Top Picks for Mental Health Professionals: Essential Reads on ADHD and Comorbid Conditions

Written by David W. Goodman, M.D., LFAPA

The study and understanding of ADHD, particularly in older adults, has been lacking due to various reasons, resulting in an absence of appropriate diagnostic and therapeutic tools. The ADHD experience of older adults, influenced by age-related cognitive changes, associated psychiatric and medical conditions among others, has individualistic aspects that clearly need to be taken into account while diagnosing and treating.

Contributed by Mary V. Solanto, Ph.D.

There is a common misconception attached to ADHD that it always exhibits physical hyperactivity and impulsivity. People, especially women and girls, presenting an inattentive type of ADHD, showing executive dysfunction and social difficulties, are often misunderstood as being careless, lazy or eccentric. This results in a distinctive underdiagnosis and inappropriate treatment of this type of ADHD.

Remarks by Tumaini Rucker Coker, M.D., MBA

The emerging literature pinpoints various obstacles to the diagnosis and treatment of ADHD, from clinical to social factors, more so for children and adolescents of colour. This exposes existing societal gaps and puts Black and Latinx children at a disadvantage in terms of educational outcomes. To address these issues, we need to understand the importance of racial and ethnic balance and the roots of healthcare disparities and their implications for overall health and wellness.

Written by Michelle Frank, Psy.D.

Increasing evidence highlights the strong connections between traumatic stress and ADHD. People with ADHD are shown to have experienced challenging situations like domestic violence, caregiver substance abuse, neglect, mental illness, poverty, and community violence at a higher percentage than neurotypical individuals. Racism, discrimination, and oppression can be traumatizing as well. The question arises as to what is the relationship between trauma and ADHD and what are its implications for diagnosis and treatment?

A piece by Stephen Hinshaw, Ph.D.; Ellen Littman, Ph.D.; and Andrea Chronis-Tuscano, Ph.D.

Critical elements of ADHD in females, including self-harm, peer relationships, trauma, and more, have been neglected in the empirical evidence. It is important that future research and clinical approaches account for these factors, addressing the significant gender differences. The conclusion, ADHD in females has been inadequately addressed for too long, and it is time to reassess the current understanding and approach towards it.

Article by Timothy Wilens, M.D.

The delayed development of the frontal lobe associated with ADHD makes it more challenging for teenagers to regulate their emotion, anxiety, reward, and risk behavior. This differential brain development can cause dysregulation and instability in adolescents with ADHD and emphasizes the need for continuous family support during these formative years.

Content by Jeanette Wasserstein, Ph.D.

The hormonal changes connected to menopause specifically impact women with ADHD. Unfortunately, despite heightened interest, there are no specific studies examining menopause in females with ADHD, resulting in a significant healthcare gap. Current knowledge about menopause, estrogen's role, and hormonal changes' effects can help understand the menopausal experience of women with ADHD and aid clinicians in their treatment approach.

Work by Roberto Olivardia, Ph.D.

Depression co-existing with ADHD sets unique risks and challenges requiring appropriate management of both conditions. People with mood disorders and ADHD are more likely to experience earlier onset depression, need more hospitalizations due to depression, encounter recurrent episodes, and have a higher suicide risk.

Contribution by Joel Nigg, Ph.D.

"Despite taking into account associated comorbid conditions, individuals with ADHD still present significant challenges in managing anger, irritability, and other emotional responses. These issues are part and parcel of the broader self-regulation difficulties that define ADHD. However, recent discoveries suggest a genetic link between problems with emotional regulation, including anger and negative emotions, and ADHD. In essence, emotional dysregulation is one major contributor to the subjective difficulty of managing ADHD and the increased risk for others issues, like depression, anxiety or harmful self-medication."

by John Piacentini, Ph.D., ABPP

"Persistent tic disorders, including Tourette's disorder, affect approximately one in fifty children in the U.S. according to the most current studies. Moreover, tic disorders are highly comorbid. Over 80% of children with Tourette's disorder also have a co-existing mental, behavioral or developmental disorder, with ADHD and anxiety being the most prevalent. These statistics suggest that healthcare professionals caring for pediatric patients are likely to encounter tic disorders."

by Roberto Olivardia, Ph.D.

"The topic of medication for children with ADHD is incredibly contentious and unclear, more so than any other condition I treat. Parents often struggle with the decision to add medication to their child's treatment plan. They invest time in researching the advantages and disadvantages of ADHD medication, but their findings are often influenced by feelings of guilt and fear of judgement. It is necessary to educate parents about how these medications work and their potential usefulness, but it is equally important for healthcare professionals to empathize with and acknowledge the unspoken concerns parents often face as they go through the decision-making process."

by Evelyn Polk Green, M.S.Ed.

"Stigma in Black and other marginalized communities poses significant barriers to accepting ADHD diagnoses and treatment. Parents may interpret an ADHD diagnosis as an indication of intellectual disability in their child. They also worry that an ADHD diagnosis would result in their child being placed in special education, where Black and Latinx children are often disproportionately enrolled, frequently with less than ideal outcomes. Decisions about treatment are further influenced by historical and systemic medical mistreatment. Such fears, although based on valid concerns, often lead to detrimental results, including reluctance of parents to incorporate medication into ADHD treatment plans."

by Kathleen Nadeau, Ph.D.

"Contrarily to what many believe, ADHD does not fade with age like stamina or hairlines. Symptoms might actually intensify and become more prevalent particularly after midlife – exacerbated by normal age-related cognitive decline, deteriorating physical health, and the absence of routine that often comes with retirement. However, it's baffling to see that the unique requirements of this sizeable and increasing population of adults with ADHD are mostly overlooked in diagnostic tests, recognized treatment methods, and scholarly research."

by Mark A. Stein, Ph.D.

"Research supports the higher prevalence of sleep disruptions among children with ADHD. Clinical experience reveals that characteristics and symptoms of ADHD – such as difficulty in 'switching off' the mind – coupled with psychiatric disorders like anxiety and oppositional defiant disorder can trigger or worsen sleep problems. Furthermore, sleep issues, including insomnia, are often a side effect of ADHD medications. This indicates that both ADHD symptoms and the foundational methods of treating these symptoms increase a person's chances of experiencing poor sleep."

by Joseph Biederman, M.D.; Mohammed R. Milad, Ph.D.; and Andrea Spencer, M.D.

"Our comprehensive analysis and review of various studies exploring the relationship between ADHD and PTSD uncovers a two-way link between these two disorders. The relative risk for PTSD in those with ADHD is four times higher than normal controls; it's almost 2 against psychiatric controls, and 1.6 against traumatized controls. The risk for ADHD in individuals with PTSD is double that observed in normal controls."

by Theresa Regan, Ph.D.

"Although there is rising 'autism awareness', what is significantly missing is a comprehensive 'autism recognition.' There are very few medical professionals and mental healthcare providers who can confidently state: 'I can identify autism in educational settings, medical clinics, families and communities.' Since ASD manifests in multiple behavioral traits, professionals frequently overlook the broader picture of autism and tend to separately diagnose various elements of the condition - such as obsessive compulsive disorder (OCD), social anxiety, eating disorder, bipolar disorder, or ADHD."

by Oren Mason, M.D.

Thomas E. Brown, Ph.D., and Ryan J. Kennedy stumbled upon the concept of 'combination therapy' - using both a stimulant and non-stimulant to alleviate ADHD symptoms. There was scant knowledge about it during their time in medical school in 2000, and they gleaned most of their understanding from their patients who found the approach efficacious in symptom management.

Russell Barkley, Ph.D., explores the omission of emotional dysregulation and moodiness from the diagnostic parameters for ADHD. He suggests that this is a significant oversight, as these symptoms are common in patients with ADHD. Conditions such as bipolar disorder also prominently feature chronic moodiness and may complicate the diagnosis process. The critical differentiation of moodiness in ADHD and bipolar disorder is complex but crucial.

An observation by Elena Man, M.D.; Amy Dryer, M.D.; and Rachel Sayer, LCPC, PCIT-C, highlights that the ADHD symptom descriptions listed in the DSM were primarily designed for children. The inability of these descriptions to accurately convey the adult experience of the condition compels clinicians to infer their relevance in adult-focused clinical practice.

William Dodson, M.D., LF-APA, discusses the disturbingly high risk of severe mental health issues among LGBTQIA+ youth, including high rates of depression, anxiety, and suicidal thoughts, as per a 2022 Trevor Project survey. He advocates for comprehensive support measures to mitigate these alarming trends.

A study from the American Academy of Child and Adolescent Psychiatry cited by Roberto Olivardia, Ph.D.; Jannice Rodden, and ADDitude Editors, recommends medication as the first line of treatment for ADHD. Despite this endorsement, the topic of ADHD is conspicuously absent in the curriculum of a large number of psychiatry and pediatric residencies, creating challenges for physicians in formulating effective treatment plans.

Adelaide S. Robb, M.D., reveals the frequent co-occurrence of Bipolar disorder (BD) and ADHD, with significant comorbidity figures. This rate necessitates dual evaluations for patients, but bipolar disorder often gets overlooked or misdiagnosed due to symptom similarities with ADHD.

According to Sarah Cheyette, M.D., ADHD rarely occurs in isolation. Hence, clinicians must diligently screen for and address ADHD and its associated conditions concurrently. A thorough psychological evaluation provides comprehensive data about a patient’s ADHD symptoms and any existing comorbidities.

Lastly, William Dodson, M.D., LF-APA draws attention to the higher susceptibility of children with ADHD to migraines and headaches compared to their non-ADHD peers. Research indicates that migraine frequency could correlate to ADHD risk and continues into adulthood. In adults, approximately 35% of patients suffering from ADHD also experience migraines.

“ADHD medications work dramatically well. Still, medication nonadherence is a serious – and often unnoticed – problem among adult patients, regardless of age or prescription. According to a recent study, fewer than half of adult patients could be considered ‘consistently medicated’ for ADHD, based on prescription renewal records. Prescribers must understand and address the barriers to ADHD medication adherence to provide the best care possible for patients and improve long-term outcomes.”

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