Clinical Hot Topic 16: Growing up with ADHD ‒ challenges and issues
Professor Sarah Kittel-Schneider (Associate Professor and Vice Director of the Department of Psychiatry, Psychotherapy & Psychosomatic Medicine, University Hospital of Würzburg, Würzburg, Germany) stated that the reported prevalence of childhood ADHD is ~5–7%,1 and 3.4% for adult ADHD.2 She discussed how 65% of childhood ADHD persists into adulthood3 and comorbid psychiatric and non-psychiatric or somatic disorders are the rule rather than exception in ADHD.2 Additionally, different comorbidities and issues can arise throughout the lifespan of an individual with ADHD.3
Over the lifespan, individuals with ADHD can have different symptom trajectories.4 Professor Kittel-Schneider presented data which highlighted that a proportion of individuals (n=56) had persistently high ADHD symptom severity throughout a 10-year period, whereas for others, ADHD symptoms were considered gradually remitting (n=60), quickly remitting (n=39) or symptom severity was persistently low (n=96).4 Another study showed that 65% of individuals with ADHD had persistent symptoms that cause functional impairment in adulthood, while 71% had persistent symptoms that remained subthreshold for a diagnosis of ADHD.5 However, 15% of individuals achieved full remission and no longer met the full diagnostic criteria for ADHD in adulthood.5
Professor Kittel-Schneider moved on to discuss the possibility of adult-onset ADHD. Study data (n=1037; 52% male) had shown that most children with ADHD (>50%) did not have symptoms of ADHD in adulthood.6 Additionally, the proportion of adults with ADHD who did not have childhood ADHD (>20%) was larger than the proportion who had childhood-onset ADHD (<5%).6 Overall, the childhood and adult ADHD groups comprised of virtually non-overlapping sets.6 Professor Kittel-Schneider questioned whether these data suggest that there are higher rates of remission of childhood-onset ADHD or if adult-onset ADHD was a possibility. These questions were supported by evidence that most adults with ADHD did not report a diagnosis of childhood ADHD and there were low symptom persistence rates in adulthood.6,7 However, possible explanations for this included: memory bias; false low persistence rates due to self-rating in adulthood versus teacher- or parent-rating in childhood; ‘subthreshold’ ADHD in childhood and exacerbation of symptoms in adolescence and young adulthood; diagnosis of another psychiatric disorder as ‘true’ diagnosis with ADHD-like symptoms; or other non-psychiatric diseases with ADHD-like symptoms.6-9 Additionally, Professor Kittel-Schneider presented data that reiterated the possible trajectories of ADHD over the lifespan such as persistent ADHD, classical remitting ADHD and ‘subthreshold’ ADHD that becomes more apparent in adulthood, as well as highlighting that brain injury may also be a trajectory.3
Treatment of ADHD across the lifespan
Professor Kittel-Schneider discussed how ADHD should be treated across the lifespan. According to the German guidelines for ADHD, in both children and adults, a multimodal treatment plan should be adopted depending on ADHD severity; in the first instance, psychoeducation is recommended for each severity level.10 For mild ADHD, psychosocial interventions are recommended. Psychosocial interventions should be intensified, medication prescribed or a combination of both if ADHD symptoms are of moderate severity.10 Finally, for severe ADHD, pharmacotherapy and psychosocial interventions are recommended. In children with ADHD aged <6 years, intervention should be primarily psychosocial, and intervention can be in the form of parent and teacher training with child-centred intervention.10 Whereas, in adults, psychosocial intervention should be cognitive behavioural therapy.10 Study data had highlighted that effect sizes of ADHD medication were more variable in adults compared with children.3 However, Professor Kittel-Schneider reiterated that ADHD medication is effective in both children and adults.3
Comorbid disorders over the lifespan
Compared with the general population, psychiatric comorbidities are significantly more common in individuals with ADHD.3 Professor Kittel-Schneider highlighted that comorbid psychiatric disorders change across the lifespan in individuals with ADHD as the most common disorders in children are oppositional defiant disorder, conduct disorder, autism spectrum disorders (ASD) and tic disorders.3 While adults are more likely to suffer from anxiety, depressive disorders and substance-use disorders.3
Transition from child and adolescent to adult mental health services
Professor Kittel-Schneider indicated that transition from childhood and adolescence to adulthood typically occurs between the ages of 16–25 years. Transition is defined as the purposeful and planned process of supporting young people moving from child health services to adult health services.11 However, there can be issues with transitioning between services as individual development does not always adhere to legal borders.12 She provided the example that an individual with ADHD who is aged 18 years may legally be an adult; however, she feels that individuals with ADHD tend to mature at a slower pace than the general population and so may not be ready for the transition to adult services. Additionally, she suggested that in adult mental health services, therapists may provide less close-meshed treatment and expect more personal responsibility which the individual with ADHD may not be ready for. Family members may also not participate as much in treatment within adult mental health services, which may come as a relief to individuals with ADHD but may not be appropriate for them.12 Finally, there can be differences in medication and psychotherapy intervention between child and adult mental health services.12
Furthermore, Professor Kittel-Schneider stated that there may be issues on the therapist’s side that can complicate the transition. There can be legal differences and different financial reimbursements available to child and adult mental health services that may mean there is less time spent with each individual with ADHD. Additionally, specialisation is completely separated (e.g. a child and adolescent psychiatry specialist versus an adult psychiatry specialist). Finally, due to the separation of specialities, adult psychotherapists and psychiatrists may have less knowledge about issues that could affect school and education facilitation in adolescents and young adults with ADHD. Overall, differences in mental health service interfaces, incomplete transfers and incomplete or stopped ongoing care can result in an individual with ADHD falling into the transition gap.12
Professor Kittel-Schneider then discussed findings of a multi-perspective study which concluded that there is an international challenge with the transition of individuals between child and adolescent mental health services and adult mental health services.13 The authors stated that the transition is poorly planned, poorly executed and poorly experienced.13 Another study reported that half of the individuals with psychiatric disorders in childhood are faced with transition problems.14 Transition issues particularly affect individuals with neurodevelopmental disorders.13 It had been noted that the only patients who typically do not fall through the transition gap have severe psychiatric illness or are currently inpatients.13
Professor Kittel-Schneider stated that there are also issues with transition during the daily clinical experience, as some individuals with ADHD want to stop pharmacotherapy 2–3 years after starting therapy.12 Some individuals may also experiment with illicit substances. Additionally, there are issues related to leaving school, such as sudden loss of structure, and symptoms can be less subjectively impairing, which can interfere with a smooth transition.12 She stated that, based on her own clinical opinion, more personal responsibility (remembering therapist appointments and adhering to therapeutic homework) can interfere with the core symptoms of ADHD. Additionally, from her observations, a substantial number of individuals with ADHD might leave treatment but return only after failure in university, jobs or personal relationships. Finally, she opined that general practitioners and adult psychiatrists may still have a lack of knowledge and reservations in regard to stimulant medication and so may be reluctant to prescribe them to individuals with ADHD.
Professor Kittel-Schneider stated that adult ADHD is still underdiagnosed and undertreated, and that this is even more pronounced in females. A study noted that out of 3,705,952 individuals, the prevalence of ADHD (n=25,300) in adult females was 0.36% (aged 18–30 years) and 0.07% (aged ≥31 years) compared with the prevalence of ADHD in adult males which was 0.96% (aged 18–30 years) and 0.09% (aged ≥31 years).15 Furthermore, another study highlighted a 90% fall in medication use within 6 years in a transition cohort of adolescents aged 15 years with ADHD (n=5593; 77.6% male).16 The study emphasised that if ADHD remains untreated, it could lead to high rates of psychiatric and non-psychiatric disorders, higher risk of accidents and injuries and worsening of psychosocial functioning and quality of life in those with ADHD.16
Professor Kittel-Schneider concluded with some key statements on how to avoid the transition gap in ADHD12:
- An individual with ADHD should be transferred to adult mental health services if they continue to present with significant ADHD symptoms.
- The transition should be pre-planned by referring and receiving services.
- An individual with ADHD should be reassessed at school leaving age with arrangements made if treatment is still required prior to transition to adult mental health services.
- During the transition, the child psychiatry and adult services should meet for transfer of the individual’s information and full information about adult mental health services should be made available to the individual with ADHD.
- After transition, adult mental health services should carry out a comprehensive assessment and individuals with ADHD should be assessed for any comorbid conditions.
- Specialist ADHD teams for children, adolescents and adults should jointly develop age-appropriate training programmes for diagnosis and management of ADHD.
Professor Kittel-Schneider: “People with ADHD should be informed of the differences [between child and adult mental health services] so they are not surprised”
Females, hormones and ADHD: through the lifecycle
Moderator: Dr Duncan Manders (Consultant Child & Adolescent and Intellectual Disabilities Psychiatrist, Royal Hospital for Sick Children, Edinburgh, UK)
In her session, Dr Sara Binder (Adult Psychiatrist/Clinical Lecturer, University of Calgary, Calgary, Canada) discussed how ADHD presents in females, treatment strategies for ADHD during pregnancy, as well as the hormonal impact of the menopause on cognition. She opened her presentation by describing the struggles that working mothers face, which only increase if that individual has ADHD. Then she explained the effect of oestrogen on mood, emotional regulation, memory, executive function and circadian rhythms. Fluctuations in oestrogen can impact mood and cognition and have physical symptoms, whether this is through the menstrual cycle or throughout the lifespan. She added that during periods of decreased oestrogen, there is an increased risk of depression and anxiety,17 as well as cognitive decline and increased ADHD symptoms.
Gender differences in ADHD
Dr Binder explained that more boys are diagnosed with ADHD than girls, ranging from 3:1 to 16:1.18,19 In adults, the prevalence of ADHD is closer to 1:1.20 Based on these data, Dr Binder asked what becomes of these young girls or teenage girls who are not diagnosed or treated but that are discovered during adulthood? Dr Binder suggested that many girls with ADHD may go undiagnosed and untreated, which may have an impact on their long-term social, educational and mental health outcomes. She then introduced the ‘female protective effect’ theory; females with ADHD may need to reach a higher threshold of exposures (both genetic and environmental) for ADHD symptoms to be expressed.21 This may account for the lower prevalence in females and the higher family transmission rates in families of females with ADHD.21 In fact, siblings of girls with ADHD may have more ADHD symptoms compared with siblings of boys.21
Dr Binder then explained the gender differences in terms of psychiatric comorbidities. She described how girls are more likely to develop emotional disorders in adolescence, such as major depressive disorder (MDD) and anxiety disorders.22 She added that girls are more likely to internalise ADHD symptoms, which may manifest as MDD or anxiety instead. It is these comorbidities that may lead them to see a medical practitioner and which will then be the focus rather than the underlying ADHD; girls are therefore more likely to be treated for MDD or anxiety.22 She expanded that high anxiety may mitigate ADHD symptoms, as girls may have some control over symptoms to avoid unwanted attention. The other key comorbidity for clinicians to look out for in girls is borderline personality disorder (BPD), as BPD shares overlapping traits with ADHD.23 Dr Binder suggested that lots of women are misdiagnosed with BPD who may have underlying ADHD, which is unfortunate as ADHD can be less stigmatising and more manageable than BPD.
Dr Binder highlighted the key vulnerabilities in females with ADHD, which included difficulties with emotional lability and emotional dysregulation; social problems; vulnerability to bullying (whether social, physical or cyberbullying); becoming sexually active earlier than peers with increased number of partners and higher rates of sexually transmitted infections and unplanned pregnancies; antisocial behaviour; increased school dropout and underachievement; decreased self-esteem and self-concept; and increased rate of accidents.24 She explained that among females with ADHD, there is a greater increase of MDD with age than in males with ADHD. The increase in multiple anxiety disorders is more comparable between the sexes in paediatrics and adulthood.25 In addition, boys tend to exhibit more externalising behaviours (hyperactivity/impulsivity) and have a rise of striatal dopamine receptors that is paralleled by their early motor symptoms.26 Dr Binder explained that this can mean boys with ADHD are more disruptive in the classroom, attracting the teacher’s attention, whereas girls present more with inattention and tend to go unnoticed. She suggested this is what results in higher rates of ADHD diagnosis in boys than girls.
Women with ADHD
Dr Binder next described a study of 107 Canadian women with ADHD, aged 20–39 years, who were found to have 3-times the prevalence of insomnia, chronic pain, suicidal ideation, childhood sexual abuse and generalised anxiety disorder compared with 3801 age-matched women without ADHD. Women with ADHD also had double the prevalence of substance abuse, current smoking, depressive disorders, severe poverty and childhood physical abuse.27 Dr Binder explained these findings suggest that women with ADHD are particularly vulnerable to early adversities, health and mental health problems. Furthermore, adolescent girls with more severe ADHD make fewer future plans than peers, have lower socioeconomic status and more problems in dating and marital relationships, social activities and completing daily responsibilities.28-30
ADHD and the menstrual cycle
Dr Binder explained that during the mid-follicular phase of the menstrual cycle, the reward system, which is primarily modulated by dopamine, is augmented. She went on to explain that oestrogen modulates dopamine, which may affect cognitive functions, emotional states and vulnerability to drug abuse.31 She described how hormones vary throughout the menstrual cycle.32,33 She explained that ADHD symptoms vary along with these cyclical changes in hormones; in the early follicular and post-ovulatory period, an increase in ADHD symptoms coincides with the oestrogen shift and lower dopamine.33 This data prompted Dr Binder to ask how clinicians adjust medication doses for these hormonal changes to control symptoms of ADHD.
Dr Binder explained that during the follicular phase (of high oestrogen), women experience greater response to stimulants.34 Clinical evidence suggests worsening of symptoms in the premenstrual period; therefore, together, these data indicate that ADHD medications may need to be titrated throughout the menstrual cycle for optimal symptoms control.35 Dr Binder then described a study that examined daily levels of reproductive hormones. This was the first study to suggest strong post-ovulatory worsening of ADHD. It also suggested that lower oestrogen levels with higher progesterone and testosterone levels predict next day increases in ADHD symptoms and confirmed that the effects of low oestrogen are only present during periods of high progesterone and testosterone.33 Dr Binder further explained that elevated progesterone heightens attention to social cues relevant to social affiliation, while elevated testosterone facilitates attention to social dominance opportunities. Therefore, high levels of both hormones may increase vulnerability to distractions in the environment and impulsive behaviour.33 She added that decreased oestrogen levels lead to decreased executive function and increased ADHD symptoms, making individuals more impulsive post-ovulation, therefore increasing the risk of unplanned sexual encounters and pregnancy.33
Pregnancy and ADHD
Dr Binder emphasised that pregnancy and ADHD is an important topic to consider. In general, many women experience increased distractibility during pregnancy and postpartum, and neurocognitive changes have been subjectively observed during pregnancy. Dr Binder described how women identify with ‘pregnancy brain’, when they complain of memory impairment and poor concentration.36,37 She added that changes in sex hormones are hypothesised to cause impaired cognition.36 She explained that all women are at risk of impaired cognition during pregnancy, mostly due to the fact that elevated prolactin causes some depression of dopamine; however, if a woman has ADHD and is already struggling with levels of dopamine, then ADHD symptoms may become more severe. Compared with non-pregnant women, women in the third trimester of pregnancy and during the postpartum period have been found to display impaired memory and lower processing speed scores.36,37 Then, in the perinatal period, Dr Binder suggested that elevated prolactin levels due to breastfeeding may impact neurotransmitters such as dopamine, which, alongside having a new baby, means women are sleep deprived and challenged, potentially worsening symptoms even further.36
Treatment during pregnancy
Next, Dr Binder stated that what we should acknowledge is that a growing number of women are entering their reproductive years while being treated for ADHD and there are no guidelines to inform treatment of ADHD during pregnancy and postpartum.36 There are concerns over stimulant exposure in utero and foetal growth, but no evidence so far to suggest stimulants are associated with major congenital malformations.36 Dr Binder explained that it is important to weigh the risks and benefits of ADHD treatment during pregnancy and that infants born to mothers taking stimulants should be monitored for withdrawal symptoms. In her clinical experience, many women stop their ADHD medications as soon as they find out they are pregnant. She described how some women may be high-functioning and have good support to cope well without medication while pregnant. However, others may suffer impairments due to their untreated ADHD, which may include a higher risk of motor vehicle accidents, impaired occupational functioning, financial trouble, problems with self-care and problems with relationships.36 Dr Binder added that they may relapse into substance use, due to a need to self-medicate.
Dr Binder stated that the baseline rate of congenital malformations is 3% of all pregnancies in the United States, regardless of stimulant use.38 She emphasised that it is hard to review stimulant use during pregnancy when cohorts include people also using stimulants of abuse, making it difficult to differentiate the effects. A study of pregnancy and neonatal outcomes for women with ADHD taking stimulants (n=153) found that the most frequent delivery complication was neonatal hypoxia (15.6%) and the most common side effect was decreased appetite (34.9%).39 Dr Binder described a separate study that reported congenital anomalies in 2.2% of pregnancies, below the baseline 3% rate.40 In another study of women abusing stimulants during pregnancy, there were relatively high rates of prematurity, growth retardation and neonatal withdrawal, as well as exposure to alcohol, smoking and other drugs.41 Dr Binder explained that the timing of stimulant exposure may determine its impact; a study found no significant impact on birth weight with discontinued use at 28 weeks but a 4% lower birth weight if discontinued after 28 weeks.42 A Swedish study of 964,743 infants found that of 0.2% exposed to ADHD medication, 50% were more likely to be admitted to a neonatal intensive care unit (NICU) and there was some increased risk of seizures and preterm birth, but no increased risk of congenital malformations.43 Dr Binder explained that when looking at the demographics of women taking ADHD medication, they tended to be younger, obese, single, smokers and users of other medications or substances, making it hard to decipher a causal link between medications and outcomes due to this ADHD group differing significantly from women who did not use ADHD medication.43 Then, Dr Binder outlined key points from a meta-analysis which found that ADHD medication use during pregnancy is associated with increased risk of NICU admissions and marginally associated with increased risk for cardiac malformation. However, no evidence of an increased risk for other adverse maternal or neonatal outcomes was found.44 Dr Binder suggested that stimulant medication should only continue during pregnancy if a potential benefit justifies any risks.
Breastfeeding and stimulants
Dr Binder described how breastfeeding is largely encouraged in general but there remains limited data on whether exposure to stimulants in breast milk can affect infant growth. A small report of four mothers taking ADHD medication did not find any adverse events and the infant plasma level of ADHD medication was low or undetectable, with a dose of 5.7% of that of the maternal dose, which is below the 10% cut-off cited in literature.45 Then, Dr Binder posed the three questions that clinicians and women with ADHD are likely to ask46:
- Should ADHD medication be stopped before, during or after pregnancy, or continued throughout?
- Should doses be adjusted during or after pregnancy or delivery?
- Should breastfeeding be encouraged or discouraged based on need for ADHD medication?
Dr Binder summarised the treatment recommendations so far, which included collaborative decision-making with the woman and spouse, the attempt of a medication-free trial to assess functional impact before conception and consideration of accommodations at work, school or home.
ADHD and the menopause
In the final part of her session, Dr Binder discussed menopausal symptoms and ADHD. She explained that, leading up to the menopause, oestrogen levels fluctuate significantly.47 However, upon reaching the menopause, there is a significant drop-off of oestrogen. Dr Binder stated that worsening of memory and cognition is related to oestrogen reduction.48 Dr Binder also suggested that ADHD symptoms may overlap with menopausal symptoms of low energy, physical pain, sleep disturbance and memory problems. She described how the early changes in working memory circuitry are evident decades before the age range typically targeted in cognitive ageing studies and that reproductive age and hormonal status are likely more important than chronological age in understanding ageing of memory circuitry in women.49 In her clinical experience, Dr Binder stated that midlife decline in cognitive and executive function is a common complaint for perimenopausal women. The perimenopause phase involves fluctuating hormones and eventual depletion of oestrogen post-menopause, which Dr Binder suggested may correlate with reduced cognition with respect to attention and memory, reliant on the prefrontal cortex. In her opinion, medications that increase dopamine may improve the executive dysfunction induced by this loss of oestrogen input to the prefrontal cortex.
Dr Binder ended her presentation with conclusions about females and ADHD. She stated that, in her opinion, girls with ADHD tend to be overlooked or misdiagnosed with only MDD or anxiety and that there is significant functional impairment in women with undiagnosed or untreated ADHD. She added that hormonal fluctuations affect ADHD symptoms and response to stimulants, and that there should be repeated assessment and management of comorbid conditions as well as a better understanding of the usefulness of dose titration throughout the menstrual cycle. In her clinical experience, stimulant treatment during pregnancy must be determined by evaluating the risks versus benefits, and infants born to mothers taking stimulants should be monitored for withdrawal symptoms. Finally, she suggested that the impact of the menopause in women with ADHD should be considered, that psychosocial interventions are necessary in combination with pharmacotherapy for optimal functional outcomes and that clinicians should ensure management of females with ADHD throughout the entire life cycle.
Dr Binder: “The hormonal fluctuations in women really affect ADHD symptoms as well as their response to stimulant treatment”
Still distracted after all these years: a study of older adults with ADHD
Moderator: Dr Duncan Manders (Consultant Child & Adolescent and Intellectual Disabilities Psychiatrist, Royal Hospital for Sick Children, Edinburgh, UK)
Dr Kathleen Nadeau’s (Psychologist, Chesapeake ADHD Centre, Bethesda, Maryland, USA) session provided a discussion of the largely ignored older population with ADHD, a population which is growing larger each day. In her opinion, clinicians need to better understand this long-ignored population and encourage much needed research.
ADHD and later cognitive impairment
Dr Nadeau stated that one of the questions most frequently asked by older adults with ADHD is whether their ADHD will predispose them to cognitive impairment as an older adult. She described a study that investigated this question in 310 geriatric participants, who ranged from having no cognitive impairment to dementia. These participants were given the Wender Utah Rating Scale (WURS), which explores ADHD patterns in early life. The frequency of WURS-positive ADHD in this population was 4.4%. It was found that WURS scores were not related to cognitive status in later life, suggesting that ADHD symptoms remain stable across the lifespan and are not a precursor for dementia.50
ADHD and memory issues
Dr Nadeau emphasised the need to routinely screen for ADHD in older adults with memory issues by describing how some memory clinics are reporting adults with undiagnosed ADHD coming for diagnosis fearing early dementia. In her clinical experience, using a standard adult ADHD screener with a lower cut-off score may be a good way to screen for ADHD in older adults, until a specific tool is developed. She added that there is a need to interview a family member regarding the individual’s forgetfulness, lack of time awareness and disorganisation if these are longstanding. Furthermore, it is important to explore whether younger family members are diagnosed with ADHD as this increases the likelihood that they may have it too, due to the high heritability of ADHD.
Mild cognitive impairment versus ADHD
Dr Nadeau went on to explain that mild cognitive impairment is often a precursor for dementia and is defined as a reported cognitive change (corroborated by a third party) or evidence of decline on repeated cognitive testing. The individual may have generally intact global cognition and there should be lack of medical cause for cognitive decline.51 She explained that ADHD differs from mild cognitive impairment in that it is always present and characterised by unpredictable gaps in memory, whilst mild cognitive impairment is characterised by poor memory for recent events. She expanded that there may be an overlap between some of the cognitive symptoms of ADHD (distractibility, misplacing objects, incomplete projects, disorganisation and poor planning) and mild cognitive impairment; however, it is the long-term history of these symptoms and family history of them that may differentiate ADHD.52
Primary ADHD challenges reported
Dr Nadeau presented five of the main challenges that older adults with ADHD report, in her clinical experience:
- Not getting things done due to procrastination, lack of motivation and poor self-discipline
- Emotions not being under control such as irritability, emotional reactivity, anxiety, inflexibility, sadness and regret
- Poor time management from always running late, having no schedule and poor time awareness
- Remnants of hyperactivity such as continual restlessness, random thoughts, talking too much and taking on too many things constantly
- Interpersonal relationships for which problems included feeling misunderstood or judged, using the wrong tone and saying the wrong thing, missing social cues and a need to be a better listener.
ADHD and reduced life expectancy
Next, Dr Nadeau described research that found that for individuals whose ADHD Combined Type or Presentation (ADHD-C) extended into adulthood, life expectancy was reduced by 12.7 years. Furthermore, even for those who no longer qualified for an ADHD-C diagnosis in adulthood, life expectancy was reduced by 8.4 years.53 Dr Nadeau stated how this could explain the research finding that ADHD decreases in old age, as perhaps this perceived decrease is instead caused by less people with ADHD living into old age. The factors suggested to lead to a reduced lifespan included low conscientiousness (an inability to delay gratification to achieve long-term goals), adverse health and lifestyle factors (smoking, alcohol consumption, obesity), driving accidents and psychiatric comorbidities.53 In her clinical opinion, the adults with ADHD who tend to live into old age are those who have predominantly inattentive ADHD, higher intelligence, better executive functioning, more education and supportive long-term relationships.
Treatment focus in older adults
Dr Nadeau suggested that ADHD treatment in older adults should include brain-friendly daily habits (sleep, good nutrition, daily exercise) to improve health and cognition; executive function coaching to help with finances, paperwork and time management; and limited social isolation by increasing support and inclusion. She described evidence that suggests that older adults can benefit from psychostimulants, so long as care is taken to explore possible contraindications related to cardiac issues.54 However, one problem is that few physicians are trained or experienced in prescribing ADHD medication to older adults and many refuse to do so. Dr Nadeau suggested that clinicians working with older adults with ADHD should look for an environment that provides structure and social interaction for them. One of the challenges for older adults with ADHD is leaving the workplace, as they lose much-needed structure that can lead to poor sleep patterns and poor nutritional habits. Therefore, they may benefit from finding a more structured situation, for example an ‘over 55 community’ with built-in activities and social life. She also suggested that a part-time job can offer older adults with ADHD some social contact, a sense of purpose, structure and supplement income.
Different presentations among older adults with ADHD
In the next part of her session, Dr Nadeau described the different presentations she has observed in her clinical practice of older adults with ADHD. To her surprise, she has found many have long-term marriages. She stated that it is important to study the characteristics of long-standing marriages affected by ADHD, as most research has only focused on divorce statistics and failed marriages. On the other hand, she described how she has also met older adults with ADHD who are still struggling after many years with anxiety, poor financial preparedness for retirement, low self-esteem and weak family connections. Another presentation of older adults with ADHD she described was those who are finally relaxed, free to be themselves with less pressure on executive functions and who have a chance to pursue gifts and talents. She concluded that those who were happiest were well-integrated into the community, knew they had value to offer, did not feel isolated, were less concerned with financial comfort and relieved to no longer have the stress of work life.
Tips for clinicians
Dr Nadeau ended her session by giving some tips for clinicians. Surrounding diagnosis, these included looking for ADHD in younger family members and to interview adult children and have them complete a questionnaire. Clinicians must recognise that ADHD is a long-term disorder, but that symptoms can increase due to stress, poor sleep and lack of structure. In terms of treatment, she suggested to consider prescribing psychostimulants, on a case by case basis; to treat co-morbid anxiety and depression but not to overlook ADHD; to refer to an executive functioning coach to build brain-healthy daily habits; and, if they live alone, to encourage them to consider living in a senior community that offers built-in social life and activities.
Dr Nadeau: “ADHD statistically is one of the top four psychiatric conditions most common in adulthood, so it is really shocking that we are not better trained in it”
Clinical Hot Topic 17: Students with ADHD – getting set for success in college/university
Dr Kathleen Nadeau (Psychologist, Chesapeake ADHD Centre, Bethesda, Maryland, USA) first presented a study of 539 males (with ADHD, n=326; without ADHD, n=213) which found that few university students with ADHD completed a 4-year degree (15%) compared with students without ADHD (48%).55 Dr Nadeau suggested that, in her opinion, very few students with ADHD complete their degree because universities are inherently ‘ADHD-unfriendly’. In her opinion, university offers very little structure and support, there is too much free time outside of class, the number of reading and writing assignments increase and there are numerous distractions that can disrupt study. Furthermore, general education classes may not align with the interests of the individual with ADHD and so they may struggle to remain focused on the class. Poor grades can also prevent the student with ADHD from being accepted into their desired area of study.
Dr Nadeau stated that pre-planned strategies can lower the risk that a student with ADHD will fail. For example, taking a gap year to allow time for the brain to mature more56 and cope better with a university environment may be useful. Also, she suggested that a student with ADHD could stay at home and attend a local university as this can offer better support and structure. A career assessment can also aid the student with finding a career direction that suits their abilities and interests.
Dr Nadeau next indicated that a study has shown that a university with a clear ADHD support programme can help the student with ADHD improve their executive functioning skills.57 Furthermore, in Dr Nadeau’s clinical opinion, a small university with small classes may be more beneficial as there is more accountability due to the lecturer knowing everyone, and it is much more noticeable if the student does not attend class. Additionally, a university that has a well-developed disabilities support office could help to develop accommodations for the student with ADHD.57 Finally, a university that offers a course that suits the interests and abilities of the student with ADHD is best.
Dr Nadeau moved on to discuss the way in which a student with ADHD can increase their chances of success at university. For example, the student could work closely with an executive functioning mentor in order to build their planning and organisational skills.57 From Dr Nadeau’s own clinical opinion, she suggested that working closely with a writing tutor could aid the student in developing their writing skills. Also, prior to attending university the student could work with an ADHD specialist who could help them choose the right university, degree route and aid them in registering for classes in a way that is ADHD-friendly. Reducing the course load and planning to do a 5-year undergraduate degree could also help the student manage their studies and allow them to take the more difficult classes in the summer when there is more time to spend studying. Considering a degree course which offers a work and study programme could provide the student with hands-on learning, which often suits a student with ADHD. Dr Nadeau stated that choosing a roommate with good study habits could aid the student with ADHD in improving their own study habits. Staying focused on the long-term goals might also remind the student with ADHD of what they are working towards. She suggested that daily aerobic exercise could aid in improving learning and memory, and keeping a regular sleep schedule could help the student stay focused throughout the day.
Finally, Dr Nadeau concluded her session by providing some key tips for clinicians who have individuals with ADHD who are thinking of going to university:
- Discuss with the parents whether the student is ready to move out of the parental home.
- Consider a specialised university counsellor to find a course with a good support programme.
- Encourage the student to find a clinician close to campus to decrease the risk of issues with attaining prescriptions and to be in a better position to help during a crisis than their provider from their home area.
- Encourage the student to work with an executive function coach as well as a tutor for the most challenging classes.
- Encourage the student to have a career assessment as individuals with ADHD may fail due to poor career choice.
Dr Nadeau: “Following these guidelines … are really a roadmap to helping students [with ADHD] succeed in university”
Clinical Hot Topic 18: Impact of lockdown on young people’s mental health
Impact of the COVID-19 pandemic in young people
Dr Regina Sala (Consultant Child and Adolescent Psychiatrist, East London Foundation NHS Trust, London, UK) opened her session by stating that the COVID-19 crisis has led to unprecedented challenges around the globe and that the impact to young people is likely to be devastating, even though those who contract COVID-19 appear to have less severe symptoms and lower mortality rates than other age groups.58 She then presented the three phases of the pandemic: the preparation phase, when the government enforces social distancing and lockdown; the natural course, when the peak of the curve is reached and the highest rate of mortality; and lastly, the return to normality.59
Impact of lockdown in young people
Dr Sala explained that the collateral effects of the pandemic in young people can be divided into three categories: mental health, physical health and abuse and neglect. Starting with mental health, Dr Sala stated that one of the main consequences has been the anxiety and stress around COVID-19 and lockdown, such as worries about personal and family health, fear to go out, maladaptive coping mechanisms of stress or to fight boredom (e.g. overeating or online gambling) and increased behavioural problems. She then described another impact as being the lack of face-to-face mental health treatment, with many sessions being replaced virtually or via telephone or even postponed. Dr Sala explained that this can lead to worries over privacy, with sessions being held in the vicinity of family members. Another impact is the loss of mental health support and protective behaviours due to social isolation, loss of social support through friends, school and family and the loss of social services support. Dr Sala explained that these factors can all lead to an increased risk of depression.60
Then, Dr Sala described the impact of lockdown on physical health. For example, the reduction in healthy behaviours due to less physical activity, being outdoors or engaging in hobbies. Additionally, young people may have much longer screen time, disrupted routines, irregular sleep patterns and poor nutrition. Another impact is the loss of free school meals; 1.7 million children are currently entitled to free school meal provision in the United Kingdom. The loss of this may result in further poor nutrition. Dr Sala explained that together these factors may increase the rate of obesity in young people.60
Dr Sala next explained the increased incidence of abuse and neglect. Stress of illness, lockdown and financial strain has led to increased risk of abuse and neglect in the home, particularly where there may be a greater risk of substance misuse and worsening mental health in parents or carers. Children are also at risk of abuse and neglect online, due to unsupervised and overall increased screen time. Dr Sala described how during lockdown young people have reduced access to report abuse and seek help and reduced access to school and youth groups, which are important for identifying those at risk and providing support. Overall, she described a strain on services that would usually help and protect children, due to staff sickness and challenges of working remotely.60
Research on the impact of lockdown in young people’s mental health
Dr Sala first presented a study of 1784 school children (56.7% male) during the COVID-19 outbreak in Hubei Province, China. These children had been restricted to home for a mean (standard deviation) of 33.7 (2.1) days when they participated in an online survey concerning their mental health status, assessed using the Children’s Depression Inventory-Short form (CDI-S) and a screen for child anxiety-related emotional disorders. This study found that 18.9% of children presented with anxiety and 22.6% presented with depressive symptoms, which may be associated to the reduction of outdoor activities and social interaction.61
Dr Sala presented another study that used a 20-minute online survey to assess the mental health consequences of the COVID-19 lockdown in the United Kingdom in young people. In total, 1507 young people (72% female) aged 16‒24 years completed the survey between May and June 2020. Over half of these young people (53%) reported higher levels of stress than before and 94% expected changes in their lives to some extent once the current crisis is over, of whom 6% expected a complete change in their lives, which Dr Sala suggested explained the overall higher levels of anxiety and depressive symptoms. This study also found that 45.7% of respondents without previous mental health problems reported high levels of depressive symptoms and a third of respondents without previous mental health problems reported moderate-to-severe anxiety symptoms (30.6%). Additionally, half of respondents reported overeating in response to their mood (55.3%). Dr Sala further described that young people indicated they would ask for help if needed from a partner (72.5%), a friend (65.2%), a parent (51.7%) or a mental health professional (31.1%) and a third would not ask for help (34.7%).62
The next study that Dr Sala presented was from a UK charity for children and young people’s mental health. In total, 2036 young people aged 13‒25 years with a history of mental health needs completed the survey between June and July 2020. For context, this was the period in which the UK government announced new measures to ease restrictions, including the target for schools to reopen to all students in the Autumn term. It was reported that 83% of respondents reported that their mental health had become worse since the first survey in March 2020; 41% reported ‘much worse’, which was an increase from 32% in the previous survey. This finding was often related to increased feelings of anxiety, isolation, a loss of coping mechanisms or a loss of motivation. Despite 71% reporting they had been able to stay in touch with friends, 87% reported they had felt lonely or isolated during the lockdown period. Furthermore, of 1081 respondents who were accessing mental health support in the 3 months leading up to the pandemic, 31% said they were no longer able to access the support that they needed. Only 11% said that their mental health had improved during the crisis and this was often because they felt it was beneficial to be away from the pressures of their normal life (e.g. bullying or academic pressure at school).63
Then, Dr Sala presented findings from a study looking at ADHD as a risk factor for infection with COVID-19. This study collected data from the electronic health record of 14,022 people (aged 2 months to 103 years) registered with Leumit Health Services between 1 February 2020 and 30 April 2020, who underwent at least one COVID-19 test. People undergoing treatment for their ADHD were defined as purchasing consecutively ≥3 ADHD medication prescriptions during the past year. This study found a total of 1416 (10.1%) people who were positive for COVID-19; this group were significantly younger (crude odds ratio [OR] 1.78 [95% confidence interval (CI) 1.57–2.03]; p<0.001) and had higher rates of ADHD (crude OR 1.47 [95% CI 1.26–1.71]; p<0.001) than those who were COVID-19-negative. Furthermore, the risk for being COVID-19-positive was higher in untreated people with ADHD compared with people without ADHD (crude OR 1.61 [95% CI 1.36–1.89]; p<0.001), whereas people with ADHD receiving treatment did not have this higher risk (crude OR 1.07 [95% CI 0.78–1.48]; p=0.65).64
Another study of the effects of the COVID-19 lockdown in young people was presented by Dr Sala. This longitudinal study of 41 overweight young people (54% male) aged 6‒18 years under national lockdown in Italy examined their diet, activity and sleep for 3 weeks between March and April 2020. The researchers compared this data with the same sample in 2019. They found an increase of potato chip (p<0.001), red meat (p<0.001) and sugary drinks intake (p=0.005); decrease in sports activities by more than 2 hours/week (p=0.003); increase in screen time by nearly 5 hours/day (p<0.001); and an increase in sleep time by 0.6 hours/day (p=0.003). The only gender difference was an increase in the number of meals eaten per day which increased significantly more in males by 1.6 meals/day than in females (0.58 meals/day; p=0.028).65
Dr Sala discussed clinical challenges during lockdown, such as how best to deliver care within the new restrictions (e.g. whether it is appropriate, and whether the benefits outweigh the risks in starting or continuing ADHD medications). She explained that there are challenges in issuing prescriptions and monitoring the effectiveness and tolerability of medications. However, she assured that despite the difficult circumstances, clinicians should ensure continuity of care during all phases of the pandemic and all relevant service provision should continue via telephone or appropriate online video technology (telepsychiatry).
On the topic of monitoring ADHD medication, Dr Sala explained that clinicians should continue to monitor effectiveness and tolerability of medication and consider changes in routine during the COVID-19 crisis. She described some recommendations for home blood pressure or pulse monitoring. For example, use of an age-adapted cuff size; taking blood pressure ≥2 hours after taking ADHD medication; sitting down for 10‒15 minutes before taking the reading; taking the reading on the left arm; and using the lowest of three readings, at approximately the same time on three separate days and sending the readings alongside the pulse values to the prescribers.66
In terms of recommendations for parents or carers, Dr Sala emphasised that psychoeducation about how difficult these times are for young people with ADHD is an important step. Parents and carers should be advised to be kind to themselves as parents and to young people, to stay connected with them and ask about their feelings and talk about a daily schedule. Further tips for parents and carers were to keep positive and motivated, make sure all family members know what is expected of them, build the child’s self-confidence and trust, help the child to follow instructions, promote better behaviour and limit conflicts. Dr Sala also explained that the use of behavioural parenting strategies has beneficial effects in reducing oppositional defiant and disruptive behaviour that is common in ADHD.66
Dr Sala explained the recommendations for schools, which were to monitor all students, especially those with mental health difficulties to check if they are participating in online classes and submitting their tasks, and whether there are any concerns regarding their social and emotional well-being. It was also suggested that clinicians liaise with teachers, in particular regarding transitioning plans.66 Finally, Dr Sala reviewed recommendations on physical health, which included to restrict intake of high fat and sugary diets, promote intake of fruits and vegetables, adjust portion sizes appropriately for age, ensure opportunity for family meals, promote physical activity at home, limit screen time, and ensure enough sleep. The family must aim to set an example and provide information and skills to make healthy food choices.
Dr Sala summarised her talk with a number of conclusions. It is important to evaluate the collateral effects of the COVID-19 pandemic in young people, such as mental and physical health consequences and the risk of abuse or neglect.60 Research on the impact of lockdown on young people’s mental health showed higher levels of anxiety and depressive symptoms, difficulties to access mental health support, and obesity.61-63,65 Untreated ADHD seems to constitute a risk factor for COVID-19 infection.64 Clinicians should ensure the continuity of care during lockdown, potentially through telepsychiatry. Finally, Dr Sala emphasised the importance of psychoeducation, parenting interventions, school liaison and physical health in the care of young people during the COVID-19 pandemic.
Dr Sala: “One of the main consequences that we have been seeing is the anxiety and stress around COVID-19 and lockdown”
Females with ADHD: different or not so different?
Moderator: Dr Duncan Manders (Consultant Child & Adolescent and Intellectual Disabilities Psychiatrist, Royal Hospital for Sick Children, Edinburgh, UK)
Dr Susan Young (Consultant Forensic and Clinical Psychologist, Private Practice, London, UK) discussed the findings of the females with ADHD consensus statement. She began her presentation by stating that symptoms of ADHD in females are similar to those in males; however, females may have lower symptom severity, particularly for hyperactivity and impulsivity. Females may also have greater and more severe comorbidity than males; for example, severe mental illness, inpatient psychiatric admissions, emotional lability, irritability, low frustration tolerance, anxiety, depression, alcohol and cannabis use, BPD, eating disorders, chronic fatigue syndrome, fibromyalgia and body dysmorphic disorder. Dr Young stated that there is anecdotal evidence that hormones may exacerbate ADHD symptoms during the menstrual cycle, pregnancy, peri/postpartum periods and the menopause.24
Next, Dr Young described how the behaviours of females with ADHD can be identified. She stated that ADHD has a public perception of being a behavioural disorder characterised by boisterousness, aggression and oppositional and conduct problems that mainly affects males. Presentation of ADHD in females can differ from this perception as females with ADHD tend to be more impulsive and emotionally driven than aggressive and increasingly oppositional. Females are also less likely to come into conduct with the criminal justice system; however, a meta-analysis showed there was no significant difference in the ratio of males and females of the prison population.67 Furthermore, mortality rate of individuals with ADHD is higher than the general population. Dr Young stated that the female mortality rate is higher than males and mainly due to accidental deaths; she hypothesised that this is due to the high number of females who are undiagnosed and so are not treated for ADHD.24
Dr Young noted that academic and occupational functioning is similar in females and males with ADHD. Typically, individuals with ADHD have later completion rates, repeating years, re-takes, suspensions, exclusions, lower attainment, drop-out, specific learning difficulties and truancy. She stated that inattention associated with ADHD is highly predictive of academic underachievement. Females with ADHD tend to change jobs quickly, the type of work alters and they have lower productivity.24
Dr Young feels there are social functioning behaviours of ADHD in females that can be spotted. Behaviours can include a high turnover of friends, as females with ADHD typically experience peer rejection and social isolation. Bullying is also experienced in higher frequency in females with ADHD than individuals without ADHD. Whereas males with ADHD are more likely to be the aggressors or victims of physical aggression. Dr Young stated that problems associated with social functioning in females with ADHD are amplified through their application of ineffective and/or dysfunctional strategies and lack of a support network. Additionally, some females with ADHD may seek a social network by forming damaging relationships (joining a gang, promiscuity, compliance or being used by others for crime).24 In Dr Young’s clinical opinion, good social networks are key to being able to figure out and talk through issues before they escalate.
Dr Young stated that individuals with ADHD may become sexually active earlier than their peers, they may have more sexual partners and are more likely to engage in unsafe sexual practices.24 She suggested that this likeliness of engaging in unsafe sexual practices could result in disproportionate social stigma for adolescents and young women with ADHD.24 Additionally, females with ADHD are more likely to contract sexually transmitted infections or experience unplanned or early pregnancies.24 She stated that there is evidence that harsh, lax or negative parenting styles are elevated in mothers with ADHD.68
Dr Young highlighted patterns of ‘red flag’ behaviours for females with ADHD. For example, academic problems, specific learning problems, a feeling of being overwhelmed, and a disparity between educational performance and achievement. Anxiety, depression, emotional volatility and dysregulation are common markers of female ADHD, in addition to self-harm. Females with ADHD are more likely to have interpersonal relationship problems, conflict and impulsive ‘lashing out’. Additionally, females with ADHD may present at sexual health services earlier than individuals without ADHD of a similar age or more frequently, as well as exhibit early sexual behaviours. Sensation seeking and risk-taking are also more common in females with ADHD compared with individuals without ADHD. Symptoms of ADHD may be elevated during times of transition (personal, education, health) and females may have inadequate or dysfunctional coping strategies. Finally, females with ADHD may ‘buffer’ and camouflage behaviours to lessen or absorb the impact of a problem in their life.24
Dr Young moved on to discuss the use of rating scales when assessing a female with possible ADHD. She emphasised that rating scales are not diagnostic instruments but tools to aid diagnosis and monitor clinical progress. If used for screening purposes, if a female exhibits scores that fall just below the cut-off, they should not be excluded from referral or full diagnostic assessment for ADHD. Also, she stated that ‘normal’ ADHD behaviours and symptoms are typically based on males, which may put females at a disadvantage due to differences in expression of ADHD. However, some scales (Conners’ Comprehensive Behaviour Rating Scales [CBRS] and Strengths and Difficulties Questionnaire [SDQ]) can provide normative data for females.24
Dr Young recommended that clinical interviews should be semi-structured as this may prevent clinicians from missing symptom changes over time in both females and males with ADHD.24 Clinicians should make small modifications to capture female-centric behaviour (e.g. ‘excessive talking and giggling’ instead of ‘excessive talking’).24 Furthermore, Dr Young opined that clinicians should be wary of collateral information from independent sources if they perceive ADHD as a ‘behavioural disorder’ and if they do not perceive ADHD as having both male and female presentation as their information may be less reliable. Additionally, school reports often omit social engagement and behaviour, which may be a key sign of ADHD symptoms.24 Dr Young stated that clinicians should be mindful that objective assessments are not specific markers of ADHD and should only be used to augment the clinical decision-making process.24 However, the QB scales do have normative data that is specific to females and males.24 Clinicians should also assess for age-appropriate common co-occurring conditions in females with ADHD and look out for the above mentioned ‘red flags’.24 Factors that make symptoms worse (e.g. stress) or better (e.g. strategies) should also be taken into consideration at clinical assessments.24 Clinicians should also be aware that female adolescents and young adults with ADHD are more likely to be applying dysfunctional strategies to manage emotional turmoil, social isolation and rejection.24
Clinicians should be conscious that symptoms of ADHD may be minimised and/or ‘camouflaged’ by accommodations at home, school or occupation and to watch out for bravado, masking and buffering. Dr Young stated that the compensatory strategies the females with ADHD may implement could be successful for a brief period of time to cope with a specific situation but they cannot generally be sustained. Finally, she emphasised that deliberate self-harm is common, is impulse driven and sometimes ‘hidden’ in females with ADHD.24
Dr Young summarised the risks that clinicians need to be aware of when assessing females with ADHD; for example, social attitudes and behaviours, quality of relationships, coping strategies, deliberate self-harm and ideation, eating habits, substance-use, internet use, unsafe sexual practices, victimisation and potential for exploitation and violence (emotional lability).24
Dr Young moved on to discuss the interventions that are available for females with ADHD. She stated that pharmacological recommendations do not differ by sex and only differ slightly by age. Psychoeducation should be provided to both the individual and parents or carers with an aim to improve engagement and adherence to treatment. Treatment responses should be assessed through individualised targets rather than strictly adhering to rating scales. The risks of substance use should also be discussed, as well as eating patterns, particularly of appetite suppression if stimulants are prescribed and there is a concern about eating problems.24
Issues and challenges
Dr Young next discussed the number of issues and challenges that pertain to identifying and treating females with ADHD. Perceived differences in symptom profiles can explain, in part, the sex differences in rates of referral and diagnosis. Males with ADHD are typically referred to health services at a young age due to their hard-to-manage behavioural problems, whereas due to differences in ADHD presentations in females, they are not typically identified until young adulthood. Typically, females with ADHD may have self-referred themselves at this stage to primary health services; they previously may have been seen for a comorbid condition, but the ADHD symptoms were missed. Dr Young opined that due to the late diagnosis of females with ADHD, there is a greater impact on academic and social issues; therefore, females with ADHD need to be identified earlier. Dr Young emphasised that there is a need to dispel the myths surrounding sex differences in ADHD symptoms. She stated that both females and males have the same symptoms and behavioural problems (internalising problems, emotional lability, risk-taking) but outwardly they present differently: males tend to be more disruptive and aggressive, while females tend to have more social-relational and psychosexual problems.24
Top tips to support females with ADHD
Dr Young next provided her clinical top tips for treating females with ADHD. She suggested clinicians should inform parents and carers of the elevated risk of specific problems that may present later in life in females with ADHD. Clinicians should also assess the risk of deliberate self-harm, eating disorders, substance-use disorders and psychosexual issues and specify them in a care plan that notes the triggers and maintenance factors. The needs of the female with ADHD should be assessed and other agencies (e.g. educational and social services) engaged where required. Clinicians should also provide support in terms of sexual health and planning; sexual harassment and exploitation; and abusive and or inappropriate relationships. Dr Young stated that pregnancy and parenting for the female with ADHD should be supported, she emphasised that mothers with ADHD may be particularly vulnerable, especially if they are young, isolated and/or the child has ADHD. Clinicians should discuss risk taking (e.g. sensation-seeking and unsafe sexual behaviours) with the female with ADHD. Reviews should be carried out during periods of personal transition and not solely based on the transition from child to adult mental health service. Additionally, liaising with schools is a good way of raising awareness of female ADHD and to provide additional support for the females in order to avoid early school leaving. Clinicians should also consider the support females with ADHD may need in terms of further education and careers advice and help with accessing work.24 Finally, Dr Young suggested, based on her own clinical experience, that clinicians should provide females with ADHD with written information about different services they may require.
Finally, Dr Young concluded by stating that clinicians need to change their perceptions because ADHD in females is often missed or misdiagnosed. Clinicians need to be mindful of the ‘red flags’ of female ADHD and to adjust assessments in order to capture ‘female-centric’ difficulties, impairments and risks. She emphasised that females with ADHD require life skills and support to develop critical reasoning skills, functional problem-solving skills and coping strategies.
Dr Young: “Please don’t let these girls [with ADHD] be left as leaves in the wind”
‘Ask the experts’ discussion forum
Panel: Dr Sara Binder (Adult Psychiatrist/Clinical Lecturer, University of Calgary, Calgary, Canada); Dr Kathleen Nadeau (Psychologist, Chesapeake ADHD Centre, Bethesda, Maryland, USA); Dr Susan Young (Consultant Forensic and Clinical Psychologist, Private Practice, London, UK)
For this session, Dr Manders presented the panel with questions put forward by the audience, which panel members answered using their own clinical expertise and experience. Below is a summary of their responses.
‘Is it not time to create a different set of diagnostic criteria that is more attuned to recognising females and adults with ADHD?’
Dr Young opined that it was a mistake to remove emotional dysregulation from the Diagnostic and Statistical Manual (DSM) as many clinicians believe it to be a major symptom of ADHD, in not just females but everyone, and one of the most impairing symptoms.
Dr Nadeau agreed with Dr Young and added that she believes impaired executive functioning should also be a core part of diagnosing an individual with ADHD. She stated that the core symptoms of ADHD to be identified during assessment should be an individual’s emotional regulation abilities, executive functioning skills and social impairment.
Dr Binder stated that she always includes emotional dysregulation when diagnosing an individual with ADHD. Emotional dysregulation does present differently and has different outcomes in males and females, but without including it in diagnostic criteria, females are at an increased risk of being diagnosed with BPD because of the high overlap between emotional dysregulation and impulsivity. She believes that ADHD, as a diagnostic term, needs to be modified in terms of DSM, and emotional dysregulation and executive function need to be included in the criteria for ADHD because without them, clinicians risk missing many individuals who would benefit from ADHD treatment.
‘How do you differentiate between BPD and ADHD?’
Dr Young explained that typically an individual with ADHD has a difficult life because of their disorder and so it is very possible for them to develop a personality disorder. She stated that the difficulty lies when a clinician has to determine whether the personality disorder is comorbid or a differential diagnosis. If an adult presents with BPD and there is a possibility they have ADHD, it is relatively easy to do a more comprehensive assessment of their childhood behavioural information. However, this assessment is difficult when you cannot get collateral information or parent interviews. She added that ADHD is a chronic disorder that initially presents in childhood, whereas BPD is not, which can help determine the diagnosis of an individual.
Dr Binder added that when she interviews individuals with BPD about why they self-harm they typically say that it is to ‘feel something’. Whereas a female with ADHD who is self-harming will say they do it impulsively but also to help them calm down and focus. When looked at neurobiologically, self-harming is driving their dopaminergic system and provides a different symptom relief than the experience of the individual with BPD. Additionally, Dr Binder has observed that individuals with BPD can have intense emotional activity and get stuck in this intensity. Whereas individuals with ADHD more frequently have periods of intense emotional activity that relatively quickly returns to baseline.
‘How underdiagnosed do you think ADHD is in girls and how can we be better at spotting ADHD in girls at a younger age?’
Dr Binder stated that ADHD in females is highly underdiagnosed, as ADHD is more prevalent in boys than girls but is equally prevalent in adulthood. She stressed that it is important to dispel the myth that girls with ADHD are inattentive and boys are hyperactive and impulsive. She emphasised that ADHD is heterogeneous and can present differently based on the individual. Lifespan-wise, in adolescent girls with ADHD, we need to look at risk-taking behaviour and hypersexuality, comorbid anxiety, eating disorders and budding borderline behaviours. Then in adulthood, we need to look at struggles with changes in the menstrual cycle and pregnancy issues and postpartum. Finally, looking at the perimenopause and menopause period, when there is empty-nest syndrome, retirement, ageing parents and the cognitive impact of drops in oestrogen impacting an ADHD brain.
Dr Nadeau suggested that in young girls, clinicians should note whether they have very little sense of time, forgetfulness, messiness, school resistance and outright avoidance, and increased emotional lability once school is over after seemingly being well-behaved during the day.
Dr Young discussed that there should be policy change to provide teachers with more education of the symptoms of ADHD in females. Also, a protocol surrounding screening females for ADHD who have repeated negative behaviour at school and multiple exclusions or expulsions that can act as markers for ADHD in school-age females.
‘Should we be screening people for ADHD when they present with self-harming behaviours in the emergency room?’
Dr Binder believed people who present with self-harming definitely warrant screening. One of the issues with screening in the emergency room, however, is that you are dealing with acute presentations of self-harm. She discussed how other clinical specialists need education in screening for ADHD due to the high comorbidity between ADHD and psychiatric disorders (BPD, self-harm, anxiety and depression).
‘How can one distinguish social skill difficulties in ADHD from social communication difficulties of ASD?’
Dr Nadeau commented from a clinical perspective that social difficulties have very different qualities between ADHD and ASD. Individuals with ASD typically do not understand the social scenario, whereas individuals with ADHD do understand the situation but do not know how to join in with the social interactions.
Dr Binder added that individuals with ASD are missing the reciprocity piece, they almost need to be taught how to interact with people. Whereas, individuals with ADHD are good at reading others and are empathic but they miss social cues and cannot communicate effectively.
Dr Young replied that there are some similarities between the two disorders, such as difficulties adjusting behaviour to different situations. Children with ADHD typically do not have difficulties taking part in imaginative play or interacting with their peers, but they are more likely to demonstrate risky behaviour or miss social cues. However, young children with ASD typically are unable to share and are not interested in playing with others. She suggested it is important to be careful when separating the fine differences between ADHD and ASD as there is some overlap.
‘Where is the evidence that hormones can affect ADHD symptomology, and if we do not have sufficient evidence presently, what do we do in order to get it?’
Dr Young commented that there was an article published that suggested that ADHD medication can be prescribed during pregnancy and that there were similar studies surrounding hormones and ADHD; however, the authors of the ‘Females with ADHD’ consensus statement agreed that there needs to be more data before they could support this view.
Dr Binder agreed that more needs to be done to provide clear guidelines surrounding female hormones and ADHD medication. There is evidence that hormonal fluctuations during the menstrual cycle, pregnancy and the menopause do have effects on ADHD symptoms and that increasing doses during hormonal fluctuations may aid ADHD symptoms; however, there are currently not enough data to support this concept.
Dr Binder concluded the session with a final take-home message. She noted that clinicians need to start considering ADHD in their differential diagnosis when they are presented with a young girl with academic and social struggles as untreated ADHD can have a severe impact on their life.
Clinical Hot Topic 19: A woman’s journey with ADHD
Dr Sarah Binder (Adult Psychiatrist/Clinical Lecturer, University of Calgary, Calgary, Canada) discussed the gender differences in obtaining a diagnosis and treatment for ADHD. She stated that more boys are diagnosed with ADHD than girls; however, in adults, the prevalence is similar between males and females.20,69 Typically, boys with ADHD are more likely to suffer from disorders presenting early in development, such as learning disability and oppositional defiant disorder.19,69 Whereas, girls are more likely to present with internalising symptoms and comorbid MDD or anxiety.19,69 Dr Binder suggested that girls are more likely to be treated for MDD or anxiety versus comorbid ADHD as the symptoms of anxiety may mitigate ADHD symptoms (e.g. impulsivity and hyperactivity).
Dr Binder discussed how ADHD symptoms can vary during the menstrual cycle due to changes in hormone levels. Post-ovulatory increase in progesterone and decrease in oestrogen leads to an increase in ADHD symptoms, possibly due to coinciding with the decrease in lower dopamine levels.33 This decrease in dopamine in females with ADHD could affect cognitive functioning, emotional states and impulsive behaviour.32 From Dr Binder’s own clinical experience, females with ADHD who are untreated are more at risk of sexually transmitted diseases and unplanned pregnancies than the general population. Dr Binder suggested that clinicians can be more strategic in treating females with ADHD by altering medication dosage throughout the menstrual cycle to regulate ADHD symptom fluctuations.35
Additionally, during the follicular phase (rising oestrogen) there is evidence that females with ADHD have a greater response to stimulants.34 Also, worsening of ADHD symptoms were suggested to occur during the pre-menstrual stage (rising progesterone).33 Dr Binder stated that there are studies that investigated day-to-day variation in hormones and observed that on days where oestrogen is lowest and progesterone is highest there is increased vulnerability of females with ADHD to exhibit social and environmental distractions and impulsive behaviour.33
During pregnancy in general, Dr Binder emphasised that many females have increased distractibility.36 There are also neurocognitive changes that have been subjectively observed during pregnancy, and complaints of memory impairment and poor concentration.36,37 It has been hypothesised that changes in sex hormones are the reason for cognitive impairment.36 She stated that there are data that show that pregnant women without ADHD in the third trimester and postpartum had lower verbal memory and processing speed scores compared with non-pregnant women.70 Additionally, elevated prolactin levels are associated with worse executive function and negatively impact dopamine levels in pregnant women without ADHD.36,70 Dr Binder suggested that in the perinatal period, ADHD symptoms may increase due to hormonal effects on dopamine and noradrenaline, sleep deprivation and changes in routines and challenges associated with parenting a newborn.
Dr Binder highlighted that it is becoming more important to treat pregnant women with ADHD as more women are being diagnosed with ADHD.36 However, there are no guidelines for treatment of ADHD during pregnancy and postpartum.36 While current evidence does appear to show that stimulants are not associated with major congenital malformations, there are still concerns about in utero exposure to stimulants regarding foetal growth.36,71 Dr Binder emphasised that it is important to weigh the risk and benefits of treatment when considering the use of ADHD medication in pregnancy, and infants who are born to mothers prescribed stimulants should be monitored for withdrawal.36 From clinical experience, Dr Binder discussed that many women with ADHD stop their medications during pregnancy and lactation with minimal negative impact. However, other women do become severely impaired after stopping their ADHD medication, which can have severe consequences (e.g. motor vehicle accidents, decreased occupational functions, financial issues, missing neonatal appointments, relationship issues and substance use).36 Dr Binder believes the increased risk of adverse maternal and neonatal outcomes with ADHD medications remains controversial. She highlighted key points from a 2019 meta-analysis which concluded that exposure to ADHD medication during pregnancy does not appear to be associated with adverse neonatal or maternal outcomes.44 ADHD medication use during pregnancy is associated with an increased risk of visits to the neonatal intensive care unit (risk ratio [RR] 1.88 [95% CI 1.7–2.08]; p<0.001), exposure to methylphenidate is marginally associated with an increased risk of cardiac malformation (RR 1.27 [95% CI 0.99–1.63]; p=0.065) and there is no evidence of an increased risk for other adverse maternal or neonatal outcomes.44 Overall, Dr Binder stated that stimulants should only be used during pregnancy if the potential benefit justifies the potential risk to the foetus.
The last topic that Dr Binder touched upon was how the menopause affects ADHD. It is common for perimenopausal women with ADHD to notice a midlife decline in cognition and executive function. Dr Binder stated that this decrease in executive function is possibly related to fluctuating hormones during the perimenopause and the eventual depletion of oestrogen in the post-menopause.72 Executive function is dependent on pre-frontal cortex functioning, which is partially regulated by oestrogen, as is dopamine. Dr Binder suggested that reduced attention and memory may be correlated with the decline in oestrogen; however, there are no consistent associations.72 From her clinical experience, Dr Binder has noticed that ADHD medications that increase dopamine may improve executive dysfunction induced by loss of oestrogen input to the prefrontal cortex.
Dr Binder: “It begs the question, what is happening with all these young girls who are left undiagnosed and untreated … and then presenting for [ADHD] treatment as adults”
Clinical Hot Topic 20: Hosting successful virtual consultations in ADHD clinical practice
Mental health and COVID-19
Dr Diane McIntosh (Clinical Assistant Professor, University of British Columbia, Vancouver, Canada) opened her session with the statistic that in any given year, one in five Canadians will personally experience a mental illness.73 She added that in the European Union, approximately 165 million people are affected each year by mental disorders, mostly anxiety, mood and substance-use disorders.74 Dr McIntosh explained that she felt this means that everyone is affected by mental illness, whether they are living with a mental illness or care about or work with someone with a mental illness. During the pandemic, the issue of mental health has become more significant, as we are facing what Dr McIntosh referred to as the COVID-19 Trifecta. People are experiencing health anxiety, whether concerned for their own health or others, as well as financial stress, either related to job loss or the global economy. Dr McIntosh also described the powerful impact of quarantine and isolation on physical and mental health.75 Dr McIntosh explained the severity of the chronic, unpredictable stress that people are currently experiencing. She described how the most reliable animal model employed to research and predict depression is created through exposure to chronic and unpredictable stress.76 Furthermore, this type of stress has been associated with structural and functional brain changes as well as depression, cognitive impairment, inflammatory illnesses and Alzheimer’s disease.
Dr McIntosh stated that the Director-General of the United Nations forecast this mental health situation back in May 2020 by stating: “The mental health and well-being of whole societies have been severely impacted by this crisis and are a priority to be addressed urgently.”77 Dr McIntosh drew upon the findings of the October 2020 World Health Organization (WHO) World Health Survey which showed that 89% of responding countries reported that supporting mental health is part of their national COVID-19 response plans, yet only 17% have ensured funding for those activities.78 Dr McIntosh indicated that access to psychiatry has been challenging during the COVID-19 pandemic. She stated how many family practitioners and nurse practitioners are not confident managing mental illness and have limited access to psychiatrists.
The economic impact of mental illness
Dr McIntosh explained that another challenge is the economic impact of the pandemic. She stated that it costs the economy $50 billion annually where there is poor mental health in the workplace (leading to absenteeism or disability related to mental illness). This is expected to reach $2.5 trillion by 2041.79 Furthermore, $16 trillion is the estimated cost of mental disorders to the global economy by 2030.80 Dr McIntosh defined what mental health is according to the WHO: ‘a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.’81 She highlighted how work was included in this definition of mental health. Dr McIntosh explained how in her clinical experience, when economists mention mental health there is a focus on happiness or well-being (satisfaction with life, positive emotions, etc), whilst in the medical field, the focus is on the absence of symptoms. However, in her opinion, the two are inextricably linked; in order to have happiness or well-being, you must have the absence of symptoms or be able to function at the highest level possible.
Dr McIntosh went on to explain the link between the economy and health. Low income is a risk to health; typically, those with a low income are more likely to suffer from mental disorders such as depression or anxiety than those with a high income.82 Furthermore, job loss and income decline often precedes mental illness.83 Lastly, recessions are associated with mental illness, substance abuse and suicide.84 Dr McIntosh stated that most individuals with mental illness, even if severe, wish to engage in meaningful work.85 Additionally, paid employment provides financial security, daily structure, a sense of worth and regular supportive social engagement.86 She summarised that many studies have found work is associated with better mental well-being, lower prevalence of depression and lower incidence of suicide.87,88
Dr McIntosh stated that COVID-19 is not associated with an increased prevalence of ADHD; however, ADHD is associated with heightened vulnerability of unemployment.89 Dr McIntosh suggested this could be worsened in the pandemic due to poor performance from a lack of a regular schedule and the changing work environment being more challenging, with tools they used at work no longer accessible and increased distractions. She expanded that the COVID-19 pandemic can lead to increased treatment non-compliance of individuals with ADHD, perhaps due to loss of schedule, lack of funds and some who do not think they need it, especially while they are just at home.90,91 There is also an increased risk of comorbidities with ADHD, such as heightened alcohol and cannabis use.92 Dr McIntosh explained that although ADHD is not associated with COVID-19, having ADHD may be a risk factor for infection with COVID-19. She presented the findings of research that showed untreated ADHD seems to constitute a risk factor for COVID-19 infection while drug-treatment ameliorates this effect. Vulnerability of individuals with ADHD to COVID-19 infection may be due to inattention, hyperactivity and impulsivity as well as difficulty in taking orders and accepting discipline. This research suggested that these ADHD characteristics may interfere with the ability to comply with preventive measures.64
The benefits of virtual care
The last part of Dr McIntosh’s talk focused on virtual care during this unprecedented time. She described how the number of virtual visits (by secure video, text or telephone) and remote monitoring have risen to allow healthcare providers and individuals to connect safely at a distance, minimising the risk of community infection. The October 2020 WHO survey found that 70% of countries have responded by using telemedicine/teletherapy to replace in-person consultations.78 Dr McIntosh emphasised her belief that virtual care provides a great opportunity to increase the accessibility of therapy, through being able to help individuals from wherever they are and taking less of their time to travel to and from appointments. However, she also explained that it is not a substitute for in-person assessments or clinical examinations, where required. She stated that one of the critical cases is making sure privacy and confidentiality is maintained, such as by encouraging virtual care in a private setting. There has also been suggestion to obtain consent from individuals following discussion of potential privacy risks associated with electronic communications. However, it is not always possible to obtain a signed consent form, in these cases it is suggested to include a record of the consent discussion in the individual’s chart.93 Dr McIntosh stated that the COVID-19 pandemic has resulted in the broader implementation and use of virtual care on short notice; however, many of the changes implemented to permit virtual care during the pandemic are likely to continue afterwards, in her opinion. In her personal reflection, she was at first anxious to offer virtual care; however, this anxiety was not shared with those she was treating. She explained how some individuals found the technology challenging at first, but overall there were no complaints and many were happy with this form of therapy, with no need to travel or find childcare making it much more accessible for them. Dr McIntosh ended her talk by stating that, in her opinion, virtual care offers a great opportunity, particularly to offer help to those otherwise hard to reach.
Dr McIntosh: “We should have been doing this long ago but sometimes out of terrible things, like this pandemic, good things come. Because I believe it truly does democratise medicine … I can see them where they are and when they need to see me … there is incredible value to this opportunity”
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