May 28, 2025

What the MAHA Report Gets Right—and Wrong—About ADHD and Children's Health

The U.S. government released a sweeping document titled The MAHA Report: Making Our Children Healthy Again, developed by the President’s “Make America Healthy Again” Commission. Chaired by public figures and physicians with ties to the current administration, the report presents a broad diagnosis of what it calls a national health crisis among children. It cites rising rates of obesity, diabetes, allergies, mental illness, neurodevelopmental disorders, and chronic disease as signs of a generation at risk.

The report's overarching goal is to shift U.S. health policy away from reactive, pharmaceutical-based care and toward prevention, resilience, and long-term well-being. It emphasizes reforming the food system, reducing environmental chemical exposure, addressing lifestyle factors like physical inactivity and screen overuse, and rethinking what it calls the “overmedicalization” of American children.

While some of the report’s arguments are steeped in political rhetoric and controversial claims—particularly around vaccines and mental health diagnoses—others are rooted in well-established public health science. This blog aims to highlight where the MAHA Report gets the science right, especially as it relates to childhood health and ADHD.

Some of the Good Ideas in the MAHA Report:

Although the MAHA Report contains several debatable assertions, it also outlines six key public health priorities that are well-supported by decades of research. If implemented thoughtfully, these recommendations might make a meaningful difference in the health of American children:

Reduce Ultra-Processed Food (UPF) Consumption

UPFs now make up nearly 70% of children’s daily calories. These foods are high in added sugars, refined starches, unhealthy fats, and chemical additives, but low in nutrients. Studies—including a 2019 NIH-controlled feeding study—show that UPFs promote weight gain, overeating, and metabolic dysfunction.  What can help: Tax incentives for fresh food retailers, improved school meals, front-of-pack labeling, and food industry regulation.

Promote Physical Activity and Limiting Sedentary Time

Most American children don’t get the recommended 60 minutes of physical activity per day. This contributes to obesity, cardiovascular risk, and even mental health issues. Physical activity is known to improve attention, mood, sleep, and self-regulation.   What can help: Mandatory daily PE, school recess policies, walkable community infrastructure, and screen-time education.

Addressing Sleep Deprivation

Teens today sleep less than they did a decade ago, in part due to screen use and early school start times. Sleep loss is linked to depression, suicide risk, poor academic performance, and metabolic problems.  What can help: Later school start times, family education about sleep hygiene, and limits on evening screen exposure.

Improving Maternal and Early Childhood Nutrition

The report indirectly supports actions that are backed by strong evidence: encouraging breastfeeding, supporting maternal whole-food diets, and improving infant nutrition. These are known to reduce chronic disease risk later in life.

What MAHA Says About ADHD:

ADHD is one of the most discussed neurodevelopmental disorders in the MAHA Report, but many of its claims about ADHD are misleading, oversimplified, or inconsistent with decades of scientific evidence, much of which is described in the International Consensus Statement on ADHDand other references given below.

✔️ Accurate: ADHD diagnoses are increasing.

This is true. Diagnosis rates have risen over the past two decades, due in part to better recognition, broadened diagnostic criteria, and changes in healthcare access.  Diagnosis rates in some parts of the country are too high, but we don’t know why.  That should be addressed and investigated.  MAHA attributes increasing diagnoses to ‘overmedicalization’.   That is a hypothesis worth testing but not a conclusion we can draw from available data.

❌ Misleading: ADHD is caused by processed food, screen time, or chemical exposures.

These have been associated with ADHD but have not been documented as causes. ADHD is highly heritable, with genetic factors accounting for 70–80% of the risk.   Unlike genetic studies, environmental risk studies are compromised by confounding variables.   There are good reasons to address these issues but doing so is unlikely to reduce diagnostic rates of ADHD. 

❌ Inaccurate: ADHD medications don’t work long-term.

The report criticizes stimulant use but fails to note that ADHD medications are among the most effective psychiatric treatments, especially when consistently used.  They cite the MTA study’s long term outcome study of kids assigned to medication vs. placebo as showing medications don’t work in the long term.  But that comparison is flawed because during the follow-up period, many kids on medication stopped taking them and many on placebo started taking medications.   Many studies document that medications for ADHD protect against many real-world outcomes such as accidental injuries, substance abuse and even premature death.

How the MAHA Report Could Still Help People with ADHD:

Despite the issues discussed above, the MAHA Report can indirectly help children and adults with ADHD by pushing for systemic changes that reduce ultra-processed food consumption, increase physical activity, and motivate better sleep practices.

In other words, you don’t need to reject the diagnosis of ADHD to support broader changes in how we feed, educate, and care for children. A more supportive, less toxic environment benefits everyone—including those with ADHD.

The MAHA Report;  https://www.whitehouse.gov/wp-content/uploads/2025/05/WH-The-MAHA-Report-Assessment.pdf 

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neuroscience and Biobehavioral Reviews, Sept 2021, Issue 128, pages 789-818. doi: 10.1016/j.neubiorev.2021.01.02

Faraone SV, Bellgrove MA, Brikell I, et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers 2024; 10(1): 11.

Faraone SV. Understanding Environmental Exposures and ADHD: a Pathway Forward. Prev Sci 2024.

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Meta-analysis finds no link between maternal exposure to PFAS and offspring ADHD

Meta-analysis Finds No Link Between Maternal Exposure to PFAS and Offspring ADHD

Perfluoroalkylated substances (PFASs), commonly known as "forever chemicals" in the media, are pollutants that do not break down in the environment. Their chemical structure includes fluorine atoms bonded to carbon, which makes them effective at repelling water. This property has led to their use in water-repellent clothing, stain-resistant carpets and furniture, and nonstick cookware.

However, the same chemical structure that makes PFASs useful also makes them a concern for human and animal health, as there are no natural biological processes to remove them from the body. Once ingested, they accumulate and become more concentrated at each level of the food chain. PFASs can also cross the placental barrier, raising concerns about potential harm to developing embryos and fetuses.

A Chinese research team conducted a systematic review of the medical literature to examine if there is a link between maternal exposure to PFASs and an increased risk of ADHD in children. They analyzed data from several studies:

- A meta-analysis of five studies involving 2,513 mother-child pairs found no increase in ADHD risk from exposure to PFOA (perfluorooctanoate) or PFOS (perfluorooctane sulfonate). The consistency across these studies was high, with little variation and no evidence of publication bias.

- Another meta-analysis of three studies with 995 mother-child pairs also showed no increase in ADHD risk from exposure to PFNA (perfluorononanoate) or PFHxS (perfluorohexane sulfonate), with similarly negligible variation between studies and no publication bias.

- In an analysis comparing the highest and lowest quartiles of maternal exposure, a slight increase in ADHD risk was observed with PFOA exposure, while a slight decrease was noted with PFOS exposure. Both findings were marginally significant and may be due to the small sample sizes. 

The researchers concluded that more studies are needed to confirm these findings due to the limited evidence available.

May 6, 2024

What The New York Times Got Wrong

Why The New York Times’ Essay on ADHD Misses the Mark

This New York Times article, “5 Takeaways from New Research about ADHD”, earns a poor grade for accuracy. Let’s break down their (often misleading and frequently inaccurate) claims about ADHD. 

The Claim: A.D.H.D. is hard to define/ No ADHD Biomarkers exist

The Reality: The claim that ADHD is hard to define “because scientists haven’t found a single biological marker” is misleading at best. While it is true that no biomarker exists, decades of rigorous research using structured clinical interviews and standardized rating scales show that ADHD is reliably diagnosed. Decades of validation research consistently show that ADHD is indeed a biologically-based disorder. One does not need a biomarker to draw that conclusion and recent research about ADHD has not changed that conclusion. 

Additionally, research has in fact confirmed that genetics do play a role in the development of ADHD and several genes associated with ADHD have been identified.  

The Claim: The efficacy of medication wanes over time

The Reality: The article’s statement that medications like Adderall or Ritalin only provide short-term benefits that fade over time is wrong. It relies almost entirely on one study—the Multimodal Treatment Study of ADHD (MTA). In the MTA study, the relative advantage of medication over behavioral treatments diminished after 36 months. This was largely because many patients who had not initially been given medication stopped taking it and many who had only been treated with behavior therapy suddenly began taking medication. The MTA shows that patients frequently switched treatments. It does not overturn other data documenting that these medications are highly effective. Moreover, many longitudinal studies clearly demonstrate sustained benefits of ADHD medications in reducing core symptoms, psychiatric comorbidity, substance abuse, and serious negative outcomes, including accidents, and school dropout rates. A study of nearly 150,000 people with ADHD in Sweden concluded “Among individuals diagnosed with ADHD, medication initiation was associated with significantly lower all-cause mortality, particularly for death due to unnatural causes”. The NY Times’ claim that medications lose their beneficial effects over time ignores compelling evidence to the contrary.

The Claim: Medications don’t help children with ADHD learn 

The Reality: ADHD medications are proven to reliably improve attention, increase time spent on tasks, and reduce disruptive behavior, all critical factors directly linked to better academic performance.The article’s assertion that ADHD medications improve only classroom behavior and do not actually help students learn also oversimplifies and misunderstands the research evidence. While medication alone might not boost IQ or cognitive ability in a direct sense, extensive research confirms significant objective improvements in academic productivity and educational success—contrary to the claim made in the article that the medication’s effect is merely emotional or perceptual, rather than genuinely educational. 

For example, a study of students with ADHD who were using medication intermittingly concluded “Individuals with ADHD had higher scores on the higher education entrance tests during periods they were taking ADHD medication vs non-medicated periods. These findings suggest that ADHD medications may help ameliorate educationally relevant outcomes in individuals with ADHD.”

The Claim: Changing a child’s environment can change his or her symptoms.

The Reality: The Times article asserts that ADHD symptoms are influenced by environmental fluctuations and thus might not have their roots in neurobiology. We have known for many years that the symptoms of ADHD fluctuate with environmental demands. The interpretation of this given by the NY Times is misleading because it confuses symptom variability with underlying causes. Many disorders with well-established biological origins are sensitive to environmental factors, yet their biology remains undisputed. 

For example, hypertension is unquestionably a biologically based condition involving genetic and physiological factors. However, it is also well-known that environmental stressors, dietary

habits, and lifestyle factors can significantly worsen or improve hypertension. Similarly, asthma is biologically rooted in inflammation and airway hyper-reactivity, but environmental triggers such as allergens, pollution, or even emotional stress clearly impact symptom severity. Just as these environmental influences on hypertension or asthma do not negate their biological basis, the responsiveness of ADHD symptoms to environmental fluctuations (e.g., improvements in classroom structure, supportive home life) does not imply that ADHD lacks neurobiological roots. Rather, it underscores that ADHD, like many medical conditions, emerges from the interplay between underlying biological vulnerabilities and environmental influences.

Claim: There is no clear dividing line between those who have A.D.H.D. and those who don’t.

The Reality: This is absolutely and resoundingly false. The article’s suggestion that ADHD diagnosis is arbitrary because ADHD symptoms exist on a continuum rather than as a clear-cut, binary condition is misleading. Although it is true that ADHD symptoms—like inattention, hyperactivity, and impulsivity—do vary continuously across the population, the existence of this continuum does not make the diagnosis arbitrary or invalidate the disorder’s biological basis. Many well-established medical conditions show the same pattern. For instance, hypertension (high blood pressure) and hypercholesterolemia (high cholesterol) both involve measures that are continuously distributed. Blood pressure and cholesterol levels exist along a continuum, yet clear diagnostic thresholds have been carefully established through decades of clinical research. Their continuous distribution does not lead clinicians to question whether these conditions have biological origins or whether diagnosing an individual with hypertension or hypercholesterolemia is arbitrary. Rather, it underscores that clinical decisions and diagnostic thresholds are established using evidence about what levels lead to meaningful impairment or increased risk of negative health outcomes. Similarly, the diagnosis of ADHD has been meticulously defined and refined over many decades using extensive empirical research, structured clinical interviews, and validated rating scales. The diagnostic criteria developed by experts carefully delineate the point at which symptoms become severe enough to cause significant impairment in an individual’s daily functioning. Far from being arbitrary, these thresholds reflect robust scientific evidence that individuals meeting these criteria face increased risks for the serious impairments in life including accidents, suicide and premature death. 

The existence of milder forms of ADHD does not undermine the validity of the diagnosis; rather, it emphasizes the clinical reality that people experience varying degrees of symptom severity.

Moreover, acknowledging variability in severity has always been a core principle in medicine. Clinicians routinely adjust treatments to meet individual patient needs. Not everyone diagnosed with hypertension receives identical medication regimens, nor does everyone with elevated cholesterol get prescribed the same intervention. Similarly, people with ADHD receive personalized treatment plans tailored to the severity of their symptoms, their specific impairments, and their individual circumstances. This personalization is not evidence of arbitrariness; it is precisely how evidence-based medicine is practiced. In sum, the continuous nature of ADHD symptoms is fully compatible with a biologically-based diagnosis that has substantial evidence for validity, and acknowledging symptom variability does not render diagnosis arbitrary or diminish its clinical importance.

In sum, readers seeking a balanced, evidence-based understanding of ADHD deserve clearer, more careful reporting. By overstating diagnostic uncertainty, selectively interpreting research about medication efficacy, and inaccurately portraying the educational benefits of medication, this article presents an overly simplistic, misleading picture of ADHD.

April 17, 2025

Meta-Analysis: Physical Activity for Children and Adolescents with ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental disorder that significantly impacts children’s academic performance, social interactions, and overall quality of life (QoL). While medication is the standard treatment, it often comes with side effects and may not always provide sufficient benefits. A new systematic review and meta-analysis aims to investigate whether physical activity can offer a viable and effective alternative or complement to medication.

About the Study
This protocol, developed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) guidelines, focuses on randomized clinical trials involving children and adolescents (ages 3–18) diagnosed with ADHD or hyperkinetic disorder. The study's goal is to evaluate the effects of physical activity on:

  • Quality of life (QoL)
  • Executive functions
  • ADHD symptoms
  • Functional impairments

Unlike earlier reviews, which often included non-randomized trials or imposed limits on activity types, this analysis takes a more robust and inclusive approach. It is the first of its kind to examine QoL as an outcome while also incorporating trial sequential analysis—a method to assess evidence strength over time.

Why Physical Activity?
Physical activity is believed to impact the same brain systems targeted by ADHD medications, particularly the catecholaminergic system. This overlap suggests that exercise could play a key role in managing symptoms, potentially reducing reliance on medication or enhancing its effects.

Methodology Highlights

  • The review will adhere to principles outlined in the Cochrane Handbook for Systematic Reviews of Interventions.
  • It incorporates the latest research and focuses on randomized trials to ensure high-quality evidence.
  • No restrictions are placed on the frequency or intensity of physical activity interventions, making the findings broadly applicable.

Significance and Dissemination
The results of this systematic review will provide critical insights into how physical activity could improve outcomes for children and adolescents with ADHD. It is also notable as the first review in this field to prioritize quality of life—a crucial, often-overlooked measure of treatment success.

The findings will be published in peer-reviewed journals and presented at relevant conferences to inform clinicians, educators, and families.

Conclusion
As concerns about the limitations of ADHD medication grow, exploring alternatives like physical activity becomes increasingly important. This systematic review has the potential to shape future treatment strategies, offering children with ADHD a chance for better symptom management and a higher quality of life.

January 21, 2025

Meta-analysis Reports Executive Function Gains from Exercise Interventions for ADHD

Background:

The development of ADHD is strongly associated with functional impairments in the prefrontal cortex, particularly the dorsolateral prefrontal cortex, which plays a key role in maintaining attention and controlling impulses. Moreover, imbalances in neurotransmitters like dopamine and norepinephrine are widely regarded as major neurobiological factors contributing to ADHD. 

Executive functions are a group of higher-order cognitive skills that guide thoughts and actions toward goals. “Executive function” refers to three main components: inhibitory control, working memory, and cognitive flexibility. Inhibitory control helps curb impulsive actions to stay on track. Working memory allows temporary storage and manipulation of information for complex tasks. Cognitive flexibility enables switching attention and strategies in varied or demanding situations. 

Research shows that about 89% of children with ADHD have specific executive function impairments. These difficulties in attention, self-control, and working memory often result in academic and social issues. Without timely intervention, these issues can lead to emotional disorders like depression, anxiety, and irritability, further affecting both physical health and social development. 

Currently, primary treatments for executive function deficits in school-aged children with ADHD include medication and behavioral or psychological therapies, such as Cognitive Behavioral Therapy (CBT). While stimulant medications do improve executive function, not all patients are able to tolerate these medications. Behavioral interventions like neurofeedback provide customized care but show variable effectiveness and require specialized resources, making them hard to sustain. Safer, more practical, and long-lasting treatment options are urgently needed. 

Exercise interventions are increasingly recognized as a safe, effective way to improve executive function in children with ADHD. However, systematic studies on school-aged children remain limited.  

Moreover, there are two main scoring methods for assessing executive function: positive scoring (higher values mean better performance, such as accuracy) and reverse scoring (lower values mean better performance, such as reaction time). These different methods can affect how results are interpreted and compared across studies. This meta-analysis explored how different measurement and scoring methods might influence results, addressing important gaps in the research. 

The Study:

Only randomized controlled trials (RCTs) involving school-aged children (6–13 years old) diagnosed with ADHD by DSM-IV, DSM-5, ICD-10, ICD-11, or the SNAP-IV scale were included. Studies were excluded if the experimental group received non-exercise interventions or exercise combined with other interventions. 

Cognitive Flexibility 

Using positive scoring, exercise interventions were associated with a narrowly non-significant small effect size improvement relative to controls (eight RCTs, 268 children). Using reverse scoring, however, they were associated with a medium effect size improvement (eleven RCTs, 452 children). Variation (heterogeneity) in individual RCT outcomes was moderate, with no sign of publication bias in both instances. 

Inhibitory Control 

Using positive scoring, exercise interventions were associated with a medium effect size improvement relative to controls (ten RCTs, 421 children). Using reverse scoring, there was an association with a medium effect size improvement (eight RCTs, 265 children). Heterogeneity was moderate with no sign of publication bias in either case. 

Working Memory 

Using positive scoring, exercise interventions were associated with a medium effect size improvement relative to controls (six RCTs, 321 children). Using reverse scoring, the exercise was associated with a medium effect size improvement (five RCTs, 143 children). Heterogeneity was low with no indication of publication bias in both instances. 

Conclusion:

The team concluded, “Exercise interventions can effectively improve inhibitory control and working memory in school-aged children with ADHD, regardless of whether positive or reverse scoring methods are applied. However, the effects of exercise on cognitive flexibility appear to be limited, with significant improvements observed only under reverse scoring. Moreover, the effects of exercise interventions on inhibitory control, working memory, and cognitive flexibility vary across different measurement paradigms and scoring methods, indicating the importance of considering these methodological differences when interpreting results.” 

Although this work is intriguing, it does not show that exercise significantly improves the symptoms of ADHD in children. This means that exercise, although beneficial for many reasons, should not be viewed as a replacement for evidence-based treatments for the disorder.

December 3, 2025

Here’s What the Wall Street Journal Got Wrong about the Medication Treatment of ADHD Patients: A Lesson in Science Media Literacy

A recent Wall Street Journal article raised alarms by concluding that many children who start medication for ADHD will later end up on several psychiatric drugs. It’s an emotional topic that will make many parents, teachers, and even doctors worry: “Are we putting kids on a conveyor belt of medications?”

The article seeks to shine a light on the use of more than one psychiatric medication for children with ADHD.   My biggest worry about the article is that it presents itself as a scientific study because they analyzed a database.  It is not a scientific study.  It is a journalistic investigation that does not meet the standards of a scientific report..

The WJS brings attention to several issues that parents and prescribers should think about. It documents that some kids with ADHD are on more than one psychiatric medication, and some are receiving drugs like antipsychotics, which have serious side effects.  Is that appropriate? Access to good therapy, careful evaluation, and follow-up care can be lacking, especially for low-income families.  Can that be improved?  On that level, the article is doing something valuable: it’s shining a spotlight on potential problems.

It is, of course, fine for a journalist to raise questions, but it is not OK for them to pretend that they’ve done a scientific investigation that proves anything. Journalism pretending to be science is both bad science and bad journalism.

Journalism vs. Science: Why Peer Review Matters

Journalists can get big datasets, hire data journalists, and present numbers that look scientific.  But consider the differences between Journalism and Science. These types of articles are usually checked by editors and fact-checkers. Their main goals are:

 Is this fact basically correct?

 Are we being fair?

 Are we avoiding legal problems?

But editors are not qualified to evaluate scientific data analysis methods.  Scientific reports are evaluated by experts who are not part of the project.  They ask tough questions like: 

Exactly how did you define ADHD? 

How did you handle missing data? 

Did you address confounding? 

Did you confuse correlation with causation?

If the authors of the study cannot address these and other technical issues, the paper is rejected.

The WSJ article has the veneer of science but lacks its methodology.  

Correlation vs. Causation: A Classic Trap

The article’s storyline goes something like this:  A kid starts ADHD medication.  She has additional problems or side effects caused by the ADHD medications.   Because of that, the prescriber adds more drugs.  That leads to the patient being put on several drugs.  Although it is true that some ADHD youth are on multiple drugs, the WSJ is wrong to conclude that the medications for ADHD cause this to occur.  That simply confuses correlation with causation, which only the most naïve scientist would do.

In science, this problem is called confounding. It means other factors (like how severe or complex a child’s condition is) explain the results, not just the thing we’re focused on (medication for ADHD). 

The WSJ analyzed a database of prescriptions.  They did not survey the prescribers who made the prescriptions of the patients who received them.  So they cannot conclude that ADHD medication caused the later prescriptions, or that the later medications were unnecessary or inappropriate. 

Other explanations are very likely.   It has been well documented that youth with ADHD are at high risk for developing other disorders such as anxiety, depression,  and substance use.  The kids in the WSJ database might have developed these disorders and needed several medications.  A peer-reviewed article in a scientific journal would be expected to adjust for other diagnoses. If that is not possible, as it is in the case of the WSJ’s database, a journal would not allow the author to make strong conclusions about cause-and-effect.

Powerful Stories Don’t Always Mean Typical Stories

The article includes emotional accounts of children who seemed harmed by being put on multiple psychiatric drugs.  Strong, emotional stories can make rare events feel common.  They also frighten parents and patients, which might lead some to decline appropriate care. 

These stories matter. They remind us that each data point is a real person.  But these stories are the weakest form of data.  They can raise important questions and lead scientists to design definitive studies, but we cannot use them to draw conclusions about the experiences of other patients.  These stories serve as a warning about the importance of finding a qualified provider,  not as against the use of multiple medications.  That decision should be made by the parent or adult patient based on an informed discussion with the prescriber.

Many children and adults with ADHD benefit from multiple medications. The WSJ does not tell those stories, which creates an unbalanced and misleading presentation.  

Newspapers frequently publish stories that send the message:  “Beware!  Doctors are practicing medicine in a way that will harm you and your family.”   They then use case studies to prove their point.  The title of the article is, itself, emotional clickbait designed to get more readers and advertising revenue.  Don’t be confused by such journalistic trickery.

What Should We Conclude?

Here’s a balanced way to read the article.  It is true that some patients are prescribed more than one medication for mental health problems.  But the article does not tell us whether this prescribing practice is or is not warranted for most patients.  I agree that the use of antipsychotic medications needs careful justification and close monitoring.  I also agree that patients on multiple medications should be monitored closely to see if some of the medications can be eliminated.  Many prescribers do exactly that, but the WSJ did not tell their stories.  

It is not appropriate to conclude that ADHD medications typically cause combined pharmacotherapy or to suggest that combined pharmacotherapy is usually bad. The data presented by the WSJ does not adequately address these concerns.  It does not prove that medications for ADHD cause dangerous medication cascades.

We have to remember that even when a journalist analyzes data, that is not the same as a peer-reviewed scientific study. Journalism pretending to be science is both bad science and bad journalism.

Oppositional Defiant Disorder, Autism, and ADHD: New Research Examines the Connection

Oppositional Defiant Disorder (ODD)—a pattern of chronic irritability, anger, arguing, or defiance—is one of the most challenging behavioral conditions families and clinicians face. 

A new study involving 2,400 children ages 3–17 offers one of the clearest pictures yet. Using parent-reported data from the Pediatric Behavior Scale, researchers compared how often ODD appears in Autism spectrum disorder (ASD), ADHD-Combined presentation (ADHD-C), ADHD-Inattentive presentation (ADHD-I), and those with both ASD and ADHD.

Results

ADHD-Combined + ODD: The Highest-Risk Group

Children with ADHD-Combined presentation show both hyperactivity/impulsivity and inattention.  They had the highest ODD rates of any single diagnosis: 53% of kids with ADHD-Combined met criteria for ODD.

But when autism was added to ADHD-Combined, the prevalence jumped to 62%. This group also had the highest overall ODD scores, suggesting more severe or more impairing symptoms. 

This synergy matters: while autism alone increases ODD risk, the presence of ADHD-Combined is what pushes prevalence into the majority range. Other groups showed lower, but still significant, rates of ODD:

  • Autism + ADHD-Inattentive: 28%
  • Autism Only: 24%
  • ADHD-Inattentive Only: 14%

These findings echo what clinicians often see: children with inattentive ADHD, while struggling significantly with attention and learning, tend to show fewer behavioral conflict patterns than those with hyperactive/impulsive symptoms.

It is important to note that ODD is considered to have two main components. Across all diagnostic groups, ODD consistently broke down into these two components: either Irritable/Angry (emotion-based) or Oppositional/Defiant (behavior-based). But the balance between these components differed depending on diagnosis. Notably, Autism + ADHD-Combined showed higher levels of the irritable/angry component than ADHD-Combined alone. The oppositional/defiant component did not differ much between groups. This suggests that autism elevates the emotional side of ODD more than the behavioral side, which is important for clinicians to note before tailoring interventions.

Understanding ADHD , ASD, & Comorbidity:

The study notes that autism, ADHD, and ODD often cluster together, with 55–90% comorbidity in some combinations.

As the authors explain, The high co-occurrence of ADHD-Combined in autism (80% in our study) largely explains the high prevalence of ODD in autism.” 

Clinical Implications: Why This Study Matters

The researchers point to a straightforward recommendation: clinicians shouldn’t evaluate these conditions in isolation. A child referred for autism concerns might also be struggling with ADHD. A child referred for ADHD might have undiagnosed ODD. And ignoring one disorder can undermine treatment for the others.

Evidence-based interventions (behavioral therapy, parent training, school supports, and/or medication) can reduce symptoms across all three diagnoses while improving long-term outcomes, including overall quality of life.

November 21, 2025