In Good Health: What We Know About ADHD

0:07This is 1A. I'm Jen White. Attention Deficit Hyperactivity Disorder, or ADHD, affects tens of millions of people in the U.S. A new study published last month shows that the medications commonly prescribed to treat ADHD work differently than researchers originally thought. That development could carry big implications for the roughly 1 in 9 children and 1 in 16 adults with ADHD. That's according to an analysis from the nonprofit Children and Adults with Attention Deficit Hyperactivity Disorder, or CHAD. As researchers learn more about the brain and its complexities, they're also gaining new insights into what ADHD looks like across different ages, genders, and races.

0:50Over the past five years, more adults, especially women, are getting diagnosed than ever before. So what do you need to know about ADHD, from symptoms and diagnoses to treatment? We're talking all about it for the latest installment of our series, In Good Health, where we tackle the health issues that most affect us and put your questions to the experts. I'm Jen White. You're listening to the 1A Podcast. We'll be back with our panel in just a moment. Stay with us.

1:21Let's get into it. And a quick note before we meet our panel, our experts cannot give personal medical advice, so please be sure to consult with your doctor about any specific questions you may have. Joining us for the conversation is Dr. Max Wisnitzer. He's a pediatric neurologist at University Hospital's Rainbow Babies and Children's Hospital in Cleveland, Ohio. He's also a professor of pediatrics and neurology at Case Western Reserve University School of Medicine and the co-chair of the Professional Advisory Board of the nonprofit Children and Adults with Attention Deficit Hyperactivity Disorder, or CHAD.

1:53Dr. Wisnitzer, it's great to have you. Thank you for having me. Also with us from Durham, North Carolina, is Jessica Lunsford-Avery. She's a clinical psychologist and a professor of psychiatry and behavioral sciences at Duke University School of Medicine. Professor Lunsford Avery, welcome to the program. It's great to be here. Thank you, Jen. And joining us from Minneapolis is Damian Fair. He's a cognitive neuroscientist and a professor in the Institute of Child Development at the Department of Pediatrics at the University of Minnesota Medical School. He's also the director of the Masonic Institute for the Developing Brain.

2:26Professor Fair, it's great to have you. Thank you. Glad to be here. Well, Professor Fehr, let's just start with how researchers define ADHD. Well, ADHD is defined as a neurodevelopmental disorder that's typically characterized by developmentally atypical patterns of inattention, hyperactivity, impulsivity, and importantly, that caused some sort of clinical impairment across various settings, school, at work, home, etc. Dr. Wisnitzer, how does a doctor make an ADHD diagnosis? The diagnosis is made by history. You get details from the patient and or their family. Plus you get, for children especially, you get information from multiple sources because the ADHD has to be symptomatic in more than one setting.

3:15School, work, home, other people's homes, places like that. So we use the criteria that are defined, and there are defined criteria that are utilized as outlined, And then we identify, as was stated, that there's no other reason for it. There's nothing else that's affecting the impulsivity or the overactivity or the inattention. And that it's causing impairments, and we go from there. So the first national parent survey about ADHD in 1997, there's been a steady increase in parent-reported ADHD diagnoses. Dr. Wisnitzer, do we know if this increase means more children are developing ADHD or if more children with ADHD are receiving a diagnosis?

4:00More likely, it's that we are better at identifying the population. If you go back one or two generations, and this is what parents tell me in the office, they basically say, I had it, but no one identified it. Nowadays, we're doing better, and we have greater recognition of the criteria, not only for children, but also for adults. and that leads to the increased numbers that we're seeing at this time. Well, Professor Lunsford-Avery, this makes me wonder how adults experience ADHD differently than children, how it might present differently. Sure. So I think I would start by saying that there are no overall differences in the symptoms of ADHD for children versus adults.

4:44The same 18 symptoms of ADHD can be experienced by individuals of any age. However, there is some evidence to suggest that the constellation and presentation of ADHD symptoms can change as individuals age. For example, for younger children, hyperactive and impulsive symptoms tend to be prominent. And as they transition to adulthood, inattentive symptoms may emerge and persist as the predominant features of the condition. The other thing that I would add is that there are differences in the areas of life in which the ADHD symptoms are impairing. Children often come to treatment due to challenges in school.

5:23There may be concerns in the home setting or with friends, but often school is a major factor. In adulthood, individuals are asked to manage a lot of daily tasks simultaneously. Work, marriage, household maintenance, finances, parenting. This multitude of daily tasks can become overwhelming quickly for an individual with ADHD. Adults are often presenting with concerns about their functioning across the board. Professor Fair, what does the research tell us about a person's likelihood of developing ADHD if they have a family history of the condition? Well, right. Well, the ADHD is definitely a highly heritable disorder.

6:04It's about 70 % to 80 % heritable compared to other. It's very high compared to other psychiatric conditions. We call it a polygenic disorder, meaning that we know that there's thousands of genetic variants that may contribute very small effects to the disorder, but there's no single gene, specifically in most cases, that influence the heritability of ADHD. It's often in the brain. It's often thought of being related to various types of synaptic signaling and regulatory systems. So in short, ADHD does run in families. It's not caused by one specific gene necessarily, but there's many small genetic effects that add up.

6:55And of course, that's always crossed with various types of environmental conditions that may contribute to the disorder. We got this question from Marvin who asks, Is ADHD something you have or don't, or is it something you can develop? For example, if I were to be diagnosed as having ADHD as an adult, does that mean I've always had it? Dr. Wisnitzer, what can you tell us? The simple answer is that unless there's something that actually hurt the brain, in the other 20 % of the cases which are not hereditable, not running in the family, it's because something happened to the brain, you had an infection or trauma of significant degree that would do that.

7:33But assuming that this individual didn't have it, it is highly likely that you always had the tendency. It may have showed itself when you were younger. It may have calmed down. But then when the environmental stressors are high enough, it brings it out. We know that ADHD symptoms fluctuate over time so that people may not always be symptomatic, but they are still what we would call syndromal. They still have the tendency. Now, Professor Lunsford-Avery, the symptoms of ADHD can present in a lot of different ways in different populations. But those symptoms generally fall into two categories. There's inattention and there's hyperactivity impulsivity.

8:10What are some of the key symptoms in each category and how might people experience them? Sure. So, yeah, so there are nine symptoms of inattention and nine symptoms of hyperactivity impulsivity. And what's really interesting is across individuals, the constellation of symptoms may differ. So which six symptoms for a child or five symptoms for an adult to get the diagnosis may differ. Under the inattention umbrella, these include things like having a short attention span, being distractible, really struggling with procrastination, initiating tasks and completing them. Under the hyperactive impulsive symptom umbrella, these tend to be things like having too much energy, fidgeting, difficulty staying seated in situations where it's really expected, and also things like having difficulty resisting the impulse to interrupt others or to finish their sentences.

9:05And so how this presents across individuals can be different, but those are some of the main categories of symptoms that we would expect to see. Well, in May 2025, a report led by Health and Human Services Secretary Robert F. Kennedy Jr. attributed the rise in ADHD diagnoses to quote, over-medicalization. It also said ADHD is caused by processed food, screen time, and chemical exposure. Professor Fehr, how do these claims compare to the decades of scientific evidence on ADHD? Yeah, well, these are very difficult, obviously difficult questions to answer. I would say that over time that what we've learned is that there are some environmental factors that relate to the, maybe may relate to the ADHD As was noted earlier by Dr.

9:55Wisnitzer, the actual rates of ADHD are probably going up much slower than the recognition of the disorder, particularly for females, which you highlighted in your earlier discussion. The things related to more closely probably to ADHD that have really popped in literature around the neurobiology revolve more around sleep, which may be related to some of the things that were described related to screen times and things of that nature, but maybe not the direct cause, but indirect through behavioral sequelae like sleep, the importance of sleep in its relationship to ADHD. Let's take a quick pause here.

10:35We'll be back with more of the conversation in a moment. Stay with us.

10:43Let's get back to our discussion with this question we got from Susan in Louisville. My 16-year-old daughter was recently diagnosed with ADHD and anxiety. I am being proactive with her treatment, but am also a little leery about pills, pills, pills. She is very intelligent, a very mature young lady, and what I prefer is for her to have better coping skills. She says she gets nothing from therapy, and we have tried several different ones, and they are so expensive. How can I best support and help her? Professor Feer, I'll come to you on that. Well, I think there's a couple of things. One, that, you know, treating, there's several different ways to treat ADHD from medications, stimulant medications and non-stimulant medications, but there's also behavioral, psychosocial treatments and other quality supports that are important for supporting folks who are impaired with ADHD.

11:40Now, it's important to note, I always say this, is that not everyone needs to be fixed for their ADHD symptoms. Particularly if there's no clear impairment, differences in attention, energy, and thinking can be a very important part of normal human variation and contributes to creativity, innovation, and things of that nature. I mean, some of our most important innovators over the course of centuries have thought to have ADHD. Now, there's several advice, you know, that our clinicians at MIDB who take this more holistic approach for treating ADHD. It's very highly individualized and often requires a process of careful trial adjustments and collaborations, starting with comprehensive evaluations, setting clear goals, but very much as a step-wide approach.

12:38And then, of course, again, it's not just all about medications, but definitely about the supports around our youth as they grow with the disorder. Dr. Wisnitzer, I think it's sometimes helpful for people to hear perhaps questions they can ask their clinician as they're navigating this space with their young person. Any advice around maybe some key questions Susan can ask on behalf of her daughter? Yes. A key question here is how much of the impairment that's going on right now is due to the ADHD diagnosis? How much of it is due to the anxiety diagnosis? The reason is that when you look at the ADHD, ADHD basically, if you think of it, has two key features.

13:21One is the core symptoms of ADHD, the inattention, the hyperactivity, the impulsivity. clearly improve best with medication. Behavioral therapies for a person of her age really do not have as great of an impact. However, the medicines don't teach you how to learn. They don't teach you how to behave. And therefore, you need to have a behavior plan in place in order to take advantage. Or as I tell people, that the medication lets you run the race equally with everybody else, but you still have to run the race. It doesn't do it for you. On the other hand, if the anxiety is the key thing that's interfering with functioning, causing inattention, maybe making her fidgety, and it can do that, then you basically have to say, what would be the appropriate intervention for that?

14:06Is it severe enough that it requires medication, or can it benefit from behavioral therapies? Also, is the anxiety caused by the ADHD impact on her day-to-day functioning? So I'm not doing well in school because of my ADHD, and it's heightening my anxiety. In that case, go after the ADHD instead of the anxiety. This is, by the way, if I may say, for adults who have not been diagnosed, frequently they will have depression and or anxiety complaints. And people try to treat those as the core features when those are actually reactions to the negative impact of the ADHD on their lives. And the fix there is to take care of the ADHD.

14:46and then that can have a ripple effect for improving the anxiety and the depression. Well, as of 2022, the Centers for Disease Control and Prevention estimated that about six in 10 children with ADHD had a moderate or severe form of the condition. And among children with ADHD, those who also had another condition, such as behavioral problems, learning disorders, anxiety, or depression, were more likely to have severe ADHD than those without. out. Professor Lunsford-Avery, what do researchers know or what are they still learning about the correlation between ADHD and those who experience behavioral problems, learning disorders, depression, anxiety?

15:27Yeah, thanks, Jen. So we do know that ADHD is frequently associated with co-occurring anxiety, depression, oppositional or conduct problems, and learning disabilities such as reading disorders. In fact, having another mental health condition or learning disorder alongside ADHD is the rule, not the exception in many cases. This high co-occurrence of ADHD and other mental health conditions likely arises for several reasons. So in some cases, just like some of my colleagues were mentioning, if you have ADHD, particularly untreated ADHD, this can increase the risk of developing other disorders. So an example with a child with untreated ADHD, if they're getting a lot of negative feedback about their behaviors and performance from parents and teachers, over time, this repeated negative feedback can result in the child developing anxiety in these situations.

16:22It is also likely that ADHD and other mental health conditions arise from overlap in underlying genetic causes. So many mental disorders share clinical features. These include things like difficulties with concentration, emotional regulation, and cognitive changes. And it's likely that shared genetic risk factors underlie some of this overlap in co-occurring disorders. We got this email from Jason in Missouri who says, I'm a 36-year-old male who was diagnosed with ADHD at the age of 30. I initially approached my doctor thinking I had depression. It seems that long-term untreated ADHD can lead to depression.

17:00And Jason asked for you to speak about the correlation between the two, which you've already addressed, at least in part, Dr. Wisnitzer. But I'm curious about if an adult like Jason comes to their doctor thinking, you know, I think I'm struggling with depression, and then they receive that ADHD diagnosis. Beyond treatment for the ADHD, it seems like there's this other perhaps emotional reckoning that has to happen, that this other struggle has been unrecognized for so long. What advice can you give to adults who are receiving a diagnosis later in life that maybe makes so many other things make sense to them all of a sudden?

17:48Well, you have to look at, we'll call it the baggage that accrues and the impact that the ADHD has when it's not diagnosed. We know that undiagnosed ADHD in adult years can have a potentially deleterious effect on functioning. It can shorten your lifespan. You have more unhealthy years of living. It can affect how you treat chronic medical conditions. And as you pointed out, it also deals with the results of developing anxiety and depression. So in addition to just being on medication for ADHD, really there's very good behavioral and cognitive therapies that can have a very positive impact and help these individuals function much, much better.

18:32And actually will lessen the amount, many times will lessen the amount of medication that's needed. Well, a new study published in the peer-reviewed scientific journal Cell shows that common ADHD medications like Ritalin and Adderall don't work by targeting the brain's attention networks like many people assume they did. Instead, the study says the medications target the brain's reward and wakefulness centers. And Professor Fair, this is something you alluded to earlier, and we'll talk more about what the study found out about sleep in a moment, but explain just a little more about these findings and how surprising they were.

19:09Yeah, there's fascinating findings. And I was actually part of this paper led by a group at Washington University with assistance from some of the work that we've done at MITB, leveraging some of the investments of the NIH on very large data sets across the country over the last 10 years. One is called the Adolescent Brain and Child Development Study, examining 12 ,000 or so youth starting from age 9 and 10 through adulthood. There are almost 10 years of that study now. And the other is called the Healthy Brain and Child Development Study, which starts during pregnancy and then follows youth with brain imaging and lots of assessments all the way through approximately age 10.

19:54These studies have been critical to our understanding of lots of developmental disabilities and disorders, but including ADHD. So this paper showed, you know, most of our thought about how stimulants, you know, or medications work on the brain was that they were affecting our attention centers, you know, the places that we that serve our executive functions in higher order cognitive functions. But what they show, what the data actually showed is that the brain and how it responds to stimulants is most strongly aligned with arousal, you know, our wakefulness and what we call norepinephrine systems and some of reward.

20:31But not only that and less about our executive function and cognitive centers. But it appears that the cognitive benefits are mostly around arousal and a bit of reward. And they mostly assist when there is a deficit. And that means whether the child actually had ADHD with kind of a gold standard diagnosis or whether there was something like sleep deprivation. But it wasn't just a universal enhancement for everybody. And the stimulants tend to normalize the function rather than enhance their performance beyond some basic baseline. So when there's a deficit, they help, but they don't necessarily turn kids into super learners, so to speak.

21:22We're talking to Damien Fair. He's a cognitive neuroscientist and a professor at the Institute for Child Development in the Department of Pediatrics at the University of Minnesota Medical School. Also with us, Jessica Lunsford-Avery. She's a clinical psychologist and a professor of psychiatry and behavioral sciences at Duke University School of Medicine, and Dr. Max Wisnitzer. He's a pediatric neurologist at University Hospital's Rainbow Babies and Children's Hospital. So there's this new understanding of how these medications work in the brain. But Professor Lunsford Avery, the study also points to the importance of sleep as it relates to ADHD, and this is your area of expertise.

22:01What does the research tell us about how a lack of adequate sleep contributes to ADHD? Absolutely. So it has been known for a long time that sleep and ADHD are intricately intertwined. In fact, in earlier conceptualizations of ADHD, poor or restless sleep was an official symptom of the disorder. Currently, we know that sleep disturbances continue to be highly prevalent in ADHD, impacting up to 70 % of individuals with the condition. And it's so common, in fact, that some experts in our field have begun to describe ADHD as a 24-hour disorder, meaning that how well someone attends, behaves, and regulates during the day likely depends on how well they are sleeping at night.

22:50And indeed, what we see is that when sleep problems are present alongside ADHD, they make a lot of things worse. The severity of the ADHD symptoms, problems with executive functioning and emotional dysregulation. And this high degree of overlap between ADHD and sleep disturbances has suggested that many individuals with ADHD may benefit from targeted sleep treatments in addition to traditional ADHD treatments. And interestingly, in the literature to date that has investigated this topic, there is some evidence that treating sleep in children with ADHD not only improves their sleep, but also to some extent, the severity of their ADHD.

23:31And when we talk about sleep treatments for children, what are we talking about specifically? Sure. So the first line sleep treatment for children is behavioral sleep therapies. So these are therapies that really focus with younger children working with the parent and as individuals age, working with the individual on things that we know that we can do to support both enough sleep, but also really high quality sleep. And so things like having a very consistent sleep schedule, the same wake time and sleep time every day is important. Having a consistent wind down routine is important as well. And I'm really kind of thinking about how much time you're spending in bed as well.

24:15So particularly I would say for adolescents and adults with ADHD, we often see insomnia. And so these are individuals who are spending a lot of time in bed, but not necessarily sleeping. And in those cases, we have really great cognitive behavioral therapy treatments that can help individuals really kind of increase their consolidation of sleep. So getting really good quality sleep in bed by doing things like limiting their time in bed when they're not sleeping. Let's take a quick pause here. We'll be back with more of the conversation in a moment. Stay with us.

24:53let's get back to our conversation about the latest of what we know about ADHD. And I just want to mention, we have been flooded with messages from you. So we will get to as many as we can in the remaining time in the program. But if we need to revisit this conversation at another time, we certainly will. Well, I want to quickly revisit this exchange from last year between Alabama Republican Senator Tommy Tuberville and now Secretary of Health and Human Services Robert F. Kennedy Jr. This was at Kennedy's Senate confirmation hearing. We have a attention deficit problem in this country. You know, attention deficit, when you and I were growing up, our parents didn't use a drug, they used a belt and whipped their butt, you know, and told us to sit down.

25:35Nowadays, we give them Adderall and Redland. They're like candy across college campuses and high school campuses. Mr. Kennedy, what are we going to do about that? Today, 15 % of American kids are on Adderall. And there's clearly a major problem with overprescription, not just with our children, but with our entire population. Dr. Wisnitzer, what do you make of Secretary Kennedy's claim that we overprescribe ADHD medication in the U.S.? It's actually the opposite. The research tells us that we're under-identifying. And not only that, when you look at the treatment, Even when it's prescribed, many of the individuals don't sustain it.

26:22Up to half the individuals will stop it after a few months, which stresses the importance of understanding why ADHD is there. So the consumers have to be informed consumers. They need to understand why we're being treated and also that the support systems are in place. May I make one other comment? Of course. The management of ADHD with a belt never works. The research that's been done tells us that negative reinforcement punishment does not help individuals with ADHD modify or improve their behavior, and it does not help address the ADHD itself. Positive reinforcement plus appropriate medical and educational management are the features that really will make a difference.

27:07The public needs to be aware of that point. We got this email from Katie who says, Growing up, many of us were taught that kids who struggled with attention, impulse control, or emotional regulation were simply choosing to misbehave. ADHD wasn't widely understood, and behavior was often framed as a discipline issue rather than a neurological one. Now, as a parent, my middle child has ADHD, and I'm working hard to support her in ways that honor how her brain is wired. One of my biggest challenges has been helping my mom understand that my daughter is navigating a brain that works differently. I would love recommendations for resources that explain ADHD in a clear, compassionate, and accessible way for grandparents.

27:48Professor Feart, anything to offer? Yeah, well, this is the challenges that I just described are not, the college should not be, don't feel alone. They're not the only ones. I mean, the reality is the history of ADHD is over, well over 100 years old. You know, it was first described mostly as clinical issues around attention and impulsivity. It later had a reframing in the 50s as being a brain injury or hyperkinetic disorder. And it wasn't really until probably the 90s with the DSM-IV that kind of our common knowledge of what ADHD looks like probably came into focus. And then even just later, even just under 15 years ago, was DSM-5 where we started recognizing the impact on adults.