Kotsi, E., Perrea, D.N. (2019). Vitamin D levels in children and adolescents with attention-deficit hyperactivity disorder (ADHD): a meta-analysis. <em>Attention deficit hyperactivity Disord. </em> https://doi.org/10.1007/s12402-018-0276-7

³ Sung, V., Hiscock, H., Sciberras, E., Efron, D. (2008). Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med. https://doi.org/10.1001/archpedi.162.4.336

⁴ Hvolby A. (2015). Associations of sleep disturbance with ADHD: implications for treatment. Atten Defic Hyperact Disord. doi: 10.1007/s12402-014-0151-0

⁵ Spruyt, K., Gozal, D. (2011). Sleep disturbances in children with attention-deficit/hyperactivity disorder. <em>Expert Rev Neurother.</em>.https://doi.org/10.1586/ern.11.7

⁶ Miller, M.C., Pan, X. Eugene Arnold, L. et al (2021). Vitamin D levels in children with attention deficit hyperactivity disorder: Association with seasonal and geographical variation, supplementation, inattention severity, and theta:beta ratio. Biological Psychology. https://doi.org/10.1016/j.biopsycho.2021.108099

Stimulant medications (amphetamine or methylphenidate) reduce ADHD symptoms better than non-pharmacological interventions, according to a meta-analysis published in The Lancet Psychiatry, which included 113 randomized clinical trials (RCTs) and 14,887 participants aged 19 to 44. ¹

The researchers analyzed self-reports and clinician-reported rating scales submitted at 12, 26, and 52 weeks regarding the efficacy of medication and non-medication treatment for ADHD.

“Stimulants were the only intervention supported by evidence of efficacy in the short term (i.e., at time points closest to 12 weeks) for core symptoms of ADHD in adults (both self-reported and clinician-reported) and were associated with good acceptability (all-cause discontinuation),” they said. (Amphetamines and methylphenidate showed no notable difference in effectiveness.)

Atomoxetine, a selective norepinephrine reuptake inhibitor (SNRI), benefited adults with ADHD during the measured time periods, but atomoxetine had worse overall acceptability compared to placebo.

A small body of evidence suggested that non-medication treatment [i.e., cognitive behavioral therapy (CBT), neurofeedback, and relaxation therapy] benefited people with ADHD over longer periods. However, those studies, the researchers noted, had inconsistent results with variations depending on whether the individual with ADHD or their clinician rated the core symptoms.

“Our findings highlight how both individuals with ADHD and clinicians should be considered as sources of evidence, with ratings of symptoms by both groups measured in RCTs,” the researchers said. “Participants in RCTs might report positive effects of the active intervention to please the interviewer (the Hawthorne effect), or might not correctly report the perceived effects of interventions (especially when they feel under pressure from the clinicians and have difficulties with executive function, as is often the case in people with ADHD).”

Neurofeedback Therapy for ADHD Not Effective

A separate meta-analysis published in JAMA Psychiatry examined the results of neurofeedback treatment in 2,472 people with ADHD aged 5 to 40 years from 38 RCTs. ²

The review, led by the University of Southampton, King’s College London, and the University of Zurich, found insufficient evidence to recommend neurofeedback as a front-line treatment for ADHD. According to the researchers, neurofeedback did not significantly reduce ADHD symptoms of inattention, hyperactivity, and impulsivity, and it did not improve cognitive performance in adults. Their findings did show that adults who used neurofeedback gained a slight improvement in their processing speed.

In addition, the researchers did not identify any differences between neurofeedback and other non-pharmacological treatments, such as physical exercise or cognitive training. Newer neurofeedback techniques, such as functional magnetic resonance imaging (fMRI) and functional near-infrared spectroscopy (fNIRS), also lack the evidence to support their efficacy at treating ADHD symptoms.

Neurofeedback is a distinct form of biofeedback that uses electroencephalography (EEG) to help patients train their brains to improve focus, impulse control, and executive function.

“The effects of neurofeedback don’t really last in the long term,” Stephanie Sarkis, Ph.D., said during the ADDitude webinar “Dispelling Myths About Supplements for ADHD.” “I know people who have used it say they felt more focused after sessions, but then they returned to baseline quickly. Neurofeedback is expensive to get that kind of a result, and insurance doesn’t cover it.”

A 2023 ADDitude survey of more than 11,000 caregivers and adults with ADHD found that 9% of adults and 14% of children have tried neurofeedback for ADHD. Of those respondents, caregivers rated the efficacy of neurofeedback as 2.9, and adults rated it as 2.88, on a five-point scale. In contrast, medication was rated 3.57 by caregivers and 3.52 by adults who responded to the ADDitude survey.

Indeed, the formal effect sizes for ADHD medication are .8 to 1.0, which are among the strongest in all of psychiatry.³ Clinical practice guidelines recommend medication as the first-line treatment for ADHD due to its overwhelming efficacy; for children with ADHD ages 4 to 6, parent behavior training is recommended by the American Academy of Pediatrics (AAP). ⁴

“Despite continuing progress in our scientific understanding of ADHD, little has changed for decades in terms of treatment,” said Edmund Sonuga-Barke, a professor of developmental psychology, psychiatry and neuroscience at King’s College London and joint senior author on the JAMA Psychiatry report. “Effective alternatives to medication as the front-line treatment for core symptoms are still lacking. The development of new, science-driven, and more effective non-pharmacological approaches for the treatment of ADHD, therefore, remains a priority for our field.”

Sources

¹ Ostinelli, E.G., Schulze, M., Zangani, C., Farhat, L.C., Tomlinson, A., Del Giovane, C., et al. (2025). Comparative efficacy and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: a systematic review and component network meta-analysis. Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(24)00360-2

² Westwood, S.J., Aggensteiner, P., Kaiser, A., Nagy, P., Donno, F. et al. (2025). Neurofeedback for attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2024.3702

³Faraone, S. V., & Buitelaar, J. (2010). Comparing the efficacy of stimulants for ADHD in children and adolescents using meta-analysis. European Child & Adolescent Psychiatry.  https://doi.org/10.1007/s00787-009-0054-3

⁴Centers for Disease Control and Prevention. (2022, March 8). Treatment recommendations for healthcare providers. https://www.cdc.gov/adhd/hcp/treatment-recommendations/index.html

Even with so little research, we can help perimenopausal women with ADHD make sound medical decisions by arming them with vital information to share with their doctors. Start here.

ADHD and Low Estrogen

Estrogen regulates the effects of neurotransmitters implicated in ADHD. When estrogen is low, dopamine and serotonin are affected, which can have a negative impact on attention, memory, mood, decision-making, sleep, emotional regulation, and other executive functions. As estrogen vacillates wildly in perimenopause (the years leading up to menopause), many women find that their ADHD symptoms grow significantly worse.

Perimenopause Treatment Options

• Selective Serotonin Reuptake Inhibitors (SSRIs): People with ADHD face an outsized risk for depression and anxiety disorders. While not a first-line treatment for ADHD, antidepressants including SSRIs and selective norepinephrine reuptake inhibitors (SNRIs) may have dual benefits for mood and ADHD symptoms in women with these comorbidities. There is also evidence that SSRIs effectively treat hot flashes as well.

[Read: How Changing Hormones Exacerbate ADHD Symptoms]

• Hormone Replacement Therapy (HRT): The current medical consensus is that, for women without risk factors such as breast cancer, or complications from diabetes, the benefits of HRT are generally considered to outweigh the potential risks. Through HRT, estrogen is delivered transdermally (via a patch, spray, or gel) or orally through pills. Women who shouldn’t use estrogen taken as a pill, such as women with migraines with aura or risk for thrombosis, can in many cases still use transdermal estrogen.
  For women who have a uterus, systemic estrogen should always be combined with progestin via an IUD or pills every day, every month, or every three months, or as a fixed estrogen-progestin combination in patch or pill form. For women who can’t take systemic HRT because of contraindications, local estrogen can be taken to treat vaginal atrophy or urinary tract symptoms.
• Alternative Options: A new treatment option for women who don’t tolerate hormonal therapy is Veozah, which targets hot flashes directly via the hypothalamus.
• Adjusting ADHD Medication: Fluctuating and declining hormone levels may affect the efficacy of stimulant or non-stimulant ADHD medication; many perimenopausal women report that their tried-and-true ADHD medications fail to adequately manage their symptoms during this time. If you’ve noticed this, talk with your doctor about tailoring your ADHD medication dosage, possibly in conjunction with hormone therapy.

[Watch: A Patient’s Guide to Talking with Your Doctor About ADHD and Menopause]

Prepping for Your Appointment

To make the most of your doctor’s visit, arrive with the following information:

• Menstrual Cycles and Symptoms: Track your cycle, and your ADHD and perimenopausal symptoms, ideally for two to three months, to help your doctor identify patterns. You can use this sample menstrual cycle tracker.
• Medications: List prescription and nonprescription medications (including the ones you’ve recently discontinued), as well as vitamins and supplements.
• Major Life Stressors or Changes: Note important life events on a timeline so your doctor has full context for your experience.
• Questions: If you’re not sure where to begin, say: “I’ve noticed changes in my ADHD symptoms, and I suspect that this may be related to perimenopause. Can we talk about treatment options for both of these conditions?”

Perimenopause Treatment and ADHD: Next Steps

• Read: We Demand Attention! A Call for Greater Research on Women with ADHD
• Download: Menopause & ADHD – Treatments & Interventions
• Read: “How I Restarted My Life After a Post-Menopausal ADHD Diagnosis”

Lotta Borg Skoglund, M.D., Ph.D., is an associate professor at Uppsala University in the Department for Women’s and Children’s Health and leader of the pioneering research group GODDESS 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.

Declining levels of hormones, especially estrogen, are to blame for the escalation of cognitive and physical symptoms that women with ADHD already experience leading up to menopause (when you’ve gone without a menstrual period for 12 consecutive months). Vaginal, sexual, and urinary symptoms are also common.

Collaborative Care

Your psychiatrist and gynecologist should collaborate to treat your symptoms of menopause and ADHD optimally. Your psychiatrist may need to adjust your ADHD medication regimen – the dosage or the formulation – to effectively treat changing ADHD symptoms as estrogen and progesterone decline. Ideally, your gynecologist would also consult with your psychiatrist about adding hormone replacement therapy (HRT) to help manage ADHD.

For women without risk factors such as breast cancer or diabetes, studies suggest that HRT can improve memory, attention, and cognitive function with benefits to sleep, muscle mass, and bone density.

The WHI Aftermath

In the early 2000s, the Women’s Health Initiative (WHI) released studies that revealed health risks associated with HRT, and many women and clinicians have feared it since. However, the WHI studies had serious limitations, including the use of a single formulation of estrogen, thought to increase risk of breast cancer.

[Get This Free Guide: ADHD Diagnosis for Women]

Subsequent studies and analyses of the WHI data have led to a better understanding of HRT, the benefits and risks of which depend on the type of HRT, age, dose, initiation and duration, and prior estrogen sensitive cancer, among other factors.

When to Start HRT

Generally, the earlier HRT is started relative to the onset of menopause, the better, and periodic re-evaluation is key. Women younger than 60 or within 10 years of menopause are ideal candidates for HRT, according to the North American Menopause Society (NAMS).

Other approaches to ease symptoms of ADHD and menopause, including hot flashes and insomnia, include cognitive behavioral therapy, exercise, and relaxed breathing techniques.

Doctor Visit Checklist

To gauge whether your providers are informed or open to learning about treatments for menopause and ADHD, ask these questions.

• How knowledgeable are you about the impact of hormonal fluctuations, especially estrogen loss, on ADHD symptoms?
• What are your thoughts on HRT? Am I a candidate for this treatment? Which other treatments and approaches might ease my menopause and ADHD symptoms?
• What do you know about how hormonal fluctuations impact the therapeutic effects of stimulants?
• How knowledgeable are you about the cognitive symptoms of menopause and how they overlap with ADHD symptoms?
• How comfortable are you with reviewing patient-provided resources on ADHD and menopause?

Low Estrogen and ADHD: Next Steps

• Learn: ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.
• Symptom Test: Signs of ADHD in Girls and Women
• Read: “We Demand Attention on How Hormonal Changes Impact ADHD Symptoms in Women”

Jeanette Wasserstein, Ph.D., is a clinical assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York.

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.

April 16, 2025

Every few years, the ADHD community must endure another skeptic – an author, a journalist, a contrarian mental health provider, quite frequently a chiropractor – recycling claims like “ADHD is overdiagnosed,” “stimulants don’t work,” or, most remarkably in one case, “ADHD does not exist.”

In every instance, including Paul Tough’s recent New York Times Magazine feature, the articles serve only to obfuscate the conversation about ADHD because:

• They attempt a critique of the diagnosis based mostly on thought experiments and persuasion rather than qualitative or quantitative analysis.
• They focus almost exclusively on the medical aspects of ADHD and not on the behavioral change that integrates with and complements it, providing a wholly reductive understanding of treatment.
• They neglect to spend sufficient time with any of the millions of children, teens, and adults who are immensely helped by an integrative treatment for ADHD, including medication management. If they interview anyone, they cherry-pick folks who decided they didn’t want or like treatment for ADHD.

Invariably, in such analyses, clients of ADHD services are portrayed as hapless dupes of a psychiatric industrial complex hellbent on profiting from a made-up affliction that is really just the same thing that everyone else experiences but somehow handles quite nobly and with aplomb. In reality, almost no one seeking help for ADHD feels hoodwinked. Why would they? The work they do to overcome ADHD is certainly difficult. I have found that anyone benefiting from stimulant medication typically has a love-hate relationship with it; if it weren’t working, nobody anywhere any time would pay their hard-earned dollars each month to receive it.

The Truth About ADHD Medication Efficacy

In his article, Tough retreads a very old tire of ADHD tropes dating back to the genesis of my career in doctoral school in the late 1980s. To do so, he latches onto the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study, without any meaningful clinical understanding of its nuances.

In my book, ADD and Zombies, I point out that a major problem with the MTA study is that it does not account for stimulant tolerance – the problem that, with prolonged usage, people adjust to medication and need more and more to get the same results. While stimulant tolerance somehow remains controversial among some prescribers, it is not controversial among the clients who take these medications. For them, it’s obvious.

As is often the case when laypeople storm the ADHD castle, the author misstates the recommended treatment as stimulant medication alone. Nearly all professional organizations recommend a combination of therapy and medication management, or what we call “integrative treatment.” As I say in my books, “If you are taking meds only for ADHD, it’s like putting gas in your car and driving around and around the parking lot.” The MTA study is simply a study of stimulants over time and, therefore, not a true reflection of real-world results for patients undergoing integrative treatment.

The Truth About ADHD Diagnoses

The author points out, somewhat ham-handedly, that the process of diagnosing ADHD is problematic. He is correct, largely because that process is mostly conducted in primary care offices, and not in collaboration with psychiatric providers and/or in tandem with a longer-term relationship with a therapist. However, he is incorrect that there is no test for ADHD. There are several.

It’s true that ADHD has no genetic marker test, but this is true also of depression, anxiety, and just about every other psychiatric condition. But, somehow, very few skeptics write articles about how “depression is overdiagnosed” or maybe “doesn’t exist.” Almost nobody claims that anxiety is a trick diagnosis to lure people into taking medication. No one disavows bipolar disorder.

As mental health providers, we don’t diagnose people with ADHD to stigmatize or pathologize them; we do so to describe their experiences and behavior so that we might, with their most enthusiastic consent, bill their insurance and devise treatment plans to reduce those symptoms. And if we do it right, we do it well.

To make these diagnoses, we use norm-referenced psychological testing, alongside a good psychiatric interview and history taking. At our office, this process takes a minimum of five sessions and is quite good at predicting who does and does not have ADHD. And contrary to Tough’s supposition in quoting me in his article, a diagnosis really is just that, a categorical variable. You either qualify for it or you don’t. And if you do, you either are impaired by it or you are not. That’s the essence of every psychiatric diagnosis in the DSM-5. Love it or hate it, it is not unique to ADHD.

If Tough wants to complain about the quality of diagnosis rendered in various medical offices, he might actually read my book and find in me a willing ally. I have that same concern, not because prescribers lack the tools or resources to do better diagnoses, but because they are not paid to use them. Had Tough asked or read beyond the popular press or the low-hanging MTA fruit, he’d have found a much more interesting story there – one that describes how to get a good ADHD diagnosis and why so many people don’t pursue that path and yet end up on stimulants.

Instead, he leans on a highly reductive approach, as evidenced in this quote: “That ever-expanding mountain of pills rests on certain assumptions: that ADHD is a medical disorder that demands a medical solution; that it is caused by inherent deficits in children’s brains; and that the medications we give them repair those deficits.”

There’s a lot to unpack here.

Yes, ADHD is a medical disorder because we have decided it is a medical disorder and because we have found that integrative treatment brings tremendous improvement to people’s lives, and people want to use their insurance to get that treatment. I know this because I, unlike the Times author, have spent thousands of hours over 32 years talking to those folks.

Wouldn’t it be great if stimulants “repaired those deficits” of attention and concentration, as Tough laments, they do not? Does Mounjaro reverse my diabetes? Does a beta-blocker repair my high blood pressure? Of course not. I got those from my mom, just as most folks with ADHD inherited it from their parents or grandparents, which is well demonstrated in the literature ignored by Tough. All we can do is treat the symptoms of most chronic health conditions with medication and lifestyle changes. That’s integrative treatment.

Far less amusing is Tough’s next quote, another tired and rather offensive supposition that ADHD is caused by some environmental bugaboo. He notes, “Scientists who study ADHD are… uncovering new evidence for the role of a child’s environment in the progression of his symptoms. They don’t question the very real problems that lead families to seek treatment for ADHD, but many believe that our current approach isn’t doing enough to help — and that we can do better. But first, they say, we need to rethink many of our old ideas about the disorder and begin looking at ADHD anew.”

While Tough doesn’t flesh out this idea, most of us recognize it as the “bad parenting” theory of ADHD that is far from new. As I point out in my books, the diathesis-stress model best explains how predisposition and environment work together to produce the actual symptoms and behavior of any given psychiatric diagnosis and many medical ones.

Tough is correct to wonder if environmental factors might also impact ADHD, but to propose it as an astounding new development that dislodges genetic predisposition as a primary contributor to ADHD is no more accepted in the field than the false belief that autism is caused by vaccines.

I could wax on responding to Tough’s analysis, but I will close my remarks, content in the understanding that people will continue to seek and receive services for ADHD, regardless of his words, because they like how the treatment impacts their lives. And if they do not, they are free not to be treated. At our clinic, that’s true regardless of one’s age or status. If children do not want to be treated, we do not treat them. We invite them to be part of our team, and most are happy to do so. Those who are not, we respect equally.

As Tough notes in the article, we do help parents encourage their children to receive treatment by pointing out how difficult their kids’ lives are in school, among friends, and at home. I saw several such teens today. But, in the end, we are radical believers in informed consent.

What is disappointing is not the return of these old saws, repackaged as new news, but the fact that too few clients receive the benefits of integrative treatment. The medical folks hand out prescriptions. The traditional therapists eschew them. And diagnosis is often eyeballed rather than scrupulously tested. There is much to critique in these bifurcated treatment models. Tough could have made that a central point of his article had he stepped a little farther into our world and shown a bit more empathy for the millions of folks who are in no way hapless dupes, and who might not appreciate the implication that they are.

ADHD Article Corrections: Next Steps

• Read: Setting the Record Straight on ADHD and Its Treatments
• Free Download: The Ultimate Guide to ADHD Medication
• Reader Reactions: MAHA Commission Means Fear, Stigma, Health Threats for Two-Thirds of ADDitude Readers
• Read: Is ADHD Real? Yes — and Still Heavily Stigmatized

Wes Crenshaw, PhD is Board Certified in Couple and Family Psychology (ABPP) and the author of I Always Want to Be Where I’m Not: Successful Living with ADD and ADHD and coauthor with Kelsey Daugherty, DNP of ADD and Zombies: Fearless Medication Management for ADD and ADHD.