October 14, 2024

CDC: ADHD Diagnosis, Treatment, and Telehealth Use in Adults

The report "Attention-Deficit/Hyperactivity Disorder Diagnosis, Treatment, and Telehealth Use in Adults" published in the CDC's Morbidity and Mortality Weekly Report provides a detailed examination of the prevalence and treatment of ADHD among U.S. adults based on data collected by the National Center for Health Statistics Rapid Surveys System during October–November 2023. This data is crucial as it offers updated estimates on the prevalence of ADHD in adults, a condition often regarded as primarily affecting children, and highlights the ongoing challenges in accessing ADHD-related treatments, including telehealth services and medication availability.

Methods:

The methods used in this study involved the National Center for Health Statistics (NCHS) Rapid Surveys System (RSS), which gathers data to approximate the national representation of U.S. adults through two commercial survey panels: the AmeriSpeak Panel from NORC at the University of Chicago and Ipsos’s KnowledgePanel. The data were collected via online and telephone interviews from 7,046 adults. The responses were weighted to reflect the total U.S. adult population, ensuring that the results approximate national estimates. In identifying adults with current ADHD, respondents were asked if they had ever been diagnosed with ADHD and, if so, whether they currently had the condition. The study also collected data on treatment types (including stimulant and nonstimulant medications), telehealth use, and demographic variables such as age, education, race, and household income.

Results:

The results showed that approximately 6.0% of U.S. adults, or an estimated 15.5 million people, had a current ADHD diagnosis. Notably, more than half of the adults with ADHD reported receiving their diagnosis during adulthood (age ≥18 years), indicating that diagnosis can occur well beyond childhood. Analysis of demographics showed significant differences between adults with ADHD and those without; adults with ADHD were more likely to be younger, with 84.5% under the age of 50. Adults with ADHD were also less likely to have completed a bachelor's degree and more likely to have a household income below the federal poverty level compared to those without ADHD. Regarding treatment, the report found that approximately one-third of adults with ADHD were untreated, and around one-third received both medication and behavioral treatment. Among those receiving pharmacological treatment, 33.4% used stimulant medications, and 71.5% of these individuals reported difficulties in getting their prescriptions filled due to medication unavailability, reflecting recent stimulant shortages in the United States. Additionally, nearly half of adults with ADHD had used telehealth services for ADHD-related care, including obtaining prescriptions and receiving counseling or therapy.

The discussion emphasizes the public health implications of these findings. ADHD is often diagnosed late, with many individuals not receiving a diagnosis until adulthood, which underscores the need for improved awareness and early identification of ADHD symptoms across the life course. Moreover, the high prevalence of untreated ADHD and the barriers to accessing stimulant medications reveal significant gaps in the healthcare system's ability to support adults with ADHD. These gaps can contribute to poorer outcomes, such as increased risk of injury, substance use, and social impairment. The report also highlights the role of telehealth, which became more prominent during the COVID-19 pandemic. Telehealth appears to provide a viable solution for expanding access to ADHD diagnosis and treatment, though challenges remain regarding the quality of care and potential for misuse. The authors suggest that improved clinical care guidelines for adults with ADHD could help reduce delays in diagnosis and treatment access, thus improving long-term outcomes for affected individuals.

Conclusion:

In conclusion, the study provides a comprehensive view of the prevalence, treatment, and telehealth use for ADHD among adults in the U.S.  These data are crucial for guiding clinical care and shaping policies related to medication access and telehealth services. The findings underscore the importance of ensuring an adequate supply of stimulant medications and reducing barriers to ADHD care, ultimately enhancing the quality of life for adults with this condition.   The good news is that many adults with ADHD are being diagnosed and treated.  It is, however, concerning that many are not treated and that many of those treated with stimulants were impacted by the stimulant shortage.

For more details, see:   https://www.cdc.gov/mmwr/volumes/73/wr/mm7340a1.htm

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Staley BS, Robinson LR, Claussen AH, et al. Attention-Deficit/Hyperactivity Disorder Diagnosis, Treatment, and Telehealth Use in Adults — National Center for Health Statistics Rapid Surveys System, United States, October–November 2023. MMWR Morb Mortal Wkly Rep 2024;73:890–895. DOI: http://dx.doi.org/10.15585/mmwr.mm7340a1

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Update: New Research about ADHD in Adults

Update: New Research about ADHD in Adults

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition that is typically diagnosed in childhood but can persist into adulthood. Its symptoms include inattention, hyperactivity, and impulsivity, and it can significantly affect daily life, academic achievement, and professional success. As scientific understanding of the condition continues to evolve, new research is revealing more insights into the prevalence, comorbidity, treatment, and physiological aspects of ADHD in adults. Here's a roundup of some recent findings:

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Location of Mental Healthcare and ADHD Treatment Prevalence

A recent study assessing the prevalence of treatment for ADHD among US college students found that the location of mental health care significantly affects treatment outcomes. Specifically, students receiving mental healthcare on campus were less likely to receive any medication or therapy for ADHD, suggesting the need to evaluate the quality of mental health services available on college campuses and their effectiveness in treating ADHD.

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 Oxidative Stress and l-Arginine/Nitric Oxide Pathway in ADHD 

Another study found a correlation between ADHD and the l-Arginine/Nitric oxide (Arg/NO) pathway, a physiological process linked to dopamine release and cardiovascular functioning. The study found that adults with ADHD who were not treated with methylphenidate (a common ADHD medication) showed variations in the Arg/NO pathway. This could have implications for monitoring potential cardiovascular side effects of ADHD medications, as well as for understanding the biochemical changes that occur in ADHD. 

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Chronic Pain in ADHD

ADHD and chronic pain appear to be related, according to a comparative study of clinical and general population samples. Particularly in females with ADHD, the prevalence of chronic and multisite pain was found to be high. This calls for longitudinal studies to understand the complex sex differences of comorbid chronic pain and ADHD in adolescents and the potential impacts of stimulant use on pain.

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ADHD and Violent Behavior

Finally, a study investigated the comorbidity of ADHD and bipolar disorder (BD) and its potential link to violent behavior. The research revealed a positive effect of ADHD symptoms on violence tendency and aggression scores. Moreover, male gender and young age were also found to have significant positive effects on violence and aggression scores, suggesting an association between these disorders and violent behavior.

June 3, 2024

Adult Onset ADHD: Does it Exist? Is it Distinct from Youth Onset ADHD?

Adult Onset ADHD: Does it Exist? Is it Distinct from Youth Onset ADHD?

There is a growing interest (and controversy) in 'adult-onset ADHD. No current diagnostic system allows for the diagnosis of ADHD in adulthood, yet clinicians sometimes face adults who meet all criteria for ADHD, except for age at onset. Although many of these clinically referred adult-onset cases may reflect poor recall, several recent longitudinal population studies have claimed to detect cases of adult-onset ADHD that showed no signs of ADHD as a youth (Agnew-Blais, Polanczyk et al. 2016, Caye, Rocha, et al. 2016). They conclude, not only that ADHD can onset in adulthood, but that childhood-onset and adult-onset ADHD may be distinct syndromes(Moffitt, Houts, et al. 2015)

In each study, the prevalence of adult-onset ADHD was much larger than the prevalence of childhood-onset adult ADHD). These estimates should be viewed with caution.  The adults in two of the studies were 18-19 years old.  That is too small a slice of adulthood to draw firm conclusions. As discussed elsewhere (Faraone and Biederman 2016), the claims for adult-onset ADHD are all based on population as opposed to clinical studies.
Population studies are plagued by the "false positive paradox", which states that, even when false positive rates are low, many or even most diagnoses in a population study can be false.  

Another problem is that the false positive rate is sensitive to the method of diagnosis. The child diagnoses in the studies claiming the existence of adult-onset ADHDused reports from parents and/or teachers but the adult diagnoses were based on self-report. Self-reports of ADHD in adults are less reliable than informant reports, which raises concerns about measurement error.   Another longitudinal study found that current symptoms of ADHD were under-reported by adults who had had ADHD in childhood and over-reported by adults who did not have ADHD in childhood(Sibley, Pelham, et al. 2012).   These issues strongly suggest that the studies claiming the existence of adult-onset ADHD underestimated the prevalence of persistent ADHD and overestimated the prevalence of adult-onset ADHD.  Thus, we cannot yet accept the conclusion that most adults referred to clinicians with ADHD symptoms will not have a history of ADHD in youth.

The new papers conclude that child and adult ADHD are "distinct syndromes", "that adult ADHD is more complex than a straightforward continuation of the childhood disorder" and that adult ADHD is "not a neurodevelopmental disorder". These conclusions are provocative, suggesting a paradigm shift in how we view adulthood and childhood ADHD.   Yet they seem premature.  In these studies, people were categorized as adult-onset ADHD if full-threshold add had not been diagnosed in childhood.  Yet, in all of these population studies, there was substantial evidence that the adult-onset cases were not neurotypical in adulthood (Faraone and Biederman 2016).  Notably, in a study of referred cases, one-third of late adolescent and adult-onset cases had childhood histories of ODD, CD, and school failure(Chandra, Biederman, et al. 2016).   Thus, many of the "adult onsets" of ADHD appear to have had neurodevelopmental roots. 

Looking through a more parsimonious lens, Faraone and Biederman(2016)proposed that the putative cases of adult-onset ADHD reflect the existence of subthreshold childhood ADHD that emerges with full threshold diagnostic criteria in adulthood.   Other work shows that subthreshold ADHD in childhood predicts onsets of full-threshold ADHD in adolescence(Lecendreux, Konofal, et al. 2015).   Why is onset delayed in subthreshold cases? One possibility is that intellectual and social supports help subthreshold ADHD youth compensate in early life, with decompensation occurring when supports are removed in adulthood or the challenges of life increase.  A related possibility is that the subthreshold cases are at the lower end of a dimensional liability spectrum that indexes risk for onset of ADHD symptoms and impairments.  This is consistent with the idea that ADHD is an extreme form of a dimensional trait, which is supported by twin and molecular genetic studies(Larsson, Anckarsater, et al. 2012, Lee, Ripke, et al. 2013).  These data suggest that disorders emerge when risk factors accumulate over time to exceed a threshold.  Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset.

In conclusion, it is premature to accept the idea that there exists an adult-onset form of ADHD that does not have its roots in neurodevelopment and is not expressed in childhood.   It is, however, the right time to carefully study apparent cases of adult-onset ADHD to test the idea that they are late manifestations of a subthreshold childhood condition.

April 7, 2021

ADHD Affects the Efficacy of Treatment for Eating Disorders in Adult Women

ADHD Affects the Efficacy of Treatment for Eating Disorders in Adult Women

Swedish researchers examined outcomes for adult women who sought treatment at the Stockholm Center for Eating Disorders over two years and nine months. Out of 1,517 women who came to the clinic, 1,143remained eligible for the study, after excluding women whose symptoms did not fulfill the DSM-IV criteria for eating disorders or had incomplete records.

Of these, seven hundred patients could not be reached or declined to participate, leaving 443 for follow-up. To guard against the possibility that the follow-up group might not be representative of the overall treatment group, researchers compared to age, body mass index, and scores on tests for depression, anxiety, compulsively, inattention, and hyperactivity. The only statistically significant differences were small ones. The median age of the group lost to follow-up was one year younger, they were less likely to be living alone, and on average scored a single point higher on the depression test. Otherwise, they were broadly similar.

The one-year follow-up on the study group found a substantial difference in the rate of recovery from eating disorders between those with and without comorbid ADHD. Almost three out of four patients (72%) who scored lower (between 0-17) on the World Health Organization adult ADHD self-report scale had recovered from their eating disorder. Among those scoring18 and higher, on the other hand, it was less than half (47%). This difference was extraordinarily unlikely (one chance in one thousand) to be due to chance(p=.001).

Another way of expressing this is through odds ratios. Those scoring 18 and up on the ADHD self-report scale were about two and a half times less likely to recover from their eating disorders following treatment. More specifically, thy were about three times less likely to recover from the loss of control and binging, and almost three and a half times less likely to recover from purging.

To improve outcomes, the researchers suggest "identifying concomitant ADHD symptoms and customizing treatment interventions based on this." They specifically propose controlled clinical trials to explore the effect of combining stimulant medications with standard treatment for eating disorders

June 10, 2021

Study Finds Association Between Childhood ADHD and Poor Dental Health

The Spanish National Health Survey tracks health care outcomes through representative samples of the Spanish population. 

A Spanish research team used survey data to explore the relationship between ADHD symptoms and dental and gum health in a representative sample of 3,402 Spanish children aged 6 to 14.

While previous studies have found associations between ADHD and poor dental health, they have not fully accounted for such important determinants of poor oral health as socioeconomic status, dental hygiene, or diet. 

The team therefore adjusted for sociodemographic factors, lifestyle variables, and oral hygiene behaviors. More specifically, they adjusted for sex, age, social class, parental education, exposure to tobacco smoke, consumption of sweets, consumption of sugary drinks, use of asthma or allergy medication, adequate oral hygiene behavior of children, adherence to regular dental visits, parental adequate oral hygiene behavior, and parental adherence to regular dental visits.

With those adjustments, children with ADHD symptoms had over twice the incidence of dental caries (cavities) as their counterparts without ADHD symptoms.

Tooth extractions and dental restorations also occurred with over 40% greater frequency in children with ADHD symptoms.

Gum bleeding, a sign of gum disease, was more than 60% more common among children with ADHD symptoms than among their non-ADHD peers.

Importantly, excluding children with daily sugar consumption, which left 1,693 children in the sample, made no difference in the outcome for cavities.

Excluding children with poor oral hygiene habits, which left 1,657 children in the sample, those with ADHD had 2.5-fold more caries than their non-ADHD counterparts.

Excluding children of low social class, which left 1,827 children in the sample, those with ADHD had 2.6-fold more caries than their non-ADHD counterparts.

Turning to a different method to address potential confounding factors, the team used nearest-neighbor propensity score matching to create virtual controls. This compared 461 children with ADHD to 461 carefully matched children without ADHD.

This time, children with ADHD symptoms had just under twice the incidence of cavities as their counterparts without ADHD symptoms, but 60% more tooth extractions and about 75% more dental restorations. The difference in gum bleeding became nonsignificant.

Noting that “The increased risk of caries was maintained when the analyses were restricted to middle/high social class families and children with low sugar intake, good oral hygiene behaviors and regular dental visits,” the team concluded, “Children with ADHD symptoms in Spain had worse oral health indicators than those without ADHD symptoms. Our results suggest that the association of ADHD symptoms with caries was independent of socioeconomic level, cariogenic diet, frequency of toothbrushing, and dental visits.”

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June 13, 2025

A Lesson in Correlation Versus Causation : Maternal Smoking and ADHD Risk in Children

Meta-analysis Finds Strong Link Between Maternal Smoking During Pregnancy and Increased Risk of ADHD in Children

This new meta-analysis confirms what other meta-analysis have already shown, i.e, that there exists in the population an association between maternal smoking during pregnancy and ADHD in their offspring.  But reader beware, association does not mean causation.

The team identified 55 studies with quantitative data suitable for meta-analysis, including 11 case-control, 13 cross-sectional, and 31 retrospective/prospective cohort studies. 

Altogether they combined more than four million persons in countries spanning six continents, including the United States, Finland, Sweden, Brazil, the Netherlands, Japan, the UK, Spain, China, Australia, New Zealand, Norway, Canada, France, Sweden, South Korea, Turkey, Romania, Bulgaria, Lithuania, Germany, Denmark, Egypt, and India.

Meta-analysis of all 55 studies found that offspring of mothers who smoked tobacco during pregnancy were about 70% more likely to develop ADHD than offspring of mothers who did not smoke during pregnancy.

Because variation in outcomes across studies was very high, the team performed subgroup analyses to explore potential sources of this heterogeneity. 

Comparing study designs, cohort studies reported roughly 50% greater odds of ADHD among children of mothers who smoked during pregnancy, whereas case-control studies reported roughly 70% greater odds and cross-sectional studies 2.3-fold greater odds.

Studies using the most reliable method of determining ADHD – clinical interview/professional diagnosis – reported 90% greater odds, contrasting with 66% through medical records/databases and 58% through self-report by child/parent or through teacher report.

Good quality studies reported roughly 75% greater odds. 

Studies with sample sizes above two thousand similarly found 70% greater odds.

There was no sign of publication bias using the more commonly used Egger’s test, but a marginal indication of publication bias using Begg’s test. Performing a standard correction reduced the effect size, indicating that the offspring of mothers who smoked tobacco during pregnancy were over 50% more likely to develop ADHD than the offspring of mothers who did not smoke during pregnancy.

The team concluded, “This systematic review and meta-analysis of 55 studies, encompassing over four million participants, provides compelling evidence that maternal tobacco smoking during pregnancy significantly increases the odds of ADHD in children … These findings underscore the critical need for public health interventions aimed at reducing tobacco smoking during pregnancy.”

However, we disagree with this conclusion; The authors ignore substantial evidence showing that maternal smoking during pregnancy is confounded by maternal ADHD. These mothers transmit ADHD via genetics, not via their smoking. This study should be seen not as "...[further evidence that smoking during pregnancy causes ADHD.] ", but as a lesson in how easy it can be to see correlation as causation.

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June 10, 2025

Meta-analysis Finds Little Evidence of Efficacy for Animal-Assisted Interventions for Treating Childhood ADHD

Study Background:

Animal-assisted interventions (AAIs) involve structured interactions with animals, designed and carried out by mental health teams assisted by trained human–animal professionals, to achieve specific therapeutic or educational goals. While a wide variety of animals may be used, horses and dogs tend to predominate. These interventions often involve physical contact, imitation, and play aimed at reducing stress and generating affection. Previous research has suggested that AAI to those with a range of developmental and mental health conditions.

Just how effective are they for treating ADHD in children and adolescents? Recent years have seen an increase in studies into AAIs for children with ADHD, but previous systematic reviews have not included quantitative meta-analysis to evaluate efficacy.

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The Study:

A Chinese study team based in Nanjing set out to remedy that with a systematic search of the peer-reviewed published medical literature aimed at performing meta-analyses of efficacy.

The team limited its search to randomized controlled trials (RCTs) and pre–post single-group studies involving children and adolescents diagnosed with ADHD.

Meta-analysis of five studies with a combined total of 95 participants reported no significant effect of AAIs on ADHD symptom severity. There was negligible variation (heterogeneity) in outcomes among the studies.

Similarly, meta-analysis of the six studies encompassing 323 individuals found no significant improvements in social behavior. There was no heterogeneity and no sign of publication bias. Breaking that down into subcategories of social interaction (4 studies, 190 persons), social skill (3 studies, 53 persons), and problem behavior (4 studies, 80 participants) made no difference.

Likewise, meta-analysis of the three studies encompassing 61 individuals found no significant improvements in emotional control. Again, there was no heterogeneity and no sign of publication bias.

Three studies combining 56 participants reported no significant reductions in anxiety and depression, again with no heterogeneity and no sign of publication bias.

However, meta-analyses of five studies encompassing 194 individuals found a medium effect size association between AAIs and declines in attention problems, and a medium-to-large effect size improvement in learning and cognition. Heterogeneity was negligible to low.

Finally, meta-analysis of three studies combining 95 participants reported a large effect size improvement in motor proficiency, with moderate heterogeneity.

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The Conclusion:

The team concluded, “As an ADHD management strategy complementary to gold-standard approaches, such as medication or multimodal interventions, AAIs did not appear to be more effective in improving the majority of core ADHD outcomes in children. Future studies should incorporate rigorous study designs with large sample sizes and a standard protocol to achieve more valid and reliable conclusions.”

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June 5, 2025

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