🤣 What a perfect time for this article considering ADHD is my topic of choice this week.
🧠 A nuanced debate surrounds the rise in ADHD diagnoses, particularly among adults. While underdiagnosis and increased awareness contribute to this trend, it’s not the sole explanation. ADHD, often linked to developmental delays, may require continued medication into adulthood for some individuals with persistent symptoms
➡️ However, the necessity for lifelong medication in all or most cases is questionable
➡️ The surge in first-time ADHD diagnoses among adults aged 30’s-40’s, often without prior documented history, raises important questions
💡 While some cases may have been previously overlooked, it’s crucial to consider:
⚡ Co-occurring disorders like depression and anxiety, which can cause similar cognitive issues
⚡ Societal factors: Increasing demands for productivity and competitiveness in modern society
⚡ The potential misuse of performance-enhancing drugs in high-pressure environments
💡 It’s essential to approach each case individually, considering both the benefits of treatment and the risks of overdiagnosis. A comprehensive evaluation, including assessment of co-existing conditions and life circumstances, is crucial for accurate diagnosis and appropriate treatment plans
Creating a structured routine is one of the most effective ways to manage ADHD symptoms. The goal is to provide consistency and reduce decision fatigue, which can make daily tasks feel overwhelming.
Step 1: Assess Your Current Habits
Track your time: Spend a few days writing down how you currently spend your time. Identify patterns, distractions, and areas where you struggle with productivity.
Note energy levels: Pay attention to when you feel most focused and energetic, as this will help in scheduling demanding tasks during peak times.
Step 2: Define Your Priorities
Identify the most important activities in your day (e.g., work, exercise, family time).
Rank these priorities, so you focus on what truly matters and avoid overloading your schedule.
Step 3: Break Down Your Day
Morning Routine: Start the day with consistent habits like making your bed, brushing your teeth, and eating breakfast. Keep it simple to reduce stress.
Work/School Blocks: Break tasks into smaller chunks with scheduled breaks. For example, use the Pomodoro Technique (25 minutes of focused work followed by a 5-minute break).
Afternoon Wind-Down: Use this time for less mentally taxing tasks like errands or light chores.
Evening Routine: Establish a calming routine to prepare for bed, such as reading, meditating, or journaling.
Step 4: Use Visual Aids and Tools
Calendars/Planners: Write down your schedule. Use color-coding for different types of tasks (e.g., green for work, blue for leisure).
Digital Apps: Tools like Google Calendar, Todoist, or Notion can send reminders and help you stay organized.
Visual Timers: Use timers or clocks to track tasks and breaks visually.
Step 5: Set Alarms and Reminders
Set alarms for key transitions (e.g., starting work, eating lunch, or ending the workday).
Use apps like Habitica or Forest to gamify task completion and make sticking to your routine more fun.
Step 6: Build Flexibility into Your Routine
ADHD often brings spontaneity or unexpected distractions.
Leave buffer time between tasks to account for delays.
Prioritize your top 3 tasks each day, so even if you deviate, the essentials get done.
Step 7: Simplify Transitions
Transitioning between activities can be challenging with ADHD.
Use auditory or visual cues to signal it’s time to switch tasks.
Prepare for the next activity in advance (e.g., set out clothes for the gym or prep your workspace for the next day).
Step 8: Keep Your Environment ADHD-Friendly
Declutter regularly to minimize distractions.
Use bins, labels, or baskets to keep essentials easily accessible.
Step 9: Reflect and Adjust
At the end of each day or week, review your routine. What worked? What didn’t?
Be flexible and tweak your schedule to fit your needs and energy levels.
Step 10: Start Small and Build Gradually
Focus on one or two parts of your routine at first, like improving your morning habits.
Celebrate small wins to build confidence and motivation.
Example Routine:
Morning:
7:00 AM: Wake up and drink water
7:15 AM: Quick workout or stretching
7:30 AM: Shower and get dressed
7:45 AM: Eat breakfast and review the day
Work/School Blocks:
9:00 AM – 12:00 PM: Focused work (Pomodoro cycles)
Medication is a cornerstone of ADHD management, but combining it with complementary strategies can significantly enhance focus, organization, and overall functioning. This post offers a high-level overview of these approaches, setting the stage for a series of actionable, in-depth posts later this week.
1. Establish a Routine
Creating a structured daily routine provides predictability and reduces distractions. Use planners, calendars, or apps to break your day into manageable chunks with clear priorities.
2. Practice Mindfulness and Meditation
Mindfulness can improve attention regulation and emotional control. Apps like Headspace or Calm offer guided practices tailored to ADHD, helping you build focus over time.
3. Exercise Regularly
Aerobic exercise boosts dopamine and norepinephrine levels, enhancing focus and motivation. Aim for 30-60 minutes of activity daily, whether it’s running, swimming, or dancing.
4. Improve Sleep Hygiene
ADHD often disrupts sleep, which worsens symptoms. Establish a consistent bedtime, avoid screens before bed, and create a calming nighttime routine to promote better rest.
5. Optimize Nutrition
Balanced meals with protein, complex carbs, and omega-3 fatty acids can stabilize energy levels and improve concentration. Consider foods like salmon, eggs, nuts, and leafy greens.
6. Break Tasks into Smaller Steps
Large tasks can feel overwhelming. Break them down into smaller, manageable steps, and use tools like timers to focus on one step at a time (e.g., the Pomodoro Technique).
7. Minimize Distractions
Create an ADHD-friendly environment by limiting noise, clutter, and interruptions. Noise-canceling headphones and tidy workspaces can significantly enhance focus.
8. Cognitive Behavioral Therapy (CBT)
CBT can help you develop coping strategies for ADHD-related challenges, such as procrastination, impulsivity, and emotional regulation.
9. Leverage ADHD-Friendly Technology
Apps like Todoist, Notion, or Forest can assist with time management, task prioritization, and focus-building. Explore tools that align with your personal workflow.
10. Foster Strong Social Connections
Supportive relationships with family, friends, or ADHD communities can provide motivation, accountability, and understanding, reducing feelings of isolation.
By implementing these strategies, individuals with ADHD can enhance their quality of life, productivity, and emotional well-being. Remember, each person’s ADHD experience is unique, so experiment with different approaches to find what works best for you!
What has worked for you or someone you know? Share your experiences below!
People with ADHD have been shown to use cannabis at higher rates than those without ADHD. Studies indicate that adolescents and adults with ADHD are more likely to use cannabis, and they may start using it at a younger age. This may be due to self-medication attempts, as people with ADHD often report using cannabis to help with symptoms like impulsivity, anxiety, and sleep difficulties which seems like a bad idea to me but lets look at the reasons.
2. Cannabis as a Self-Medication Attempt
Some people with ADHD use cannabis in an attempt to self-manage their symptoms. Anecdotally, users report feeling more focused, relaxed, and less anxious, though the scientific evidence on cannabis’s effectiveness for ADHD symptom management is not robust. Studies show that while some ADHD symptoms like restlessness might feel alleviated short-term, long-term outcomes often do not show sustained benefit, and impairment can increase over time.
3. Impact on ADHD Symptoms
Research on cannabis’s effect on ADHD symptoms is mixed:
Impulsivity and Attention: Cannabis can impair attention, memory, and executive functioning, which are already areas of struggle for individuals with ADHD. Heavy cannabis use is associated with poorer performance on tasks measuring these cognitive domains.
Cognitive Function: Longitudinal studies have shown that chronic cannabis use can worsen cognitive functions over time, especially if use begins in adolescence. These cognitive impacts may compound ADHD-related deficits.
Motivation and Goal-Directed Behavior: Cannabis can affect motivation and goal-directed behavior, which can exacerbate some ADHD symptoms, particularly in individuals who already struggle with organization and task completion.
4. ADHD as a Risk Factor for Cannabis Use Disorder
Studies suggest that people with ADHD may be more prone to developing cannabis use disorder (CUD) compared to the general population. Traits like impulsivity and sensation-seeking, common in ADHD, may increase vulnerability to addiction. Additionally, the reinforcing effects of cannabis (e.g., reduction in perceived anxiety) may lead to increased use and dependency in those with ADHD.
5. Genetic and Neurobiological Factors
There is some evidence suggesting that the overlap between cannabis use and ADHD may have a genetic or neurobiological basis:
Genetic Overlap: Studies have found that genes linked to ADHD, particularly those affecting dopamine function, are also implicated in substance use disorders, including cannabis use disorder.
Endocannabinoid System: ADHD and cannabis use affect dopamine and endocannabinoid systems. Some research posits that dysregulation in these systems might underlie both the propensity for ADHD and substance use, but this remains an area for further research.
6. Cannabis and Medication Interactions
For those with ADHD taking stimulant medications, cannabis use can interfere with treatment. THC, the psychoactive component of cannabis, can interact with medications like methylphenidate or amphetamine-based treatments, potentially reducing their effectiveness or exacerbating side effects like anxiety and heart palpitations.
7. Longitudinal and Population Studies
Long-term studies generally show that early and heavy cannabis use is associated with worse outcomes for individuals with ADHD. These include lower academic achievement, increased rates of unemployment, and higher incidences of mental health issues, especially when cannabis use starts in adolescence.
Summary
While some people with ADHD report short-term symptom relief with cannabis, research shows that heavy, frequent use tends to worsen cognitive deficits associated with ADHD over time. Additionally, ADHD may predispose individuals to higher rates of cannabis use and a greater risk of developing cannabis use disorder. While cannabis might seem beneficial for symptom relief in the short term, its long-term use is generally not supported as an effective management strategy for ADHD.
A JAMA study found a significant rise in stimulant prescriptions between 2019 and 2022, with a 37.5% increase in total volume. This trend was particularly noticeable through telehealth, where stimulant prescriptions soared from 1.4% to 38.1%, peaking at 51.8% in mid-2020. The shift was largely influenced by COVID-19 pandemic policies, which eased telehealth restrictions. While antidepressant prescriptions also rose, opioid prescriptions declined by 17.2%. The study emphasizes the need to balance access with monitoring for potential misuse as telehealth policies evolve
Today’s post is more of a clinical reflection. I’ve been sharing a lot about research studies lately, but I want to pause and talk about polypharmacy in psychiatry and off-label prescribing. Have you ever been in a situation where a patient comes in, and as you review their medications, you see they’re taking a benzodiazepine for anxiety, an antidepressant for depression, a dopamine blocker for psychosis, and a mood stabilizer for mood swings? Maybe even a stimulant for ADHD is thrown in the mix. While I say that with some humor, in reality, this is a common scenario. As an educator, it’s crucial to discuss rational polypharmacy and evidence-based off-label prescribing, as well as the dangers of irrational, off-evidence prescribing.
There are times when using more than one dopamine-blocking medication is necessary in the short term—I’ve done it myself to achieve short-term stabilization—but it would never be my long-term plan. Treatment resistance is another situation where off-label medication, if supported by evidence, could be beneficial. However, if none of these justifications apply and the patient isn’t improving, yet they’re on a potentially risky combination of medications, this is the moment to reconsider the diagnosis. It may sound surprising, but misdiagnosis in psychiatry happens often. If the patient isn’t getting better, it could be because you’re treating the wrong condition.
It’s also possible that you’re addressing a disorder that isn’t the primary issue. For example, a patient being treated for ADHD may have attention and impulsivity problems, but these could actually stem from an underlying bipolar disorder. Since symptoms in psychiatry frequently overlap across multiple disorders, it’s essential to maintain a diagnostic hierarchy in your mind. Sorting out which disorder should be prioritized can often resolve other symptoms that might be masquerading as a different psychiatric condition.
So, if treatment isn’t working and the medication list keeps growing, consider that there may have been a mistake in the diagnosis, or that the focus has been on the wrong condition. Often, many symptoms are driven by a more serious underlying disorder, like bipolar disorder.
The diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) is well established in the field of psychiatry. Not only is it well accepted, but ADHD has dramatically increased over the past 10 years. Some would even say it’s an epidemic in its own right. The use of psychostimulants as a treatment is common practice, and today we are here to discuss the risk of neurotoxicity with ADHD medication.
What Are Psychostimulants
Psychostimulants include methylphenidate (MPH) and mixed amphetamine salts such as Adderall. These remain the most effective and widely used medications for the treatment of ADHD. These medications function by blocking the dopamine reuptake transporter and increase dopamine stimulation at the postsynaptic receptors. These medications work to increase attention and reduce impulsivity but the long-term implications of consistent use are largely unknown.
Substance Use and Stimulant Prescribing
Most lines of evidence in the literature indicate that these medications do not promote substance use later in life and may even decrease the potential for future substance abuse. I’ve also found lines of evidence that indicate the opposite, but the general consensus in the field is that there is not increased risk for future substance abuse. We do know that drugs that function in a similar manner to these medications result in molecular and structural changes to neurons. It is unknown if this also occurs with stimulant medications used to treat ADHD.
Neuronal Effects of Amphetamine
Methamphetamine is a known neurotoxin and several studies have indicated this in animal models. Recently exposure to amphetamine has been sown to cause impairments on the development of dendritic branching up to 3 months after stopping methylphenidate. In mice there is evidence that MPH use causes loss of dopamine neurons in the substantia nigra which may increase the risk of Parkinson’s disease. Other groups have shown alterations in nerve growth factors and brain derived neurotrophic factor in the frontal cortex after chronic MPH use. When neurons from the prefrontal cortex are exposed to MPH it alters their electrical activity. MPH was found to reduce electrical activity and it persists in a dose dependent fashion even 10 weeks post exposure. In rats the use of MPH is associated with decreased response to normal stimuli and increased response to adverse stimuli. We need to be careful extrapolating this information to humans as these studies were conducted in animal models.
Attention deficit hyperactivity disorder (ADHD) in the adult population is a topic of great debate. There are many psychiatrists who say ADHD symptoms do not suddenly disappear as a person continues into adulthood. On the other hand, there are some psychiatrists who do not think ADHD is a real diagnosis.
The term ADHD might be better thought of as attention deficit disorder (ADD). The concept of hyperactivity is more common in the child/adolescent patient population. It’s unclear if the hyperactivity is related to executive dysfunction which is the hallmark of ADHD. It may be that the hyperactivity is within the range of normal (agitation or activation) for a child, or signs of another mood disorder such as mania in bipolar illness (especially true in the adult population as bipolar diagnosis is commonly reserved for adult patients).
We can make an argument that placing children in a traditional school setting where they are asked to sit and pay attention to uninteresting material for 7 hours is unnatural and directly against the way humans evolved to function. The human body and mind evolved to move and be active not to sit in classrooms. As a result, agitation, hyperactivity, and acting out can be the result of this unnatural state.
The hallmark of ADHD is attentional impairment and executive dysfunction. Hyperactivity is not seen in adult populations with ADD.
Attention As a Trait
Attention can be thought of in the same manner as blood pressure. There is a mean blood pressure in the population but there will be individuals that fall outside the standard curve. Most people in the population will fall in the middle having a reasonable amount of attention and those with low attention levels do not necessarily have a disease although they may have consequences associated with reduced attentional activity. When someone is overly attentive it can be a symptom of disorders like obsessive compulsive disorder (OCD) or psychosis. Like blood pressure, having readings that are too high or too low can cause problems. It’s normal to have a certain amount of inattention, and we can think of attention as a spectrum with a range of normal levels.
What are the Causes of Inattention
-It could be a perfectly normal trait, as we explained some people have lower attention spans naturally as a personality trait
-Mood disorders like depression and bipolar disorder have in inattention as a possible consequence of the change in mood
-Psychotic disorders also have cognitive changes that may cause inattention (internal preoccupation)
-Anxiety disorders
-Neurocognitive disorders
-We should avoid diagnosing ADD in the setting of one of these other conditions.
Would you diagnosis ADD during a manic episode?
Prevalence of ADHD in the U.S.
-The prevalence of ADHD in the U.S. ranges from 5.6% to 15.9% and there is great variability depending on the geographic region
-For most biological diseases we should see similar prevalence rates across populations and geographic regions. For example, schizophrenia has a prevalence of about 1% worldwide. So why do we see significant differences across the U.S.?
-We do not know much about the role socioeconomic factors, diet, exercise, and other social factors play in the development of ADHD. It’s possible that these are significant contributing factors resulting in the symptoms associated with ADHD.
Is ADHD a neurodevelopmental issue?
-One way of thinking about ADHD is as a neurodevelopmental problem that eventually improves over time.
-In children with ADHD they seem to achieve peak cortical thickness later than children without ADHD, this has been confirmed on imaging studies.
-The important part is eventually these children catch up with the normal controls. It’s more a delay in brain development and not a permanent state.
-The ADHD children are about 2 years behind the normal controls and the area of greatest delay is the prefrontal cortex which is responsible for executive function.
How Common is ADHD and Does it Last into Adulthood?
Over the past decade ADHD in adult populations has gotten more attention. Some would say the prevalence in adults is 4% to 5% with equal rates being seen in men and women.
The national comorbidity survey estimated 46% of children with ADHD have symptoms that persist into adulthood. Many of these individuals had comorbid anxiety disorders and we know anxiety can be a major cause of inattention and executive dysfunction.
In other studies, similar findings were reported. What stands out to me in all these studies is the high rates of comorbid mood disorders including depression and bipolar disorder. It’s hard to make a diagnosis of adult ADHD in the presence of other conditions considering the significant overlap of symptoms and cognitive dysfunction associated with mood disorders.
It’s possible that mood and anxiety disorder can account for most adult ADHD cases and a variation of a normal trait could explain the rest (individuals with low attention)
Looking at medication response doesn’t help us much as amphetamines are helpful in everyone even those who do not have a psychiatric disorder (think college kids taking them for midterms)
When you correct for comorbidities in Adult ADHD, only about half of the young adults meeting criteria for ADHD had ADHD only. Estimates from this showed that most children diagnosed with ADHD were no longer meeting criteria in adulthood (83% no longer had symptoms). Many of the newly diagnosed cases of ADHD were in individuals who did not have ADHD as children (87% did not have ADHD as children).
This indicates that about 20% of children diagnosed with ADHD will have symptoms persist into adulthood, the other 80% will not
In animal models, amphetamines have been shown to have some dangerous effects
-Decrease response to reward stimuli
-increased anxiety
-decreased dopamine activity
-decreased long-term survival of neuronal cell in the hippocampus (excitotoxicity)
Risk of Substance Use With Stimulant Prescriptions
Most psychiatrists will tell you the risk of substance use disorder does not increase with stimulant medication treatment; in fact it’s reduced when ADHD is treated. However, a well-designed randomized controlled trial of delinquent behavior and emerging substance use in medication treated children found significantly higher rates of substance use in the stimulant treated individuals. The conclusion by Molina et al. was we need to re-evaluate the risk of substance use disorder as children age when they are prescribed stimulants. Now correlation does not equal causation, but this should give us some pause when blinding stating there is no risk for addiction with stimulant use (this claim is mostly based off observational data and not randomized controlled trial data).
-This is one of the only disorders where medication is the first line treatment in children and adolescents.
-There is a 70%-80% response rate to psychostimulants, and medication consistently outperforms behavioral interventions in RCTs.
-For preschool age children, behavioral interventions are first line and medications are considered if there is a poor response to behavioral intervention and functional impairment.
Psychostimulants
–Methylphenidate (MPH or Ritalin) should be started at 2.5 to 5 mg twice daily (before breakfast and lunch). It can be increased by 2.5 to 5 mg/day reaching an optimal dose of 1 mg/kg/day and a maximum dose of 2 mg/kg/day.
–Side effects include insomnia, decreased appetite, mood disturbance, tics, headaches, GI distress, and rarely psychosis.
-There are several long-acting preparations including Ritalin XR, Ritalin LA, metadate, Concerta, Daytrana, Focalin XR and several others. The important point about long-acting preparation is they provide a sustained second release with resulting plasma levels lasting 4-12 hours depending on the preparation.
–Amphetamine sulfate (Adderall): should be started at 2.5-5 mg once or twice per day. It can be increased by 5 mg per week with an optimal dose of 0.5-1 mg/kg/day. Dextroamphetamine is twice as potent as amphetamine. The side effect profile is similar to MPH.
Longer-acting amphetamine preparations include Adderall XR, Dexedrine, Dyanavel XR, and Vyvanse (formulated as a prodrug to reduce the risk of abuse). These will provide coverage for about 12 hours.
-There is a black box warning for the risk of abuse and dependence. In addition, there is a cardiovascular safety warning regarding the risk of sudden cardiac death in children and adolescents with structural heart defects or other severe cardiac conditions. Patients should be screened for any cardiovascular disorders, family history of sudden cardiac death, and an EKG should be performed.
-ADHD is the most common physiocratic disorder in children.
-Its prevalence is 5-11% in school-aged children
-It often presents with a classic triad of inattention, hyperactivity, and impulsivity
– However, it can present as mixed, or primarily inattentive or hyperactive
-Symptoms must include at least 6 signs of inattention and/or six signs of hyperactivity/impulsivity for 6 months.
-For patients 17 years and older on 5 symptoms are required
Symptoms of inattention include:
-failure to pay close attention
-difficulty sustaining attention on tasks or activities
-failure to listen when spoken to
-difficulty organizing tasks
-avoidance of activities that require mental effort
-losing things necessary for tasks or activities
-distractibility and forgetfulness in daily activities
Symptoms of hyperactivity:
-fidgeting with hands or feet
-inability to sit still
-running around when not appropriate
-difficulty engaging quietly in activities
-feeling on the go or driven by a motor
-talking excessively
Symptoms of Impulsivity:
-answering questions before they are completely asked
-having trouble waiting ones turn
-interrupting others
The pattern of behavior must be more severe and occur more often than in other children of the same age. The symptoms of the disorder must be present before the age of 12 years. The diagnosis can be made after 12 years of age but there must be evidence of symptoms before the age of 12. The last important point is the symptoms must occur in two different settings (e.g., home and school).
Many patients may be familiar with screening scales like the Vanderbilt or Conners which can be used to help confirm the diagnosis usually one is completed by the parent the other by a teacher.
