A newly-published systematic review by a British team identified 48 qualitative and quantitative studies that explored “ADHD in primary care, including beliefs, understanding, attitudes, and experiences.” The studies described primary care experiences in the U.S., Canada, Europe, Australia, Singapore, Iran, Pakistan, Brazil, and South Africa.

More than three out of four studies identified deficits in education about ADHD. Of particular concern was the training of primary care providers (PCPs), most of whom received no specific training on ADHD. In most places, a quarter or less of PCPs received such training. Even when such training was provided, PCPs often rated it as inadequate, and said they did not feel they could adequately evaluate children with ADHD. There was even less training for adult ADHD.

A 2009 survey of 194 PCPs in Pakistan found that ADHD was not included at all in medical training there, and that most learned from colleagues. Half readily admitted to having no competence, and less than one in five were shown to have adequate knowledge about ADHD. In a 2009 survey of 229 South African PCPs, only 7 percent reported adequate training in childhood ADHD, and a scant one percent in adult ADHD.

These problems were by no means limited to less developed countries. A 2001 U.K. survey of 150 general practitioners found that only 6 percent of them had received formal ADHD training. In a 2002 study of 499 Finnish PCPs, only half felt confident in their ability to diagnose ADHD. A 2005 survey of 405 Canadian PCPs likewise found that only half reported skill and comfort in diagnosis. In a 2009 survey of 400 U.S. primary care physicians, only 13 percent said they had received adequate training. A 2017 study of Swiss PCPs found that only five of the 75 physicians in the sample expressed competence in diagnosis.

Eight studies explored knowledge of DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria and clinical guidelines among PCPs. Only a quarter of PCPs were using DSM criteria, and only one in five were using published guidelines. In a 1999 survey of 401 pediatricians in the U.S. and Canada, only 38 percent reported using DSM criteria. A 2004 survey of 723 U.S. PCPs found only 44 percent used DSM criteria. In a 2006 UK study of 40 general practitioners, only 22 percent were aware of ADHD criteria. In the same year, a survey of 235 U.S. physicians found that only 22 percent were familiar with ADHD guidelines, and 70 percent used child behavior in the office to make a diagnosis. More encouragingly, a 2010 U.S. study reported that use of APA (American Psychological Association) guidelines by PCPs had expanded markedly between 1999 and 2005, from one in eight to one in two.

Given these facts, it is unsurprising that many PCPs expressed lack of confidence in treating ADHD. In a 2003 survey of 143 South African general practitioners, two thirds thought it was difficult to diagnose ADHD in college students. A 2012 U.S. study of 1,216 PCPs found that roughly a third lacked confidence in diagnosis and treatment. More than a third said they did not know how to manage adult ADHD. In a 2015 survey of 59 physicians and 138 nurses in the U.S., half lacked confidence in their ability to recognize ADHD symptoms. This was especially pronounced among the nurses. A 2001 U.K. survey of 150 general practitioners found that nine out of ten wanted further training in drug treatment, and more than one out of ten were unwilling to prescribe due to insufficient knowledge.

Misconceptions about ADHD were widespread. In a survey of 380 U.S. PCPs, almost half thought ADHD medications were addictive, one in five thought ADHD was “caused by poor diet,” more than one in seven thought “the child does it on purpose,” and one in ten thought medications can cure ADHD. Some studies reported that many PCPs believed ADHD was related to consumption of sugary food and drink. Others reported a gender bias. A 2002 U.S. study of 395 PCPs found that when presented with boys and girls with parent reported problems, they were significantly more likely to diagnose ADHD in boys.

A 2010 Iranian study of 665 PCPs found that 82 percent believed children adopted ADHD behavior patterns as a strategy to avoid obeying rules and doing assignments. One third believed sugary food and drink contributed to ADHD. Only 6 percent believed it could be a lifelong condition. Half blamed dysfunctional families. The aforementioned large 2012 U.S. study similarly found that almost half of PCPs believed ADHD was caused by absent or bad parenting. More than half of 399 Australian PCPs surveyed in 2002 believed inadequate parenting played a key role. In a 2003 study of 48 general practitioners in Singapore, a quarter blamed sugar for ADHD. A 2014 survey of 57 French pediatricians found that a quarter thought ADHD was a foreign construct imported into France, and 15 percent attributed it to bad parenting.

In all, ten studies reported a widespread belief that ADHD was due to bad parenting, with ratios varying from over one in seven PCPs to more than half. They were particularly likely to attribute hyperactivity to dysfunctional families, and to dismiss parents’ views of hyperactivity as a medical problem as a way to deflect attention from inadequate parenting.

While a third of the studies reported on stigma, the surprise was that it did not seem to play as big a role as expected. A 2012 study in the Netherlands found that 74 physicians and 154 non-medical professionals matched by age, sex, and education showed no differences in level of stigmatization toward ADHD.

On the other hand, the studies identified significant resource constraints limiting more effective understanding, diagnosis, and treatment. Given the complex nature of ADHD, the time required to gain relevant information, especially in the context of competing demands on the attention of PCPs, was a limiting factor. Many studies identified a need for better assessment tools, especially for adults.

Another major constraint was PCP uneasiness about medication. Studies found a widespread lack of knowledge about treatment options, and more specifically the pros and cons of medication relative to other options. This often led to an unwillingness to prescribe.

Yet another limitation was difficulties PCPs had in communicating with mental health specialists. One study found that less than one in six PCPs received communications from psychiatrists. Much of this was ascribed to “system failure”: discontinuity of care, no central accountability, limited resources, buck passing. Many PCPs were unsure who to turn to.

Another problem is in often faulty interactions between schools, parents, children, and providers. Parents often fail to keep appointments. Schools and parents often are less than cooperative in providing information. In a 2004 survey of 786 U.S. school nurses, less than half reported good levels of communication between schools and physicians. Schools and parents often apply pressure on PCPs to issue a diagnosis. In a U.S. survey of 723 PCPs, more than half reported strong pressure from teachers to diagnose ADHD, and more than two-thirds said they were under pressure to prescribe medication.

The authors noted, “The need for education was the most highly endorsed factor overall, with PCPs reporting a general lack of education on ADHD. This need for education was observed on a worldwide scale; this factor was discussed in over 75% of our studies, in 12 different countries, suggesting that lack of education and inadequate education was the main barrier to understanding of ADHD in primary care.”

In addition, “time and financial constraints affect the opportunities for PCPs to seek extra training and education but also affect the communication with other professionals such as secondary care workers, teachers and parents.”

The authors cautioned that only eleven of the 48 studies were published since 2010. Also, because it was a systematic review and not a meta-analysis, there was no way to evaluate publication bias.

They concluded, “Better training of PCPs on ADHD is, therefore, necessary but to facilitate this, dedicated time and resources towards education needs to be put in place by service provider and local authorities.”

B. French, K. Sayal, D. Daley, “Barriers and facilitators to understanding of ADHD in primary care: a mixed‐method systematic review,” European Child & Adolescent Psychiatry (2018), https://doi.org/10.1007/s00787-018-1256-3.

Stephen V. Faraone, Michael J. Silverstein , Kevin Antshel, Joseph Biederman, David W. Goodman, Oren Mason, Andrew A. Nierenberg, Anthony Rostain, Mark A. Stein and Lenard A. Adler

Journal of Attention Disorders, 1–15, 2018, DOI: 10.1177/1087054718804354

Lenard Adler, MD ADHD in AdultsThis manuscript reviews the results of the first phase of Quality Measures (QM) Initiative of the American Professional Society of ADHD and Related Disorders (APSARD). QMs (sometimes described as Quality Indicators) are critical metrics to the delivery and assessment of state-of-the-art health care; QMs numerically describe outcomes, patient perceptions, processes quantify health care processes, outcomes, patient perceptions, and systems. The authors followed the pathway outlined by the U.S. Agency for Healthcare Research and Quality (AHRQ) for the development of QMs; the manuscript describes the first phase, the development of draft QMs. This was a four-step process: 1) a literature search for adult ADHD QMs; (2) having experts develop a “wide net” of potential QMs in the areas of screening, diagnosis, treatment, follow-up, care coordination, and patient experience; (3) cross-referencing this “wide-net” of QMs to existing adult ADHD guidelines; (4) have ADHD experts rate the importance, reliability, validity, feasibility, and usability of the QMs via an online survey. The top 10 QMs from the expert survey were: Screening: % high-risk patients screened (e.g., depressed patients, family history of ADHD), Diagnosis: % patients treated for ADHD having documented DSM-5 diagnosis of ADHD, % patients with ADHD with review of other psychiatric disorders, % patients with ADHD with documentation of impairment, Treatment initiation: % patients receiving ADHD medications for whom treatment alternatives, benefits and risks have been discussed, % patients with ADHD assessed for vitals prior to medication treatment, % patients with ADHD for whom warnings and contraindications for medication were reviewed, Treatment follow-up: % patients with ADHD where validated measure of symptom change used to assess treatment efficacy at least annually, % patients stabilized on an ADHD medication seen at least once per year, % patients prescribed medication for ADHD seen within 1 month of initial prescription. This manuscript is important for clinicians because it is the first step toward the development of QMs for adult ADHD, which have not existed to date; if validated through field testing in the second phase of the initiative, these QM may be important metrics of health care quality in the care of patients with ADHD.

A German team recruited 104 adults with ADHD at both inpatient and outpatient ADHD clinics, and from ADHD self-help groups. Just under two-thirds were being treated with ADHD drugs, most with methylphenidate.

Just under a quarter reported high internalized stigma. Two in five reported high levels of alienation, meaning a sense of “not being a fully functioning, valuable member of society.” Three in ten reported high levels of social withdrawal.

On the other hand, only two participants reported high levels of stereotype endorsement, meaning personal acceptance of stereotypes associated with mental illness. And more than two-thirds reported high stigma resistance, meaning they were internally resistant to stigmatization. Thus, while most were free of significant internalized stigma, a still substantial minority were not.

Most of the participants expected to be discriminated against and treated unfairly by employers, colleagues at work, neighbors, and teachers should they reveal that they have ADHD. Relatively few expected to be discriminated against by health professionals, family, and friends. Almost half expected discrimination if they confided to strangers they were dating.

Over two-thirds of participants reported they had encountered public stereotypes concerning ADHD. But, on balance, they rated these at low levels of intensity. Nevertheless, among those perceiving such stereotypes, eight out of nine sensed some degree of public doubt about the validity of ADHD as a genuine ailment (“ADHD does not exist in adults”), and three out of four had at some point encountered the argument that “ADHD is invented by drug companies.” More than four out of five had heard allegations that ADHD results from bad parenting, and almost three in four had heard the claim that it results from watching too much television or playing too many video games.

These data call for more education of the public about the nature and causes of ADHD. Information reduces stigmatization so the widespread dissemination of the facts about ADHD is warranted.

Theresa Vera Masuch, Myriam Bea, Barbara Alm, Peter Deibler, Esther Sobanski, “Internalized stigma, anticipated discrimination and perceived public stigma in adults with ADHD,” ADHD Attention Deficit and Hyperactivity Disorders (2018), doi.org/10.1007/s12402-018-0274-9.

This two-year study examined the effect of digital media use on ADHD symptoms in over 2500 adolescents. An earlier meta-analysis found that traditional media use (TV and video console games) was modestly associated with ADHD-like behaviors (Nikkelen et al 2014). The current study extends the examination to a large sample, with modern digital media delivery of high-intensity stimuli, including mobile platforms. The authors used the Current Symptom Self-Report Scale (Barkley R 1998) to establish ADHD symptoms at baseline and at six-month assessments over a 24 month period. None of the subjects reported having ADHD at study entry. Subjects were considered to be ADHD symptom positive (the primary binary outcome) is they had greater than or equal to six inattentive and/or hyperactive-impulsive symptoms rated on this frequency-based scale (0-3).

Modern digital media use was surveyed on a frequency basis for 14 media activities (including checking social media sites, texting, browsing, downloading or streaming music, posting pictures, online chatting, playing games, online shopping, and video chatting). The most common media activity was high-frequency checking of social media. Of note, high-frequency engagement in each of the digital media activities was significantly, but moderately, associated with having ADHD symptoms at each six-month follow-up (OR 1.10), even after adjusting for covariates.

High-frequency media use at baseline seemed to be associated with development of ADHD symptoms. Among the 495 students who reported no high-frequency media use at baseline, 4.6% met ADHD symptom criteria at follow-up. Among 114 students scoring 7 for high-frequency media use at baseline 9.5% met the symptoms criteria. For the 51 students with a score of 14 for high-frequency media use at baseline, the rate was 10.5% (both comparisons were statistically significant).

This study is important in that it notes that an association between high-frequency digital media use (in current platforms and modalities) may be associated with the development of ADHD-like symptoms. A significant limitation of the study, as noted by the authors, is that ADHD-like symptoms do not establish a diagnosis of ADHD and do not assess impairment; therefore, these results must be interpreted with some caution. It does highlight that even with the current level of understanding it might be prudent for clinicians to recommend limiting high-frequency media use for adolescent patients.

Barkley RA. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. 2nd ed. New York, NY: Guilford Press; 1998.

Nikkelen SW, Valkenburg PM, Huizinga M, Bushman BJ. Media use and ADHD-related behaviors in children and adolescents: a meta-analysis. Dev Psychol. 2014;50(9):2228-2241. doi:10.1037/a0037318

Ra CK, Junhan Cho J, Stone MD, De La Cerda J, Goldenson NI, Moroney E, Tung I, Lee SS, Leventhal AM. Association of Digital Media Use With Subsequent Symptoms of Attention-Deficit/Hyperactivity Disorder Among Adolescents JAMA. 2018;320(3):255-263. doi:10.1001/jama.2018.8931

Stephen V. Faraone, PhDA Spanish team of researchers recently completed a comprehensive review of studies looking for links between compulsive video gaming (both online and offline) and a variety of psychological disorders, including anxiety, depression, social phobia, and ADHD. The focus was on behavior “of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

The team identified 24 studies, of which eight with a combined total of 16,786 participants looked for associations with either ADHD or its hyperactivity component. Participants included children, adolescents, and adults. One large longitudinal study, with 3,034 participants, found no association. Another study with 1,095 participants found a small effect. Two more, with a combined total of 11,868 found medium effect sizes. Four studies found large associations, but their combined total number of participants was 789, comprising less than a twentieth of the combined participants.

The authors concluded, “The relationship between Internet Gaming Disorder and ADHD and hyperactivity symptoms were analyzed in eight studies. Seven of them reported full association, with four finding large, two finding small, and one reporting moderate, effect sizes. The studies comprised two case-control, five cross-sectional and one longitudinal design; the latter found no association between the two variables.”[1] They also emphasized that 87 percent “of the studies describe significant correlations … with ADHD or hyperactivity symptoms.”[2]

Yet they did not note that all of the studies with large effect sizes were comparatively small. And while they presented funnel charts evaluating publication bias for anxiety and depression, they did not do so for ADHD, where the small studies with very large effect sizes suggest publication bias (i.e., that that evidence for association is exaggerated due to the early publication of positive findings).

Leaving out these small studies, the four high-powered studies with 15,997 participants reported effect sizes ranging from none to medium. Overall that suggests that there is an association between ADHD and videogaming, though not a particularly strong one. Moreover, due to the nature of the study designs, this work cannot conclude that the small effect observed is due to the playing video games being a risk factor for ADHD or to the possibility that ADHD youth are more attracted to video games than others.

Vega González-Bueso, Juan José Santamaría, Daniel Fernández, Laura Merino, Elena Montero and Joan Ribas, “Association between Internet Gaming Disorder or Pathological Video-Game Use and Comorbid Psychopathology: A Comprehensive Review,” International Journal of Environmental Research and Public Health, vol. 15, 668 (2018).

[1] One effect size was mischaracterized as small when in fact it was medium (OR = 2.43).

[2] In the abstract this was misleadingly worded, “The significant correlations reported comprised: 92% between IGD and anxiety, 89% with depression, 85% with symptoms of attention deficit hyperactivity disorder (ADHD),” suggesting a very strong correlation rather than an association of greatly varying effect size in seven of eight studies.


Stephen V. Faraone, PhDWe are only beginning to explore how ADHD affects sleep in adults. A team of European researchers recently published the first meta-analysis on the subject, drawing on thirteen studies with 1,439 participants. They examined both subjective evaluations from sleep questionnaires and objective measurements from actigraphy and polysomnography. However, due to differences among the studies, only two to seven could be combined for any single topic, generally with considerably fewer participants (88 to 873).

Several patterns emerged. Looking at results from sleep questionnaires, they found that adults with ADHD were far more likely to report general sleep problems (very large SMD effect size 1.55). Getting more specific, they were also more likely to report frequent night awakenings (medium effect size 0.56), taking longer to get to sleep (medium-to-large effect size 0.67), lower sleep quality (medium-to-large effect size 0.69), lower sleep efficiency (medium effect size 0.55), and feeling sleepy during the daytime (large effect size 0.75). There was little to no sign of publication bias, though considerable heterogeneity on all but night awakenings and sleep quality.

Actigraphy readings confirmed some of the subjective reports. On average, adults with ADHD took longer to get to sleep (large effect size 0.80) and had lower sleep efficiency (medium-to-large effect size 0.68). They also spent more time awake (small-to-medium effect size 0.40). There was little to no sign of publication bias and there was little heterogeneity among studies.

None of the polysomnographic measurements, however, found any significant differences between adults with and without ADHD. All effect sizes were small (under 0.20), and none came close to being statistically significant.

There were four instances where measurement criteria overlapped those from actigraphy and self-reporting, with varying degrees of agreement and divergence. There was no significant difference in total sleep time, matching findings from both the questionnaires and actigraphy. On percent time spent awake, polysomnography found little to no effect size with no statistical significance, whereas actigraphy found a small-to-medium effect size that did not quite reach significance, and self-reporting came up with a medium effect size that was statistically significant. On sleep onset latency and sleep efficiency, for which questionnaires and actigraphy found medium-to-large effects, the polysomnographic measurements found little to none, with no statistical significance.

Polysomnography found no significant differences in stage 1 sleep, stage 2 sleep, slow wave sleep, and REM sleep. With the exception of slow wave sleep, there was no sign of publication bias. Heterogeneity was generally minimal.

One problem with the extant literature is that many studies did not take medication status into account. In fact, the authors concluded, “future studies should be conducted in medication naïve samples of adults with and without ADHD matched for comorbid psychiatric disorders and other relevant demographic variables.”

In summary, these findings provide robust evidence that ADHD adults report a variety of sleep problems. In contrast, objective demonstrations of sleep abnormalities have not been consistently demonstrated. More work in medication naïve samples is needed to confirm these conclusions.

Amparo Díaz-Román, Raziya Mitchell, Samuele Cortese, “Sleep in adults with ADHD: Systematic review and meta-analysis of subjective and objective studies,” Neuroscience and Biobehavioral Reviews, vol. 89, p. 61-71 (2018).

In the popular media, ADHD is sometimes portrayed as a minor condition or not a disorder at all.   In fact, it is easy to find web sites claiming that ADHD is an invention of the medical profession and that the symptoms used to diagnose the disorder are simply normal behaviors that have been “medicalized”.   These claims are wrong.  They miss the main point of any psychiatric diagnostic process which is to identify people who experience distress or disability due to a set of well-defined symptoms.  So, does ADHD cause serious distress and disability?   It is a serious psychiatric condition?  To illustrate the strong evidence base for the “Yes” answer to that question, my colleagues and I constructed this infographic for our “Primer” about ADHD,
http://rdcu.be/gYyV.   It describes the many ways in which the symptoms of ADHD impact and impair the lives of children, adolescents and adults with the disorder.  We divided these ‘impacts’ into four categories: other disorders (both psychiatric and medical), psychological dysfunction, academic and occupational failure, social disability and risky behaviors.  Let’s start with other health problems.  We know from many studies that have followed ADHD children into adolescence and adulthood that having the disorder puts patients at risk for several psychiatric disorders, addictions, criminality, learning disabilities and speech/language disorders. ADHD even increases the risk for non-psychiatric disease such as obesity, hypertension and diabetes.  Perhaps most worrisome is that people with ADHD have a small increased risk for premature death.  This increased risk is due in part to their having other psychiatric and medical conditions and also to their risky behaviors which, as research documents, lead to accidents and traumatic brain injuries.   In the category of ‘psychological dysfunction’ we highlighted emotional dysregulation, which makes ADHD people quick to anger or to fail to tame extreme emotions.  Other serious psychological issues are low self-esteem and increased thoughts of suicide, which lead to more suicide attempts than for people without ADHD.  This increased risk for suicide is small, but it is real.    A more prevalent impact of ADHD is the broad category of social disability, which includes marital discord, poor parenting, legal problems, arrests and incarceration.   This typical starts in youth with poor social adjustment and conflict with parents, siblings and friends.  Another common impact of ADHD is on academic and vocational pursuits.  ADHD youth are at risk for underachievement in school, repeating grades and dropping out.  As adults, they are more likely to unemployed or underemployed, which leads to them having lower incomes than expected for their level of achievement in school.   So, don’t believe anyone who claims that ADHD is not a disorder or is only a mild one.   To be sure, there is a wide range of impairment among people with ADHD but, in the absence of treatment, they are at risk for adverse outcomes.  Fortunately, the medications that treat ADHD have been documented to reduce this risk, which is why they are typically the first line treatment for most people with ADHD.


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

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Betsy_Busch_with_creds_aB8shI Jessica_Uno_w_creds_QOALfX  
Childhood ADHD is known to persist into adolescence and adulthood in 40-70% of patients. However, its presentation changes with age; symptoms of hyperactivity become less prominent, while difficulties with attention and impulsivity may remain, and executive function problems become increasingly important[i]. Due to this evolving presentation, those with a childhood history of ADHD may not meet full ADHD diagnostic criteria, as adults. Yet, even high-functioning individuals who perform adequately on neuropsychological testing may continue to experience executive dysfunction, emotional dysregulation, and psychosocial impairment in their personal and professional lives[ii]. Over the last decade, longitudinal follow-up studies of clinic-referred adults who had childhood ADHD have begun to characterize the deleterious effects of childhood ADHD on adult functioning in various domains.

Recently, Voigt and colleagues from the Barbaresi group recently published the first prospective, population-based study documenting adult academic outcomes among patients with research-identified (including DSM-IV diagnostic criteria) childhood ADHD versus non-ADHD referents[iii]. The study sample, drawn from a 1976 to 1982 birth cohort, was unique in that 1) both ADHD and No-ADHD study subjects were members of a population-based sample, not clinic-referred individuals; 2) the subjects’ lifetime medical and school records were available to the investigators; and 3) the Barbaresi group has followed this birth cohort for over 15 years.

For this follow-up study, an academic achievement battery was administered to 232 young adults (mean age 27 years) with research-identified ADHD and 335 referents (mean age 28 years) from the birth cohort. The battery included tests of basic reading, vocabulary, passage comprehension, and arithmetic. After controlling for age, sex, comorbid learning disability status, and maternal education level, Voigt, et al. found that participants with childhood ADHD scored 3 to 5 grade equivalents lower on all academic tests, compared with their non-ADHD peers. All findings had moderate-to-large effect sizes (Cohen’s d= -.55 to -.82). 

Interestingly, only 68 of the 232 (29%) participating childhood ADHD cases met the DSM-IV diagnostic criteria for adult ADHD. Yet, there was no significant difference in test scores between childhood ADHD cases with remitted and persistent ADHD, even after controlling for the presence of a co-morbid learning disability (LD). Voigt, et al. believe that this lack of difference indicates that ADHD alone is responsible for the poorer acquisition of academic skills during childhood and adolescence. Academic underachievement in math and reading is strongly associated with lower academic motivation, shorter duration of education, and longer-term socioeconomic adversity, as Biederman and Faraone demonstrated, over a decade ago4. Consistent with their findings, Voigt’s study highlights ADHD as an independent risk factor for poor long-term academic outcomes, predicting far-reaching challenges for adult well-being.

Regarding potential interventions, Voigt, et al. suggest that their findings demonstrate that early and continuous academic interventions for ADHD should be the norm for students with ADHD, since it has a chronic course and long-term consequences, even in those whose ADHD eventually remits. Unfortunately, very few students with ADHD get more than in-class accommodations, under Section 504 of the Rehabilitation Act. While ADHD can qualify many children for specific remedial academic instruction with an Individualized Educational Plan (IEP), when ADHD is considered under the “Other Health Impairment” category of disabilities, few children with ADHD actually receive these services, unless they have a comorbid LD. Based on the positive outcomes from remedial tutoring and teaching of strategies to cope with executive dysfunction demonstrated by other studies, Voigt, et al. advocates for the more frequent inclusion of students with ADHD in formal remedial education programs. Other studies suggest that long-term treatment with stimulant medication can protect many children with ADHD from repeating a grade, and may even protect some from some of ADHD’s common psychiatric comorbidities5. Both pharmacotherapy and educational intervention are likely to produce the best outcomes.

Voigt, et al.’s findings also suggest another mechanism for the association between ADHD and poorer adult outcomes. If childhood ADHD interferes with the acquisition of foundational academic skills, perhaps it also hinders the development of other life skills important to navigating adulthood successfully. With so much at stake, it becomes crucial for patients diagnosed with ADHD as children to receive adequate and ongoing multimodal treatments, with adjustments over time as new challenges appear. Multiple interventions and careful follow-up throughout the lifespan must become the norm in the treatment of those with ADHD, as it is for all other chronic medical disorders.



  1. Faraone SV, Asherson P, Banaschewski T, Biederman J, Buitelaar JK, Ramos-Quiroga JA, Rohde LA, Sonuga-Barke EJS, Tannock R, Franke B. Attention-deficit/hyperactivity disorder. Nature Reviews Disease Primers 2015; Aug 6: 15020.
  1. Torralva T, Gleichgerrcht E, Lischinsky A, Roca M, Manes F. “Ecological” and Highly Demanding Executive Tasks Detect Real-Life Deficits in High-Functioning Adult ADHD Patients. Journal of Attention Disorders 2012; 17(1): 11–19.
  1. Voigt RG, Katusic SK, Colligan RC, Killian JM, Weaver AL, Barbaresi WJ. Academic Achievement in Adults with a History of Childhood Attention-Deficit/Hyperactivity Disorder. Journal of Developmental & Behavioral Pediatrics 2017; 38(1): 1–11.
  1. Biederman J, Faraone SV. The effects of attention-deficit/hyperactivity disorder on employment and household income. MedGenMed 2006; 8(3): 12.
  1. Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV. Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics 2009; 124(1): 71-78.




I have too often seen on the Internet or media the statement that ADHD is a recent invention of psychiatrists and/or pharmaceutical companies.  Such statements ignore the long history of ADHD that my colleague and I reviewed in our “Primer” about ADHD, http://rdcu.be/gYyV.   As you can see from The Figure, ADHD has a long history.  The first ADHD syndrome was described in a German medical textbook by Weikard in 1775.  That’s not a typo.  The ADHD syndrome had been identified before the birth of the USA.   Dr. Weikard did not use the term ADD or ADHD, yet he described a syndrome of hyperactivity and inattention that corresponds to what we call ADHD today.  As you can see from the Figure, ADHD-like syndromes were described in Scotland in 1798 and in France in the late 19th century.  The first description of an ADHD-like syndrome in a medical journal was by Dr. George Still in 1901 who described what he called a ‘defect of moral control” in The Lancet.  The discovery that stimulant drugs are effective in treating ADHD occurred in 1937 when Dr. Charles Bradley discovered that Benzedrine (an amphetamine compound) improved the behavior of children diagnosed with behavioral disorders.  In subsequent years, several terms were used to describe children with ADHD symptoms.  Examples are Kramer-Pollnow syndrome, minimal brain damage, minimal brain dysfunction and hyperkinetic reaction.  It was not until the 1980s that the term Attention Deficit Disorder (ADD) came into widespread use with the publication of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM).   During the ensuing decades, several changes were made to the diagnostic criteria and the term ADD was replaced with ADHD so as not to overemphasize either inattention of hyperactivity when diagnosing the disorder.  And, as the graphic below describes, these new and better diagnostic criteria led to many breakthroughs in our understanding of the nature of the disorder and the efficacy of treatments.   So, if you think that ADHD is an invention of contemporary society, think again.  It has been with us for quite some time.


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

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Eight Pictures Describe Brain Mechanisms in ADHD

When my colleagues and I wrote our “Primer” about ADHD, http://rdcu.be/gYyV, the topic of brain mechanisms was a top priority.   Because so much has been written about the ADHD brain, it is difficult to summarize.   Yet we did it with the eight pictures reproduce here in one Figure.   A quick overview of this Figure shows you the complexity of ADHD’s pathophysiology.  There is no single brain region or neural circuit that is affected.   Figures (a) and (b) show you the main regions implicated by structural and functional neuroimaging studies.  As (c) shows, these regions are united by neural networks rich in noradrenalin (aka, norepinephrine) and dopamine, two neurotransmitters whose activity is regulated by medications that treat ADHD.  Figure (d) describes two functional networks.   The Executive Control network is, perhaps, the best described network in ADHD.  This network regulates behavior by linking dorsal striatum with the dorsolateral prefrontal cortex.  This network is essential for inhibitory control, self-regulation, working memory and attention.  The Corticocerebellar network is a well-known regulator of complex motor skills.  Data also suggest it play a role in the regulation of cognitive functions.   Figure (d) describes the Reward Networks of the brain that link ventral striatum with prefrontal cortex.   This network regulates how we experience and value rewards and punishments.   In addition to its involvement in ADHD, this network has also been implicated in substance use disorders, for which ADHD persons are at high risk. Figures (f) (g) and (h) complete the puzzle with additional regions implicated in ADHD whose role is less well understood.  One role for these regions is in the regulation of the Default Mode Network, which controls what the brain does when it is not focused on any specific task (e.g., daydreaming, mind wandering).  People differ in the degree to which they shift between the default mode network and networks like Reward or Executive Control, which are active when we engage the world.  Recent data suggest that the brains of ADHD people may be in ‘default mode’ when they ought to be engaged in the world.    


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

Faraone 8 Brain Images