tag:theconversation.com,2011:/nz/topics/adhd-1676/articlesADHD – The Conversation2024-03-14T19:25:21Ztag:theconversation.com,2011:article/2256802024-03-14T19:25:21Z2024-03-14T19:25:21ZCould ADHD drugs reduce the risk of early death? Unpacking the findings from a new Swedish study<figure><img src="https://images.theconversation.com/files/581833/original/file-20240314-23-yi6tr0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C8192%2C5457&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-beautiful-woman-taking-tablet-glass-2177446101">Dragana Gordic/Shutterstock</a></span></figcaption></figure><p>Attention-deficit hyperactivity disorder (ADHD) can have a considerable impact on the day-to-day functioning and overall wellbeing of people affected. It causes a variety of symptoms including difficulty focusing, impulsivity and hyperactivity. </p>
<p>For many, a diagnosis of ADHD, whether in childhood or adulthood, is life changing. It means finally having an explanation for these challenges, and opens up the opportunity for treatment, including medication.</p>
<p>Although <a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">ADHD medications</a> can cause side effects, they generally improve symptoms for people with the disorder, and thereby can significantly boost quality of life.</p>
<p>Now a <a href="https://jamanetwork.com/journals/jama/fullarticle/2816084">new study</a> has found being treated for ADHD with medication reduces the risk of early death for people with the disorder. But what can we make of these findings?</p>
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<h2>A large study from Sweden</h2>
<p>The study, published this week in JAMA (the prestigious journal of the American Medical Association), was a large cohort study of 148,578 people diagnosed with ADHD in Sweden. It included both adults and children.</p>
<p>In a cohort study, a group of people who share a common characteristic (in this case a diagnosis of ADHD) are followed over time to see how many develop a particular health outcome of interest (in this case the outcome was death). </p>
<p>For this study the researchers calculated the mortality rate over a two-year follow up period for those whose ADHD was treated with medication (a group of around 84,000 people) alongside those whose ADHD was not treated with medication (around 64,000 people). The team then determined if there were any differences between the two groups.</p>
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<h2>What did the results show?</h2>
<p>The study found people who were diagnosed and treated for ADHD had a 19% reduced risk of death from any cause over the two years they were tracked, compared with those who were diagnosed but not treated. </p>
<p>In understanding this result, it’s important – and interesting – to look at the causes of death. The authors separately analysed deaths due to natural causes (physical medical conditions) and deaths due to unnatural causes (for example, unintentional injuries, suicide, or accidental poisonings).</p>
<p>The key result is that while no significant difference was seen between the two groups when examining natural causes of death, the authors found a significant difference for deaths due to unnatural causes.</p>
<h2>So what’s going on?</h2>
<p>Previous studies have suggested ADHD is associated with an increased risk of <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789090?">premature death</a> from unnatural causes, such as injury and poisoning.</p>
<p>On a related note, <a href="https://pubmed.ncbi.nlm.nih.gov/32662370/">earlier studies</a> have also suggested taking ADHD medicines may reduce premature deaths. So while this is not the first study to suggest this association, the authors note previous studies addressing this link have generated mixed results and have had significant limitations.</p>
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<p>In this new study, the authors suggest the reduction in deaths from unnatural causes could be because taking medication alleviates some of the ADHD symptoms responsible for poor outcomes – for example, improving impulse control and decision-making. They note this could reduce fatal accidents.</p>
<p>The authors cite a number of studies that support this hypothesis, including research showing <a href="https://publications.aap.org/pediatrics/article-abstract/124/1/71/71653/Do-Stimulants-Protect-Against-Psychiatric?redirectedFrom=fulltext">ADHD medications</a> may prevent the onset of mood, anxiety and <a href="https://publications.aap.org/pediatrics/article-abstract/104/2/e20/62430/Pharmacotherapy-of-Attention-deficit-Hyperactivity?redirectedFrom=fulltext">substance use disorders</a>, and <a href="https://www.biologicalpsychiatryjournal.com/article/S0006-3223(19)31274-0/abstract">lower the risk</a> of accidents and criminality. All this could reasonably be expected to lower the rate of unnatural deaths.</p>
<h2>Strengths and limitations</h2>
<p>Scandinavian countries have well-maintained national registries that collect information on various aspects of citizens’ lives, including their health. This allows researchers to conduct excellent population-based studies. </p>
<p>Along with its robust study design and high-quality data, another strength of this study is its size. The large number of participants – almost 150,000 – gives us confidence the findings were not due to chance.</p>
<p>The fact this study examined both children and adults is another strength. Previous research relating to ADHD has often focused primarily on children.</p>
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<p>One of the important limitations of this study acknowledged by the authors is that it was observational. Observational studies are where the researchers observe and analyse naturally occurring phenomena without intervening in the lives of the study participants (unlike randomised controlled trials). </p>
<p>The limitation in all observational research is the issue of confounding. This means we cannot be completely sure the differences between the two groups observed were not either partially or entirely due to some other factor apart from taking medication.</p>
<p>Specifically, it’s possible lifestyle factors or other ADHD treatments such as psychological counselling or social support may have influenced the mortality rates in the groups studied.</p>
<p>Another possible limitation is the relatively short follow-up period. What the results would show if participants were followed up for longer is an interesting question, and could be addressed in future research.</p>
<h2>What are the implications?</h2>
<p>Despite some limitations, this study adds to the evidence that diagnosis and treatment for ADHD can make a profound difference to people’s lives. As well as alleviating symptoms of the disorder, this study supports the idea ADHD medication reduces the risk of premature death. </p>
<p>Ultimately, this highlights the importance of diagnosing ADHD early so the appropriate treatment can be given. It also contributes to the body of evidence indicating the need to <a href="https://theconversation.com/with-rising-mental-health-problems-but-a-shortage-of-services-group-therapy-is-offering-new-hope-214711">improve access</a> to mental health care and support more broadly.</p><img src="https://counter.theconversation.com/content/225680/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hassan Vally does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The study found people with ADHD who took medication had a lower risk of dying from unnatural causes than those with ADHD who were not taking medication.Hassan Vally, Associate Professor, Epidemiology, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2222922024-03-01T17:24:49Z2024-03-01T17:24:49ZYoung people are losing sleep over energy drinks – but a ban won’t be enough to protect them<figure><img src="https://images.theconversation.com/files/578725/original/file-20240228-24-66bbn5.jpg?ixlib=rb-1.1.0&rect=31%2C31%2C5187%2C3489&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/teenage-boy-drinking-caffeine-energy-drink-1571400820">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>There’s <a href="https://www.theguardian.com/business/2023/jul/27/prime-energy-drinks-teenagers-alarm-marketing">no calming the buzz</a> around energy drinks. And it’s not just because of their notoriously <a href="https://www.sciencefocus.com/the-human-body/how-long-do-energy-drinks-last">high caffeine content</a>. </p>
<p>In the first few weeks of 2024, the <a href="https://www.theguardian.com/politics/2024/feb/10/labour-considers-banning-sale-of-energy-drinks-to-children">UK Labour party proposed</a> including a ban on energy drinks for under-16s in their election manifesto due to concerns about their health impact. Soldiers belonging to the <a href="https://www.nam.ac.uk/explore/blues-and-royals-royal-horse-guards-and-1st-dragoons">Blues & Royals</a> – part of the king’s ceremonial bodyguards, the Household Cavalry – have also been <a href="https://www.forces.net/services/army/british-army-regiment-cans-red-bull-relentless-and-monster-energy-drinks-ban#:%7E:text=Soldiers%20belonging%20to%20the%20Blues,they%20break%20the%20new%20rules.">ordered to stop consuming energy drinks</a>. </p>
<p>Since then, one of <a href="https://www.forbes.com/profile/dwayne-johnson/">Hollywood’s highest paid</a> actors, Dwayne “The Rock” Johnson has <a href="https://www.prnewswire.com/news-releases/zoa-energy-and-dwayne-the-rock-johnson-launch-new-campaign-packed-with-bde-big-dwayne-energy-302063746.html">launched a new campaign</a> for his “healthy” energy drink brand, Zoa. No doubt Johnson is hoping to capitalise on the <a href="https://www.bbc.co.uk/news/newsbeat-64145389">thirst for energy drinks that helped Prime</a>, a brand promoted by popular but controversial <a href="https://theconversation.com/prime-a-youtuber-expert-explains-how-logan-paul-and-ksis-drink-became-so-popular-201792">YouTube personalities KSI and Logan Paul</a>, <a href="https://www.theguardian.com/food/2023/feb/18/how-the-world-got-hopped-up-on-energy-drinks-prime-logan-paul-ksi">achieve cult status</a> among school-aged children, <a href="https://www.thetimes.co.uk/article/logan-paul-ksi-energy-drink-prime-secret-to-success-2023-pmslz25dw">especially boys</a>. </p>
<p>But young people’s consumption of energy drinks isn’t likely to be completely driven by influencer trends. If we want to help young people suffering the health consequences of consuming energy drinks too often, regulation is no doubt part of the picture. But we also need to examine the root causes of young people’s attraction to energy drinks.</p>
<p>Recent evidence suggests that in the UK up to <a href="https://www.bmj.com/company/newsroom/up-to-half-of-kids-worldwide-and-up-to-third-of-uk-kids-consume-energy-drinks-weekly/">a third of children and young adults</a> consume energy drinks regularly. <a href="https://bmjopen.bmj.com/content/6/10/e010380">A 2016 systemic review</a> of energy drink consumption by children and young people found boys are more likely to consume higher amounts than girls. </p>
<p>Energy drinks can contain as much as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10535526/">505mg of caffeine per serving</a> (equivalent to over <a href="https://www.ukactive.com/blog/energy-drinks-and-young-people/">fourteen cans of cola</a>), with <a href="https://www.which.co.uk/news/article/prime-energy-caffeine-children-aYYmC0M1DTCe">most containing around 160mg per can</a>. For comparison, <a href="https://www.sciencefocus.com/the-human-body/how-long-do-energy-drinks-last">a typical 250ml cup of coffee</a> contains about 90-140mg.</p>
<p>Owing to this high caffeine content, the consumption of energy drinks has been <a href="https://bmjopen.bmj.com/content/14/2/e072951">linked to poor sleep quality</a>. Research has found that the drinks may also contribute to <a href="https://www.sciencedirect.com/science/article/pii/S0033350623003189?via%3Dihub">mental health</a> issues among young people, including anxiety, stress, irritability, and depression. All of which are almost certainly linked to disrupted sleep patterns.</p>
<p>So why are young people so keen on energy drinks? Academic research shows that reasons for consumption include <a href="https://bmjopen.bmj.com/content/6/10/e010380">enjoying the taste</a>, as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166148/">measure to deal with fatigue</a> and boost mood – and to improve mental and <a href="https://bmjopen.bmj.com/content/6/10/e010380">sporting performance</a>.</p>
<p>Another common use for energy drink is as a mixer. Energy drinks are often <a href="https://www.cdc.gov/alcohol/fact-sheets/caffeine-and-alcohol.htm">combined with alcohol and consumed at parties</a> to give an extra buzz. The energy drink <a href="https://www.cdc.gov/alcohol/fact-sheets/caffeine-and-alcohol.htm">counteracts the depressive effect</a> of the alcohol so the drinker feels more alert than they might otherwise. </p>
<p>But this trend also has its dangers. People can end up drinking more alcohol than they realise because its effects are suppressed by the energy drinks. </p>
<p>Branding, marketing and peer influence encourage their use among young people, many of whom <a href="https://research.uhs.nhs.uk/news/energy-drink-intake-rising-among-teens-in-deprived-areas-amid-widening-inequality">are unaware of possible harms</a> of energy drink usage. <a href="https://bmjopen.bmj.com/content/12/2/e047746">A UK study conducted in 2022</a> found that only about half of children knew that energy drinks contained caffeine. </p>
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<h2>Young people lacking in sleep</h2>
<p>Though some academic <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9502542/">studies have</a> reported a link between young people’s use of energy drinks and a <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-12972-w">lack of sleep</a>, the exact relationship between the two isn’t clear.</p>
<p>Numerous factors such as <a href="https://www.weforum.org/agenda/2023/09/screen-time-affecting-sleep-mental-health/">night-time screen use and social media scrolling</a>, academic pressures, and mismatches between school start times and natural sleep-wake rhythms conspire to see many of the world’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019014/">young people falling short</a> of recommended sleep targets. </p>
<p>Whetever the cause of young people’s lack of sleep, energy drinks offer a fast and convenient way to counteract the effects of poor sleep on mood and <a href="https://pubmed.ncbi.nlm.nih.gov/19482732/#:%7E:text=Conclusions%3A%20Many%20adolescents%20used%20multiple,impaired%20by%20excessive%20daytime%20sleepiness.">day-to-day functioning</a>. It’s possible, then, that young people can become trapped in vicious cycles of energy drink use, poor sleep, and deteriorating mental health. </p>
<p>Energy drink use has also been linked to attention deficit hyperactivity disorder (<a href="https://www.liebertpub.com/doi/10.1089/jcr.2015.0018">ADHD</a>). However, while some acute effects of energy drinks, such as increased activity, resemble ADHD symptoms, it is currently unclear whether there is any long term increased risk of developing ADHD as a result of energy drink consumption. </p>
<p>Young people with ADHD symptoms might also be more likely to use energy drinks as a form of “self-medication” or because they enjoy the feeling or lower impulse control. As young people with ADHD are already more likely to experience sleep difficulties, they might also be an especially vulnerable group for whom energy drink use could exacerbate pre-existing sleep issues. </p>
<h2>Bans and regulation are only part of the answer</h2>
<p>In light of the accumulating evidence for the harms of energy drinks, several countries have started to regulate or outright ban their sale minors. In <a href="https://www.ncl.ac.uk/press/articles/latest/2024/01/energydrinksandchildrensmentalhealth/">Lithuania and Turkey</a>, for example, sales of energy drinks to under 18s is not allowed. </p>
<p>In the UK, a <a href="https://www.independent.co.uk/news/uk/home-news/jamie-oliver-energy-drink-ban-chef-urges-government-a8142516.html">2018 social media campaign</a> spearheaded by <a href="https://www.jamieoliver.com/features/energy-drinks-are-not-for-children/">celebrity chef Jamie Oliver</a> led to many supermarkets implementing a voluntary ban on sales to under-16s. The following year, the UK government said they would <a href="https://www.bbc.co.uk/news/health-67962147">ban energy drinks for under-16s</a> in England. But the ban has not been implemented.</p>
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<p>Bans and regulation can help to change behaviour, but they are usually not enough on their own. Equipping young people with the knowledge and skills to manage their sleep and energy cycles will play a crucial role in tackling the global shortage of sleep among young people. </p>
<p>Most crucial of all, we need to listen to young people and understand their motivations for using energy drinks so that we can design effective strategies to support them to reduce their consumption.</p><img src="https://counter.theconversation.com/content/222292/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Energy drinks are a growing worldwide trend for young people and, for the sake of their health, we must understand whyAja Murray, Reader in Psychology, The University of EdinburghIngrid Obsuth, Senior Lecturer in Clinical Psychology, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2234302024-02-21T19:13:05Z2024-02-21T19:13:05ZADHD drug shortages: what to expect if you take Vyvanse and can’t access your usual dose<figure><img src="https://images.theconversation.com/files/576647/original/file-20240220-16-k72tyz.jpg?ixlib=rb-1.1.0&rect=41%2C13%2C4608%2C3049&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/spilled-green-pill-bottle-vyvanse-medication-2380197771">Colleen Weisner/Shutterstock</a></span></figcaption></figure><p>Imagine you or your child has attention deficit hyperactivity disorder (ADHD), and after several weeks, or even months, you’ve found a dose of medication you’re happy with. </p>
<p>The problems you previously experienced with ADHD have improved significantly. You’re no longer constantly being distracted by your phone, or procrastinating for long periods instead of getting started on a piece of work. Perhaps your child is focusing better at school.</p>
<p>But always in the back of your mind is a worry: what would happen if you or your child ran out of medication? What if your doctor is ill and cannot prescribe it for you? Or what if your medication is no longer available at the pharmacy? </p>
<p>Many Australians with ADHD who take Vyvanse, a drug commonly prescribed to treat the condition, are facing this <a href="https://www.abc.net.au/news/2024-01-25/adhd-drug-shortage-vyvanse-australia-doctors/103369526">medication crisis</a> at the moment. The drug has been <a href="https://www.tga.gov.au/safety/shortages/information-about-major-medicine-shortages/about-shortages-vyvanse-lisdexamfetamine-dimesilate-capsules">in short supply</a> in Australia for the past few months.</p>
<h2>Getting the dose right</h2>
<p>If you have ADHD and are taking medication, it’s likely you have reached your current dose by a careful process of medication optimisation in consultation with your specialist. </p>
<p>You may have started off with dexamfetamine or methylphenidate tablets, short-acting stimulants that take effect quickly and last for about four hours. During a process called titration, the dose is gradually increased, looking for the dose that <a href="https://www.ncbi.nlm.nih.gov/pubmed/29955166">works best for you</a>, with the least side effects.</p>
<p>You may have tried modified stimulant formulations – capsules that release the medication <a href="https://theconversation.com/adhd-medication-can-you-take-it-long-term-what-are-the-risks-and-do-benefits-continue-218694">more slowly</a>. These include Ritalin LA (long-acting) and Concerta, which both <a href="https://pubmed.ncbi.nlm.nih.gov/23611637/">contain methylphenidate</a> and are designed to last either six to eight hours (Ritalin LA) or eight to 12 hours (Concerta).</p>
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<img alt="A man sitting on a couch taking a tablet." src="https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/576649/original/file-20240220-20-qi0t3y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Many people with ADHD take medication.</span>
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<p>Or you may have gone straight onto lisdexamfetamine (Vyvanse), a “prodrug” of dexamfetamine. Vyvanse has a protein molecule (lysine) attached which makes it inactive until it has been broken down in the body and <a href="https://theconversation.com/adhd-medication-can-you-take-it-long-term-what-are-the-risks-and-do-benefits-continue-218694">releases dexamfetamine</a>. This means a single dose of Vyvanse, like Concerta, may be effective for the entire day. </p>
<p>Although both of these once-daily formulations have similar effects and side effects, you might feel better on one than the other. You might have to try both to find the one which suits you best. Then the dose would be carefully worked out with your specialist. </p>
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<a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">How do stimulants actually work to reduce ADHD symptoms?</a>
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<h2>Shortages have affected different doses</h2>
<p>In August 2023 the first shortages occurred <a href="https://www.abc.net.au/news/2024-01-25/adhd-drug-shortage-vyvanse-australia-doctors/103369526">in Australia</a>, affecting the 20mg and 30mg strengths.</p>
<p>Then these lower strengths came back and the 50mg was unavailable. Most recently, since December 2023, most pharmacies have only been able to obtain the <a href="https://www.tga.gov.au/safety/shortages/information-about-major-medicine-shortages/about-shortages-vyvanse-lisdexamfetamine-dimesilate-capsules">20mg and 70mg capsules</a>.</p>
<p>Splitting the dose (for example prescribing 40g to a patient who takes 20g) <a href="https://corerevitalizingcenter.com/vyvanse-water-titration-in-8-steps/">can be done</a> by mixing the contents of a capsule in water, and reserving half. But this is not recommended by the manufacturer, who will not guarantee the effectiveness of the half dose kept overnight. </p>
<p>Combining doses if available (say 20g and 30g for a patient who normally takes 50g) would require two new prescriptions. These strengths might not be available at the pharmacy the following month, and writing new prescriptions for each patient month by month is not sustainable.</p>
<p>Stimulant prescribing is heavily regulated, with pharmacies allowed to dispense only one month’s supply at a time. Prescriptions, which last for up to six months, are retained at the patient’s nominated pharmacy and cannot be released to be used elsewhere.</p>
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<img alt="A man, with his daughter, talks to a pharmacist." src="https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/576651/original/file-20240220-24-k72tyz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Stimulant prescribing is heavily regulated.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-pharmacist-using-digital-tablet-while-2260500939">Drazen Zigic/Shutterstock</a></span>
</figcaption>
</figure>
<p>Of course, Vyvanse is not the only ADHD medication. Some people may have been taking Concerta or Ritalin prior to starting Vyvanse, and could revert to their previous dose. Changing medication is not normally a problem, but it might be for someone who responds better to Vyvanse. </p>
<p>Another alternative would be going back to multiple doses of short-acting dexamfetamine. Unfortunately the correct dose of dexamfetamine tablets cannot be calculated from a patient’s Vyvanse dose because of the differences in pharmacokinetics – how long it takes for the drug to start working balanced against how quickly it’s cleared from the body.</p>
<p>So changing to dexamfetamine would have to involve some flexibility to adjust the dose up or down as needed. This may also have a positive side, because the process depends on the person developing a good understanding of their response to each dose of medication.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/adhd-medication-can-you-take-it-long-term-what-are-the-risks-and-do-benefits-continue-218694">ADHD medication – can you take it long term? What are the risks and do benefits continue?</a>
</strong>
</em>
</p>
<hr>
<p>There’s no ideal solution to this problem. Leaving patients unmedicated is perhaps the worst option because the functional improvement they have come to depend on is withdrawn and the problems associated with untreated ADHD recur. This can leave people in crisis and <a href="https://www.theguardian.com/society/2023/dec/17/uk-firms-exploit-adhd-medication-shortage-to-push-unproven-smart-supplements">seeking unproven alternative treatments</a>. </p>
<h2>How long will the shortage last?</h2>
<p>In Australia, Vyvanse is only available from one company, Takeda, that manufactures it <a href="https://www.federalregister.gov/documents/2024/01/03/2023-28962/established-aggregate-production-quotas-for-schedule-i-and-ii-controlled-substances-and-assessment">in the United States</a>. </p>
<p>The Therapeutic Goods Administration anticipates <a href="https://www.tga.gov.au/safety/shortages/information-about-major-medicine-shortages/about-shortages-vyvanse-lisdexamfetamine-dimesilate-capsules">the shortages</a> in Australia will last until March or April, depending on the dose.</p>
<p>It can be extremely stressful when your ADHD medication is suddenly unavailable. If you are in this situation and wondering how to manage, remember Vyvanse is not the only formulation available. It’s worth getting in touch with your specialist to find out about the alternatives. This could involve an initial period of dose adjustment, but it might be a great deal better than going without.</p><img src="https://counter.theconversation.com/content/223430/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Poulton is a director of the Australasian ADHD Professionals Association. She has previously taken part in an advisory panel and received personal fees and non-financial support from Takeda Pharmaceuticals, which manufactures ADHD medications including some mentioned in this article. She has received book royalties from Disruptive Publishing (ADHD Made Simple).</span></em></p>Many Australians with ADHD are having trouble accessing their usual medication. This can create difficulties for people who have previously been managing their symptoms well.Alison Poulton, Senior Lecturer, Brain Mind Centre Nepean, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2173812024-01-11T19:10:53Z2024-01-11T19:10:53ZWhat is ‘parent training’ for families of children with ADHD?<figure><img src="https://images.theconversation.com/files/566509/original/file-20231219-21-5nuf85.jpg?ixlib=rb-1.1.0&rect=9%2C9%2C6125%2C3439&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-man-telling-his-wife-front-1677115807">DC Studio/Shutterstock</a></span></figcaption></figure><p>Problems with focus and impulse control can be common developmental stages through which children and adolescents naturally progress. But they can also be symptoms of attention-deficit hyperactivity disorder <a href="https://www.cdc.gov/ncbddd/adhd/facts.html">(ADHD)</a>, a chronic condition. </p>
<p>ADHD is a pattern of inattention or hyperactivity and impulsivity (or both) that interferes with functioning or development, and persists <a href="https://theconversation.com/do-kids-grow-out-of-adhd-as-they-get-older-218692">into adulthood</a>. ADHD affects around <a href="https://link.springer.com/article/10.1186/s13052-023-01456-1">7.6% of children</a> aged three to 12 years and 5.6% of teens.</p>
<p>ADHD can significantly influence family dynamics and can affect a child’s ability to learn and interact socially. Raising children with behavioural, developmental or learning difficulties can also make parenting more challenging, with parents navigating feelings of frustration, grief and guilt.</p>
<p>While medication is <a href="https://adhdguideline.aadpa.com.au/wp-content/uploads/2022/10/ADHD-Clinical-Practice-Guide-041022.pdf">most effective</a> at minimising core ADHD symptoms, non-drug interventions can also <a href="https://adhdguideline.aadpa.com.au/wp-content/uploads/2022/10/ADHD-Clinical-Practice-Guide-041022.pdf">reduce</a> the daily impacts of ADHD symptoms. Parenting/family training is one such <a href="https://www.tandfonline.com/doi/full/10.1080/15374416.2017.1390757?needAccess=true">intervention</a>. So what does it involve and is it effective?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/adhd-medications-have-doubled-in-the-last-decade-but-other-treatments-can-help-too-191574">ADHD medications have doubled in the last decade – but other treatments can help too</a>
</strong>
</em>
</p>
<hr>
<h2>Positive praise and natural consequences</h2>
<p>Parenting training is widely used and can take different forms. Sometimes a psychologist works with one or both parents to give them skills specific to their family and situation. It’s sometimes a structured in-person program for groups of parents. It can also be delivered online, at parents’ own pace or in virtual classrooms.</p>
<p>Most parent/family training will teach parents forms of:</p>
<ul>
<li><p><strong>positive praise</strong>. Notice when your child is behaving in a desirable way and give them positive feedback. For example,“Wow, you’re playing so nicely. I really like the way you’re keeping all the blocks on the table.” Praise nurtures self esteem and their sense of self. Praise teens for starting homework without being reminded or coming home at the agreed time </p></li>
<li><p><strong>effective limit-setting</strong>. Establish ground rules in a quiet moment of family time, where everyone has a say and understands the boundaries, consequences, and expectations </p></li>
<li><p><strong><a href="https://pubmed.ncbi.nlm.nih.gov/30738545/">natural consequences</a></strong>, such as missing out on watching a TV show because packing up took too long. This allows the child to experience failure or loss, but empowers them with what they can focus on or improve the next time round</p></li>
<li><p><strong>planned ignoring of annoying but not serious behaviours</strong> such as making faces or messy rooms. Make a decision to ignore it and breathe. Model desirable behaviours, such as looking after your possessions and fitting in with family life </p></li>
<li><p><strong>positive parent-child interactions</strong>. “Connection before correction” helps a parent shape their child’s behaviour and can <a href="https://linkinghub.elsevier.com/retrieve/pii/S0890-8567(18)31980-4">reduce disruptions</a>.
Emotionally connect by, for example, establishing eye contact, using a gentle tone and getting down on their level. This attunement allows the child to be able to regulate their behaviour and better manage their emotions. </p></li>
</ul>
<figure class="align-center ">
<img alt="Dad talks to child in garden" src="https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566515/original/file-20231219-29-tw0fa5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your responses can reduce their disruptive behaviour.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/man-in-blue-crew-neck-t-shirt-beside-woman-in-blue-crew-neck-t-shirt-eyfaunEy9dM">Max Harlynking/Unsplash</a></span>
</figcaption>
</figure>
<p>Parents aren’t to blame for their child’s symptoms; the aim of training is to teach parents skills to meet the above-average parenting needs of children with ADHD. </p>
<p>Take inattention, for example. If a task is boring to a child with ADHD, their brain will struggle to pay attention – even if they want to. <a href="https://www.youtube.com/watch?v=_tpB-B8BXk0">ADHD</a> clinical neuropsychologist Russell Barkley explains ADHD like this: the back part of the brain is where you learn, the front part is what you do, and ADHD splits them apart. You can know things but you won’t do them – it’s a performance disorder.</p>
<p>Having a few household rules, schedules, opportunities to problem-solve, effectively using instructions and, most importantly, expressions of <a href="https://5lovelanguages.com/">love</a> can give children positive environments that will help their mental health over time. </p>
<h2>How effective is parent training?</h2>
<p>The <a href="https://adhdguideline.aadpa.com.au/">Australian evidence-based ADHD treatment guidelines</a> reviewed the evidence and found medication treatment was more effective than non-pharmacological treatment in reducing core ADHD symptoms. But combined therapies were better than either treatment alone. </p>
<p>The United Kingdom’s National Institute of Clinical Excellence <a href="https://www.nice.org.uk/guidance/ng87/chapter/Recommendations#managing-adhd">recommends</a> ADHD management plans include treatments to address the child’s psychological, behavioural and educational or occupational needs.</p>
<p>There is <a href="https://adhdguideline.aadpa.com.au/wp-content/uploads/2022/10/ADHD-Clinical-Practice-Guide-041022.pdf">evidence to support</a> parenting training for children aged five to 17, and greater evidence for its use in children under five and families of children who also have <a href="https://www.mayoclinic.org/diseases-conditions/oppositional-defiant-disorder/symptoms-causes/syc-20375831">oppositional defiant disorder</a> or <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/conduct-disorder">conduct disorder</a>, who require more intensive support. </p>
<p>But more research is needed about the duration and form of the parent training. </p>
<p>The <a href="https://www.who.int/publications/i/item/9789240065505">World Health Organization</a> also recommends parenting interventions because they strengthen the parent-child relationship, assist with alternatives to <a href="https://www.cam.ac.uk/research/news/harsh-discipline-increases-risk-of-children-developing-lasting-mental-health-problems">violent discipline</a> and reduce emotional problem behaviours in children. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/1-in-4-adults-think-smacking-is-necessary-to-properly-raise-kids-but-attitudes-are-changing-218837">1 in 4 adults think smacking is necessary to 'properly raise' kids. But attitudes are changing</a>
</strong>
</em>
</p>
<hr>
<h2>How do you access parent training?</h2>
<p>Most psychologists offer family training and will charge you the same fee as a normal session. </p>
<p>You can also upskill with the free <a href="https://www.triplep-parenting.net.au/qld-en/free-parenting-courses/triple-p-online-under-12/?gad_source=1&gclid=CjwKCAiAvdCrBhBREiwAX6-6UlIdcIunlsTq4iB0-J6xZN1Bl3wA1Dj9bmN6GuXUG_InDq5HeYHPSxoCjuIQAvD_BwE#au-parents-register-now">Triple P Parenting Program</a> online. </p>
<p>Happy Families also has an online <a href="https://www.happyfamilies.com.au/shop/product/pin-parenting-adhd-the-course">parenting ADHD course</a>. </p>
<figure class="align-center ">
<img alt="Mother sits on laptop in doorway" src="https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566513/original/file-20231219-15-d4eqa7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">You can do parent training online.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/a-woman-sitting-on-the-floor-using-a-laptop-ddcLX7Iis44">Surface/Unsplash</a></span>
</figcaption>
</figure>
<p>Bond University researchers are also conducting a free, <a href="https://research.bond.edu.au/en/persons/cher-mcgillivray/?_ga=2.48431014.1617715341.1703022536-540923691.1665619219">online group parenting program</a>, which includes positive parenting skills. This will be part of a randomised control trial to develop an evidenced-based parenting intervention.</p>
<p>The aim with all of these programs is to better understand the child’s life and have <a href="https://self-compassion.org/wp-content/uploads/publications/GilbertCFT.pdf">compassionate</a> responses to their ADHD and behavioural symptoms. So rather than just focusing on their behaviour – which is an outward expression of an inward emotion – it encourages parents to embrace their uniqueness and help them in their struggles. </p>
<h2>How else can you support your child with ADHD?</h2>
<p>Set <a href="https://drsharonsaline.com/2021/05/18/parenting-older-teens-with-adhd-land-the-helicopter-and-focus-on-scaffolding/">boundaries</a> and be clear about your expectations, but also be compassionate to your child and pick your battles.</p>
<p>Break instructions into simple tasks and allow them to choose and focus on one thing they’re struggling with at a time. Brainstorm what they need to improve, or an area that frustrates them. This will often be organisation, time management and planning. Ask how you can help and stay calm. Celebrate the small wins along the way. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-kid-is-biting-hitting-and-kicking-im-at-my-wits-end-what-can-i-do-194639">My kid is biting, hitting and kicking. I’m at my wit’s end, what can I do?</a>
</strong>
</em>
</p>
<hr>
<p>Be curious and seek to understand and connect with your child. Even though your relationship may feel strained or disconnected at times, remember disagreement need not destabilise the relationship. Children express their full emotions, without restraint, among people they feel most safe with. </p>
<p>Finally, ensure you look after yourself, connect with other parents who can support you. Try not to place your anxiety, stress and fears onto your child. Talk to a friend or psychologist so your child feels safe and able to share anything with you and knows you will cope.</p><img src="https://counter.theconversation.com/content/217381/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cher McGillivray does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Raising children with behavioural, developmental or learning difficulties can also make parenting more challenging. So how can parent training help?Cher McGillivray, Assistant Professor Psychology Department, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2186942024-01-10T19:14:38Z2024-01-10T19:14:38ZADHD medication – can you take it long term? What are the risks and do benefits continue?<figure><img src="https://images.theconversation.com/files/566443/original/file-20231218-19-ldln3o.jpg?ixlib=rb-1.1.0&rect=16%2C16%2C5447%2C3620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/concept-suffering-terrible-pain-beautiful-sad-2114963093">Shutterstock</a></span></figcaption></figure><p>Attention deficit hyperactivity disorder (<a href="https://www.healthdirect.gov.au/attention-deficit-disorder-add-or-adhd">ADHD</a>) is a condition that can affect <a href="https://theconversation.com/do-kids-grow-out-of-adhd-as-they-get-older-218692">all stages of life</a>. Medication is not the only treatment, but it is often the treatment that can make the most obvious difference to a person who has difficulties focusing attention, sitting still or not acting on impulse. </p>
<p>But what happens once you’ve found the medication that works for you or your child? Do you just keep taking it forever? Here’s what to consider.</p>
<h2>What are ADHD medications?</h2>
<p>The mainstay of medication for ADHD is stimulants. These include methylphenidate (with brand names Ritalin, Concerta) and dexamfetamine. There is also lisdexamfetamine (branded Vyvanse), a “prodrug” of dexamfetamine (it has a protein molecule attached, which is removed in the body to release dexamfetamine). </p>
<p>There are also non-stimulants, in particular atomoxetine and guanfacine, which are used less often but can also be highly effective. Non-stimulants can be prescribed by GPs but this may not always be covered by the Pharmaceutical Benefits Scheme and could cost more.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-kids-grow-out-of-adhd-as-they-get-older-218692">Do kids grow out of ADHD as they get older?</a>
</strong>
</em>
</p>
<hr>
<h2>How stimulants work</h2>
<p>Some <a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">stimulants prescribed for ADHD</a> are “short acting”. This means the effect comes on after around 20 minutes and lasts around four hours. </p>
<p>Longer-acting stimulants give a longer-lasting effect, usually by releasing medication more slowly. The choice between the two will be guided by whether the person wants to take medication once a day or prefers to target the medication effect to specific times or tasks. </p>
<p>For the stimulants (with the possible exception of lisdexamfetamine) there is very little carry-over effect to the next day. This means the symptoms of ADHD may be very obvious until the first dose of the morning takes effect. </p>
<p>One of the main aims of treatment is the person with ADHD should live their best life and achieve their goals. In young children it is the parents who have to consider the risks and benefits on behalf of the child. As children mature, their role in decision making increases. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/Cyu6WfEM9TA/?img_index=1","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-anxiety-or-adhd-or-both-how-to-tell-the-difference-and-why-it-matters-205304">Is it anxiety or ADHD, or both? How to tell the difference and why it matters</a>
</strong>
</em>
</p>
<hr>
<h2>What about side effects?</h2>
<p>The most consistent <a href="https://theconversation.com/my-child-has-been-diagnosed-with-adhd-how-do-i-make-a-decision-about-medication-and-what-are-the-side-effects-161411">side effects</a> of the stimulants are they suppress appetite, resulting in weight loss. In children this is associated with temporary slowing of the growth rate and perhaps a slight delay in <a href="https://www.ncbi.nlm.nih.gov/pubmed/23330767">pubertal development</a>. They can also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5336546/pdf/40263_2017_Article_410.pdf">increase the heart rate</a> and may cause a rise in blood pressure. Stimulants <a href="https://link.springer.com/article/10.1007/s40263-020-00725-5">often cause insomnia</a>.</p>
<p>These changes are largely reversible on stopping medication. However, there is concern the small rises in blood pressure could <a href="https://www.ncbi.nlm.nih.gov/pubmed/37991787">accelerate the rate of heart disease</a>, so people who take medication over a number of years might have heart attacks or strokes slightly sooner than would have happened otherwise. </p>
<p>This does not mean older adults should not have their ADHD treated. Rather, they should be aware of the potential risks so they can make an informed decision. They should also make sure high blood pressure and attacks of chest pain are taken seriously.</p>
<p>Stimulants can be associated with stomach ache or headache. These effects may lessen over time or with a <a href="https://link.springer.com/article/10.1007/s40263-020-00725-5">reduction in dose</a>. While there have been reports about stimulants being <a href="https://www.tandfonline.com/doi/abs/10.3810/pgm.2014.09.2801">misused by students</a>, research on the risks of long-term prescription stimulant dependence <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2011.03720.x?download=true">is lacking</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-child-has-been-diagnosed-with-adhd-how-do-i-make-a-decision-about-medication-and-what-are-the-side-effects-161411">My child has been diagnosed with ADHD. How do I make a decision about medication and what are the side effects?</a>
</strong>
</em>
</p>
<hr>
<h2>Will medication be needed long term?</h2>
<p>Although ADHD can affect a person’s functioning at all stages of their life, most people stop medication <a href="http://online.liebertpub.com/doi/pdfplus/10.1089/cap.2014.0151">within the first two years</a>. </p>
<p>People may stop taking it because they don’t like the way it makes them feel, or don’t like taking medication at all. Their short period on medication may have helped them develop a better understanding of themselves and how best to manage their ADHD. </p>
<p>In teenagers the medication may lose its effectiveness as they <a href="https://doi.org/10.1007/s40263-020-00725-5">outgrow their dose</a> and so they stop taking it. But this should be differentiated from tolerance, when the dose becomes less effective and there are only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9332474/">temporary improvements with dose increases</a>. </p>
<p>Tolerance may be managed by taking short breaks from medication, switching from one stimulant to another or using a non-stimulant.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="boy looks frustrated, sitting at table with adult" src="https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566444/original/file-20231218-19-s1fo8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Medication is usually prescribed by a specialist but rules differ around Australia.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tired-young-boy-sitting-by-desk-1745295473">Ground Picture/Shutterstock</a></span>
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</figure>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">How do stimulants actually work to reduce ADHD symptoms?</a>
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<h2>Too many prescriptions?</h2>
<p>ADHD is becoming increasingly recognised, with more people – <a href="https://www.deloitte.com/au/en/services/economics/perspectives/social-economic-costs-adhd-Australia.html">2–5% of adults</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26644606">5–10% of children</a> – being diagnosed. In Australia stimulants are highly regulated and mainly prescribed by specialists (paediatricians or psychiatrists), though this differs from state to state. As case loads grow for this lifelong diagnosis, there just aren’t enough specialists to fit everyone in. </p>
<p>In November, a Senate inquiry <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ADHD/Report">report</a> into ADHD assessment and support services highlighted the desperation experienced by people seeking treatment. </p>
<p>There have already been changes to the legislation in New South Wales that may lead to <a href="https://www.health.nsw.gov.au/pharmaceutical/doctors/Pages/prescribe-psychostimulant.aspx">more GPs being able to treat ADHD</a>. Further training could help GPs <a href="https://www.healthed.com.au/clinical_articles/will-gps-diagnose-and-treat-adhd-if-the-rules-change/">feel more confident</a> to manage ADHD. This could be in a <a href="https://www.racgp.org.au/gp-news/media-releases/2023-media-releases/june-2023/racgp-gps-should-play-greater-role-in-adhd-diagnos">shared-care arrangement</a> or independent management of ADHD by GPs like a model being piloted at <a href="https://www.nsw.gov.au/health/nbmlhd/service-directory/adhd-clinic-nepean">Nepean Blue Mountains Local Health District</a>, with GPs training within an ADHD clinic (where I am a specialist clinician). </p>
<p>Not every person with ADHD will need or want to take medication. However, it should be more easily available for those who could find it helpful.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gps-could-improve-access-to-adhd-treatment-but-we-still-need-specialists-to-diagnose-and-start-medication-210803">GPs could improve access to ADHD treatment. But we still need specialists to diagnose and start medication</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/218694/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Poulton is a director of the Australasian ADHD Professionals Association. She has previously taken part in an advisory panel and received personal fees and non-financial support from Takeda Pharmaceuticals, which manufactures ADHD medications including some mentioned in this article. She has received book royalties from Disruptive Publishing (ADHD Made Simple).</span></em></p>Most people stop taking ADHD medication within two years of starting it. The hope is that they’ve developed successful strategies to manage the condition in that time.Alison Poulton, Senior Lecturer, Brain Mind Centre Nepean, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2185662024-01-09T23:08:30Z2024-01-09T23:08:30ZHearing the voices of Indigenous people with neurodevelopmental disabilities<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/hearing-the-voices-of-indigenous-people-with-neurodevelopmental-disabilities" width="100%" height="400"></iframe>
<p>Indigenous Peoples with neurodevelopmental disabilities (NDDs) and mental health challenges are among the most marginalized groups in the country. NDDs include things like autism and attention-deficit/hyperactivity disorder (ADHD). </p>
<p>Research points to <a href="https://uwaterloo.ca/canadian-index-wellbeing/reports/canadian-index-wellbeing-national-report">persistent health inequities</a>, and <a href="https://doi.org/10.1016/j.socscimed.2017.01.021">mental health research</a> has tended to overemphasize suicide and substance use in Indigenous populations. </p>
<p>Although their stories also tell of strengths, struggles and important community contributions, the voices of Indigenous Peoples with NDDs often go unheard. </p>
<p>A report that includes immediate and long-term calls to action was developed to shed light on the experiences of this under-represented group and create meaningful change in their lives. </p>
<p>“<a href="https://brocku.ca/thomson-lab/wp-content/uploads/sites/209/Forming-the-Circle-Indigeneity-Neurodevelopmental-Disability-Mental-Health-Sept-2023-1.pdf">Forming the Circle: 2023 Gathering on Indigeneity, Neurodevelopmental Disabilities and Mental Health</a>” was informed by a community event held last spring that brought together Indigenous community members, Knowledge Keepers and Elders, service providers, researchers and non-Indigenous allies from across Canada. </p>
<p>The report was authored by researchers from Brock University (Kendra Thomson) and the Centre for Addiction and Mental Health - CAMH (Louis Busch) and reflects the findings from the event and recommendations for future actions. Attendees provided feedback on the report in focus groups after the event and before the report was released.</p>
<h2>The gathering</h2>
<p><a href="https://brocku.ca/thomson-lab/2023-gathering-on-indigeneity-neurodevelopmental-disabilities-and-mental-health-in-ontario/">The gathering</a> explored how colonization, systemic discrimination and determinants of health such as food insecurity, housing and access to cultural safe services impact individuals, families and communities. </p>
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<figcaption><span class="caption">At the 2023 Gathering on Indigeneity, Neurodevelopmental Disabilities and Mental Health at the Centre for Addiction and Mental Health in Toronto, people with lived experience, traditional Knowledge Keepers, clinicians and researchers from across Canada shared knowledge and expertise.</span></figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/as-an-indigenous-doctor-i-see-the-legacy-of-residential-schools-and-ongoing-racism-in-todays-health-care-162048">As an Indigenous doctor, I see the legacy of residential schools and ongoing racism in today's health care</a>
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</em>
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<p>Gathering attendees concluded that the path forward should begin with establishing a national network on Indigeneity, neurodevelopmental disabilities and mental health to take action that will enhance the health and well-being of Indigenous Peoples with NDDs and mental health challenges. </p>
<p>Some of the long-term recommendations within the report call for: </p>
<ul>
<li><p>The creation of programs to promote and preserve culture;</p></li>
<li><p>Partnerships between Indigenous and non-Indigenous organizations, with training provided to enhance the cultural safety of programs;</p></li>
<li><p>The development of culturally appropriate assessment tools and supportive programs for Indigenous Peoples with NDDs;</p></li>
<li><p>Examination of the experience of Indigenous Peoples with NDDs within the criminal justice system, youth populations, child welfare system and those impacted by environmental issues; and </p></li>
<li><p>Evaluation of the impact of incorporating traditional teachings and medicines within educational, social and health-related programs.</p></li>
</ul>
<h2>JJ’s story</h2>
<p>Among those in attendance was JJ Thunder Bear Man, an Anishinaabe man who travelled almost 2,000 kilometres from Dryden to Toronto to share his story at the gathering. </p>
<p>Born in the early 1980s in a community in northern Ontario, JJ was put into the foster-care system at age five as his parents faced the realities of their experiences at <a href="https://nctr.ca/education/teaching-resources/residential-school-history/">residential schools</a>. </p>
<p>Adolescence came with its own challenges, with JJ getting involved in a gang and struggling with addiction. His journey toward healing and recovery began when he joined Community Living in Dryden at the age of 18. His support team helped him to connect to his culture and to community.</p>
<p>The revelation of his spirit helper, the bear, and his spirit name, Thunder Bear Man, offered a powerful lens into JJ’s path to healing and connection to culture. </p>
<p>His heartfelt desire to reconnect with his family’s language, lost over time, also added a poignant layer to his story. He recalls having to ask his sister what his mother was saying when they finally got to visit years later, as she didn’t speak English, and he couldn’t speak Ojibwe. </p>
<p>JJ’s story, not unlike other young Indigenous Peoples living with NDDs and mental health challenges, highlights the <a href="https://afn.ca/community-services/languages/">dire need for preserving language and tradition</a>. </p>
<h2>Beautiful differences</h2>
<p>JJ’s story is one that contains experiences familiar to many Indigenous Peoples with neurodevelopmental differences and mental health challenges.</p>
<p>During the event, JJ issued a plea for kindness, understanding and companionship for neurodiverse individuals within Indigenous communities, reflecting on the impact acknowledgement and support can have. </p>
<p>The importance of a supportive “strength-based” approach was a theme that emerged again and again at the gathering, stressing the need to recognize individuals’ unique contributions, accomplishments and abilities. Many participants used the term “neurodevelopmental difference” rather than disability or disorder.</p>
<p>This report is intended to mark only the start of a broader discussion, new and strengthened relationships and a collective commitment across the country to take action to improve the lives of Indigenous Peoples with beautiful differences.</p>
<p><em>We would like to acknowledge JJ Thunder Bear Man for bravely sharing his moving story with us, and his helper, Lesley Barreira of Surrey Place, for supporting him in doing so.</em></p><img src="https://counter.theconversation.com/content/218566/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kendra Thomson receives funding from the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Louis Busch receives funding from the Social Sciences and Humanities Research Council (SSHRC).</span></em></p>Although their stories often tell of strengths, struggles and important community contributions, the voices of Indigenous people with neurodevelopmental disabilities often go unheard.Kendra Thomson, Associate Professor in the Department of Applied Disability Studies, Brock UniversityLouis Busch, Community Support Specialist, Shkaabe Makwa Centre for First Nations, Inuit, and Métis Wellness at CAMH, Doctoral Student, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2181402024-01-03T13:13:02Z2024-01-03T13:13:02ZSchool uniforms may trigger sensory overload in kids who are sensitive to fabrics – our research can help<figure><img src="https://images.theconversation.com/files/563331/original/file-20231204-29-a7dx3k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children who experience sensory overload struggle with many items of clothing, including school shirts.</span> <span class="attribution"><span class="source">macniak</span></span></figcaption></figure><p>Many people live with what’s known as <a href="https://www.sciencedirect.com/topics/psychology/overresponsiveness">sensory over-reactivity or over-responsiveness</a>. Those with this condition experience an over-reaction to sensory stimuli, such as touch. When overstimulated, the brain <a href="https://www.mdpi.com/2076-3425/9/7/153">triggers a fight-or-flight response</a>, which can lead to irritability, withdrawing from people, and temper tantrums.</p>
<p>Over time individuals can learn to manage this condition, but children often struggle. This can significantly affect their daily lives, from morning routines to school work and participation in sports. Although anyone can experience these challenges, they are particularly prevalent in children diagnosed with conditions such as attention-deficit/hyperactivity disorder (<a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1469-8749.2001.tb00228.x">ADHD</a>) and <a href="https://link.springer.com/article/10.1007/s10803-019-04180-0">autism spectrum disorders</a>. </p>
<p>Clothing plays a role in worsening these sensory issues because it remains in constant contact with the skin, providing sensory input. While it is acknowledged in research <a href="https://link.springer.com/article/10.1007/s10803-021-05140-3">literature</a> and by <a href="https://www.theottoolbox.com/clothing-sensitivity-red-flags/#:%7E:text=Clothing%20Sensory%20Issues,-Depending%20on%20preferences&text=Certain%20textures%20can%20feel%20uncomfortable,or%20hairy%20textures%20on%20sweaters">practitioners like occupational therapists</a> that items and elements like socks, shoes, seams and labels are major triggers, research in this area is limited. This is likely due to people underestimating the effects of these seemingly minor everyday elements.</p>
<p>It is important to study clothing items to pinpoint the triggers for sensory over-stimulation. These answers can assist in developing clothing that’s comfortable for every child. By combining the expertise of two distinct disciplines – clothing & textiles and occupational therapy – our multidisciplinary team has initiated a research project focused on exploring the diverse elements inherent in clothing and textiles and their relationship to sensory irritation.</p>
<h2>Our study</h2>
<p>The team’s <a href="https://journals.sagepub.com/doi/abs/10.1177/0887302X231187777">first study focused on school uniforms</a>. Occupational therapists, teachers and parents of children with sensory over-reactivity participated in four focus groups. These were virtual meetings, as we started collecting data during the COVID pandemic. </p>
<p>Sample packs of different seams and fabric swatches typically found in school uniforms were compiled and couriered to participants across South Africa to help prepare them for the discussions.</p>
<p>One of our findings was that the collar of a typical school shirt (a collar with a stand) causes irritation, especially if the top button is fastened and worn with a tie. The main reason for this is that they feel restricted and that the clothes are in very close contact with the skin. Parents also mentioned that children often preferred second-hand school uniforms, which they experienced as softer and more tolerable than new items. Pilling – balls of fluff that form on the surface of textiles – can be very intolerable. However, it can easily be removed with a bobble-off device; these are sold at most pharmacies. In all cases, among the participants, labels were removed or completely unpicked from garments.</p>
<p>Apart from providing rich data about clothing and textiles, the study revealed the effect of the clothing on the participation of a child in their daily activities (such as education). </p>
<p>One participant said of her child:</p>
<blockquote>
<p>When she was in class, with her uniform on, she was very distracted, because she constantly stood up and had to sort out her clothes and sit down again.</p>
</blockquote>
<p>It was also highlighted that children are often misunderstood or wrongly labelled as disobedient when, in reality, the issue could be as simple as <a href="http://hdl.handle.net/2263/90419">discomfort caused by the school uniform</a>. One parent said of their child: </p>
<blockquote>
<p>Teachers had tagged or labelled him as disruptive or, as the one teacher even wrote on the board, that this child is ill-mannered.</p>
</blockquote>
<p>Through our research it became apparent that this issue extended beyond the child to affect parents, caregivers and siblings. Many parents expressed feelings of guilt, fear and constant uncertainty. An everyday task, such as dressing their child in the morning, could badly disrupt family life.</p>
<h2>Simple interventions help</h2>
<p>The good news is that simple interventions can make a substantial, positive difference. Awareness of these realities should be highlighted and interventions should focus on improving outcomes not just for the child but for their entire family. </p>
<p>Teachers should be trained to manage sensory over-reactivity in the classroom. They should understand the importance of allowing exceptions in clothing rules for children who experience difficulties in tolerating existing uniforms.</p>
<p>School management should consider modifying school uniform policies to meet everyone’s needs. </p>
<p>Clothing retailers also have a crucial role to play by sensitising designers, developers and buyers to prioritise comfort. </p>
<p>More comfortable clothing would not disadvantage anyone – in fact it could benefit everyone.</p>
<h2>More to come</h2>
<p>Currently our research team is focusing on underwear and socks, since these are big culprits of sensory irritation. We are also conducting a separate analysis on the tactile properties of various textiles used in children’s wear. In future we would also like to look at sportswear and how clothing might affect participation.</p>
<p><em>The school uniform study was co-authored by Masters student Wenette Jordaan and Leoné Gouws, also a Masters student, is a co-author of the underwear study.</em></p><img src="https://counter.theconversation.com/content/218140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The work is based on the research supported wholly/ in part by the National Research Foundation of South Africa (Grant Number: 129842).</span></em></p><p class="fine-print"><em><span>Karin van Niekerk does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It is important to study clothing items to pinpoint the triggers for sensory over-stimulation.Lizette Diedericks, Lecturer, University of PretoriaKarin van Niekerk, Senior Lecturer in Occupational Therapy, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2174932024-01-02T20:38:27Z2024-01-02T20:38:27ZParenting with ADHD: 7 practical tips for success<figure><img src="https://images.theconversation.com/files/566382/original/file-20231218-29-ec0niw.jpg?ixlib=rb-1.1.0&rect=40%2C70%2C6669%2C4386&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Parents with ADHD may have challenges, but also strengths, particularly when their child also has ADHD. In these families, parents may have more empathy and tolerance for their child’s difficulties and may be able to play more effectively with their child.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/parenting-with-adhd-7-practical-tips-for-success" width="100%" height="400"></iframe>
<p>Attention-deficit/Hyperactivity Disorder (ADHD) often goes undiagnosed in adults — including parents — but it has a significant impact on family life.</p>
<p>A parent with ADHD may struggle with time management and staying focused. They may appear to be in control, but their daily life can be chaotic with missed appointments, trouble remembering and enforcing rules at home and a struggle to meet responsibilities. </p>
<p>When under stress, a parent with ADHD may be prone to moments of frustration and anger in response to minor provocations. This emotional struggle can lead to harsh responses to children, which parents often regret once the moment has passed.</p>
<h2>Understanding ADHD in adults</h2>
<p>ADHD involves patterns of inattention (forgetfulness, being easily distracted), hyperactivity (fidgeting, restlessness) and impulsivity (interrupting conversations or speaking out of turn). <a href="https://doi.org/10.1017/S0033291713002493">ADHD is highly heritable</a>, which mean parents with ADHD will often have a child with ADHD.</p>
<figure class="align-center ">
<img alt="A man, a woman and two children reading a book together" src="https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566385/original/file-20231218-19-776d0i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Parents’ ADHD symptoms do not appear to impact their ability to be warm, caring and loving parents.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>An estimated <a href="https://doi.org/10.1016/j.jad.2023.07.071">eight per cent of children worldwide have ADHD</a>, while only <a href="https://doi.org/10.7189%2Fjogh.11.04009">three per cent of adults meet criteria for ADHD</a>. One reason for this difference may be that symptoms of ADHD become milder as individuals age, <a href="https://doi.org/10.1007/s00787-018-1258-1">especially hyperactivity/impulsivity symptoms</a>.</p>
<p>While some individuals may no longer meet ADHD diagnostic criteria in adulthood, they can still experience significant life impairments. These include <a href="https://doi.org/10.1192/bjp.2018.97">poorer physical health and socioeconomic outcomes compared to those with no history of ADHD</a>.</p>
<p>However, research has shown an increase <a href="https://doi.org/10.1001/jamanetworkopen.2019.14344">over the last decade in diagnosis of adult ADHD</a>, potentially due to <a href="https://doi.org/10.1093/ije/dyt261">increased awareness of ADHD</a> and/or availability of clinical assessments. Several anecdotal reports indicate that parents only realized their own ADHD symptoms when <a href="https://www.additudemag.com/adhd-parent-child-diagnosis-stories/">seeking help for their child</a>.</p>
<h2>ADHD’s impact on parenting</h2>
<p>ADHD’s tendency to be passed down in families has important implications because it can affect the way parents interact with their children. <a href="https://doi.org/10.1016/j.cpr.2017.05.003">Research</a> has found that ADHD symptoms in parents are associated with harsher parenting behaviours (like yelling at a child, overreactive and severe punishments) and more lax parenting practices (like inconsistent discipline or providing few or no boundaries). </p>
<p>This makes sense in light of the symptoms of ADHD, including difficulties with forgetfulness and impulsivity. <a href="https://doi.org/10.1007/s11920-019-1003-6">People with ADHD also often struggle with regulating intense emotions</a>. Together, these symptoms can make it more difficult for parents to remain calm and consistent when interacting with their child.</p>
<p>However, <a href="https://doi.org/10.1016/j.cpr.2017.05.003">research also</a> indicates that parents’ ADHD symptoms do not appear to impact their ability to be warm, caring, and loving. </p>
<p>Other research also suggests there is a “<a href="https://doi.org/10.1080/15374416.2016.1169538">similarity fit</a>” if a parent and child both have ADHD. In these families, parents with ADHD may also have more empathy and tolerance for their child’s difficulties and may be able to play more effectively with them because they can follow the pace of their child’s play.</p>
<h2>Practical strategies for parents with ADHD</h2>
<figure class="align-center ">
<img alt="A woman and child on a sofa in a therapist's office, with a therapist seen from behind" src="https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566384/original/file-20231218-15-hhu5h5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Seek professional support when needed for your own symptoms of ADHD.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Raising kids with ADHD can be challenging. Children with ADHD often benefit from specific strategies like setting clear rules and consistent boundaries, using a system that rewards appropriate behaviour, and spending lots of quality time together. These strategies <a href="https://doi.org/10.1521/adhd.2019.27.3.1">can be difficult to maintain for parents dealing with their own ADHD</a>.</p>
<p>Here are some practical strategies that may be helpful to parents who have ADHD, or believe they might have ADHD:</p>
<p><strong>1. Seek professional support when needed for your own symptoms of ADHD</strong> </p>
<p>If you suspect you have ADHD but have not been diagnosed, consult a health-care professional. Family doctors and psychiatrists can offer medication options, while psychologists can provide cognitive behavioural therapy, <a href="https://div12.org/treatment/cognitive-behavioral-therapy-for-adult-adhd/">a highly effective treatment for adult ADHD</a>.</p>
<p><strong>2. Seek out supports for specific parenting issues</strong></p>
<p>There are some free research-backed courses available online such as <a href="https://www.coursera.org/learn/everyday-parenting">this one</a>, and <a href="https://familyman.movember.com/en-au/">this one specifically designed for dads (though moms and other caregivers are welcome too!)</a>. </p>
<p>Another avenue of support is clinical psychologists or social workers who specialize in working with children and adolescents, and their parents. Look for someone who can provide <a href="https://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/inattention-and-hyperactivity-adhd/">behavioural parent training, which is an evidence-based treatment for child ADHD</a>. </p>
<p>It’s helpful to let the therapist know that you are also struggling with ADHD symptoms. There is <a href="https://doi.org/10.1521/adhd.2019.27.3.1">some evidence</a> that adjustments — including flexible pacing (for example, focusing only on one thing during a session, lots of repetition), extra practice and supportive group therapy — may be particularly helpful for parents with ADHD.</p>
<p><strong>3. Be gracious to yourself</strong> </p>
<p>ADHD involves certain areas of the brain, and remember, it’s highly heritable. If you have a child with ADHD, it’s not because of your parenting or anything you did. </p>
<p>Also, parenting is a hard job that’s made even harder when you are experiencing symptoms of ADHD and/or when your child has ADHD. It makes sense that things can feel out of control sometimes! You are allowed to experience negative emotions, and to ask for support from family and friends if you are able. </p>
<p>Working on developing effective coping techniques (either with or without professional help) may have the bonus effect of providing an opportunity for your child to observe and learn through your example.</p>
<p><strong>4. Use organizational aids to help manage your ADHD symptoms</strong></p>
<p>Instead of relying solely on memory, individuals with ADHD often find it effective to keep a calendar, planner, daily agenda or a to-do list. Creating an external record of tasks and appointments, even if you don’t check it constantly, can increase the chances of remembering these responsibilities. Research shows that, for individuals with high levels of ADHD symptoms, using these types of compensatory strategies was associated with <a href="https://doi.org/10.1007/s12402-016-0205-6">fewer negative parenting practices</a>.</p>
<p><strong>5. Think proactively about recurring situations</strong></p>
<figure class="align-center ">
<img alt="Cropped image of a pop-it toy in a child's hands, and two other toys in the background." src="https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566383/original/file-20231218-27-dorj7s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">If you notice your child always acts out when bored, you can prepare an activity bag to take with you in these situations.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>For difficult parenting situations that seem to happen again and again, it can be helpful to think back to see if there are common issues that can be addressed proactively. Think about specific problem behaviours you experience with your child, as well as their context (such as where you were, and what happened before and after). </p>
<p>This may help identify common triggers that you can modify proactively the next time you are in a similar situation (see <a href="https://depts.washington.edu/uwhatc/PDF/TF-%20CBT/pages/8%20Parent%20Management%20Training/Tracking%20Behavior%20-Detailed.pdf">this worksheet)</a>. As a simple example: if you notice your child always acts out when bored, you can prepare an activity bag to take with you in these situations.</p>
<p><strong>6. Consider how you think about your child</strong></p>
<p><a href="https://doi.org/10.1177/1087054716669590">Research</a> suggests that parents with ADHD tend to attribute more blame to children (for instance: “my child spilled the milk on purpose”) compared to parents without ADHD. These types of attributions <a href="http://dx.doi.org/10.1080/15374416.2016.1144191">can make a parent more prone to responding harshly</a>. </p>
<p>If you notice yourself having these kinds of thoughts, it might be helpful to pause and think through other possible reasons for your child’s behaviour (for example, they were too excited and spilled the milk by accident). </p>
<p>Research also suggests that <a href="http://dx.doi.org/10.1080/15374416.2016.1144191">it can be helpful to notice times when your child is behaving well, and give them credit for this behaviour</a>.</p>
<p><strong>7. Remember your strengths</strong></p>
<p><a href="https://doi.org/10.1016/j.cpr.2017.05.003">Adults with ADHD are fully capable of being warm, loving and highly engaged parents</a>. Positive parenting is <a href="https://doi.org/10.1111/cdev.13764">consistently linked with improved child mental health</a>, so it is worth focusing on building these more positive aspects of your relationship with your child. </p>
<p>By implementing effective strategies for managing ADHD, and seeking out resources when needed, parents with ADHD can create a positive and fulfilling family life, and be a strong supportive source for their children who may be struggling with similar issues.</p><img src="https://counter.theconversation.com/content/217493/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sheri Madigan receives funding from the Social Sciences and Humanities Research Council, the Canadian Institutes of Health Research, the Alberta Children's Hospital Foundation, an anonymous donor, and the Canada Research Chairs program.</span></em></p><p class="fine-print"><em><span>André Plamondon and Joanne Park do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Parenting with ADHD presents unique challenges but also strengths. By using strategies for managing ADHD, and seeking resources when needed, parents can create a positive and fulfilling family life.Joanne Park, Assistant Professor, Department of Psychology, Mount Royal UniversityAndré Plamondon, Full Professor, Faculty of Educational Sciences, Université LavalSheri Madigan, Professor, Canada Research Chair in Determinants of Child Development, Owerko Centre at the Alberta Children’s Hospital Research Institute, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2186922023-12-20T19:08:25Z2023-12-20T19:08:25ZDo kids grow out of ADHD as they get older?<figure><img src="https://images.theconversation.com/files/565110/original/file-20231212-27-bd7ibu.jpg?ixlib=rb-1.1.0&rect=7%2C15%2C5149%2C3394&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/depressed-upset-young-woman-feeling-hurt-1463204258">Shutterstock</a></span></figcaption></figure><p>Attention-deficit hyperactivity disorder (ADHD) is more often <a href="https://theconversation.com/how-can-you-support-kids-with-adhd-to-learn-parents-said-these-3-things-help-187012">diagnosed in children</a>. That might make you wonder if people grow out it as they reach adulthood. </p>
<p>ADHD is a neurodevelopmental disorder that involves difficulties focusing attention (for study or work) and/or sitting still or keeping impulsive actions in check. This means people with ADHD are different and the differences are there for life. But development is a dynamic process because people change, mature and develop their skills.</p>
<p>If people have ADHD, the way it affects them can change over time too.</p>
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Read more:
<a href="https://theconversation.com/is-it-anxiety-or-adhd-or-both-how-to-tell-the-difference-and-why-it-matters-205304">Is it anxiety or ADHD, or both? How to tell the difference and why it matters</a>
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<h2>When kids change, ADHD can be easier to spot</h2>
<p>As children’s skills develop, differences due to ADHD may become easier to spot. </p>
<p>So hyperactivity may not be noticed in a baby who waves their arms and legs around, but once the child develops new skills and starts to run and climb, the hyperactivity may be obvious. </p>
<p>As children develop their cognitive skills, like listening and understanding and learning to talk, they have to learn from other people. This requires the child’s attention. As a child progresses through school, the demands on their attention increase. </p>
<p>Finally a person has to function independently as an adult. This may involve a career, running a household and raising a family.</p>
<p>ADHD can’t be <a href="https://theconversation.com/you-might-have-heard-adhd-risks-being-over-diagnosed-heres-why-thats-not-the-case-208581">formally diagnosed</a> until it affects a person’s functioning. This will depend on the balance of their natural abilities and the demands of life. </p>
<p>So a bright child may not have to try very hard while learning to read and write. But as the child progresses through school, lapses in concentration, particularly if prolonged, may mean that important information is missed. </p>
<p>If this is happening a lot, the person may struggle to keep up, particularly if catch-up studying at home requires a “super-human” level of effort due to their difficulty with concentration. </p>
<p>Other children may struggle with the more fundamental learning or tasks and may be diagnosed earlier.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/Cyu6WfEM9TA/?img_index=1","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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<strong>
Read more:
<a href="https://theconversation.com/you-might-have-heard-adhd-risks-being-over-diagnosed-heres-why-thats-not-the-case-208581">You might have heard ADHD risks being over-diagnosed. Here's why that's not the case</a>
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<h2>Brain differences and checklists</h2>
<p>Studies of people with ADHD <a href="https://pubmed.ncbi.nlm.nih.gov/28219628/">show subtle differences</a> in the overall size of the brain and the sizes of some of the structures such as the nucleus accumbens, amygdala, caudate and hippocampus (which help <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6763812/#:%7E:text=As%20components%20of%20the%20limbic,coordinate%20emotional%20and%20cognitive%20behavior.">coordinate</a> emotion, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548359/#:%7E:text=Learning%20and%20Memory%3A%20Hippocampus%20is,of%20experiences%20from%20frontal%20lobe.">learning</a> and behaviour). </p>
<p>The brain also <a href="https://pubmed.ncbi.nlm.nih.gov/18024590/">matures more slowly</a>. These changes are so small they cannot be used for diagnosing ADHD. But they do demonstrate <a href="https://www.additudemag.com/current-research-on-adhd-breakdown-of-the-adhd-brain/">ADHD is real</a>.</p>
<p>So the key to diagnosing ADHD is in the answer to the question: is this person having difficulties in managing in life (functional impairment) due to their impulsiveness or difficulties with attention? </p>
<p>Generally, impairment is assessed based on <a href="https://pubmed.ncbi.nlm.nih.gov/33634278/">whether the person</a>: </p>
<ul>
<li>is considered capable of higher achievement; that is they could or should do better </li>
<li>behaves in a way that causes unreasonable stress or disruption in class or at work </li>
<li>behaves in a way that unreasonable stress or disruption in the family </li>
<li>behaves in a way that significantly affects peer relationships </li>
<li>is aware of having difficulties and has low self-esteem.</li>
</ul>
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<strong>
Read more:
<a href="https://theconversation.com/how-hormones-and-the-menstrual-cycle-can-affect-women-with-adhd-5-common-questions-210627">How hormones and the menstrual cycle can affect women with ADHD: 5 common questions</a>
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<h2>ADHD can appear differently over time</h2>
<p>A person’s ability to manage will change over time. The formal diagnosis of ADHD is dependent on meeting the required number of diagnostic criteria as well as showing functional impairment. </p>
<p>This may involve a <a href="https://www.cdc.gov/ncbddd/adhd/diagnosis.html">symptom checklist</a>. Globally, around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916320/">5% of children and 2.5% of adults</a> meet the <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t3/">full diagnostic criteria</a> for ADHD. </p>
<p>A person’s ADHD may only be diagnosable at particular stages of their life when the demands on their abilities are greatest, particularly at transitions such as moving into a new educational stage or starting a new job. </p>
<p>ADHD is most often diagnosed in primary school children, with <a href="https://pubmed.ncbi.nlm.nih.gov/25300816/">more boys diagnosed than girls</a>. </p>
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<a href="https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="girl hugs teddy while adults sits nearby with clipboard" src="https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/565108/original/file-20231212-23-grcikl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Checklists may not be the best way to diagnose ADHD over time.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/upset-african-american-girl-autism-hugging-1869024514">Shutterstock</a></span>
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<h2>So if ADHD is stable, why is it hard to consistently diagnose?</h2>
<p>As people mature they develop coping strategies, which can make their ADHD much less obvious. Some adults may not meet enough of the diagnostic criteria, because they have learned effective coping strategies. </p>
<p>For example, when asked whether they often lose things necessary for tasks or activities (such as keys, their glasses or phone) they may respond “No”. But this is because they always put their keys on the same hook as soon as they get home, and they keep their mobile phone or glasses on a lanyard around their neck. </p>
<p>Others might have learned to control some of their impulsive behaviour. But they may still show ADHD-related functional impairment.</p>
<p>ADHD used to be considered solely a condition of childhood and the diagnostic criteria are biased towards identifying hyperactive boys. The criteria are less applicable to adults and as a result, adults who were treated in childhood but <a href="https://pubmed.ncbi.nlm.nih.gov/16420712/">no longer meet the full diagnostic criteria</a> may be considered to have ADHD “in remission” even when they continue to experience ADHD-related difficulties.</p>
<p>The current diagnostic criteria are not sensitive enough to identify ADHD consistently. </p>
<p>In the future, instead of an over-reliance on symptom checklists for diagnosis, clinicians should seek to understand the person’s <a href="https://www.mdpi.com/1660-4601/20/6/5077">lived experience</a> of the way their attentional difference affects their daily functioning – and how it might change over the years as demands shift and successful strategies develop.</p><img src="https://counter.theconversation.com/content/218692/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Poulton is a board member of the Australasian ADHD Professionals Association. She has received personal fees and non-financial support from Shire/Takeda; and book royalties from Disruptive Publishing (ADHD Made Simple).</span></em></p>ADHD is a lifelong condition. But a person’s ability to cope – and the demands on their attention – can change over time.Alison Poulton, Senior Lecturer, Brain Mind Centre Nepean, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2189702023-12-11T15:50:03Z2023-12-11T15:50:03ZDopamine menus: the science behind the trend – and how it might help people with ADHD<figure><img src="https://images.theconversation.com/files/564871/original/file-20231211-29-qfmhks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The 'dopamine menu' concep was first popularised in 2020. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/level-mental-health-assessment-max-positive-2259611099">MMD Creative/ Shutterstock</a></span></figcaption></figure><p>Menus are usually something you’d expect to come across in a restaurant. But one <a href="https://www.instagram.com/p/CxrSkHoJI8j/">social media influencer</a> went viral recently for sharing a different kind of menu – a “dopamine menu” or dopamenu. </p>
<p>The dopamine menu concept comes from a 2020 YouTube video by Jessica McCabe (How to ADHD). In her video, she suggests that dopamine menus are a tool that people with attention deficit hyperactivity disorder (ADHD) can use when they find they need stimulation – but may be at a loss for what to do. Each person can design their menu based on what they like, dividing it into appetisers, mains, sides and desserts.</p>
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<p>Appetisers are activities that are quick to do and give immediate pleasure. Mains are activities that take longer to do, but are ultimately more rewarding. Sides can be paired with less enjoyable activities to make them more pleasurable. Desserts provide enjoyment, but should be taken in moderation. </p>
<p>The dopamine menu concept is based on the notion that people with ADHD have lower levels of dopamine (a neurotransmitter that plays a role in pleasure, learning and motivation) in their brains. As a result, they need more stimulation. </p>
<p>So, is there any scientific evidence to support the use of dopamine menus? Maybe – but to understand why, we must examine the brain reward pathway. </p>
<h2>Brain reward pathway</h2>
<p>The main pathway in the brain reward system is from the <a href="https://human-memory.net/ventral-tegmental-area-vta/">ventral tegmental area</a> (VTA) to the <a href="https://openbooks.lib.msu.edu/neuroscience/chapter/motivation-and-reward/">nucleus accumbens</a>, where dopamine is released. It’s hypothesised that evolutionary advantageous activities (such as sex, eating and socialising) cause activity in the VTA. This leads to an increase in dopamine levels in the accumbens, which makes us feel good.</p>
<p>Numerous activities can cause dopamine to be released – including many of those which are commonly included on dopamine menus, such as playing a board game or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085579/">solving a puzzle</a>, visiting with <a href="https://pubmed.ncbi.nlm.nih.gov/23850525/">friends or family</a>, playing an instrument or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC58814/">listening to a favourite song</a>, cooking, baking or <a href="https://www.sciencedaily.com/releases/2018/12/181227111420.htm">having a snack</a>, <a href="https://www.mdpi.com/2076-3425/11/7/829">exercising</a> and <a href="https://buffer.com/resources/novelty-and-the-brain-how-to-learn-more-and-improve-your-memory/">trying something new</a>. </p>
<p>But the amount of dopamine that’s released (and how sustained that release is) will depend on the activity. Some activities, such as <a href="https://pubmed.ncbi.nlm.nih.gov/7953756/#:%7E:text=The%20threshold%20for%20the%20increase%20in%20DA%2C%20DOPAC%2C,min%2C%20there%20was%20a%20further%20increase%20to%20180%25.">running</a>, can cause sustained low-level increases in dopamine for several hours. On the other hand, having a <a href="https://journals.physiology.org/doi/full/10.1152/ajpregu.00282.2003">sugary drink</a>, for example, leads to a high but only short-term increase in dopamine.</p>
<p>The frequency that we do certain activities in order to get bursts of dopamine can also work against us.</p>
<figure class="align-center ">
<img alt="A person drinks a glass of cola." src="https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564872/original/file-20231211-25-f1br5q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some activities only provide a short burst of dopamine.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-drinking-glass-cola-ice-619622795">nednapa/ Shutterstock</a></span>
</figcaption>
</figure>
<p>A good example of this can be found in rats, where we can measure dopamine levels directly in the accumbens. The first time a male rat meets with a female rat he gets a large burst of dopamine. But if you introduce another female rat shortly afterwards, it results in <a href="https://www.jneurosci.org/content/22/23/10477">less dopamine</a>. This phenomenon is called habituation or tolerance.</p>
<p>Similarly, illicit drugs (such as cocaine) that hijack the natural reward system can have large initial effects on dopamine. But rodent studies show that this effect is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3947316/">diminished</a> the more often you use the drug. <a href="https://pubmed.ncbi.nlm.nih.gov/9509494/">Tolerance</a> to cocaine is also seen in humans.</p>
<p>This tolerance to short-acting rewards usually causes us to do one of two things: we move quickly on to a different activity to get a reward, or we do much more of the same activity to achieve the initial effect again. </p>
<h2>Dopamine and ADHD</h2>
<p>One popular hypothesis for ADHD is that it’s caused by a <a href="https://pubmed.ncbi.nlm.nih.gov/15949990/">dysregulated dopamine</a> system. </p>
<p>Dopamine levels in the brain come from “tonic” and “phasic” <a href="https://pubmed.ncbi.nlm.nih.gov/17907872">dopamine release</a>. Tonic dopamine is the baseline level of dopamine that the resting dopamine neurons pump out. </p>
<p>But when something interesting happens to us or we do certain activities, we get a “phasic” (short, intense burst) of dopamine. This phasic release of dopamine is on top of the baseline tonic dopamine.</p>
<p>Dopamine levels in the brain are under a <a href="https://pubmed.ncbi.nlm.nih.gov/24463000/">negative feedback mechanism</a>, so when baseline levels are low, the phasic bursts tend to be higher. Conversely, when baseline levels are high (causing a lot of negative feedback) the phasic bursts are lower.</p>
<p>It’s hypothesised that people with ADHD have <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2F0033-295X.114.4.1047">low background</a> levels of dopamine. As a result, they continually seek the short-acting bursts of phasic dopamine, which are higher (and more rewarding) under these conditions. This is why drugs such as <a href="https://www.mayoclinicproceedings.org/article/S0025-6196(11)64618-1/fulltext">methylphenidate</a> (Ritalin), which increase background levels of dopamine, work well for people with ADHD. </p>
<p>Brain imaging studies that differentiate between tonic and phasic dopamine levels confirm that people with ADHD have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085579/#R25">low levels of tonic dopamine</a> at rest, and higher levels of phasic dopamine during a task that requires attention.</p>
<p>Taking the above information together, for someone with ADHD (who has reduced baseline dopamine), the best thing to include on a dopamine menu would be activities that provide sustained, low-level release of dopamine.</p>
<p>Examples of this might include <a href="https://www.thelist.com/598141/exercises-that-will-boost-your-dopamine-levels/">doing some exercise</a>, <a href="https://www.frontiersin.org/articles/10.3389/fnbeh.2010.00022/full#B33">socialising</a> or listening to <a href="https://www.bbc.co.uk/news/health-12135590">music</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/34764893/">Physical activity</a> may be particularly beneficial in improving ADHD symptoms.</p>
<p>Activities involving <a href="https://pubmed.ncbi.nlm.nih.gov/9439796/">novelty</a> or having a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259316/pdf/nihms-1586073.pdf">sweet treat</a> will do little to help people with ADHD as they only provide a short, sharp burst of dopamine – and we can quickly habituate to short-acting rewards. </p>
<p>Whether you have ADHD or not, engaging in healthy, long-acting pleasurable activities will invariably have a positive impact on health. So when it comes to dopamine menus, rather than having a three-course meal with sides and dessert, we suggest your menu should focus on healthy main courses that can give us a sustained boost in dopamine levels.</p><img src="https://counter.theconversation.com/content/218970/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Exercising and socialising with friends may be the best kinds of activities to put on your ‘dopamine menu’.Colin Davidson, Professor of Neuropharmacology, University of Central LancashireClaire Hutchinson, Professor of Experimental Psychology, University of the West of ScotlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2169192023-11-07T14:37:14Z2023-11-07T14:37:14ZADHD drug shortages are affecting patients in the UK – here’s why they’re happening<figure><img src="https://images.theconversation.com/files/558023/original/file-20231107-15-vsg3vz.jpg?ixlib=rb-1.1.0&rect=46%2C0%2C5184%2C3437&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's hoped shortages will be resolved soon.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacy-vial-empty-stock-bottles-background-76248451">DavidPinoPhotography/ Shutterstock</a></span></figcaption></figure><p>Millions of people in the UK who take drugs for attention deficit hyperactivity disorder (ADHD) are facing difficulties getting their prescriptions filled due to shortages. These shortages are currently affecting <a href="https://cpe.org.uk/our-news/national-patient-safety-alert-shortage-of-methylphenidate-prolonged-release-capsules-and-tablets-lisdexamfetamine-capsules-and-guanfacine-prolonged-release-tablets">four of the five types of medicine</a> licensed in the UK to treat ADHD. Certain products and dosages may be <a href="https://www.sps.nhs.uk/articles/prescribing-available-medicines-to-treat-adhd/">more affected than others</a>.</p>
<p>This <a href="https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2023/10/19/statement-on-shortage-of-adhd-medication">severe disruption in supply</a> is taking a toll on many peoples’ mental health and wellbeing and negatively affecting their daily life. Fortunately, it’s expected these shortages will be resolved <a href="https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103238">by the end of 2023</a>. </p>
<h2>What’s causing these shortages?</h2>
<p>The two major causes of the current shortages appear to be <a href="https://www.leedsandyorkpft.nhs.uk/news/articles/shortage-of-medicines-for-adhd/">manufacturing issues and an increase in global demand</a> for these products.</p>
<p>Prescriptions for ADHD medications continue to rise globally. Not only that, but a growing number of <a href="https://www.fiercepharma.com/pharma/adults-are-now-prime-market-for-adhd-drugs-u-s">adults</a> are now being diagnosed with ADHD – meaning that even more people are seeking access to ADHD drugs. </p>
<p>For example, between April and June 2023 about <a href="https://www.theguardian.com/society/2023/sep/29/doctors-in-england-told-not-to-start-new-patients-on-adhd-drugs-due-to-shortage">202,000 new people</a> in England received a prescription for these drugs. This is up from 103,000 in the same period in 2018 and 2019. </p>
<p>The <a href="https://edition.cnn.com/2023/03/30/health/adhd-stimulant-prescriptions-increasing/index.html">rise of online prescribing</a> for these medicines, which grew during the pandemic, has also led to a greater volume of patients accessing ADHD drugs – and continuing these treatments in the longer term. But, in the UK at least, private assessments of new patients can then <a href="https://www.pulsetoday.co.uk/news/clinical-areas/mental-health-and-addiction/concerns-raised-over-adhd-overdiagnosis-by-private-prescribers/">cause problems for NHS providers</a> in supplying medicines to meet the assessed need.</p>
<p>When certain prescriptions are in short supply, alternative drugs may be supplied to patients instead. But this can subsequently lead to a domino effect, creating additional shortages – as has been the case with <a href="https://www.newscientist.com/article/2400281-why-is-there-a-shortage-of-adhd-drugs-and-what-can-people-do/">less commonly used</a> ADHD medicines. </p>
<p>The UK isn’t the only place experiencing these shortages. In the US, the ADHD drug Adderall has been in short supply for the past year. <a href="https://www.additudemag.com/adhd-medication-shortage-adderall-vyvanse/#:%7E:text=ADHD%20Medication%20Shortage%20Trajectory&text=While%20the%20shortage%20was%20initially,caused%20the%20shortage%20to%20persist.">Multiple factors</a> have been linked to this shortage – including a manufacturing delays, increased demand, restrictions on what drugs pharmacists can supply and quota issues. </p>
<figure class="align-center ">
<img alt="A young woman looks stressed while working on her laptop." src="https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=472&fit=crop&dpr=1 754w, https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=472&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/558025/original/file-20231107-19-tcts9g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=472&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Being unable to access prescriptions could have a serious affect on many peoples’ daily lives.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/student-woman-finding-difficult-study-comprehend-1752225026">NDAB Creativity/ Shutterstock</a></span>
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<p>Quotas are government restrictions on the amount of controlled substances (with psychoactive effects) that manufacturers can use to make medicines. In the US, the quotas may be too low, manufacturing may not be optimised, or the right people may not be receiving the products, <a href="https://www.nbcnews.com/health/mental-health/adderall-shortage-adhd-medication-2023-rcna99019">causing shortages</a>.</p>
<p>Adderall shortages have subsequently led to shortages of Vynase, a substitution drug. There are now reports that people are also having <a href="https://www.additudemag.com/adhd-medication-shortage-adderall-vyvanse/">difficulty filling</a> other ADHD medications, such as Concerta and Focalin. </p>
<h2>Managing shortages</h2>
<p>For patients diagnosed with ADHD, these prescription drugs are important. They can help them concentrate better, be less impulsive, feel calmer and learn and practise new skills. Without them, it can jeopardise a patient’s ability to <a href="https://www.bbc.co.uk/news/newsbeat-67010493">perform within the workplace</a> or make it harder for children who rely on these to <a href="https://www.cbsnews.com/losangeles/news/adhd-medication-shortage-continues-causing-students-to-struggle/">help them in school</a>. Some patients report rationing their prescriptions to make them last longer or have <a href="https://www.bbc.co.uk/news/newsbeat-67010493">taken to stockpiling</a> them. </p>
<p>Patients who have been affected will have been notified by their normal pharmacy of any supply issues. If you <a href="https://www.cntw.nhs.uk/services/adult-adhd-service/shortage-of-medicines-for-attention-deficit-hyperactivity-disorderadhd-information-for-patients-families-and-carers/#:%7E:text=There%20is%20a%20worldwide%20shortage,until%20this%20problem%20is%20resolved.">have been affected</a>, you can try <a href="https://www.nhs.uk/service-search/pharmacy/find-a-pharmacy">contacting other pharmacies</a> to check their stock levels. You may also not receive your <a href="https://www.alderhey.nhs.uk/shortages-of-some-adhd-medications">usual amount of medication</a> as pharmacies attempt to share the supply equitably. This may mean you may not be able to fill more than six weeks at a time. </p>
<p>Changing medications or prescribed dosages can sometimes be a strategy to manage shortages so that patients can continue treatment. But if this happens, you’ll be given additional guidance from your pharmacist or doctor on how it affects you. </p>
<p>Not all products can be stopped immediately or changed (and not all alternatives are suitable for all patients). Some children may be advised to reduce their doses where safe to do so and <a href="https://www.nhsgrampian.org/service-hub/child-and-adolescent-mental-health-services-camhs/news/adhd-medication-shortage-13th-october-2023/">select specific times to take their medicines</a> – such as on school days – in order to make their current supply last longer. People should only make such changes in consultation with their pharmacist or doctor.</p>
<p>The government has stated that it is working with product manufacturers to address <a href="https://www.theyworkforyou.com/wrans/?id=2023-09-15.199794.h&s=Lisdexamfetamine+and+%28b%29+Bupropion+Hydrochloride.#g199794.q0">ADHD product supply continuity</a>. According to the Medicines and Healthcare Products Regulatory Agency, it’s expected the current supply disruption in the UK <a href="https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103238">will be resolved</a> between October and December 2023. </p>
<p>Until then, doctors have been asked <a href="https://www.bmj.com/content/382/bmj.p2250.full">not to put new patients on ADHD medicines</a>. Doctors may also prescribe patients <a href="https://www.sps.nhs.uk/articles/prescribing-available-medicines-to-treat-adhd/">alternative products</a> where appropriate. </p>
<p>In the US, the Drug Enforcement Administration has agreed to temporarily <a href="https://www.bloomberg.com/news/articles/2023-09-29/dea-loosens-adhd-drug-production-controls-amid-shortage?leadSource=uverify%20wall">increase quota levels</a> and increase production of ADHD drugs to help reduce supply issues. It’s unclear what specific actions government agencies are taking in the UK and Europe. However, the supply chains are global, so resolving the situation in the largest market (which is the US), should also help in smaller markets.</p>
<p>While we know some of the reasons for the current shortage, there’s still a lack of transparency about all of the reasons behind it – and of the scale of it. It’s also unclear if the shortages will be resolved by the end of 2023 as predicted. </p>
<p>What is clear is that there’s a higher demand for these products than there was previously. Given how many people rely on these medications to help them in their daily lives, it will be important for supply issues to be addressed promptly so they don’t happen in the future.</p><img src="https://counter.theconversation.com/content/216919/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An increase in global demand for ADHD drugs is one reason for ongoing shortages.Liz Breen, Director of the Digital Health Enterprise Zone (DHEZ), University of Bradford, Professor of Health Service Operations, University of BradfordJonathan Silcock, Associate Professor in Pharmacy Practice, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2157982023-11-07T01:10:01Z2023-11-07T01:10:01ZA Senate inquiry says Australia needs a national ADHD framework to improve diagnosis and reduce costs<p>Around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10363932/">800,00 Australians</a> live with attention-deficit hyperactivity disorder (ADHD). It is the <a href="https://www.aihw.gov.au/mental-health/topic-areas/mental-illness">most common mental health condition</a> in children aged four to 17, and around half of those with childhood ADHD continue to have significant difficulties as adults. </p>
<p>Without appropriate support, ADHD often has lifelong negative impacts on education and employment. The current cost of ADHD to Australia is estimated at <a href="https://journals.sagepub.com/doi/full/10.1177/1087054720961828">more than A$20 billion every year</a>. </p>
<p>Until recently, ADHD was very much under-recognised and under-treated in Australia. However, public awareness and acceptance of ADHD has led to a sharp increase in people seeking assessment and support and <a href="https://journals.sagepub.com/doi/full/10.1177/00048674221114782">receiving treatment</a>. This has highlighted the significant barriers faced by those trying to access services, and there are now <a href="https://www.abc.net.au/listen/programs/healthreport/adhd-health-report/102405098">long wait times</a>, rising costs and concerns about the quality of services on offer. </p>
<p>In response to these concerns, a Greens-chaired Senate inquiry looked at how people <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ADHD/Terms_of_Reference">access ADHD diagnosis</a> and get support afterwards, the international evidence base, as well as practitioner training and cost. Yesterday, after more than 700 submissions and evidence from 79 witnesses at three public hearings, the inquiry <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000138/toc_pdf/AssessmentandsupportservicesforpeoplewithADHD.pdf">delivered its findings</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/you-might-have-heard-adhd-risks-being-over-diagnosed-heres-why-thats-not-the-case-208581">You might have heard ADHD risks being over-diagnosed. Here's why that's not the case</a>
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<h2>Not just a mental health issue</h2>
<p>The report makes 15 recommendations, all of which should be welcomed by Australians with ADHD and those involved in supporting them. The committee emphasises that ADHD is not just a mental health issue but a public health concern.</p>
<p>The committee members agreed there is a need for a government-funded national framework for ADHD, developed in consultation with people with lived experience. They supported the broad implementation of the Australian ADHD Professionals Association’s <a href="https://adhdguideline.aadpa.com.au/">guideline</a> – an evidence-based roadmap for ADHD clinical practice, research and policy. </p>
<p>A national framework should include shared and collaborative models of care, the committee said. This would increase the range of healthcare professionals, particularly GPs and nurse practitioners, who can contribute to assessment and support services for people with ADHD. </p>
<p>They also found funding models should be reviewed to reduce the financial burden of ADHD highlighted by many of the <a href="https://twitter.com/MatildaBoseley/status/1706829927608406270">lived-experience submissions</a>.</p>
<p>The committee said Medicare and bulk-billing incentives should be considered to reduce out-of-pocket expenses for diagnosis and management for people on low incomes and families who have multiple members with ADHD. </p>
<p>On top of this, this inquiry recommended more telehealth and better access to care in rural, regional and remote areas. The government should “review the Pharmaceutical Benefits Scheme (PBS) to improve the safe and quality use of medications by people with ADHD”, the recommendations said.</p>
<p>While the committee clarified that National Disability Insurance Scheme (NDIS) supports can currently be accessed with ADHD as a “primary or secondary disability”, they highlighted people with ADHD find the process of making an NDIS application difficult. They recommended the NDIS improve the accessibility and quality of information around the eligibility of ADHD as a condition under NDIS.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="boy at desk doing homework" src="https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/557906/original/file-20231106-29-yrnh31.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The inquiry looked at the costs and access barriers for ADHD diagnosis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boy-89-years-writes-homework-home-453728290">Shutterstock</a></span>
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<strong>
Read more:
<a href="https://theconversation.com/gps-could-improve-access-to-adhd-treatment-but-we-still-need-specialists-to-diagnose-and-start-medication-210803">GPs could improve access to ADHD treatment. But we still need specialists to diagnose and start medication</a>
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<hr>
<h2>Learning from people with ADHD</h2>
<p>The focus on improving lived experience is particularly welcome. Trying to navigate pathways to care, even as an expert in ADHD, can be challenging and at times painful in my experience.</p>
<p>While public awareness of ADHD has improved greatly in recent years there are still those spreading misinformation and increasing the stigma of people living with ADHD. </p>
<p>The committee said the Australian government should implement a neurodiversity-affirming public health campaign. This could shift social attitudes and reduce the <a href="https://pubmed.ncbi.nlm.nih.gov/33769111/">stigma felt so acutely</a> by those with ADHD. </p>
<p>Also welcome is the committee’s recognition we have a long way to go in addressing the gender bias experienced by girls, women, and gender-diverse people with ADHD. Our understanding of ADHD in the context of First Nations and culturally and linguistically diverse communities was also acknowledged as lacking. The committee said this could lead to <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000138/toc_pdf/AssessmentandsupportservicesforpeoplewithADHD.pdf">misdiagnosis or inappropriate treatment</a>.</p>
<p>ADHD impacts on the whole of peoples’ lives. The committee recommended improving training across settings from workplaces to schools and universities and institutional settings including out-of-home care and correctional facilities – both places where people with ADHD are over-represented.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/adhd-medications-have-doubled-in-the-last-decade-but-other-treatments-can-help-too-191574">ADHD medications have doubled in the last decade – but other treatments can help too</a>
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<h2>A first step</h2>
<p>The committee <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/reportsen/RB000138/toc_pdf/AssessmentandsupportservicesforpeoplewithADHD.pdf">recommends</a> </p>
<blockquote>
<p>all levels of government consider investing in the implementation of the Australian ADHD Professionals Association’s Australian evidence-based clinical practice guideline for ADHD. </p>
</blockquote>
<p>Further investment will be needed to ensure the guideline is used properly to promote more holistic care with broader access to key supports. The committee’s final recommendations call for better funding for ADHD disability and advocacy organisations to provide advice and support helplines, legal aid, financial counselling and assistance. Finally, the committee recommends funds for further research to better understand the neurodevelopmental condition, how it affects brain function and the stigma it can carry. </p>
<p>The inquiry’s recommendations will now be tabled in federal parliament, with government to respond within three months. </p>
<p>Making this work is going to be a big job but one that will payback in increased productivity, educational outcomes and a better quality of life for all Australians living with ADHD. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-stimulants-actually-work-to-reduce-adhd-symptoms-215801">How do stimulants actually work to reduce ADHD symptoms?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/215798/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Coghill receives funding from the National Health and Medical Research Council and the Medical Research Futures Fund. He is the President of the Australian ADHD Professionals Association and a director of the European ADHD Guidelines Network both not for profit organizations working in the field of ADHD. He has received research funding and/or honoraria from Takeda, Medice, Novartis and Servier. </span></em></p>After more than 700 submissions and evidence from 79 witnesses at three public hearings, the senate inquiry into ADHD diagnosis and treatment barriers has delivered its findings.David Coghill, Financial Markets Foundation Chair of Developmental Mental Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2158012023-10-26T19:03:17Z2023-10-26T19:03:17ZHow do stimulants actually work to reduce ADHD symptoms?<figure><img src="https://images.theconversation.com/files/555465/original/file-20231024-19-97bd36.jpg?ixlib=rb-1.1.0&rect=100%2C63%2C5976%2C3981&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthy-liquid-beautiful-brunette-woman-drinking-1891473649">Shutterstock</a></span></figcaption></figure><p>Stimulants are <a href="https://adhdguideline.aadpa.com.au/">first-line drugs</a> for children and adults diagnosed with attention-deficit hyperactivity disorder (ADHD). But how do they actually work?</p>
<h2>First, let’s look at the brain</h2>
<p>ADHD is a neurodevelopmental condition, which means it affects how the brain functions. </p>
<p>Medical imaging indicates people with ADHD may have slight differences in their brain’s <a href="https://jamanetwork.com/journals/jama/article-abstract/195386">structure</a>, the way their brain regions work together to perform tasks, and how their brain’s chemical messengers, called neurotransmitters, pass on information. </p>
<p>These brain differences are associated with the symptoms of ADHD, including inattention, impulse control and problems with memory. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-might-have-heard-adhd-risks-being-over-diagnosed-heres-why-thats-not-the-case-208581">You might have heard ADHD risks being over-diagnosed. Here's why that's not the case</a>
</strong>
</em>
</p>
<hr>
<h2>What stimulants are prescribed in Australia?</h2>
<p>The three main stimulants prescribed for ADHD in Australia are dexamfetamine, methylphenidate (sold under the brand names Ritalin and Concerta) and lisdexamfetamine (sold as Vyvanse). </p>
<p>Dexamfetamine and methylphenidate have been around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666194/">since</a> the 1930s and 1940s respectively. Lisdexamfetamine is a newer stimulant that has been around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873712/">since</a> the late 2000s. </p>
<p>Dexamfetamine and lisdexamfetamine are amphetamines. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873712/">Lisdexamfetamine</a> is inactive when it’s taken and actually changes into active dexamfetamine in the red blood cells. This is what’s known as a “prodrug”. </p>
<h2>So how do they work for ADHD?</h2>
<p>Stimulant drugs are thought to alter the activity of key neuotransmitters, dopamine and noradrenaline, in the brain. These neurotransmitters help with attention and focus, among other things.</p>
<p>Stimulants increase the amount of dopamine and noradrenaline in the tiny gaps between neurons, known as synapses. They do this by predominantly blocking a transporter that then prevents their re-uptake back into the neuron that released them. </p>
<p>This means more dopamine and noradrenaline can bind to their respective receptors. This <a href="https://www.tga.gov.au/sites/default/files/auspar-lisdexamfetamine-dimesilate-180515-pi.pdf">helps</a> connected neurons in the brain talk to one another. </p>
<p>Amphetamines also increase the amount of dopamine the neuron releases into the synapse (the tiny gaps between neurons). And it stops the enzymes that break down dopamine. This results in an increase of dopamine in the synapse. </p>
<figure class="align-center ">
<img alt="Counsellor talks to teen" src="https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555472/original/file-20231024-25-fvkgqq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">ADHD medications can help people with the disorder to concentrate, remember things and complete tasks.</span>
<span class="attribution"><a class="source" href="http://shutterstock.com">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What effect do they have on ADHD symptoms?</h2>
<p>We still don’t fully understand the underlying brain mechanisms that change behaviour in people with ADHD. </p>
<p>But <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109107/">research shows</a> stimulants that modulate noradrenaline and dopamine can improve brain processes such as:</p>
<ul>
<li>attention</li>
<li>memory</li>
<li>decision-making</li>
<li>task completion</li>
<li>hyperactivity. </li>
</ul>
<p>They can also improve general behaviour, such as self-control, not talking over the top of others, and concentration. These behaviours are important for social interactions.</p>
<p>Stimulants <a href="https://pubmed.ncbi.nlm.nih.gov/15737659/">reduce ADHD symptoms</a> in about 70% to 80% of children and adults who take them.</p>
<p>Some people will notice their symptoms improve right away. Other times, these improvements will be more noticeable to parents, carers, teachers, colleagues and partners. </p>
<h2>Not everyone gets the same dose</h2>
<p>The optimal stimulant dose varies between individuals, with multiple dosage options available. </p>
<p>This enables a “start low, go slow” approach, where the stimulant can be gradually increased to the most effective dose for the individual. </p>
<figure class="align-center ">
<img alt="Therapist talks to boy with ADHD" src="https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/555470/original/file-20231024-19-3rs77r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Different people will need different doses and formulations.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-autism-boy-during-therapy-school-1914170926">Shutterstock</a></span>
</figcaption>
</figure>
<p>There are also different delivery options. </p>
<p>Dexamfetamine and methylphenidate are available in immediate-release preparations. As these have short half-lives (meaning they act quickly and wear off rapidly), they are often taken multiple times a day – usually in the morning, lunch and afternoon. </p>
<p>Methylphenidate is also <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-PI-03175-3&d=20231023172310101">available</a> in long-acting tablets (Concerta) and capsules (Ritalin LA). They are released into the body over the day. </p>
<p>Lisdexamfetamine is a long-acting drug and is not available in a short-acting formulation. </p>
<p>The long-acting stimulants are generally taken once in the morning. This avoids the need to take tablets during school or work hours (and the need to store a “controlled drug”, which has the potential for abuse, outside the home). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gps-could-improve-access-to-adhd-treatment-but-we-still-need-specialists-to-diagnose-and-start-medication-210803">GPs could improve access to ADHD treatment. But we still need specialists to diagnose and start medication</a>
</strong>
</em>
</p>
<hr>
<h2>What are the side effects?</h2>
<p>The most common side effects are sleep problems and decreased appetite. A <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012069.pub2/full">recent study</a> showed children and young people taking methylphenidate for ADHD were around 2.6 times more likely to have sleep problems and 15 times more likely to have a decreased appetite than those not taking methylphenidate. </p>
<p>Headache and abdominal pain are also relatively common.</p>
<h2>Can someone without ADHD take a stimulant to improve productivity?</h2>
<p>Stimulants are tightly controlled because of their potential for abuse. In Australia, only paediatricians, psychiatrists or neurologists (and GPs in special circumstances) can prescribe them. This follows a long assessment process.</p>
<p>As stimulants increase dopamine, they can cause euphoria and a heightened sense of wellbeing. They can also cause <a href="https://www.ncbi.nlm.nih.gov/books/NBK576548/#:%7E:text=The%20immediate%20psychological%20effects%20of,and%20may%20result%20in%20insomnia.">weight loss</a>. </p>
<p>A common myth about stimulant medicines is they can improve the concentration and productivity of people without ADHD. A <a href="https://www.science.org/doi/full/10.1126/sciadv.add4165">recent study shows</a> the opposite is true. </p>
<p>This study gave a group of 40 people online arithmetic tasks to complete across four sessions. At each of the sessions, participants were given either a placebo or a stimulant before completing the task. </p>
<p>The results showed that while stimulants did not impact getting the correct answer, it increased the number of moves and time to solve the problems compared to a placebo. This indicates a reduction in productivity. </p>
<p>However, the myth that stimulants improve study prevails. It’s likely that users feel different – after all, they are taking a medicine that speeds up messages between the brain and body. It may make them “feel” more alert and productive, even if they’re not.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/adhd-medications-have-doubled-in-the-last-decade-but-other-treatments-can-help-too-191574">ADHD medications have doubled in the last decade – but other treatments can help too</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/215801/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mary Bushell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stimulants are first-line drugs for attention-deficit hyperactivity disorder. But how do they actually work?Mary Bushell, Clinical Assistant Professor in Pharmacy, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2081022023-10-24T19:19:31Z2023-10-24T19:19:31ZWhy do people with hoarding disorder hoard, and how can we help?<figure><img src="https://images.theconversation.com/files/532818/original/file-20230620-21-5g5yq2.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5296%2C3673&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Hoarding disorder is an under-recognised serious mental illness that <a href="https://pubmed.ncbi.nlm.nih.gov/25909628/">worsens with age</a>. It affects <a href="https://pubmed.ncbi.nlm.nih.gov/31200169/">2.5% of the working-age population</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/27939851/">7% of older adults</a>. That’s about 715,000 Australians.</p>
<p>People who hoard and their families often feel ashamed and don’t get the support they need. Clutter can make it hard to do things most of us take for granted, such as eating at the table or sleeping in bed. </p>
<p>In the gravest cases, homes are completely unsanitary, either because it has become impossible to clean or because the person <a href="https://pubmed.ncbi.nlm.nih.gov/23482436/">saves garbage</a>. The <a href="https://pubmed.ncbi.nlm.nih.gov/18275935/">strain on the family</a> can be extreme – couples get divorced, and children grow up feeling unloved. </p>
<p>So why do people with hoarding disorder hoard? And how can we help?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532822/original/file-20230620-27-dakmks.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Research has shown genetic factors can play a role in hoarding.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/obsessive-compulsive-disorder-is-more-common-than-you-think-but-it-can-take-9-years-for-an-ocd-diagnosis-196651">Obsessive compulsive disorder is more common than you think. But it can take 9 years for an OCD diagnosis</a>
</strong>
</em>
</p>
<hr>
<h2>What causes hoarding disorder?</h2>
<p>Saving millions of objects, many worthless by objective standards, often makes little sense to those unfamiliar with the condition. </p>
<p>However, most of us<a href="https://www.sciencedirect.com/science/article/pii/S2352250X21000282?via%3Dihub"> become attached to at least a few possessions</a>. Perhaps we love the way they look, or they trigger fond memories.</p>
<p>Hoarding involves this same type of object attachment, as well over-reliance on possessions and <a href="https://pubmed.ncbi.nlm.nih.gov/32402421/">difficulty being away from them</a>.</p>
<p>Research has shown genetic factors play a role but there is no one <a href="https://pubmed.ncbi.nlm.nih.gov/27445875/">single gene that causes hoarding disorder</a>. Instead, a range of psychological, neurobiological, and social factors can be at play.</p>
<p>Although some who hoard report being deprived of material things in childhood, emotional deprivation may play a <a href="https://pubmed.ncbi.nlm.nih.gov/20934847/">stronger role</a>. </p>
<p>People with hoarding problems often report excessively cold parenting, difficulty connecting with others, and more <a href="https://pubmed.ncbi.nlm.nih.gov/34717158/">traumatic experiences</a>.</p>
<p>They may end up believing people are unreliable and untrustworthy, and that it’s better to rely on objects for comfort and safety. </p>
<p>People with hoarding disorder are often as attached or perhaps <a href="https://akjournals.com/view/journals/2006/11/3/article-p941.xml">more attached to possessions</a> than to the people in their life. </p>
<p>Their experiences have taught them their self-identity is tangled up in what they own; that if they part with their possessions, they will lose themselves.</p>
<p>Research shows <a href="https://www.sciencedirect.com/science/article/pii/S0005789421000253?via%3Dihub">interpersonal problems</a>, such as loneliness, are linked to greater <a href="https://pubmed.ncbi.nlm.nih.gov/32853881/">attachment to objects</a>.</p>
<p>Hoarding disorder is also associated with high rates of <a href="https://pubmed.ncbi.nlm.nih.gov/34923357/">attention deficit and hyperactivity disorder</a>. Difficulties with <a href="https://pubmed.ncbi.nlm.nih.gov/30907337/">decision-making</a>, planning, <a href="https://akjournals.com/view/journals/2006/12/3/article-p827.xml">attention</a> and categorising can make it hard to organise and <a href="https://pubmed.ncbi.nlm.nih.gov/20542489/">discard possessions</a>. </p>
<p>The person ends up avoiding these tasks, which leads to unmanageable levels of clutter.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A room is filled wall-to-wall with electronic equipment and other items." src="https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554198/original/file-20231017-27-lby73s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some end up believing it’s better to rely on objects rather than people.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Not everyone takes the same path to hoarding</h2>
<p>Most people with hoarding disorder also have strong beliefs about their possessions. For example, they are more likely to see beauty or usefulness in things and believe objects possess <a href="https://link.springer.com/article/10.1023/A:1025428631552">human-like qualities</a> such as intentions, emotions, or free will.</p>
<p>Many also feel responsible for objects and for the environment. While others may not think twice about discarding broken or disposable things, people with hoarding disorder can <a href="https://pubmed.ncbi.nlm.nih.gov/30041077/">anguish over their fate</a>. </p>
<p>This need to control, rescue, and protect objects is often at odds with the beliefs of friends and family, which can lead to conflict and <a href="https://pubmed.ncbi.nlm.nih.gov/32853881/">social isolation</a>. </p>
<p>Not everyone with hoarding disorder describes the same pathway to overwhelming clutter. </p>
<p>Some report more cognitive difficulties while others may have experienced more emotional deprivation. So it’s important to take an individualised approach to treatment. </p>
<h2>How can we treat hoarding disorder?</h2>
<p>There is specialised cognitive-behavioural therapy (CBT) tailored for hoarding disorder. <a href="https://academic.oup.com/edited-volume/46862/chapter-abstract/413932715?redirectedFrom=fulltext">Different strategies</a> are used to address the different factors contributing to a person’s hoarding. </p>
<p>Cognitive-behavioural therapy can also help people understand and gradually challenge their beliefs about possessions. </p>
<p>They may begin to consider how to remember, connect, feel safe, or express their identity in ways other via inanimate objects.</p>
<p>Treatment can also help people learn the skills needed to organise, plan, and discard. </p>
<p>Regardless of their path to hoarding, most people with hoarding disorder will benefit from a degree of exposure therapy. </p>
<p>This helps people gradually learn to let go of possessions and resist acquiring more.</p>
<p>Exposure to triggering situations (such as visiting shopping centres, op-shops or mounds of clutter without collecting new items) can help people learn to tolerate their urges and distress.</p>
<p>Treatment can happen in an individual or group setting, and/or via <a href="https://pubmed.ncbi.nlm.nih.gov/35640322/">telehealth</a>.</p>
<p>Research is underway on ways to <a href="https://pubmed.ncbi.nlm.nih.gov/34409679/">improve</a> the <a href="https://www.sciencedirect.com/science/article/pii/S2666915322001421">treatment</a> options further through, for example, learning different emotional regulation strategies.</p>
<h2>Sometimes, a harm-avoidance approach is best</h2>
<p>Addressing the emotional and behavioural drivers of hoarding through cognitive behavioural therapy is crucial.</p>
<p>But hoarding is different to most other psychological disorders. Complex cases may require lots of different agencies to work together.</p>
<p>For example, health-care workers may work with fire and housing officers to ensure the person can <a href="https://pubmed.ncbi.nlm.nih.gov/31984612/">live safely at home</a>.</p>
<p>When people have severe hoarding problems but are reluctant to engage in treatment, a <a href="https://pubmed.ncbi.nlm.nih.gov/21360706/">harm-avoidance approach</a> may be best. This means working with the person with hoarding disorder to identify the most pressing safety hazards and come up with a practical plan to address them.</p>
<p>We must continue to improve our understanding and treatment of this complex disorder and address barriers to accessing help.</p>
<p>This will ultimately help reduce the devastating impact of hoarding disorder on individuals, their families, and the community.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-possessions-spark-joy-will-the-konmari-decluttering-method-work-for-me-110357">My possessions spark joy! Will the KonMari decluttering method work for me?</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/208102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jessica Grisham has received funding from the International Obsessive-Compulsive Disorder Foundation.</span></em></p><p class="fine-print"><em><span>Keong Yap receives funding from the International Obsessive-Compulsive Disorder Foundation. </span></em></p><p class="fine-print"><em><span>Melissa Norberg has received funding from the International Obsessive-Compulsive Disorder Foundation and the Psyche Foundation for her research on hoarding disorder. </span></em></p>Addressing the emotional and behavioural drivers of hoarding through therapy is crucial. But sometimes, a harm-avoidance approach is best.Jessica Grisham, Professor in Psychology, UNSW SydneyKeong Yap, Associate Professor of Psychology, Australian Catholic UniversityMelissa Norberg, Professor in Psychology, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2108032023-10-08T19:27:16Z2023-10-08T19:27:16ZGPs could improve access to ADHD treatment. But we still need specialists to diagnose and start medication<figure><img src="https://images.theconversation.com/files/547723/original/file-20230912-24-cj1yeb.jpg?ixlib=rb-1.1.0&rect=30%2C230%2C6650%2C4216&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-student-girl-sit-table-textbooks-2139744577">Shutterstock</a></span></figcaption></figure><p>Attention deficit-hyperactivity disorder (ADHD) is a neurodevelopmental condition that affects <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7880081/">2.5–5% of people</a>. Less than <a href="https://www.tandfonline.com/doi/full/10.1080/15374416.2017.1417860">half</a> of people with ADHD have been diagnosed and treated – though more and more people are <a href="https://www.abc.net.au/news/2023-09-08/impacts-of-lack-of-services-for-adult-adhd/102811864">presenting</a> for help. </p>
<p>Like other neurodevelopmental conditions, there are <a href="https://bmjopen.bmj.com/content/13/2/e069500">long delays</a> to diagnosis. The current pathways to diagnosis and care can <a href="https://theconversation.com/wondering-about-adhd-autism-and-your-childs-development-what-to-know-about-getting-a-neurodevelopmental-assessment-197528">involve multiple assessments</a> from different professionals who are in short supply, making the process confusing, expensive and time-consuming. </p>
<p>Yet many Australians have a GP on local clinic they can access. That’s why some medical groups are <a href="https://www.racgp.org.au/gp-news/media-releases/2023-media-releases/june-2023/racgp-gps-should-play-greater-role-in-adhd-diagnos">advocating</a> for GPs to have a role in the diagnosis and management of ADHD. </p>
<p>But while GPs should have an expanded role in the ongoing management of ADHD, it’s important for specialists to diagnose and initiate treatment.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/myths-and-stigma-about-adhd-contribute-to-poorer-mental-health-for-those-affected-161591">Myths and stigma about ADHD contribute to poorer mental health for those affected</a>
</strong>
</em>
</p>
<hr>
<h2>What is ADHD?</h2>
<p>ADHD is associated with inattention, or difficulty holding and sustaining concentration over periods of time, particularly on tasks that are less interesting or require significant mental effort. </p>
<p>It is also often associated with hyperactivity and high levels of impulsivity and arousal, and difficulty planning, coordinating and remaining engaged in tasks. </p>
<p>In order to meet criteria for ADHD, these difficulties must be present over a long period and have a negative impact on a person’s day-to-day life. This is why an ADHD assessment requires a clinical interview from specialists, and should never be done by questionnaires alone.</p>
<p>ADHD assessments are performed by psychiatrists, paediatricians and clinical and neuropsychologists with specialist training.</p>
<figure class="align-center ">
<img alt="Man helps young child with a puzzle" src="https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547964/original/file-20230913-27-eslwpf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">To meet the criteria, difficulties must impact on day to day life over a long period.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/autistic-boy-during-therapy-home-his-1914170725">Shutterstock</a></span>
</figcaption>
</figure>
<p>An ADHD assessment must be comprehensive enough that if a diagnosis is made, it can be followed up with a management plan that:</p>
<ul>
<li>addresses the person’s individual needs</li>
<li>is culturally appropriate for them and their circumstances</li>
<li>takes into consideration all of the issues identified. </li>
</ul>
<p>When a diagnosis of ADHD is made, medication is often part of the management plan. Stimulant medications are usually the first-choice medication. Psychological therapies may also be recommended. </p>
<h2>Treatment can ease some of the struggles</h2>
<p>ADHD increases the risk for poor academic, occupational, social and mental health outcomes, and has even been associated with <a href="https://pubmed.ncbi.nlm.nih.gov/33047627/">higher rates</a> of accidental injury and death. </p>
<p>However, these risks decrease when ADHD is <a href="https://pubmed.ncbi.nlm.nih.gov/19372500/">effectively treated</a>. One front-line treatment, stimulants, have about a <a href="https://pubmed.ncbi.nlm.nih.gov/8919704/">70% efficacy rate</a> for managing symptoms. Research shows stimulants can effectively <a href="https://pubmed.ncbi.nlm.nih.gov/8919704/">reduce</a> many of the adverse impacts of ADHD.</p>
<p>Stimulants have a good safety profile, with relatively <a href="https://pubmed.ncbi.nlm.nih.gov/31135892/">few serious side effects</a> in most children and <a href="https://pubmed.ncbi.nlm.nih.gov/33017854/">adults</a>.</p>
<p>However, stimulants can be very hard to access. States and territories have <a href="https://aadpa.com.au/adhd-stimulant-prescribing-regulations-in-australia-new-zealand/">different laws about stimulant prescribing</a>, and your prescription from one state may not be honoured in another. </p>
<h2>Why are medications difficult to access?</h2>
<p>Stimulants are tightly regulated because they have been assessed as having the potential for abuse. Prescribing or supplying them requires prior authorisation by the state authorities and must be in accordance with criteria set out by each state. </p>
<p>While GPs and nurse practitioners can apply for authorisation in some situations in some states, the legislation generally identifies specialists (paediatricians and psychiatrists for children and adolescents, and psychiatrists for adults) as the main prescribers. </p>
<p>Currently, there are too few specialists, in both rural and urban areas of Australia, to ensure access to ADHD medication. </p>
<p>As our recognition of ADHD increases, especially in adults, alternative approaches are needed, since this skills shortage is unlikely to resolve soon. </p>
<figure class="align-center ">
<img alt="Woman holds drink of water" src="https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547966/original/file-20230913-29-eslwpf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medication is often part of an ADHD management plan.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/clear-drinking-glass-1785881/">Pexels/Lisa Fotois</a></span>
</figcaption>
</figure>
<h2>So what role should GPs have in managing ADHD?</h2>
<p>We advocate for a “collaborative care” model, with GPs playing a greater role in managing patients’ ongoing ADHD care, including prescribing and monitoring medication. </p>
<p>However, it’s important for specialists to perform the initial diagnosis and identify the right treatment for the patient. Diagnosing ADHD can be complex – other <a href="https://theconversation.com/around-half-of-kids-getting-neurodevelopmental-assessment-show-signs-of-mental-distress-we-can-support-them-better-205225">psychiatric</a> and medical conditions may need to be ruled out. And it can <a href="https://pubmed.ncbi.nlm.nih.gov/35397064/">be difficult</a> to match patients with an appropriate treatment. </p>
<p>GPs are specialists in chronic disease management and already provide ongoing care for many chronic physical and mental health conditions. GPs are generally easier and cheaper to access than other specialists, know their patients well and are embedded in their communities. Models of collaborative care for ADHD are <a href="https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04290-7">already common</a> in many other countries including the United Kingdom and United States.</p>
<p>A collaborative care model would also allow specialists to spend more of their time on initial consults and the management of complex cases, rather than the ongoing management of less complex cases.</p>
<p>For collaborative care models to work, national programs will be required that can train and register GPs in ADHD management, to meet the needs of their patients with ADHD and, most importantly, improve patient outcomes. </p>
<p>Resources and support will be needed to ensure practitioners are <a href="https://ncbi.nlm.nih.gov/pmc/articles/PMC6452334/">supported</a> to deliver shared care for ADHD. If GPs don’t receive adequate support, fewer may be willing to provide this care. </p>
<p>Ultimately, the model could transform access to effective treatment for people with ADHD and their families. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-might-have-heard-adhd-risks-being-over-diagnosed-heres-why-thats-not-the-case-208581">You might have heard ADHD risks being over-diagnosed. Here's why that's not the case</a>
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</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/210803/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Guastella is scientific director of Neurodevelopment Australia and the Child Neurodevelopment and Mental Health team of the University of Sydney. </span></em></p><p class="fine-print"><em><span>David Coghill has consulted with Takeda, Medice, Novartis and Servier. They have received research funding from the NHMRC. They are the president of the Australian ADHD Professionals Association.</span></em></p>A limited number of specialists are able to diagnose and treat ADHD, making it difficult to even start the process of getting diagnosed. Should GPs play a greater role?Adam Guastella, Professor and Clinical Psychologist, Michael Crouch Chair in Child and Youth Mental Health, University of SydneyDavid Coghill, Financial Markets Foundation Chair of Developmental Mental Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2071442023-09-27T20:05:08Z2023-09-27T20:05:08ZGabor Maté claims trauma contributes to everything: from cancer to ADHD. But what does the evidence say?<p>Our health consumes a growing share of our economy and our attention, but we are not in great shape. Even as a ruinous pandemic subsides, epidemics of chronic disease, obesity, addiction and mental illness continue. Systems of care strain to cope and many of us engage in an anxious and often thankless quest for wellbeing.</p>
<p>In his latest book, <a href="https://www.penguin.com.au/books/the-myth-of-normal-9781785042713">The Myth of Normal</a>, Gabor Maté offers a diagnosis for our health crisis. The problem, he suggests, is the burden of <a href="https://theconversation.com/more-than-half-of-australians-will-experience-trauma-most-before-they-turn-17-we-need-to-talk-about-it-159801">trauma</a> people endure and the toxic culture that creates and compounds it. He prescribes profound societal change, holistic healing practices and spiritual growth assisted by <a href="https://theconversation.com/psychedelic-medicine-is-on-its-way-but-its-not-doing-shrooms-with-your-shrink-heres-what-you-need-to-know-208568">psychedelics</a>.</p>
<p>Both diagnosis and prescription have proven to be controversial. Skeptics worry that Maté’s explanations for ill health oversimplify a complex and incompletely understood web of causes and that his solutions dart ahead of the scientific evidence, sometimes veering towards quackery.</p>
<p><a href="https://en.wikipedia.org/wiki/Gabor_Mat%C3%A9">Maté</a> is a Canadian physician who has become a global celebrity in wellness circles. He recently participated in a very public <a href="https://www.thestar.com/life/i-talked-to-prince-harry-about-trauma-and-therapy-here-s-what-he-got-right/article_56d7fe40-5927-52cf-986b-682b62b09e36.html">therapeutic dialogue with Prince Harry</a>, in which he conversationally “diagnosed” the prince with ADHD.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/XHL9iwyoaTw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Gabor Maté conversationally diagnosed Prince Harry with ADHD, based on reading his book.</span></figcaption>
</figure>
<p>The Budapest-born son of Holocaust survivors, Maté has profound personal experience of trauma and suffering. As an infant, his mother left him in the care of strangers for several weeks to save his life, and he believes the themes of abandonment, loss and rage have continued to play out in his adult life. </p>
<p>In previous books, Maté has explored addiction and <a href="https://theconversation.com/is-it-anxiety-or-adhd-or-both-how-to-tell-the-difference-and-why-it-matters-205304">attention deficit hyperactivity disorder (ADHD)</a>, both of which he has identified in himself, as well as the nature and cause of chronic disease. </p>
<p>Reverberating throughout his work are a few fundamental ideas: the centrality of trauma, the intimacy of the mind-body connection, and the culpability of capitalism and the materialistic and individualistic culture it breeds.</p>
<h2>The trauma explanation</h2>
<p>Maté’s 2018 book <a href="https://www.penguin.com.au/books/in-the-realm-of-hungry-ghosts-9781785042201">In the Realm of Hungry Ghosts</a> prosecutes the case that <a href="https://theconversation.com/a-mental-disorder-not-a-personal-failure-why-now-is-the-time-for-australia-to-rethink-addiction-151686">addictions</a> spring from the pain of unresolved trauma, rather than from brain disease or self-destructive choices. Maté combines a compassionate lack of judgement for addicts with fierce condemnation of a society that foments and criminalises substance use. </p>
<p>His subsequent work, <a href="https://www.penguin.com.au/books/scattered-minds-9781785042218">Scattered Minds</a>, argues ADHD is a way of coping with childhood trauma, rather than the <a href="https://www.additudemag.com/is-adhd-hereditary-yes-and-no/">highly heritable brain disorder</a> or <a href="https://theconversation.com/what-causes-adhd-and-can-it-be-cured-170179">form of neurodivergence</a> it is usually taken to be. (Maté has three children diagnosed with ADHD, as he is, but <a href="https://www.healthyplace.com/adhd/transcripts/alternative-thoughts-about-add-adhd">attributes this</a> to “emotional stresses” in their early environment, including his own parenting.) This unorthodox position, which dismisses the genetic contribution to the condition and sees it as linked to sensitivity to stress and anxiety, has been controversial.</p>
<p><a href="https://scribepublications.com.au/books-authors/books/when-the-body-says-no-9781925849646">When the Body Says No</a> argues that life stress plays a part in conditions as varied as cancer, multiple sclerosis and diabetes, whereas <a href="https://www.penguin.com.au/books/hold-on-to-your-kids-9781785042195">Hold on to Your Kids</a> makes an extended plea for more actively engaged and attuned parenting.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549976/original/file-20230925-29-l5awth.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>The Myth of Normal, written with his son Daniel, is a culmination of Maté’s prior work, drawing its threads together into a large and sometimes tangled skein of ideas. Its ambitions are grand. </p>
<p>Illness, he writes, is “a function or feature of how we live” in a time of deteriorating collective health. It is rooted in a society where “much of what passes for normal […] is neither healthy nor natural” and where conformity is “profoundly abnormal in regard to our Nature-given needs”. </p>
<p>To Maté, “normal” is a myth because our culture has skewed our sense of what is acceptable and accustomed us to damaging ways of living.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-psychiatry-shrinking-whats-considered-normal-142477">Is psychiatry shrinking what's considered normal?</a>
</strong>
</em>
</p>
<hr>
<h2>Trauma and ‘illness of all kinds’</h2>
<p>Fittingly, Maté opens the book with a discussion of trauma, his pivotal concept. He sees it as an experience of being emotionally wounded rather than an extreme event, as it is typically seen within mainstream psychiatry. </p>
<p>It encompasses relatively severe “big-T trauma” – responses to extraordinary events – but also “small-t trauma”, which includes more mundane experiences of stress and adversity or even of “good things not happening”. </p>
<p>In promoting this expansive, subjectivised definition, by which “someone without the marks of trauma would be an outlier in our society”, Maté follows current trends favouring a <a href="https://muse.jhu.edu/article/773952">broadened concept of trauma</a>. </p>
<p>This shift has been documented in <a href="https://sciendo.com/article/10.58734/plc-2023-0002">recent</a> <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Famp0000847">studies</a>, and although it arguably draws welcome attention to the prevalence of adversity, it also risks diluting the concept, trivialising the experiences of “big-T” trauma survivors and promoting a counterproductive sense of being permanently damaged by one’s past.</p>
<p>To Maté, trauma is a contributor to “illness of all kinds”, as well as causing personal fragmentation, disconnection from other people, shame, a loss of flexibility in how we behave and alienation from the present. How we cope with trauma forges our personality, which is therefore implicated in susceptibility to a wide range of medical conditions, through immune and inflammatory processes. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549977/original/file-20230925-19-chu55b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Maté believes trauma is a contributor to ‘illness of all kinds’.</span>
<span class="attribution"><span class="source">Michelle Leman/Pexels</span></span>
</figcaption>
</figure>
<p>Often, Maté argues, disease-prone people suppress and repress their emotions, and appear stoical, hyper-responsible and overly conscientious. These and other strong claims about links between personality and illness overstate the scientific evidence – which typically finds them to be small, absent or inconsistent with the hypothesis of excessive responsibility.</p>
<p>For example, very large studies have found no links between personality traits and suffering or dying from <a href="https://www.nature.com/articles/bjc201458">cancer</a>, and revealed a small association between <a href="https://psycnet.apa.org/record/2013-29655-001">diabetes</a> and low, rather than high, conscientiousness. The research literature on this topic is littered with <a href="https://www.sciencedirect.com/science/article/abs/pii/B9780128053003000116?via%3Dihub">debunked theories</a>, such as the supposed association between <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.300816">Type A personality</a> and heart disease.</p>
<p>Personality aside, Maté proposes that trauma and abuse histories underpin many autoimmune disorders – a case of <a href="https://www.healthdirect.gov.au/scleroderma">scleroderma</a> is ascribed to “inflamed emotions” – in a way that demonstrates the hyphen-dissolving unity of the “bodymind”. Disease, Maté believes, is a systemic imbalance of the whole person rather than something external that afflicts them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-body-keeps-the-score-how-a-bestselling-book-helps-us-understand-trauma-but-inflates-the-definition-of-it-184735">The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it</a>
</strong>
</em>
</p>
<hr>
<h2>Nature and nurture</h2>
<p>Maté traces a great deal of the trauma that ails us to our childhood. He amplifies the many obstacles to healthy child development: the effects of parental stress on the growing child <em>in utero</em>, medicalised birth, weakened communal ties, excessive screen time and corporate marketing to children. </p>
<p>In one instance of intra-Canadian sniping directed at <a href="https://theconversation.com/is-jordan-peterson-the-philosopher-of-the-fake-news-era-91308">Jordan Peterson</a>, his political mirror image, Maté disparages parenting advice that aims to socialise and shape desired behaviour. Instead, parents are counselled to express an innate parenting “instinct” whose call, he argues, is better heeded by First Nations people.</p>
<p>Maté’s commitment to the “nurture” side of <a href="https://theconversation.com/nature-v-nurture-score-one-all-3697">the nature-nurture binary</a> is accompanied by a dismissal of “the prevalent myth that genetic traits account for human behavior.” What a “genetic trait” might be, as distinct from a genetically influenced one – essentially <a href="https://www.nature.com/articles/ng.3285">all of them</a>, according to behavioural genetic research – is not clarified. </p>
<p>To Maté, any genetic influences that exist are typically conditional on environmental conditions (<a href="https://theconversation.com/explainer-what-is-epigenetics-13877">epigenetics</a>) and have been exaggerated by problematic science. </p>
<h2>‘Addiction is a kind of refugee story’</h2>
<p>Developmental processes underpin psychological problems. Addiction – understood expansively as any behaviour that brings relief or pleasure, causes lasting suffering to the self or others, and is difficult to stop – is ascribed to trauma. </p>
<blockquote>
<p>All addiction is a kind of refugee story: from intolerable feelings incurred through adversity and never processed, and into a state of temporary freedom, however illusory. </p>
</blockquote>
<p>Addiction – whether to heroin or <a href="https://theconversation.com/can-gaming-addiction-lead-to-depression-or-aggression-in-young-people-heres-what-the-evidence-says-168847">video games</a> – is a way of coping with pain and a lack of love, writes Maté. The addict attempts to reproduce feelings of warmth that should arise naturally if development had not blocked them. </p>
<p>Genes play no meaningful role in addiction, Maté advises. “No single addiction gene has ever been found – nor will ever be,” is a flatly false statement. Unless “addiction gene” is straw-manned as a gene that singlehandedly and invariably causes addiction, a requirement that would also be failed by every life experience, personality trait, brain chemical, or subjective feeling. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549978/original/file-20230925-27-gt7fhf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Addiction, whether to heroin or video games, is a way of coping with pain and a lack of love.</span>
<span class="attribution"><span class="source">Jaroslav Nymbursky/Pexels</span></span>
</figcaption>
</figure>
<p>Maté acknowledges genes may contribute to our susceptibility to addiction, but imagines that contribution to be causally irrelevant.</p>
<p>The same dogmatic and disingenuous rejection of genetic influence is repeated in the book’s exploration of mental illness, which it conceptualises as trauma-caused psychological injury. </p>
<p>Despite the identification of <a href="https://www.nature.com/articles/s41588-021-00857-4">64 genomic loci</a> associated with <a href="https://theconversation.com/explainer-what-is-bipolar-disorder-7502">bipolar disorder</a>, Maté finds the scientific evidence for a genetic contribution to it to be “nearly nonexistent” and he rejects twin studies, a staple of genetic research in psychiatry and far beyond, as fatally flawed.</p>
<p>Here, as elsewhere, Maté’s extreme position against genetic and brain disease explanations contains germs of truth. Biologically reductionist explanations deserve to be challenged, even if they are caricatures of how most mental health professionals understand or treat mental illness in practice. The role of trauma in mental ill health has indeed often been neglected in psychiatry. </p>
<p>But to neglect the role of genetic factors in mental illness is just as ideologically distorted and over-simplifying as neglecting the role of adversity. The truth here is frustratingly complex. Decades of research show that myriad life experiences and genetic variants combine in intricate ways to make some people more vulnerable to illness than others. </p>
<p>Genetic influences may be expressed only in specific environmental conditions, and apparent environmental influences – such as traumas – may themselves be <a href="https://journals.sagepub.com/doi/full/10.1177/1077559519888587">genetically influenced</a>, rather than being uncaused causes. <a href="https://acamh.onlinelibrary.wiley.com/doi/abs/10.1111/jcpp.12621">Recollections of childhood adversity</a> are themselves influenced and distorted by adult personality and emotional distress.</p>
<p>A more evenhanded evaluation of the scientific evidence would recognise this complexity, rather than wish it away out of a desire to highlight the undoubted importance of adverse life experiences.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treatment-for-drug-and-alcohol-misuse-should-involve-families-and-communities-197536">Treatment for drug and alcohol misuse should involve families and communities</a>
</strong>
</em>
</p>
<hr>
<h2>A toxic culture</h2>
<p>Maté’s analysis of the forces responsible for the excess of trauma in the world condemns several societal and cultural pathologies. A series of chapters in The Myth of Normal variously identify corporate malfeasance, poverty and inequality, racism and the patriarchy. </p>
<p>Women’s anger suppression and self-silencing, and the burdens of care they shoulder, are identified as sources of their high rates of anxiety, depression and a range of autoimmune diseases.</p>
<p>National leaders are dissected under a harsh surgical light. Stephen Harper, Justin Trudeau, Donald Trump and Hillary Clinton receive quick, trauma-centred psychobiographies. The take-home message is bracing, though it comes close to pantomime villainy. </p>
<blockquote>
<p>Those with the sorts of early coping mechanisms that prime them to deny reality, block out empathy, fear vulnerability, mute their own sense of right and wrong, and abjure looking at themselves too closely – will be elevated to power.</p>
</blockquote>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/mb5W9cMi6C8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The Myth of Normal identifies various problems with our culture, from corporate malfeasance to racism.</span></figcaption>
</figure>
<p>What is to be done about this mess? Maté advocates an ongoing process of healing that has political and spiritual – as well as psychological – dimensions. We need to become more authentic, agency-seizing, (healthily) angry and accepting, and practice compassion. We must learn to say no, try not to be overly selfless, avoid self-blame and undo self-limiting beliefs. </p>
<p>Beyond this rather standard guidance on how to iron out our psychic wrinkles, Maté has some more radical advice. He promotes the use of psychedelics to get to the unconscious roots of our problems and to activate against “the global corporate capitalist system” to create a trauma-conscious society. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-doppelganger-naomi-klein-says-the-world-is-broken-conspiracy-theorists-get-the-facts-wrong-but-often-get-the-feelings-right-209990">In Doppelganger, Naomi Klein says the world is broken: conspiracy theorists 'get the facts wrong but often get the feelings right'</a>
</strong>
</em>
</p>
<hr>
<h2>Holistic health</h2>
<p>Maté’s vision is a rousing and almost prophetic one that has won him many dedicated followers. His work speaks to a widely held dissatisfaction with the state of contemporary society, health and politics, and offers some powerful correctives. </p>
<p>It’s true that the rise of biological psychiatry has led to a neglect of the role of the social environment and life adversity in mental illness. It’s also true that stigmatising views of substance users and the mentally ill are often grounded in moralistic beliefs about bad choices and fatalistic beliefs about brain disease. Maté’s trauma-focused approach rejects both.</p>
<p>There is a deep appetite for more holistic health care that recognises the emotional suffering in (primarily) physical illness and the embodiment of mental illness. Equally, many people hope for a kind of health and wellbeing that transforms them, rather than merely reduces their symptoms and helps them better tolerate intolerable life circumstances.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549979/original/file-20230925-25-4iz9b4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many people hope for a kind of health and wellbeing that transforms them, rather than merely reduces symptoms.</span>
<span class="attribution"><span class="source">RDNE Stock Project/Pexels</span></span>
</figcaption>
</figure>
<h2>Timely corrective or a step too far?</h2>
<p>Even so, The Myth of Normal has its own contradictions. It sometimes swings the corrective pendulum to snapping point. </p>
<p>There is something puzzling about a worldview that criticises <a href="https://theconversation.com/atlas-shrugged-ayn-rands-hero-burns-the-world-down-when-he-doesnt-get-his-way-her-fans-run-the-world-should-we-worry-192510">individualism</a> as a source of human misery but presents personal authenticity as the goal of healing, refers to each person’s “own unique and genuine essence”, and urges us to resist conforming to a sick society. This is just another, therapy-culture form of individualism.</p>
<p>Maté’s focus on trauma as the singular primary cause of ill health is also unbalanced. It’s every bit as reductive and oversimplifying as a single-barrelled genetic or neurobiological explanation. At times, it applies an evidential double standard. To be legitimate explanations, <a href="https://theconversation.com/blame-it-on-biology-how-explanations-of-mental-illness-influence-treatment-48578">biogenetic factors</a> must fully determine illness. But for trauma to count as the primary source of a problem, some measure of adversity must simply be associated with it.</p>
<p>There is now very solid evidence, for example, that the number of adverse experiences people encounter in childhood is associated with their risk of developing <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30118-4/fulltext">a wide range of illnesses and life problems</a>. This is a genuinely vital insight. </p>
<p>However, many of these associations are relatively modest (like obesity, diabetes, cancer, heart disease) and even the strongest (like problematic drug use, perpetration of violence) are far from perfect. Most people who live through the greatest levels of adversity do not become ill or impaired. And many whose early lives were entirely unruffled do. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=322&fit=crop&dpr=1 600w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=322&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=322&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=404&fit=crop&dpr=1 754w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=404&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/549980/original/file-20230925-19-9tk98s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=404&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There’s solid evidence childhood adversity is associated with risk of illnesses and life problems – but it’s complex.</span>
<span class="attribution"><span class="source">Aa Dil/Pexels</span></span>
</figcaption>
</figure>
<p>The influences of adversity and trauma on mental illness are real and crucially important, but they are not consistently stronger than other influences. Understandings of illness need to recognise this <a href="https://www.nature.com/articles/mp2011182">dappled complexity</a> rather than simplify it with overconfident claims.</p>
<p>Too often, Maté writes that some X “invariably” leads to some Y, or that in his clinical experience he has “yet to find an exception” to a pattern he has detected. In the slippery, probabilistic world of human psychology, claims to certainty are simply not credible. They should raise red flags.</p>
<p>Even if they find some questionable assertions in the book, many readers will also find inspiration. It is full of hope and laced with compelling stories of personal transformation and recovery, many drawn from interviews with public figures. Several chapters offer practical advice and exercises.</p>
<p>Readers will also find comfort and solace. The book teaches that we are not alone in our suffering, nor responsible for it. At root, our troubles are caused by what others have done to us and they implicate our selfless, overly obliging personalities. In Maté’s broad world view, individual distress is connected to a larger social justice narrative.</p>
<p>More skeptical readers, who find Maté’s good-individual-broken-by-bad-society framework too stark, will also benefit from reading The Myth of Normal. His voice is an influential example of the increasingly prominent nexus between progressive politics and mental health discourse. Its popularity is all the more reason to take it seriously.</p><img src="https://counter.theconversation.com/content/207144/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council. </span></em></p>Our health consumes a growing share of our economy and our attention, but we are not in great shape. Even as a ruinous pandemic subsides, epidemics of chronic disease, obesity, addiction and mental illness…Nick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2114172023-08-28T20:03:47Z2023-08-28T20:03:47ZTranscranial magnetic stimulation can treat depression. Developing research suggests it could also help autism, ADHD and OCD<p>Since the start of the COVID pandemic, there has been more attention given to problems of mental ill-health including depression <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01328-9/fulltext">than ever before</a>. A new therapeutic option, especially for depression, transcranial magnetic stimulation, is slowly helping to address some of these considerable unmet needs in our community. </p>
<p>Research is also exploring the use of transcranial magnetic stimulation in many other conditions, including obsessive compulsive disorder, autism, attention deficit hyperactivity disorder, chronic pain and perhaps to slow the progression of dementia symptoms.</p>
<p>What do we know so far about this emerging form of treatment? And is it living up to its promise for people with depression?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/treating-mental-illness-with-electricity-marries-old-ideas-with-modern-tech-and-understanding-of-the-brain-podcast-195071">Treating mental illness with electricity marries old ideas with modern tech and understanding of the brain – podcast</a>
</strong>
</em>
</p>
<hr>
<h2>How does it work and who’s getting it now?</h2>
<p><a href="https://theconversation.com/what-is-repetitive-transcranial-magnetic-stimulation-and-how-does-it-actually-work-160771">Transcranial magnetic stimulation</a> involves the application of a series of magnetic pulses through a coil placed on the scalp. While the patient sits in a chair awake and relaxed, the magnetic field activates nerve cells in the brain, gradually changing the activity of brain circuits disrupted in depression. This is thought to help restore the normal interaction between brain regions.</p>
<p>Side effects are <a href="https://www.mayoclinic.org/tests-procedures/transcranial-magnetic-stimulation/about/pac-20384625#:%7E:text=Serious%20side%20effects%20are%20rare,t%20well%2Dprotected%20during%20treatment.">usually mild</a> and temporary. They may include scalp discomfort, headache, tingling or facial twitching, and feeling lightheaded for a short time after a treatment session.</p>
<p>There is consistent evidence for the <a href="https://journals.sagepub.com/doi/10.1177/00048674211043047">effectiveness</a> of transcranial magnetic stimulation treatment for acute episodes of depression. Its use is supported by many clinical trials as well as real-world studies showing benefits in more than <a href="https://pubmed.ncbi.nlm.nih.gov/32799106/">50% of patients receiving treatment</a>. It attracted Medicare funding several years ago and is now being progressively rolled out around Australia. </p>
<p>But there are several remaining problems with the use of transcranial magnetic stimulation treatment. First, it involves a patient coming into the clinic daily, Monday to Friday, for four to six weeks. This is inefficient and costly. </p>
<p>Both these problems may ultimately be solved through the development of what are referred to as “accelerated” protocols – treatments that give higher doses on fewer days. A patient may have four or five days of high-dose treatment in one week rather than having all of the treatment dose spread out over a month or more. </p>
<p><a href="https://www.nature.com/articles/s41386-023-01599-z">Studies</a> both locally and overseas have started to show more efficient delivery and <a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.19070720">very rapid clinical benefits</a> with these new treatment regimes.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&rect=65%2C5%2C3928%2C1988&q=45&auto=format&w=1000&fit=clip"><img alt="man sits in lab setting with equipment on" src="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&rect=65%2C5%2C3928%2C1988&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543401/original/file-20230818-4259-mewpzs.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The lasting effects and need for maintenance doses of transcranial magnetic stimulation need further study.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-transcranial-magnetic-stimulation-tms-experiment-426901186">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What about for other conditions?</h2>
<p>Alongside the clinical rollout of transcranial magnetic stimulation for depression, research is increasingly demonstrating its potential value in other conditions. </p>
<p>A series of studies have demonstrated that a somewhat different type of transcranial magnetic stimulation, which is able to stimulate deeper regions of the brain but which still comes from a scalp based coil, can be effective in the treatment of symptoms in some patients with <a href="https://iocdf.org/about-ocd/ocd-treatment/tms/">obsessive compulsive disorder</a> (OCD). This is a critical development as many patients with OCD fail to improve with medication and psychological treatments and there are few new therapies in development for the condition. </p>
<p>Transcranial magnetic stimulation for OCD has been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8864803/#:%7E:text=Aside%20from%20MDD%2C%20the%20next,adults%20in%202017%20(DEN170078).">approved</a> for clinical use in the United States and is available in a limited number of clinical services in Australia.</p>
<p>The treatment is showing promise for <a href="https://www.mdpi.com/2077-0383/11/3/624">addiction disorders</a>, including the development of an approach using transcranial magnetic stimulation to <a href="https://www.sciencedirect.com/science/article/pii/S0165178123002901">help patients stop smoking</a>. The initial trial of this approach showed at least a doubling of the percentage of patients who did not smoke over the first six weeks. </p>
<p>Transcranial magnetic stimulation may also help people manage chronic pain. Multiple approaches that use the technology show promise and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0987705319301789?via%3Dihub">guidelines are emerging</a>, but a consistent clinical pathway has not yet been well defined.</p>
<p>A group of researchers across the country, led by <a href="https://tmsautism.com/">Professor Peter Enticott in Melbourne</a>, are conducting world-leading research trying to develop ways of using transcranial magnetic stimulation to help adolescent and adult patients with autism, especially to improve capacity for social understanding and interaction.</p>
<p>As clinical need escalates, early research is also exploring whether transcranial magnetic stimulation might alleviate symptoms of <a href="https://mecp.springeropen.com/articles/10.1186/s43045-022-00210-3">attention deficit hyperactivity disorder (ADHD)</a>. </p>
<p>Research has already demonstrated transcranial magnetic stimulation may improve, at least temporarily, thinking abilities in a range of disorders including <a href="https://www.frontiersin.org/articles/10.3389/fnagi.2022.984708/full">Alzheimer’s disease</a>. This is now being applied to see if it can improve attention for patients with ADHD. For now, this research remains in its infancy.</p>
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<h2>Do the effects last?</h2>
<p>So far, the quality of the <a href="https://doi.org/10.1016/j.jad.2021.09.040">evidence</a> on the persistence of effects and the need for maintenance treatment with the use of transcranial magnetic stimulation in depression is patchy. Research is looking at whether ongoing transcranial magnetic stimulation less often (for example one treatment every two weeks) may prevent the recurrence of depression in patients who have responded well. <a href="https://pubmed.ncbi.nlm.nih.gov/31399997/">Preliminary studies</a> suggest maintenance treatment is effective, but there there have been insufficient high-quality studies to convince Medicare to provide a subsidy for it. </p>
<p>Medicare funding also does not fund the provision of transcranial magnetic stimulation for patients who experience the return of their depression on more than one occasion.</p>
<p>This is highly unusual. Patients with depression can have multiple courses of antidepressant medication, psychotherapy or electroconvulsive therapy based on similar levels of evidence. This is also true of most other medical therapies. </p>
<p>In clinical practice, and from the <a href="https://doi.org/10.1016/j.jad.2020.06.067">limited evidence available</a>, it seems clear that if a patient has responded on one occasion to transcranial magnetic stimulation, they are likely to again. Until this is resolved, patients are in an unenviable situation. They know there is an effective treatment that has worked for them already, but they can only access it at considerable expense or via lengthy private hospital admission.</p><img src="https://counter.theconversation.com/content/211417/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Fitzgerald is a founder of TMS Clinics Australia / Monarch Mental Health Group which provides rTMS therapy through 21 clinics in three states of Australia. He has received grant funding from the NHMRC to support clinical trials into the use of rTMS. He was the author of several applications to the Medicare Services Advisory Committee seeking an item number for rTMS therapy for depression which led to the current approval.</span></em></p>What do we know so far about this promising form of treatment and how it might help people with a range of neurological conditions? And is it living up to its promise for people with depression?Paul B. Fitzgerald, Professor of Psychiatry, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2120972023-08-28T01:53:41Z2023-08-28T01:53:41Z20% of children have developmental delay. What does this mean for them, their families and the NDIS?<p>Professor Bruce Bonyhady is often described as the architect of the National Disability Insurance Scheme (NDIS) and is co-chair of the panel reviewing it. He <a href="https://www.ndisreview.gov.au/sites/default/files/2023-08/a-question-of-balance-speech.pdf">spoke last week</a> about the sustainability challenges faced by the scheme. </p>
<p>Among the key issues identified was that <a href="https://www.abc.net.au/news/2023-08-22/concerns-about-ndis-raised-by-co-chair-of-review/102758296">20% of Australian children</a> experience learning difficulties, developmental concerns, developmental delay or are found to have disability. Bonyhady <a href="https://www.ndisreview.gov.au/news/future-ndis-and-where-we-are-heading">said</a> this made it a “mainstream issue”. He added the NDIS was never designed to be the main support system for the majority of these children. </p>
<p>With the <a href="https://www.ndisreview.gov.au/resources/reports/what-we-have-heard-report">NDIS review</a> due to report to state and federal ministers in October, the comments signal a re-calibration of the scheme. </p>
<p>This presents another challenge: which government systems outside the NDIS will embrace the large number of children who need developmental support?</p>
<h2>What is a developmental delay?</h2>
<p><a href="https://raisingchildren.net.au/guides/a-z-health-reference/developmental-delay#:%7E:text=Developmental%20delay%20can%20show%20up,short%20term%20or%20long%20term.">Developmental delay</a> is a general term that refers to young children who are slower to develop communication, physical, social, emotional and cognitive skills than typically expected. The pace of a child’s development can be measured in many ways, one of which is comparing their development to established <a href="https://www.healthdirect.gov.au/developmental-milestones">milestones</a>, such as when they learn their first word or when they learn to walk.</p>
<p>Many things can cause developmental delay. These include biological differences (such as genetic conditions), environmental challenges (including deprivation) or a combination of both. In many cases, the causes of a child’s developmental delay remain unknown.</p>
<p>Developmental delay is a term commonly used in clinical practice, but not included in official diagnostic manuals like the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">Diagnostic and Statistical Manual</a>. This is because developmental delay is viewed as a temporary state in child development. It is most often used for children under five. </p>
<p>As children grow older, some developmentally catch up with their peers. Others continue to lag behind. At a certain point in development – typically around five - children in the latter group will start to be referred to as having a developmental disability. </p>
<p>Developmental disabilities are included in official diagnostic manuals and include autism, attention deficit hyperactivity disorder (ADHD), intellectual disability, specific learning disorders, communication disorders and developmental coordination disorder.</p>
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<h2>Developmental delay and the NDIS</h2>
<p>The NDIS has a <a href="https://www.ndis.gov.au/understanding/families-and-carers/early-childhood-approach-children-younger-9/developmental-delay-and-early-childhood-approach#how-an-early-childhood-partner-will-evidence-developmental-delay-for-children-younger-than-6">specific definition of developmental delay</a> which encompasses three areas. Children are considered to have a developmental delay if their delay is: </p>
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<li>due to mental or physical impairments</li>
<li>substantially reduces functional capacity</li>
<li>requires specialist services. </li>
</ul>
<p>Around <a href="https://www.ndis.gov.au/about-us/publications/quarterly-reports">11% of all NDIS participants</a> are classified as having a developmental delay. There are also a significant number of children with developmental delay who are not within the NDIS. Taken together, these groups make up about 20% of Australian children under five. </p>
<p>While there is a general community view that developmental delay is an increasing issue in Australia, there is a lack of data tracking over time to understand if this view is accurate.</p>
<p>Our clearest indication comes from <a href="https://www.aedc.gov.au/early-childhood/findings-from-the-aedc">Australian Early Development Census</a>, which surveys more than 300,0000 children entering primary school. </p>
<p>The latest available data indicate there are now slightly fewer children who are “developmentally on track” (down from 55.4% in 2018 to 54.8% in 2021) and an increase in the number of children who are “developmentally vulnerable” in any one area of development (up from 21.7% in 2018 to 22% in 2021). </p>
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Read more:
<a href="https://theconversation.com/a-decade-on-the-ndis-has-had-triumphs-challenges-and-controversies-where-to-from-here-208463">A decade on, the NDIS has had triumphs, challenges and controversies. Where to from here?</a>
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<h2>Supporting children with developmental delay</h2>
<p>There has always been a large number of children experiencing developmental delay. But the fragmentation across state/territory and Commonwealth health and disability systems has meant the true scale of children struggling with development has not been clear. The unified system of the NDIS has made the percentage of children with delays clearer.</p>
<p>But, as Bonyhady notes, the NDIS was not designed to support all these children. The NDIS was meant to complement existing systems such as health and education, and to provide additional support to children with the most significant disability impacts. This figure is estimated to be a small proportion of the 20% of children who meet criteria for developmental delay.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-early-intervention-for-infants-with-signs-of-autism-and-how-valuable-could-it-be-205839">What is 'early intervention' for infants with signs of autism? And how valuable could it be?</a>
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<h2>Meeting children and families where they are</h2>
<p>The NDIS is rightly <a href="https://www.ndisreview.gov.au/news/future-ndis-and-where-we-are-heading">described</a> as a policy miracle, and has benefited hundreds of thousands of Australians – with millions more to come. Its future thriving is highly dependent on how our community supports children with developmental delay. </p>
<p>The NDIS has accelerated a trend for the <a href="https://www.afr.com/policy/economy/children-undermining-the-sustainability-of-the-ndis-20230630-p5dkp7">medicalisation</a> of development supports. Children with developmental delays receive supports within clinics, rather than in the natural settings in which they live and function every day. </p>
<p>This has <a href="https://theconversation.com/more-children-than-ever-are-struggling-with-developmental-concerns-we-need-to-help-families-connect-and-thrive-209866">weakened major protective factors</a> known to support child development, such as community connection and parental empowerment.</p>
<p>Building capacity to support children with developmental delay in their everyday contexts – at home, in childcare, kindergartens or preschools, in the local community – will be crucial to ensuring children with developmental delay and their families thrive into later childhood. </p>
<p>And it will help the NDIS remain the life-changing system it is.</p>
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Read more:
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<img src="https://counter.theconversation.com/content/212097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Whitehouse is the Director of CliniKids, which is the community health arm of the Telethon Kids Institute. Children accessing CliniKids may be supported through the NDIS. Andrew receives research funding from NHMRC, ARC, the Autism CRC, and the Angela Wright Bennett Foundation</span></em></p>Developmental delay is viewed clinically as a temporary state where children are slower to develop than expected. It is most often used for children under five.Andrew Whitehouse, Bennett Chair of Autism, Telethon Kids Institute, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2106272023-08-16T20:04:57Z2023-08-16T20:04:57ZHow hormones and the menstrual cycle can affect women with ADHD: 5 common questions<figure><img src="https://images.theconversation.com/files/541399/original/file-20230807-4145-24ggu2.jpg?ixlib=rb-1.1.0&rect=35%2C0%2C5955%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/crop-pitiful-black-woman-embracing-knees-on-bed-5700205/">Pexels</a></span></figcaption></figure><p>Have you noticed that your levels of attention may slightly change during your menstrual cycle? </p>
<p>This may be particularly noticeable for women and people assigned female at birth with attention deficit hyperactivity disorder (ADHD). They have differences in their ability to easily focus and sustain their attention. There may be times during their menstrual cycle when it seems harder to plan, organise and focus their attention. And they may find their ADHD medication doesn’t seem to work as well. </p>
<p>Very little research has explored the interaction between <a href="https://link.springer.com/article/10.1007/s00737-021-01181-w">female hormones and symptoms of ADHD</a>. But women with ADHD could gain much from greater insights into the mechanisms of this effect. </p>
<p>Here are five questions women and girls commonly ask about their hormones and ADHD symptoms.</p>
<h2>1. Can hormones impact ADHD symptoms?</h2>
<p>There is growing awareness of the relationship between <a href="https://www.sciencedirect.com/science/article/abs/pii/B978044464123600014X#:%7E:text=In%20this%20connection%2C%20sex%20hormones,et%20al.%2C%202015">sex hormones and neurotransmitters</a>. Neurotransmitters pass messages between neurons in the brain. </p>
<p><a href="https://www.healthdirect.gov.au/dopamine">Dopamine</a> is a neurotransmitter important for motivation, reinforcement and reward. It’s a chemical that makes you feel good and has key roles for our executive functions, including attention. </p>
<p>For people with ADHD, the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2626918/#:%7E:text=People%20with%20ADHD%20have%20at,and%20the%20regulation%20of%20attention.">regulation of dopamine</a> is thought to differ. For example, it is thought there are lower levels of dopamine in the brain’s synapses (the connections between neurons) in people with ADHD. Our best current theory is that lowered synaptic dopamine <a href="https://link.springer.com/article/10.1007/s40474-019-00182-w">contributes to ADHD symptoms</a> and difficulties with focusing attention in a flexible way, maintaining attention and regulating activity levels.</p>
<p>Medications for ADHD, such as the <a href="https://www.health.nsw.gov.au/pharmaceutical/patients/Pages/faq-adhd-consumers.aspx#bookmark8">psychostimulant methylphenidate</a> (usually called Ritalin), help to make more dopamine available in the synapse. We think this is one of the reasons why symptoms of ADHD reduce and attention is improved with ADHD medication.</p>
<p>Sex hormones, including estrogen and progesterone, fluctuate naturally through different phases of a woman’s life. Fluctuations in sex hormone levels can affect brain function by altering levels of neurotransmitters, including dopamine and serotonin which is important for mood. </p>
<p>The relationship between sex hormones and neurotransmitter levels is complex. Animal studies have shown <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820286/">higher levels of estrogen</a> are linked to increased levels of dopamine. Progesterone also appears to influence dopamine levels, but the relationship between dopamine and progesterone is <a href="https://www.frontiersin.org/articles/10.3389/fnins.2017.00403/full">less clear</a>.</p>
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Read more:
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<h2>2. What happens to my attention over my menstrual cycle?</h2>
<p>Estrogen and progesterone levels fluctuate across the menstrual cycle. The <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/menstrual-cycle">key phases</a> of the menstrual cycle are the follicular phase (referring to the first days of menstruation until ovulation), and the luteal phase (the days between ovulation and the following the period). </p>
<p>Estrogen levels gradually rise during the follicular phase, fall after ovulation and rise again during the mid-luteal phase, before decreasing at the end of the cycle. Progesterone levels are low during the follicular phase and rise in the luteal phase. </p>
<p>Research exploring whether attention changes across the menstrual cycle is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7226433/">inconsistent</a>. </p>
<p>However, for women sensitive to menstrual cycle hormone fluctuations, the premenstrual or late luteal phase is associated with poorer attention, higher anxiety and stress, or at the more severe end of the mood spectrum, <a href="https://www.jeanhailes.org.au/health-a-z/periods/premenstrual-syndrome-pms">premenstrual dysphoric disorder</a> (a severe form of premenstrual syndrome). </p>
<p><a href="https://www.sciencedirect.com/science/article/abs/pii/S0028393201001269">Studies</a> show some attention-related tasks are performed better when there are higher levels of estrogen, such as before ovulation. Performance may be poorer when there are lower levels of estrogen and higher levels of <a href="https://www.sciencedirect.com/science/article/abs/pii/009130579090262G">progesterone</a>, such as in the couple of weeks after ovulation and before menstruation. This fits with what many women with ADHD report anecdotally: their attention is better before ovulation and can <a href="https://www.additudemag.com/pms-adhd-hormones-menstrual-cycle/">worsen after</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hand drawn chart of hormones levels over time" src="https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541409/original/file-20230807-23-az1tf8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Levels of hormones fluctuate with the menstrual cycle.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-view-hand-drawn-female-menstrual-2052064121">Shutterstock</a></span>
</figcaption>
</figure>
<h2>3. What if I’m on the contraceptive pill?</h2>
<p>There is little research on this for women with ADHD. Oral contraceptive pills do not appear to alter attention in the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0091302222000759#:%7E:text=The%20systematic%20review%20found%20that,auditory%20attention%20and%20psychomotor%20performance">general population</a>, but they can increase depression risk in <a href="https://theconversation.com/theres-convincing-evidence-the-pill-can-cause-depression-and-some-types-are-worse-than-others-184248">some women</a>. </p>
<p>For girls and women with ADHD, research suggests the risk of depression when using oral contraceptives is <a href="https://pubmed.ncbi.nlm.nih.gov/36332846/">even higher</a>. </p>
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<strong>
Read more:
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<h2>4. What will happen to my ADHD symptoms if I have a baby?</h2>
<p>Estrogen levels increase during pregnancy and drop after <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8385721/">birth</a>. These and other hormonal changes at this time have potential to impact <a href="https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2013.13050680">cognition and ADHD symptoms</a>. </p>
<p>However, there is a lack of research in pregnant women with ADHD, how ADHD symptoms might change and whether ADHD medications may need to be stopped or adjusted. </p>
<h2>5. What about when I’m perimenopausal or in menopause?</h2>
<p>The fluctuating and eventually declining levels of estrogen (specifically estradiol) during perimenopause are associated with “<a href="https://theconversation.com/brain-fog-during-menopause-is-real-it-can-disrupt-womens-work-and-spark-dementia-fears-173150">brain fog</a>” for many women. Symptoms often include difficulties with attention and higher order executive functions (such as planning, organising and decision making). </p>
<p>While studies have not specifically investigated ADHD symptoms during menopause, a recent study found four weeks of psychostimulant use improved mid-life onset executive-function difficulties in <a href="https://pubmed.ncbi.nlm.nih.gov/26063677/">perimenopausal and early post-menopausal women</a>. </p>
<p>Anecdotally women with ADHD report their ADHD symptoms can worsen during <a href="https://pubmed.ncbi.nlm.nih.gov/26914101/">perimenopause and menopause</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/brain-fog-during-menopause-is-real-it-can-disrupt-womens-work-and-spark-dementia-fears-173150">'Brain fog' during menopause is real – it can disrupt women's work and spark dementia fears</a>
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<h2>What needs to happen next</h2>
<p>Women and girls with ADHD have been neglected for too long. Learning more about how hormones impact ADHD symptoms in women and girls with ADHD is an urgent research need. </p>
<p>Such work could lead to clinical guidelines about altering medications for ADHD as hormones fluctuate, specific hormone treatments for girls and women with ADHD, and how women with ADHD can best be supported. For now, girls and women with ADHD should talk to their doctor (a general practitioner, psychiatrist, paediatrician or gynaecologist/obstetrician) about their individual circumstances and what support they may benefit from. </p>
<p>As researchers, we want to hear about your experiences. If you are interested in participating in a survey about how ADHD presents in women at different life phases, please follow <a href="https://redcap.helix.monash.edu/surveys/?s=X3J4CET7N9CD3AK4">this link</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/hot-flushes-night-sweats-brain-fog-heres-what-we-know-about-phytoestrogens-for-menopausal-symptoms-204801">Hot flushes, night sweats, brain fog? Here's what we know about phytoestrogens for menopausal symptoms</a>
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<img src="https://counter.theconversation.com/content/210627/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamara May works as a psychologist in private practice. </span></em></p><p class="fine-print"><em><span>Caroline Gurvich has received funding from the NHMRC, the Rebecca Cooper Foundation and Perpetuel Trustees.</span></em></p><p class="fine-print"><em><span>Mark Bellgrove receives funding from the NHMRC and MRFF. He is affiliated with The Australian ADHD Professionals Association. </span></em></p>Experts examine the five questions they commonly hear from women and girls about their hormones and ADHD symptoms.Tamara May, Psychologist and Research Associate in the Department of Paediatrics, Monash UniversityCaroline Gurvich, Associate Professor and Clinical Neuropsychologist, Monash UniversityMark Bellgrove, Professor in Cognitive Neuroscience, Director of Research, Turner Institute for Brain and Mental Health, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2102292023-08-15T12:35:07Z2023-08-15T12:35:07ZDaily report cards can decrease disruptions for children with ADHD<figure><img src="https://images.theconversation.com/files/542161/original/file-20230810-23-1fhmc8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Students with ADHD who get a daily report card had 4.5 fewer rule violations per 30-minute class than those without one, one study found.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/father-looking-very-happy-looking-at-his-daughters-royalty-free-image/1389796720">Hispanolistic/E+ Collection/Getty Images</a></span></figcaption></figure><p>As another school year approaches, some caregivers, students and teachers may be feeling something new needs to happen to promote success in the classroom. </p>
<p>Daily report cards can be a great starting point.</p>
<p>As a clinical psychologist who studies <a href="https://scholar.google.com/citations?user=BRXERkMAAAAJ&hl=en">how schools can help students with attention-deficit/hyperactivity disorder</a>, I know traditional report cards distributed three or four times per year don’t do enough to make a difference for children who are prone to outbursts or other challenging behaviors. </p>
<p>Studies <a href="https://doi.org/10.1177/0014402917706370">conducted by my team</a> <a href="https://doi.org/10.1177/1087054717734646">and others</a> support the idea that these students are better served by <a href="https://doi.org/10.1080/02796015.2010.12087748">daily report cards</a>. </p>
<h2>Track daily progress</h2>
<p>Daily report cards date back at least to the 1960s, when they were used in a study involving children attending a <a href="https://doi.org/10.1901/jaba.1970.3-223">special education summer school</a>. </p>
<p>Today they are commonly used for <a href="https://doi.org/10.1177/0014402917706370">children with ADHD</a> in both <a href="https://doi.org/10.1007/s12310-020-09375-w">general education</a> and <a href="https://doi.org/10.1080/02796015.2010.12087775">special education</a> classrooms. Daily report cards have also been used for <a href="https://files.eric.ed.gov/fulltext/ED607134.pdf">students with autism</a> without intellectual disability. And one study found that many teachers say they use <a href="https://doi.org/10.1177/10983007060080030601">versions of a daily report card</a> for brief periods to address behaviors across many different school situations.</p>
<p>A daily report card can be very <a href="https://ccf.fiu.edu/research/_assets/how_to_establish_a_school_drc.pdf">easy for teachers</a> to <a href="https://doi.org/10.1080/10474412.2013.785182">create and use</a>, either with <a href="https://mygoalpal.fiu.edu">an app</a> or by developing them on their own. First, the teacher along with others – who may include the parents, principal, school psychologist or counselor, and even the child if appropriate – should meet to establish goals. Goals should be positively phrased, such as: “Completed work within time given” or “Participated in class discussions without interruption.” </p>
<p>Once set up, the daily report card can take just 10 seconds to complete. The time savings are significant when one considers the alternatives typically used in schools, such as repeated redirection or reprimanding, or sending the student to the principal’s office to be monitored.</p>
<p>Daily report cards also work. </p>
<p>A 2010 study evaluated children with ADHD where half had a daily report card and half did not. Those with the daily report card had an average of <a href="https://doi.org/10.1080/02796015.2010.12087775">4.5 fewer rule violations</a> per 30-minute class than those without one. Extrapolating across a school day, that is 54 fewer daily rule violations on average, and over 10,000 per school year. </p>
<figure class="align-center ">
<img alt="Example of a daily report card used in schools" src="https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=464&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=464&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=464&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=583&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=583&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542048/original/file-20230810-25-k9dewx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=583&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An example of a daily report card.</span>
<span class="attribution"><span class="source">Florida International University Center for Children and Families</span></span>
</figcaption>
</figure>
<h2>Realistic goals</h2>
<p>For many children with challenging behaviors, it is important to set goals that can be easily reached – at least at first. </p>
<p>Over time, the goals can be made more challenging as the child experiences success – a <a href="https://www.routledge.com/Behavior-Modification-What-It-Is-and-How-To-Do-It/Martin-Pear/p/book/9780815366546">process called shaping</a>. For example, if a child interrupts a lesson by calling out about five times per class, the initial goal may be set at “Participates in lesson with no more than four interruptions.” </p>
<p>This would represent an improvement, and it would also ensure the goal was reachable. Once the child met the goal for three to five days in a row, the goal could be changed to “Participates in lesson with no more than three interruptions.”</p>
<h2>Positive parent-teacher communications</h2>
<p>Teachers tend to <a href="https://doi.org/10.1037/spq0000442">communicate with caregivers more frequently</a> when a child is experiencing difficulties in the classroom. But these communications often focus on <a href="https://www.additudemag.com/mean-teacher-comments-adhd-students/">negative behaviors</a>. As a result, they can <a href="https://doi.org/10.1080/00131911.2019.1666794">strain relationships</a> between the caregiver and the teacher. Other times, it may result in the caregiver’s avoiding communication with the school. </p>
<p>Daily report cards can result in more positive and solution-focused communication instead of reports focusing only on what went wrong and can therefore enhance caregiver-teacher communication.</p>
<h2>Motivating rewards</h2>
<p>Importantly, the daily report card should be linked to home-based privileges and rewards so that children are motivated to meet daily goals.</p>
<p>At the end of the day, the child brings their daily report card home and, based on their behavior at school that day, home privileges such as an allotment of screen time or a slightly later bedtime can be used as rewards.</p>
<p>Importantly, this is not a punishment program in which a child loses privileges if goals are not met. It also is not bribing the child by providing a reward before an appropriate behavior is completed. Rather, the child starts the day without home privileges and earns them based on positive school behavior. The daily report card tells the child exactly what goals need to be met to earn the motivating privileges. This small difference can be quite powerful for the child because it puts them in charge of how they earn access to things they like to do at home based on how they behaved at school that day.</p>
<p>Evidence suggests this home-based reward system is <a href="https://doi.org/10.1080/02796015.2010.12087775">one of the biggest factors</a> in whether the daily report card is successful. It also provides a new opportunity for the child and caregiver to have a positive discussion about school each day.</p>
<h2>Better than medication?</h2>
<p>There is also evidence that the daily report card is a <a href="https://doi.org/10.1080/15374416.2015.1055859">cost-effective approach</a> for children with ADHD as an <a href="https://doi.org/10.1080/15374416.2015.1105138">alternative to medication treatment</a>. </p>
<p>My colleagues and I conducted a study in which children with ADHD were randomly assigned to start the school year with either medication or a daily report card. The parents of those assigned the daily report cards took part in classes that taught them how to provide home rewards for it. At the end of the year, the students who started with the daily report card had half as many discipline referrals and 33% fewer disruptive behaviors observed in the classroom than the students receiving medication. The daily report card approach also <a href="https://doi.org/10.1080/15374416.2015.1055859">cost less than daily medication</a>. The students who started the school year with the daily report card had overall treatment costs of US$708 less than the students starting with medication.</p>
<p>Teachers and caregivers who want to learn more about daily reports cards can check out the <a href="https://ccf.fiu.edu/research/_assets/how_to_establish_a_school_drc.pdf">downloadable workbook</a> or <a href="https://mygoalpal.fiu.edu">free app</a> designed by my colleagues at Florida International University’s <a href="https://ccf.fiu.edu/">Center for Children and Families</a>. Both resources allow caregivers and teachers to set goals and track a student’s progress. Starting the school year with a daily report card should help the child achieve the positive days needed to get a good grade on their report card at the end of the grading period.</p><img src="https://counter.theconversation.com/content/210229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gregory Fabiano receives funding from the Department of Education and the National Institutes of Health to study positive behavioral supports like the Daily Report Card. Gregory Fabiano also receives royalties from Guilford Publications for a book written about Daily Report Cards.</span></em></p>Traditional report cards sent home every few months are fine for most students. But for kids with behavioral issues, a daily report card can be a better option.Gregory Fabiano, Professor of Psychology, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2060522023-08-04T12:30:20Z2023-08-04T12:30:20ZMore adults than ever have been seeking ADHD medications – an ADHD expert explains what could be driving the trend<figure><img src="https://images.theconversation.com/files/534656/original/file-20230628-23-d348x8.jpg?ixlib=rb-1.1.0&rect=101%2C0%2C5516%2C4211&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">During the height of the COVID-19 pandemic, social media was awash with promotions for ADHD as an explanation for people's overwhelmed state of mind.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/woman-suffers-from-obsessive-thoughts-royalty-free-illustration/1412359050?phrase=ADHD+adults&adppopup=true">useng/iStock via Getty Images Plus</a></span></figcaption></figure><p>As a woman in my 30s who was constantly typing “ADHD” into my computer, I had something interesting happen to me in 2021. I started receiving a wave of advertisements beckoning me to get online help for ADHD, or <a href="https://www.cdc.gov/ncbddd/adhd/facts.html#">attention-deficit/hyperactivity disorder</a>. One was a free, one-minute assessment to find out if I had the disorder, another an offer for a digital game that could help “rewire” my brain. Yet another ad asked me if I was “delivering” but still not moving up at work. </p>
<p>The reason the term ADHD litters my digital life is because I am a clinical psychologist who exclusively treats patients with ADHD. I’m also a <a href="https://psychiatry.uw.edu/profile/maggie-sibley/">psychiatric researcher</a> at the University of Washington School of Medicine who studies ADHD trends across the life span. </p>
<p>But these advertisements were a striking new trend.</p>
<p>The following year, in October 2022, the U.S. Food and Drug Administration announced a <a href="https://www.fda.gov/drugs/drug-safety-and-availability/fda-announces-shortage-adderall">nationwide shortage of mixed amphetamine salts</a>, a drug that is marketed as Adderall. The brand name Adderall and its generic counterparts have become one of the most <a href="https://theconversation.com/misuse-of-adderall-promotes-stigma-and-mistrust-for-patients-who-need-it-a-neuroscientist-explains-the-science-behind-the-controversial-adhd-drug-198223">common medication treatments for ADHD</a>. Over the next several months, additional ADHD medications joined Adderall on the list of prescription drugs in short supply. </p>
<p>As of August 2023, the U.S. is still experiencing a <a href="https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?">shortage of several ADHD medications</a>, with some not expected to be resolved for at least a few more months.</p>
<p>The shortage appears to have been triggered by a combination of <a href="https://www.npr.org/sections/health-shots/2023/02/18/1157832613/adderall-shortage-forces-some-patients-to-scramble-ration-or-go-without">high demand and access to key ingredients</a>. In recent months, millions of Americans have found themselves with no <a href="https://www.nytimes.com/2022/10/13/health/adderall-shortage-adhd.html">guarantee of access to their daily medications</a>. </p>
<p>In March 2023, the U.S. Centers for Disease Control and Prevention reported <a href="https://www.cdc.gov/mmwr/volumes/72/wr/mm7213a1.htm">an unprecedented spike in stimulant prescriptions</a> <a href="https://www.washingtonpost.com/business/2023/03/30/adhd-stimulants-adults/">between 2020 and 2021</a>. Perhaps most surprising was that the demographic showing the greatest increases in stimulant use – an increase of almost 20% in one year – were in women in their 20s and 30s.</p>
<p>The CDC’s findings, along with the stimulant shortage, <a href="https://doi.org/10.1177/10870547231164155">raise some interesting</a> – and still unanswered – questions about what factors are driving these trends.</p>
<p><iframe id="98fSQ" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/98fSQ/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>The challenge of diagnosing adult ADHD</h2>
<p>Despite the growth in awareness of ADHD over the past couple of decades, many people with ADHD, <a href="https://doi.org/10.1111/jcpp.13480">particularly women</a> and <a href="https://doi.org/10.1542/peds.2012-2390">people of color</a>, go undiagnosed in childhood. </p>
<p>But unlike depression or anxiety, ADHD is quite complicated to diagnose in adults. </p>
<p>Diagnosing ADHD in either kids or adults first involves establishing that ADHD-like traits, which <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618695/">exist on a continuum</a> and <a href="https://doi.org/10.1176/appi.ajp.2021.21010032">can fluctuate</a>, are severe and chronic enough to prevent a person from living a normal, healthy life.</p>
<p><a href="https://doi.org/10.1111/ijcp.13260">The average person has a couple of symptoms of ADHD</a>, so it can be hard to draw the line between ADHD-like tendencies – such as a tendency to lose keys, having a messy desk or often finding your mind wandering during a dull task – and a diagnosable medical disorder. There is no objective test to diagnose ADHD, so doctors typically conduct a structured patient interview, ask family members to fill out rating scales and review official records to come up with an actual diagnosis.</p>
<p>Diagnostic challenges can also arise for psychiatrists and other health care practitioners because ADHD shares features with many other conditions. In fact, difficulty concentrating is the <a href="https://doi.org/10.31234/osf.io/u56p2">second most common symptom</a> across all psychiatric disorders. </p>
<p>Further complicating things, ADHD is also a <a href="https://doi.org/10.1186/s12888-017-1463-3">risk factor for many of the conditions that it resembles</a>. For example, years of negative feedback may lead some adults with ADHD to develop secondary depression and anxiety. Zeroing in on the correct diagnosis requires a well-trained clinician who is able to take enough time to thoroughly gather necessary patient history.</p>
<h2>Stress of the COVID-19 pandemic</h2>
<p>Looking back, some clear factors have been at play, but it remains unclear the degree to which they are driving the spike in stimulant prescriptions.</p>
<p>In 2021, the U.S. was still deep in the acute phase of the COVID-19 pandemic. People were <a href="https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-effects-on-food-housing-and">still losing jobs</a>, facing financial strains and juggling work-from-home challenges such as having children at home doing online schooling. Many <a href="https://theconversation.com/losing-a-grandmother-can-have-long-lasting-mental-health-effects-for-kids-and-adolescents-a-new-study-finds-186106">families were losing loved ones</a>, and there was a huge sense of uncertainty over when normal life would return.</p>
<p>The demands of the pandemic took a toll on everyone, but research shows that <a href="https://doi.org/10.1177/15394492221076516">women may have been disproportionately affected</a>. This may have led to a greater proportion of adults seeking stimulant treatments to help them keep up with the demands of daily life.</p>
<p>In addition, without access to in-person recreational spaces, the pandemic increasingly drove many people to spending more time on digital media. </p>
<p>In 2021, a social justice movement focused on “neurodiversity” was gaining momentum online. <a href="https://my.clevelandclinic.org/health/symptoms/23154-neurodivergent#:">Neurodiversity is a nonmedical term</a> that refers to the wide diversity of brain processes that diverge from what has traditionally been considered “typical.” In this moment, #ADHD became the <a href="http://dx.doi.org/10.1136/bmjgh-2021-007648">seventh most popular health topic on TikTok</a>. Relatable anecdotes of missing keys, procrastination, romantic mishaps and secret signs of ADHD began to flood the internet. </p>
<p>But while the internet exploded with ADHD content, researchers in Canada began sorting #ADHD TikTok videos into categories based on their accuracy and helpfulness. They <a href="https://doi.org/10.1177/07067437221082854">reported something important</a>: A majority of #ADHD content was misleading. Only 21% of the posts provided useful and accurate information.</p>
<p>So, amid the growing online community of newly self-diagnosed people with ADHD, many probably did not actually have the condition. For some, <a href="https://doi.org/10.1007/s11920-020-01179-8">cybochondria</a> – or health-focused anxiety after online searching – may have been creeping in. Others may have mistaken ADHD for another condition, which is <a href="https://www.nytimes.com/2022/10/29/well/mind/tiktok-mental-illness-diagnosis.html">surprisingly easy to do</a>. Still others may have had mild attentional issues that do not rise to the severity of ADHD.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two blue and white Adderall capsules lie the in the foreground with a medicine bottle sitting behind them." src="https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/537552/original/file-20230714-25-rbv5ib.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Adderall and its generic counterparts have been in short supply in recent months.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/DrugShortagesExplainer/7383f39153cb40c884c42971b3176711/photo?Query=drug%20shortage&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=180&currentItemNo=1">AP Photo/Jenny Kane</a></span>
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<h2>What ADHD care looked like in 2021</h2>
<p>In 2021, the U.S. mental health system was overloaded. Most traditional ADHD providers such as psychiatrists, psychologists, mental health therapists and psychiatric nurse practitioners, had monthslong wait lists for new patients. People who were newly seeking help for ADHD found faster appointments with their primary care providers, who may or may not <a href="https://doi.org/10.1007/s00787-018-1256-3">be comfortable diagnosing and treating adult ADHD</a>. Since demand for ADHD care exceeded capacity, new options were needed to meet patient needs.</p>
<p>Around that time, <a href="https://time.com/6225361/telehealth-startups-cerebral-done-ahead/">online ADHD care startups</a> began to pop up, reaching prospective consumers with <a href="https://www.wsj.com/articles/telehealth-cerebral-done-ads-mental-health-adhd-11672161087">appealing digital ads</a> like the ones I received. </p>
<p>Compared with traditional care, the startup models were <a href="https://www.wsj.com/articles/cerebral-adderall-adhd-prescribe-11654705250">reportedly using cost-cutting methods</a>, such as favoring quick assessments and a low-cost workforce. The startups were also reported to be relying on a uniform care model that did not adequately personalize treatments, often prescribing stimulants over treatments that may have been better indicated.</p>
<p>Some of these companies are now <a href="https://www.wsj.com/articles/cerebral-receives-subpoena-from-federal-prosecutors-11651950307">under investigation</a> by <a href="https://www.businessinsider.com/dea-cerebral-questions-license-issues-2022-5">the federal government</a>.</p>
<p>Although they were controversial in the medical community, these models may also have reduced barriers to ADHD care for many people.</p>
<h2>The verdict is still out</h2>
<p>Until the CDC releases its 2022 and 2023 stimulant prescription data, researchers like me will not know whether the 2021 trends of increased prescribing to adults and high demand for ADHD medications will continue.</p>
<p>If the trends stabilize, it may mean that patients who have been unable to access care may finally be getting the help they need. </p>
<p>If ADHD prescribing returns to pre-pandemic levels, we may learn that a perfect storm of COVID-19-related factors caused a momentary blip in people seeking ADHD treatment. </p>
<p>What is clear is that the <a href="https://usafacts.org/articles/over-one-third-of-americans-live-in-areas-lacking-mental-health-professionals/#">current shortage of mental health care workers</a> who feel comfortable diagnosing and treating ADHD in adults will continue to affect the ability of new patients to get proper diagnostic evaluation for ADHD.</p><img src="https://counter.theconversation.com/content/206052/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In the past 12 months, Margaret Sibley has consulted with Supernus Pharmaceuticals, Tris Pharma, and Tieffenbacher Pharmaceuticals. She receives funding from the National Institute of Mental Health and the Institute of Education Sciences. She is a professional advisory board member for Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) and the secretary of the American Professional Society for ADHD and Related Disorders (APSARD). </span></em></p>The COVID-19 pandemic may have played a considerable role in the uptick of adults being treated for ADHD. But more data is needed to determine whether the trends will continue.Margaret Sibley, Professor of Psychiatry and Behavioral Sciences, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2085812023-06-28T20:03:33Z2023-06-28T20:03:33ZYou might have heard ADHD risks being over-diagnosed. Here’s why that’s not the case<figure><img src="https://images.theconversation.com/files/534246/original/file-20230627-27-6tmj9a.jpg?ixlib=rb-1.1.0&rect=36%2C9%2C5970%2C3998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-schoolboy-hard-work-classroom-sitting-310987667">Shutterstock</a></span></figcaption></figure><p>At the same time as it has attracted support and understanding, attention deficit hyperactivity disorder (ADHD) has invoked passionate debate in recent years. One hot topic is whether ADHD is being over-diagnosed.</p>
<p>This concern dovetails with <a href="https://www.racgp.org.au/gp-news/media-releases/2023-media-releases/june-2023/racgp-gps-should-play-greater-role-in-adhd-diagnos">calls from GPs</a> to be able to help provide wider access to diagnosis and for the condition to be <a href="https://theconversation.com/should-adhd-be-in-the-ndis-yes-but-eligibility-for-disability-supports-should-depend-on-the-person-not-their-diagnosis">added</a> to the National Disability Insurance Scheme (NDIS). </p>
<p>Public hearings for the Australian Senate’s <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ADHD">inquiry</a> into “consistent, timely and best practice assessment” of ADHD and support services begin today. </p>
<p>Reflecting on the unique features of ADHD, as well as how the idea of overdiagnosis came about, shows this misplaced concern should not distract us from helping people impacted by the condition.</p>
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Read more:
<a href="https://theconversation.com/wondering-about-adhd-autism-and-your-childs-development-what-to-know-about-getting-a-neurodevelopmental-assessment-197528">Wondering about ADHD, autism and your child’s development? What to know about getting a neurodevelopmental assessment</a>
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<h2>What is ADHD?</h2>
<p>ADHD is a neurodevelopmental condition that involves a person’s ability to regulate their behaviour, attention, and/or activity levels. Worldwide, around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916320/">5% of children and 2.5% of adults</a> meet the <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t3/">full diagnostic criteria</a> for ADHD. </p>
<p>Importantly, just having hyperactive, impulsive and inattentive symptoms is not sufficient to qualify for a diagnosis of ADHD. To meet current <a href="https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t3/">diagnostic criteria</a>, these symptoms must have a negative effect on a person’s “social, school, or work functioning”. </p>
<p>This makes ADHD (and other mental health conditions) different from most physical health problems like cancer, diabetes, or heart disease. You can have cancer without it affecting your family, work, or social life. Some people might have cancer but not show any symptoms and still be doing well. </p>
<p>But by definition, you can’t have ADHD without both showing its symptoms and feeling their impact.</p>
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<strong>
Read more:
<a href="https://theconversation.com/29-000-cancers-overdiagnosed-in-australia-in-a-single-year-127791">29,000 cancers overdiagnosed in Australia in a single year</a>
</strong>
</em>
</p>
<hr>
<h2>Overdiagnosis or misdiagnosis?</h2>
<p>Overdiagnosis is a concept <a href="https://academic.oup.com/jnci/article/102/9/605/894608">first developed in cancer</a> screening to highlight situations <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8819710/">where</a> “the diagnosis of disease that would never cause symptoms or death during a given patient’s lifetime”. This definition has since been employed in many other areas of medicine, as well as analyses of health systems. </p>
<p>When defined in this way, <a href="https://www.ncbi.nlm.nih.gov/books/NBK430655/">overdiagnosis is distinct</a> from the concept of misdiagnosis, which is where an incorrect diagnosis has been made. Misdiagnosis is when someone is diagnosed with a condition when they do not meet diagnostic criteria.</p>
<p>Overdiagnosis is something we should avoid. If a condition is not going to cause a person harm, we should not waste medical resources identifying it, or use invasive procedures to treat it. But when we reflect on the fact it’s impossible to have ADHD and not experience negative effects, we can see ADHD is not a condition that can be over-diagnosed in the way a disease such as cancer can.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-anxiety-or-adhd-or-both-how-to-tell-the-difference-and-why-it-matters-205304">Is it anxiety or ADHD, or both? How to tell the difference and why it matters</a>
</strong>
</em>
</p>
<hr>
<h2>Different definitions</h2>
<p>Of course, there are other ways we could define overdiagnosis, so that it could apply to ADHD. </p>
<p>One 2021 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042533/">article</a> on ADHD and overdiagnosis defined it as occurring when the “net effect of the diagnosis is unfavourable”. But the implications of this definition of overdiagnosis are difficult to unpack.</p>
<p>There are many reasons an ADHD diagnosis may be “unfavourable”, for some individuals. It could be a misdiagnosis. A person might not have access to any needed treatments and/or social supports. Some people experience negative side effects from ADHD treatments, or experience <a href="https://www.additudemag.com/overcoming-adhd-stigma/">stigma</a> as a result of ADHD diagnosis. </p>
<p>One finding sometimes quoted as <a href="https://www.huffpost.com/entry/conclusive-proof-adhd-is-overdiagnosed_b_10107214">evidence</a> for overdiagnosis of ADHD is that children who are youngest in their class are the ones most likely to be diagnosed.</p>
<p>But when you think about ADHD as not just having certain symptoms, but as having harmful outcomes, this might be expected. Trouble staying focused during class is more likely to be harmful if you are already behind your classmates – so harms are compounded. </p>
<p>In contrast to over-diagnosed physical diseases, it will still be important to identify such children, to reduce the negative impact of their inattentiveness. This need not involve medications but could involve environmental interventions – including perhaps repeating a year of school.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-adhd-coaching-and-do-i-really-need-it-191948">What is ADHD coaching and do I really need it?</a>
</strong>
</em>
</p>
<hr>
<h2>Not a medical condition</h2>
<p>Some concerns about ADHD overdiagnosis appear to be based on a belief ADHD <a href="https://www.institute4learning.com/2019/08/29/17-reasons-why-i-believe-adhd-is-not-a-legitimate-medical-disorder/">should not</a> be considered as a medical condition. From this perspective, the concerns would again be more accurately and transparently phrased in terms of misdiagnosis. </p>
<p>It is true some children who currently have an ADHD diagnosis might in fact be hyperactive, impulsive, or inattentive, but these traits may have neutral or positive effects on their lives. Again, this would not be an overdiagnosis, but an incorrect diagnosis. </p>
<p>Even in the United States where rates of ADHD diagnosis <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2778451">exceed 5%</a>, they still fall short of the <a href="https://ijponline.biomedcentral.com/articles/10.1186/s13052-023-01456-1#:%7E:text=According%20to%20the%20findings%2C%20the,teenagers%20aged%2012%20to%2018.">estimated epidemiological prevalence</a>. That means even though there have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/">significant increases</a> in the rates of diagnosis of ADHD over recent years, there are still many more children, adolescents and adults who likely meet the diagnostic criteria for ADHD. They may never have had these problems recognised, do not have a diagnosis and do not get any support.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1641305973016104960"}"></div></p>
<h2>Where to from here?</h2>
<p>So GPs and others – like <a href="https://acmhn.org/nurse-practitioner-sig/">Mental Health Nurse Practitioners</a> – may well play an important role in assessing and managing ADHD.</p>
<p>There would clearly need to be extensive training and support and also changes in the way assessments are funded. A good assessment takes time and at the moment funding preferences shorter appointments.</p>
<p>As things stand, we are a long way from “overdiagnosis”. In fact, we are still a long way from adequately supporting those who need it.</p><img src="https://counter.theconversation.com/content/208581/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Gyngell via his affiliation with the Murdoch Children's Research Institute received funding from the Victorian State Government via the Operational Infrastructure Support Program. He also receives funding from the Medical Research Future Fund</span></em></p><p class="fine-print"><em><span>David Coghill receives funding from The National Health & Medical Research Council and the Medical Research Future Fund. He consults to Takeda, Medice, Novartis & Servier. He is a board member and director of the Australian ADHD Professionals Association.</span></em></p><p class="fine-print"><em><span>Jonathan Payne does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Just having hyperactive, impulsive, and inattentive symptoms is not sufficient to qualify for a diagnosis of ADHD. Symptoms need to have a negative effect.Christopher Gyngell, Research Fellow in Biomedical Ethics, The University of MelbourneDavid Coghill, Financial Markets Foundation Chair of Developmental Mental Health, The University of MelbourneJonathan Payne, Principal research fellow, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2074012023-06-25T13:34:53Z2023-06-25T13:34:53ZMaking pride more inclusive means creating space for 2SLGBTQ+ people with disabilities<figure><img src="https://images.theconversation.com/files/532792/original/file-20230619-19-gs4r05.jpg?ixlib=rb-1.1.0&rect=27%2C0%2C4585%2C3070&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Volunteers carry a large rainbow flag during the 2019 Pride Parade in Toronto.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Lahodynskyj</span></span></figcaption></figure><p>Pride month is a celebratory time for many queer people. It is an opportunity for greater visibility in the public sphere. Although 2SLGBTQ+ people are becoming more accepted, those living with disabilities still struggle to be seen and heard.</p>
<p>Queer disabled people, particularly those with invisible disabilities like autism, attention deficit hyperactivity disorder or obsessive-compulsive disorder, are sometimes faced with the complex decision of whether or not to come out. That would often mean battling false stereotypes that <a href="https://www.bbc.com/news/stories-55586657">disabled and autistic people cannot be queer</a>.</p>
<p>Previous studies have shown how <a href="https://doi.org/10.5772/intechopen.95964">mainstream queer spaces can be inaccessible and not accepting of disabled people</a>. For instance, in <a href="https://doi.org/10.1080%2F15532739.2019.1594484">one study</a> from the United States, LGBTQ+ autistic people reported: </p>
<blockquote>
<p>feeling “othered,” discredited [and] tolerated rather than accepted.</p>
</blockquote>
<p>As a consequence, some disabled people choose to avoid disclosing their disability in queer spaces to avoid negative responses and rejection. At the same time, disabled communities can lack supports appropriate for 2SLGTBQ+ people and <a href="https://doi.org/10.3390/ijerph17218080">even present homophobic attitudes</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a wheelchair with people walking carrying placards." src="https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532793/original/file-20230619-36266-4a5amn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People with disabilities attending a Pride Parade in Santa Pola, Spain in July 2022. Mainstream queer spaces can be inaccessible and not accepting of disabled people.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Feeling like outsiders in their own communities</h2>
<p><a href="https://thesocietypages.org/ccf/2022/07/19/still-being-left-behind-the-intimate-lives-of-queer-disabled-people/">Through our research</a>, we have heard how 2SLGTBQ+ people with developmental and mental disabilities struggle to find space to explore their identities, meet intimate partners, find community and form a sense of belonging. However, despite these struggles, their desire for community was clear.</p>
<p>Some disabled people reported feeling like outsiders in queer spaces and communities. As a participant noted: “I didn’t really want to participate in queer spaces because I felt like an interloper. I felt like I did not belong.” </p>
<p>This feeling of exclusion is further accentuated by the fact that, as some of our participants highlighted, <a href="https://www.cbc.ca/radio/nowornever/accessibility-in-action-meet-people-fighting-for-access-to-a-full-life-1.6491088/i-m-queer-and-disabled-pride-isn-t-accessible-for-me-1.6497282">Pride events can be inaccessible to disabled people</a>.</p>
<p>Participants also spoke about wanting more representation of disabled and autistic people within queer spaces. One participant noted that most queer spaces “are very predominantly white and predominantly able-bodied, predominantly a certain beauty standard, and all those things…people with disabilities may or may not fit that criteria for the queer communities, especially as a romantic partner.”</p>
<p>People with disabilities can sometimes find queer spaces, like bars and dance clubs, inaccessible due to loud noises, lack of open spaces and strong scents. Connecting with the broader 2SLGBTQ+ community is challenging because <a href="http://dx.doi.org/10.13140/RG.2.2.16004.91528">2SLGBTQ+ events are not always welcoming to their needs</a>.</p>
<p>Such sentiments are echoed by other research. <a href="https://doi.org/10.1007/s10803-020-04696-w">In another study with autistic adults</a>, participants talked about how both the disabled and queer communities can sometimes ostracize autistic people rather than being “open-minded” and “accepting” spaces. </p>
<p>Having a community that supports and affirms your identities is important and <a href="https://doi.org/10.1093/heapro/dax016">good for mental health</a>. For those who are disabled and queer, being left out of 2SLGBTQ+ spaces means they do not receive the benefits of feeling like they belong. </p>
<p>More importantly, folks in the community remind us that real accessibility means more than building a ramp to access a building. Meaningfully inviting 2SLGTBQ+ people with disabilities involves non-disabled queer people doing their homework, making meaningful space and <a href="https://digitalcommons.wcl.american.edu/jgspl/vol28/iss3/2/?utm_source=digitalcommons.wcl.american.edu%2Fjgspl%2Fvol28%2Fiss3%2F2&utm_medium=PDF&utm_campaign=PDFCoverPages">addressing their own ableism</a>.</p>
<figure class="align-center ">
<img alt="A man in a wheelchair waves a rainbow flag while other people wave him on." src="https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&rect=27%2C32%2C3602%2C2383&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532772/original/file-20230619-23-89ut46.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man in a wheelchair at the Toronto Pride Parade in June 2019. LGBTQ+ people with disabilities can sometimes feel like outsiders in the community.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Making queer spaces more accessible</h2>
<p>Participants from <a href="https://doi.org/10.1007/s10803-020-04696-w">various</a> <a href="https://doi.org/10.1080%2F15532739.2019.1594484">studies</a> have shared suggestions for making queer spaces more accessible. This includes creating <a href="https://www.autismbc.ca/blog/intro-to-sensory-friendly/">sensory-friendly spaces</a>: for instance, offering noise-free areas, avoiding specific colours and patterns, reducing visual overload, relying on natural or dim lighting or creating opportunities for participation through online spaces.</p>
<p>Above all, <a href="https://www.cbc.ca/news/canada/saskatchewan/pride-2023-saskatchewan-accessibility-1.6860787">people want access to more spaces where disabled people can feel safe and included</a>. They do not wish to have to fight for the right to exist in queer spaces safely.<br>
2SLGBTQ+ spaces should inherently be where people can learn more about different identities and build communities, not spaces of exclusion. </p>
<p>There is a need for greater solidarity between queer, neurodiverse and disabled communities. More importantly, it is essential for queer communities to be proactive. Why wait until someone requests accommodations to take action? Instead, we should educate ourselves about disability, access and accessibility.</p>
<p>Disabled people should be meaningfully invited into queer spaces. It is crucial to have spaces and opportunities that are inclusive and celebratory for everyone. Such were the intentions of activists like <a href="https://www.them.us/story/brenda-howard">Brenda Howard</a> who paved the way for the Pride celebrations we have today. Intrinsically we are a community full of diversity, and that diversity is something to celebrate.</p><img src="https://counter.theconversation.com/content/207401/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alan Santinele Martino receives funding from the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Emily Coombs does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Queer disabled people struggle to be seen in queer spaces that often do not accommodate them.Alan Santinele Martino, Assistant Professor, Community Rehabilitation and Disability Studies, University of CalgaryEmily Coombs, Master's student, Werklund School of Education, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2053042023-06-20T20:13:34Z2023-06-20T20:13:34ZIs it anxiety or ADHD, or both? How to tell the difference and why it matters<figure><img src="https://images.theconversation.com/files/531037/original/file-20230608-13385-suqccx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5593%2C3717&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/close-up-shot-of-a-stressed-woman-8810553/">Pexels/Los Muertos Crew</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>“Cassie” is an anxious adult. She stresses and puts off tasks that should be simple. Seeing others succeed makes her feel inadequate. It’s easier to avoid challenges than risk failing again. She has taken anxiety medication but it didn’t help much.</p>
<p>This hypothetical example illustrates a situation many people have faced. Social media abounds with stories of people who have, without success, taken medication for anxiety and are now wondering about possible undiagnosed ADHD. </p>
<p>So, how can you tell if it’s anxiety or ADHD, or both? And why does it matter?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Both anxiety and depression can mimic ADHD.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/upset-black-woman-on-bed-in-house-5700165/">Pexels/Alex Green</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/myths-and-stigma-about-adhd-contribute-to-poorer-mental-health-for-those-affected-161591">Myths and stigma about ADHD contribute to poorer mental health for those affected</a>
</strong>
</em>
</p>
<hr>
<h2>ADHD and anxiety can go hand-in-hand</h2>
<p>Anxiety and depression can mimic ADHD. Either can be <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">associated</a> with lack of motivation and difficulty focusing the attention. </p>
<p>On the other hand, a pattern of being late, missing deadlines and forgetting appointments due to ADHD may <em>lead</em> to anxiety and a sense of failure.</p>
<p>Anxiety and depression are both commonly associated with ADHD, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976041/">particularly in women</a>. Anxiety tends to be more severe and persistent and with a <a href="https://pubmed.ncbi.nlm.nih.gov/28830387/">younger age of onset</a> in people with ADHD.</p>
<p>Generalised anxiety features <a href="https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/">symptoms</a> such as frequent and excessive worry about different aspects of life (such as work, school and family). The worry can be difficult to control. Restlessness, fatigue, irritability and sleep problems are common.</p>
<p>For some, anxiety can be controlled through therapy, mindfulness techniques, a change in life or at work and/or medication.</p>
<p>For others, no amount of anxiety treatment seems to help. The problems persist. For these people, it could be worth investigating whether undiagnosed ADHD is a factor.</p>
<p>Successful treatment of co-existing ADHD may, for some, be the best way of getting relief from chronic anxiety. </p>
<h2>Could ADHD be a factor?</h2>
<p>ADHD is often subtle in girls and women, who are <a href="https://pubmed.ncbi.nlm.nih.gov/20591126/">less likely</a> to show the disruptive hyperactive behaviour that draws attention to ADHD in men and boys.</p>
<p>This matters because women with ADHD have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976041/">higher rates</a> of depression, anxiety, <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">eating and sleep disorders</a>.</p>
<p>Old school reports may give telling clues, such as:</p>
<blockquote>
<p>Cassie spends more time socialising than working. She is capable, but is frequently distracted and is not achieving her potential.</p>
</blockquote>
<p>“Cassie’s” parents may recall hearing such comments from teachers. She may remember feeling bored in class and looking out the window instead of listening and concentrating. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/25998281">not all adults</a> with ADHD showed signs of it in childhood.</p>
<h2>ADHD in adulthood</h2>
<p>ADHD is generally diagnosed according to the <a href="https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596">criteria</a> of the American Psychiatric Association.</p>
<p>Problematically, these criteria require that to be diagnosed with ADHD, an adult should have experienced difficulties before the age of 12. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/25998281">Studies</a> have identified ADHD in adults who didn’t show evidence of it when previously assessed in childhood.</p>
<p>And ADHD is generally assessed in adults as if it were a continuation of the childhood condition. The diagnostic criteria – such as interrupting, fidgeting, not completing tasks, losing things, forgetting things – are derived from observations of children.</p>
<p>When applied to adults, these criteria still relate to behaviour seen from the outside by an observer. They miss the depth and insight an <a href="https://pubmed.ncbi.nlm.nih.gov/36981985/">adult can provide</a> about their inner world and mind.</p>
<p>A woman with no history of ADHD-related problems in childhood and no overt signs of restlessness or hyperactivity may have had her ADHD missed, particularly if she’s developed coping skills to seemingly stay on track. </p>
<p>She may feel <a href="https://pubmed.ncbi.nlm.nih.gov/33769111/">stigmatised</a> by those who believe ADHD is being self-diagnosed in treatment-seeking adults who are over-influenced by social media.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Only consider a diagnosis of ADHD if you’re facing significant difficulties in life.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/young-annoyed-female-freelancer-using-laptop-at-home-3808008/">Pexels/Andrea Piacquadio</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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</figure>
<h2>If I suspect ADHD, what now?</h2>
<p>If you suspect ADHD but are able to get on fine in life, you probably don’t need a diagnosis. You should only consider a diagnosis of ADHD if you’re facing <a href="https://www1.racgp.org.au/ajgp/2021/march/recognising-attention-deficit-hyperactivity-disord/">significant difficulties</a>. </p>
<p>This could <a href="https://www1.racgp.org.au/ajgp/2021/march/recognising-attention-deficit-hyperactivity-disord/">mean</a> <a href="https://pubmed.ncbi.nlm.nih.gov/20591126/">disorganisation, inefficiency, difficulty with relationships</a> at work or in the family, or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552915/">depression</a> or anxiety so severe it affects your ability to function. </p>
<p>To be assessed for ADHD, you’ll need a GP referral to a psychiatrist. However, many people who outwardly appear to be coping well may find it difficult to convince a GP an assessment is necessary. </p>
<p>You could bring copies of school reports if they suggest ADHD. <a href="https://novopsych.com.au/assessments/diagnosis/adult-adhd-self-report-scale-asrs/">Checklists</a> with ADHD criteria can help, but <a href="https://adhdguideline.aadpa.com.au">cannot</a> reliably either diagnose or exclude ADHD.</p>
<p>Clear descriptions of difficulties you experience when attempting mentally demanding task can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10049217/">help</a>.</p>
<p>These may <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10049217/">include</a> repeated lapses in attention, or having to multitask to provide sufficient stimulation to keep working. </p>
<p>You might detail, for example, the average number of minutes per hour of your working day you are actually working productively or how long you can focus on a hard task before losing concentration. How often do you get distracted? How long does it take to get back on task? What strategies have you tried?</p>
<p>An ADHD diagnosis can be a relief for some, who may find treatment helps alleviate problems they’d previously blamed on anxiety. It can also provide an <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">explanation</a> for past difficulties attributed to personal inadequacy.</p>
<p>ADHD <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">treatments</a> can include medication, learning more about it, developing new strategies, counselling and having an ADHD coach.</p>
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Read more:
<a href="https://theconversation.com/adhd-claims-were-diagnosing-immature-behaviour-make-it-worse-for-those-affected-72180">ADHD: claims we're diagnosing immature behaviour make it worse for those affected</a>
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<img src="https://counter.theconversation.com/content/205304/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Poulton is affiliated with the Australian ADHD Professionals Association (AADPA). Dr Poulton discloses personal fees and non-financial support from Shire/Takeda, and royalties from Disruptive Publishing for her book: ADHD Made Simple.</span></em></p>For some people, successful treatment of co-existing ADHD may be the best way of getting relief from chronic anxiety.Alison Poulton, Senior Lecturer, Brain Mind Centre Nepean, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2072792023-06-09T15:53:33Z2023-06-09T15:53:33ZADHD: inattention and hyperactivity have been the focus of research – but emotional problems may be the missing link<figure><img src="https://images.theconversation.com/files/531105/original/file-20230609-23-mpmo53.jpg?ixlib=rb-1.1.0&rect=499%2C34%2C4951%2C3797&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/angry-asian-cute-girl-screaming-after-1022405713">japansainlook/Shutterstock</a></span></figcaption></figure><p>Attention deficit hyperactivity disorder (ADHD) is one of the most <a href="https://www.cdc.gov/childrensmentalhealth/symptoms.html">common mental health disorders</a> in children, affecting 7.2% of people <a href="https://publications.aap.org/pediatrics/article-abstract/135/4/e994/77059/Prevalence-of-Attention-Deficit-Hyperactivity?redirectedFrom=fulltext">under the age of 18</a> worldwide. Many of these children <a href="https://www.cdc.gov/ncbddd/adhd/facts.html#ADHDAdults">will still have ADHD</a> in adolescence and adulthood. </p>
<p>ADHD is diagnosed using criteria from a document called DSM-5, which <a href="https://www.cdc.gov/ncbddd/adhd/diagnosis.html">include symptoms</a> of inattention, hyperactivity and impulsivity. But it is becoming increasingly clear to researchers that the condition also comes with self-control problems, affecting the ability to regulate emotions.</p>
<p>For example, 2.1% of children with a diagnosis of ADHD also have <a href="https://www.jaacap.org/article/S0890-8567(22)00190-3/fulltext">a mood disorder</a>, such as depression, while 27.4% have an anxiety disorder. Many also have outbursts of verbal or physical aggression.</p>
<p>These previously understudied aspects of the condition are now providing fresh insights into what’s going on in the brain of someone with ADHD – raising hopes for new and improved treatments.</p>
<p>If ADHD is not treated effectively, it can have major effects on a child’s mental health and wellbeing, as well as educational attainment. It may also impact on parents and siblings, as well as other children in the classroom. </p>
<p>So what is the neural link between ADHD and emotions? In our new study, <a href="https://www.nature.com/articles/s41591-023-02317-4">published in Nature Medicine</a> with colleagues at Fudan University in China, we identified a general brain basis – that we call the Neuropsychopathological Factor (NP Factor) – underlying symptoms of multiple mental health disorders, from depression to ADHD. </p>
<p>By using a combination of neuroimaging, cognitive and genetic data, we discovered that many mental health conditions may be linked to a unified, genetically determined problem of “synaptic pruning”. </p>
<p>This process typically occurs in childhood and removes extra synapses (brain structures that help brain cells transmit electrical or chemical signals) in order to ensure that our brains are efficient and connections between regions are optimal. </p>
<p>This problem with pruning may be an underlying cause, explaining why children with ADHD often have other mental health conditions too. Ultimately, it leads to delayed development of the prefrontal cortex, which is responsible for the “cognitive control” we have over our emotions and behaviour. That means people with ADHD can struggle with their emotions.</p>
<p>Delayed development of the prefrontal cortex may also explain why children with ADHD often have cognitive deficits, such as problems with executive functions (for example planning, self-monitoring, self-control and working memory). But then, so do children with depression and anxiety. So which is ultimately the root of the problem? </p>
<p>One <a href="https://www.nature.com/articles/s41598-023-34399-y">recent and large study</a> of 11,876 children, aged 9-12, provides a clue. At the University of Cambridge, we found that the cognitive deficits in children with more ADHD symptoms were related specifically to problems with attention, rather than emotions. </p>
<p>Children with anxiety and depression symptoms only exhibited those deficits if they also had problems with attention. So it seems that one possible route to helping children with ADHD or mood disorders with cognitive development is to focus on improving their attention.</p>
<h2>Treatments</h2>
<p>Another way to learn more about ADHD is by studying the effects of the drugs used to treat it. The main pharmacological treatment for ADHD is called methylphenidate, or Ritalin. </p>
<p>Methylphenidate roughly works by increasing <a href="https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1471-4159.1997.68052032.x">three chemicals in the brain</a>: dopamine, serotonin and noradrenaline. Dopamine <a href="https://www.sciencedirect.com/science/article/pii/S0006322311002605?casa_token=OGt2TaYTtQEAAAAA:6Pv1jpx9uBdUU1ntKTyae80j6G1UlPk35Ax8SVp1ifTwoHmibi2MFMFcxdJMgYXWH05V-0VQ#sec1">can improve</a> attention, learning, working memory and motivation, while noradrenaline <a href="https://pubmed.ncbi.nlm.nih.gov/16469930/">reduces impulsivity</a> and boosts attention. Serotonin is known to <a href="https://www.nature.com/articles/npp2011183">improve symptoms</a> of anxiety and depression. </p>
<figure class="align-center ">
<img alt="Image of a brain, with reduced volume in the prefrontal cortex." src="https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531107/original/file-20230609-15-o8jhd0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">ADHD can lead to delayed development of the prefrontal cortex, seen in blue.</span>
<span class="attribution"><span class="source">wikipedia</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>We know a considerable amount about which areas of the brain these drugs target. Indeed, the dopamine system affects multiple brain regions. </p>
<p>One study showed that attention was improved by methylphenidate treatment and that this was associated with increases in dopamine in the brain’s <a href="https://www.jneurosci.org/content/jneuro/32/3/841.full.pdf">ventral striatum</a> (a region involved with reward and motivation). This means the dopamine reward/motivation circuit in the brain is probably important in ADHD. </p>
<p>Another study showed that methylphenidate improved working memory, which is known to be affected by dopamine, and showed increased blood flow to the <a href="https://www.jneurosci.org/content/jneuro/20/6/RC65.full.pdf">prefrontal and parietal cortices</a> –important areas for executive function. This research suggests that cognitive control, which is associated with frontal areas, can be improved by methylphenidate. </p>
<p>It also backs up our finding that ADHD is linked to delayed development of the prefrontal cortex, making it harder to exert cognitive control.</p>
<p>Similarly, a further study showed that methylphenidate <a href="https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=9c94dadf44cbadd490d2516b8b2bc241eb17b366#page=29">significantly improved</a> emotional symptoms in adults with ADHD. But we still don’t know whether methylphenidate is working to control emotion in a top-down way through the prefrontal cortex, or whether it is working directly on emotion processing itself, or a combination of both.</p>
<p>That said, it is now becoming clearer that a problem with regulating emotions is a core symptom of ADHD, and not simply a co-occurring issue. As such, emotional dysregulation is an important target for treatment. </p>
<p>Cognitive behavioural therapy is effective in treating problems of self-control and low mood. This should be offered to children with ADHD, in conjunction with pharmacological treatments. </p>
<h2>ADHD on the rise</h2>
<p>The number of ADHD diagnoses are rising across the world, and so are prescriptions of methylphenidate. Indeed, according to the National Health Interview Survey, the prevalence of diagnosed ADHD among children and adolescents aged four to 17 in the past 20 years <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2698633">have increased</a> from 6.1% to 10.2% in the US. </p>
<p>In the UK, a study estimated that the use of ADHD medications <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338115/">has increased by almost 800%</a> from 2000 to 2015. </p>
<p>With the increasing use of technology and remote school and work, we are multi-tasking and splitting our attention, <a href="https://mitpress.mit.edu/9780262534437/">rather than focusing it</a> on one task at a time, more than ever. It may be that the prevalence of ADHD will increase even more in the future as coping strategies become less effective and people seek help and ultimately receive a diagnosis.</p>
<p>Ironically, some of the solutions may rely on technology, such as cognitive training using game apps on an iPad or mobile phones, <a href="https://www.frontiersin.org/articles/10.3389/fnbeh.2019.00002/full">for example Decoder</a>, which has been shown to improve attention in young adults. </p>
<p>The more we learn about brain basis of ADHD, the easier it will get to treat.</p><img src="https://counter.theconversation.com/content/207279/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Jacquelyn Sahakian receives funding from the Leverhulme Trust and the Lundbeck Foundation. Her research work is conducted within the NIHR Cambridge Biomedical Research Centre (BRC) Mental Health and Neurodegeneration Themes and the NIHR MedTech and in vitro diagnostic Co-operative (MIC). She consults for Cambridge Cognition. Cambridge Enterprise has technology transferred Decoder to PEAK and PopReach. She receives royalties from PopReach.</span></em></p><p class="fine-print"><em><span>Christelle Langley is funded by the Leverhulme Trust. Her research work is conducted within the NIHR Cambridge Biomedical Research Centre (BRC) Mental Health and Neurodegeneration Themes and the NIHR MedTech and in vitro diagnostic Co-operative (MIC).</span></em></p>It is becoming increasingly clear that ADHD comes with self-control problems, suggesting therapy should be offered alongside drugs.Barbara Jacquelyn Sahakian, Professor of Clinical Neuropsychology, University of CambridgeChristelle Langley, Postdoctoral Research Associate, Cognitive Neuroscience, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.