Dr. Daniel Knoepflmacher (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind. Our focus today is on attention deficit hyperactivity disorder or ADHD, a a neurodevelopmental condition that emerges in children, but can persist into adulthood. ADHD affects millions of children and adults globally, making it one of the most commonly diagnosed psychiatric conditions across the lifespan.

While ADHD generates a lot of attention in our contemporary culture, the condition has been observed in children for more than 200 years. In 1798, the Scottish physician Alexander Crichton described a condition of distractibility in children that rendered them, in his words, incapable of attending with constancy to any one object of education. Other doctors observe common characteristics of what some called fidgety children. Through the 19th Century into the 20th Century until in 1937, Charles Bradley reported a positive effect of stimulant medication on children who were hospitalized for difficulties in learning and behavior. It was an accidental discovery with him observing what he described as a remarkably improved school performance in approximately half the children who were given the stimulant, benzedrine.

We now know that ADHD is characterized by patterns of inattention, hyperactivity, and impulsivity. But the way these symptoms present can vary widely among individuals reflecting a complex interplay of genetic, neurobiological, social, psychological, and environmental factors that underlie the condition. When left unrecognized, aDHD can lead to significant challenges in academic, occupational, and social functioning. But with timely diagnosis and a combination of evidence-based treatments, including behavioral interventions and medication, many individuals with ADHD thrive building on their innate strengths.

In this episode, we'll explore the evolving understanding of ADHD, discuss strategies for effective diagnosis, and review the current best practices for treatment. To help us explore this topic today, I'm thrilled to welcome our guest, Dr. Anne McBride, who is a Senior Professor of Clinical Psychiatry at Weill Cornell Medicine. Anne, thank you so much for joining me today.

Dr. Anne McBride: Well, thank you, Daniel, for inviting me. It's quite an honor to participate in the On the Mind series.

Dr. Daniel Knoepflmacher: Well, we have a lot to talk about, and I'm very excited to hear what you're going to say. But I always begin by asking each of my guests about their story. And in your case, I know that in the 1980s, you became one of the first New York City psychiatrists specializing in pediatric psychopharmacology, and you really gained prominence for your expertise within Child and Adolescent Psychiatry. So, can you share how you came to specialize in this area?

Dr. Anne McBride: I'd be glad to. As a Payne Whitney Clinic resident in Adult Psychiatry during the late 1970s and early '80s, I was among a small number of trainees, more drawn to Neurobiology and to Psychopharmacology than to Psychoanalytic Psychotherapy. During my third year of adult residency training, I was approached by Dr. John Mann, a newly arrived faculty member, to work in his lab. The focus of study was serotonergic function in neuropsychiatric disorders and suicide.

After completing adult training in 1982, I began a fellowship in Child Adolescent Psychiatry at Payne Whitney. Like so many entering the field of Child Psychiatry, I appreciated the opportunity for early intervention. Moreover, I enjoy children. During both Adult and Child Psychiatry residency training, I was provided dedicated time to conduct projects in association with Dr. Mann. . The focus of my work was serotonergic function in autistic disorder.

In 1986, I joined the faculty of the Payne Whitney Clinic, Division of Child and Adolescent Psychiatry. I founded the Pediatric Psychopharmacology Clinic while directing the Child Psychiatry Consultation liaison service. I simultaneously started a faculty practice largely devoted to diagnostic assessment and medication management with children and adolescents. At that time, Pediatric Psychopharmacology was an emerging field. In the early years of my career, I used to say you could count on the fingers of one hand the number of clinicians in New York City specializing in the use of psychotropic medication in children. As is the case in most pediatric psychopharmacology practices, a sizable number of the children were undergoing treatment for ADHD using stimulant medication.

In 1989, I was awarded a five-year NIMH first award for studies of serotonergic function and autistic disorder. I inherited Dr. Mann's laboratory when he moved to the University of Pittsburgh in 1990. For an array of personal and professional reasons, I left laboratory research in the late 1990s, expanding my faculty practice and my role in Child Psychiatry Residency Training. My research training provided invaluable understanding about the evolving literature on the neurobiological basis of psychiatric disorders, and the use of medication as an aspect of a treatment plan.

Dr. Daniel Knoepflmacher: So, research really was your inspiration initially, but you really became a primary clinician. Is that right?

Dr. Anne McBride: Yes.

Dr. Daniel Knoepflmacher: I want to begin by asking you about the core features and symptoms of ADHD. What does ADHD look like?

Dr. Anne McBride: There are two categories of symptoms that comprise the diagnosis of ADHD in the Diagnostic and Statistical Manual of Mental Disorders, the Fifth Edition, known as DSM-5. These are, one, inattention and, two, hyperactivity and impulsivity. Individuals with ADHD often have difficulty sustaining and modulating attention. They are prone to lose focus during conversation, during instruction, when reading and when engaged with activities. They often fail to pay attention to details and make careless mistakes. They often have challenges with following directions and completing tasks. For example, schoolwork in the case of children, work related tasks in the case of adults. Individuals with ADHD tend to become bored easily and are prone to avoid tasks that require sustained mental effort.

In association with inattention, persons with ADHD typically have relatively weak executive function. They struggle to organize tasks and activities, especially when multiple steps are involved. They may forget deadlines and appointments. They lose things more often than other people do. They tend to be easily distracted by environmental stimuli such as noise. Symptoms of hyperactivity and impulsivity include excessive motor activity or an internal sense of physical restlessness. As young people mature, they often are less hyperactive, but more describe a sense that they're restless even when they look like they're sitting still. It is hard to be comfortable sitting still for more than brief periods. Individuals with ADHD may be boisterous or talk excessively. They have trouble waiting their turn patiently. Impulsivity may be evident in intrusive behavior in social situations like interrupting, finishing other people's sentences.

DSM-5 criteria require that symptoms of inattention and/or hyperactivity-impulsivity were present before the age of 12 years and have been present in at least two settings. Symptoms should not be better explained by another disorder.

Dr. Daniel Knoepflmacher: It's really remarkable when Dr. Crichton in 1798 was describing this. Actually, he was right on the money with a lot of the symptoms that are now being described in DSM-5. In my introduction, I talked about this being a very common disorder around the world. I'm wondering if you could tell us what the prevalence of ADHD is.

Dr. Anne McBride: The reported prevalence of ADHD in the U.S. has shifted over time. When I took the Child Psychiatry board exam in 1983, the expected answer was 3-5%. DSM-5 published in 2013 cites population surveys suggesting ADHD is found in most cultures at a rate of about 5% in children and 2.5% in adults. However, in 2024, the CDC reported that 11.4% of U.S. children under age 18 years carry a diagnosis of ADHD. The figure was 15% for adolescents. ADHD is more common in boys than in girls, currently with two boys for every girl.

Dr. Daniel Knoepflmacher: So, it's interesting you're talking about the prevalence and there being some questions around this and how there's a really high prevalence found in adolescents. And I think this brings up a question that is true with many psychiatric diagnoses. And it's whether this is a distinct neurobiologically-based disorder or a condition that is part of a continuum of attentional and executive functioning within a general population that's basically just trying to deal with the demands of our modern society. So that when we look at that percentage, if the way that the expectations were set up, let's say for adolescents, if they were different, then maybe that percentage would be different. So, I'm wondering how you conceptualize ADHD in these terms.

Dr. Anne McBride: It has long been my belief that symptoms of ADHD are on a continuum with typical attentional and executive functioning, but where issues with modulating and sustaining attention. With regulating one's impulses and motor activity caused challenges managing in the modern world. It is likely that the person meeting criteria for ADHD had an advantage back when humans lived in the wild and hunted and gathered for their food. It was adaptive to rapidly shift focus to every noise and movement in the brush, to be physically active, ready to pounce. However, in our classroom-based education system, students are expected to sit quietly for hours and to maintain focus on a single subject, person or activity for an extended period. They are expected to remain focused even when the material is boring or requires extensive rote memorization. It is absolutely the case that a person's level of ADHD symptoms varies with the environment and with the demands. Many children show fewer symptoms of ADHD outside of academic settings and activities. It is common for adults to describe a significant reduction in symptoms once they have the freedom to study subjects of interest, or they have landed jobs that speak to their interests and strengths.

What defines ADHD to my mind is the magnitude, the severity of challenges related to attention, impulse control, motor activity and executive function. There needs to be a functional impairment. The person who warrants a diagnosis of ADHD should have a history of significantly more difficulty than their peers with managing age and context-appropriate tasks involving information processing and work output. Impairments may vary significantly by setting or by phase of life, but should be sufficient that the individual has suffered from persistent challenges with educational achievement, establishing and maintaining peer friendships and/or appropriately managing activities of daily living. The foregoing said it remains an open question. What neurobiological factors render a person more likely to struggle with attention and executive function than most individuals in the general population?

Dr. Daniel Knoepflmacher: So, Anne, I'm wondering how you think about this estimated prevalence that you described and how it corresponds with the actual amount of diagnosis and treatment of ADHD in the U.S. In other words, do you have a sense of whether there's overdiagnosis and/or underdiagnosis of this condition in children generally?

Dr. Anne McBride: Historically, there was likely underdiagnosis of ADHD in children. During the past couple decades, medical organizations have supported case finding, particularly in pediatric practices. It is now common for children and/or their parents to complete ADHD screening questionnaires such as the Conners, the Vanderbilt, the SNAP at their annual physical exams.

 Educators are more aware of ADHD as a potential contributing factor to students' academic and behavioral challenges. So, there are legitimate reasons for the rising prevalence of ADHD. This said, there is currently an appearance of overdiagnosis among adolescents and young adults. The diagnosis is sometimes sought with the goal of obtaining extended time on classroom tests or college entrances exams.

Stimulant abuse is likely common on college campuses. Several of my patients have commented that just about everyone in their dorm has a prescription for a stimulant medication. It is common for students to snort ground up what are called little blue pills at parties. There may be an increase in medical practitioners who overprescribe stimulant medication as an aspect of their business model. I believe such practice was uncommon before the advent of widescale telemedicine.

Dr. Daniel Knoepflmacher: What you're describing, Anne, is kind of pressures on both sides. It sounds like there's pressures from parents and kids sometimes who are in competitive environments where they may feel like they need an edge, that that's part of a culture in colleges where everybody, as people feel that you're describing, that everybody is using stimulants.

And then, on the other side, unscrupulously, that there are some physicians or providers who are making money prescribing these or overprescribing these. Those are kind of the tensions that are driving overdiagnosis, you think?

Dr. Anne McBride: Well, it's become a lot easier to obtain a prescription for a stimulant medication. It is my understanding that the evaluations by several telemedicine providers are quite brief. Answering a few questions, stating that one has difficulty concentrating. I don't think this was so common before the telemedicine era went into effect during the pandemic, although I was aware in past decades of a very small number of prescribers who are very quick to give a stimulant prescription.

Dr. Daniel Knoepflmacher: Well, this really brings up a lot of questions. First of all, I think your emphasis on level of impairment and distress is such an important focus, and that's true for most psychiatric treatment, that that's when it reaches the threshold that we treat. But it does bring up questions around culture and difference in different contexts. And I'm wondering if you see variations between the way that ADHD is identified or is treated in the U.S. versus the rest of the world.

Dr. Anne McBride: So, my answer to your question is largely based on my experience seeking to help my American patients with ADHD who are living or traveling abroad. The prevailing view in most European countries and in Japan is that ADHD is America's excuse for poor parenting and a lack of limit setting. There is a widespread belief that ADHD is not a valid diagnosis. It is extremely difficult to obtain a prescription for a stimulant medication in the U.K. Japan bans tourists from bringing most stimulant medications into the country for their own personal use. Until a couple years ago, Japan did not allow the non-stimulant medication into the country, because it's FDA approved to treat ADHD.

Dr. Daniel Knoepflmacher: Well, it's interesting the perceptions in Japan or the U.K. about American parenting, I think we both could have a lot to say on that, but that's not what we're going to focus on today. Instead, I want to actually speak a bit about the underlying neurobiology. Can you explain what we know about the neurobiology of ADHD?

Dr. Anne McBride: What we do know is that ADHD is highly heritable. Beyond that, not much has been established. No single gene has been associated with ADHD. Reports of alterations in brain electrical activity and in cortical and subcortical volume have either failed replication or have been so slight as to lack apparent significance. Among the more robust findings are deficiencies in executive function and in motivation found with neuropsychological testing. As of now, there is no biomarker or diagnostic test for ADHD.

Dr. Daniel Knoepflmacher: So without any distinct biological markers for diagnosis, I'd like you to tell us what is involved in a gold standard clinical evaluation for ADHD.

Dr. Anne McBride: The first step is obtaining a detailed, comprehensive history. This should include not only a review of symptoms constituting DSM-5 criteria for ADHD, but of one's overall emotional, social, and cognitive functioning. A medical history should be obtained and, in the case of adolescents and adults, a history of substance use and trouble with the law. Discussion of family function is relevant along with a history of family neuropsychiatric disorders. Parents usually provide the history in the case of children. Adolescents may join their parents for the initial evaluation. Adults provide their own history, but it is so useful to have parental input where it's available.

 The next step is the mental status exam. I typically meet with children in the office on a day following my interview with their parents. The visit includes observations of attention, impulse control, and motor activity during conversation, play, and the execution of graphomotor tasks at my desk. I watch for signs of anxiety, depression, and deficits in cognitive or language development. By the latter part of elementary school, children are often able to provide relevant self observations. Adolescents and adults may undergo a mental status exam on the initial day of the evaluation.

 Next, one obtains collateral observations from a child's educators and, where relevant, therapist. Sometimes kids are referred by a therapist. I seek a telephone interview with the child's teacher and/or advisor, sometimes with a school psychologist. It is requested that the classroom teachers complete standardized ADHD rating scales. Some individuals have had a neuropsychological evaluation. I ask for a copy of the report to review before the first appointment. Neuropsychological testing is not necessary to make a diagnosis if ADHD, but can be a valuable source of information about attentional and executive function. School records are useful when they contain narrative accounts of a student's learning profile and classroom behavior.

 The final step in a goals standard evaluation is the feedback visit, during which the clinician provides a diagnostic impression and options for intervention. Adolescents often join their parents for the feedback visit. Potential interventions include educational support, social skills training, parent management training, individual psychotherapy for anxiety and/or other comorbidities as well as medication FDA approved to treat ADHD patients. And their parents benefit from discussion of the nature of ADHD and what to expect over time. An appointment may be made for followup care if the patient and/or family wish to proceed.

Dr. Daniel Knoepflmacher: And one thing you didn't mention in all of that that I want to ask you about is a screening or some kind of tool like the Conners that you can use to evaluate for ADHD. Can you speak about those scales specifically?

Dr. Anne McBride: Yeah. Well, that's what I was referring to with regard to classroom teachers completing ADHD rating scales. Parents also will complete them. In my evaluation though, I find that what the parents have to say in describing their child is far more informative than the checklists. People fill out these checklists in a different manner. If you obtain Conners rating scales from high school teachers, usually, it's about five academic subjects. The results often come back quite discrepant, same patient, but very different ratings. So, a student may appear to have the worst ADHD ever or none at all in the same batch of rating scales from the teachers.

Dr. Daniel Knoepflmacher: That discrepancy, do you think that has to do with the level of interest that the individual with the ADHD has in that subject or what?

Dr. Anne McBride: I think that's sometimes a big factor. The student who's very engaged in a given subject or really likes a given teacher is probably going to be more attentive. I also think sometimes, the teachers have different notions of what is distractibility. And sometimes, they're invested in a diagnosis being present or not present. Sometimes teachers feel awkward about endorsing symptoms in a student. In some public schools, teachers are advised not to say much about a child's symptoms that may require some kind of evaluation. So, those rating scale sometimes come back with little symptoms.

Dr. Daniel Knoepflmacher: Those scales, as you described them, are not perfect tools, it sounds like. There can be some variability in there, and that's why I guess it's really important to have them as one piece of a really comprehensive valuation, which you described in great detail. I'm wondering if you can talk to us about the clinical variations that you see encompassed within the diagnosis of ADHD, both in terms of severity, but also the distinct types such as hyperactive versus more inattentive.

Dr. Anne McBride: There are three ADHD subtypes in the DSM-5: ADHD, combined presentation; ADHD, predominantly inattentive presentation; and ADHD, predominantly hyperactive-impulsive presentation. Individuals with the combined presentation have significant symptoms in the areas of both inattention and hyperactivity impulsivity.

The combined presentation is the most common subtype. As you would imagine, those with predominantly inattentive presentation are distractible without significant hyperactivity and impulsivity. Those with a hyperactive-impulsive presentation are physically restless and impulsive, but do not have enough symptoms to meet full criteria for inattention. This is the least common subtype. I have encountered this subtype, mostly in little boys where there is not much demand for sustained attention yet. There is a fourth ADHD category: ADHD, unspecified, for individuals who have significant ADHD symptoms, but who do not have enough symptoms to meet full criteria for any of the three primary subtypes.

It is worth noting it is not uncommon for a person to move from one subtype to another over the course of time. For example, a hyperactive child may present as predominantly an attentive in late adolescence. With each subtype, there is a wide range in symptom severity. Individuals with relatively mild symptoms often function pretty well when circumstances are conducive, though they struggle in some environments and with some tasks.

In its most severe form, ADHD is very debilitating. Individuals with severe symptoms often perform poorly in school and in the workplace, achieving less success in life than what would have predicted by their overall intelligence. Distractibility, impaired executive function and impulsivity often negatively impact their social relationships as well as their economic stability.

Dr. Daniel Knoepflmacher: Thank you for going through the differences in severity and types. I'm curious how, if at all, you see this tracking on differences between boys and girls who have ADHD.

Dr. Anne McBride: Girls are significantly more likely than boys to have predominantly inattentive presentation. It is thought the inattentive presentation is the most common form in girls. However, the combined presentation is frequently found in girls as well as in boys. So certainly, we do see girls who are hyperactive and impulsive as well as inattentive.

Dr. Daniel Knoepflmacher: Well, you mentioned that boys are twice as likely to be diagnosed with ADHD. Do you think part of that might be that sometimes inattentive ADHD is missed in girls?

Dr. Anne McBride: It probably is sometimes missed or felt to be due to another cause, the inattention. However, it is also worth noting that neuropsychiatric disorders across the board are more common in boys than in girls. So, there may well be a biological difference.

Dr. Daniel Knoepflmacher: In your discussion of the gold standard evaluation, you talked about really investigating for other psychiatric diagnoses as well. So, I'm wondering, what are comorbid diagnoses that are often seen along with ADHD?

Dr. Anne McBride: Approximately three quarters of children who carry a diagnosis of ADHD meet criteria for another psychiatric disorder or a learning disorder. Among the most common comorbid disorders is oppositional defiant disorder. Some studies have found about a quarter of adolescents with ADHD combined presentation have a comorbid conduct disorder, though rates vary by setting.

I would say that in my own practice, I do not find many kids with conduct disorder. This may be more common in more disadvantaged populations for psychosocial reasons. About a third of youth with ADHD carry a diagnosis of an anxiety disorder. Children with disruptive mood dysregulation disorder or autism spectrum disorder often meet criteria for ADHD as well. However, DMDD and autism are not common among the overall population of youth with ADHD. Rates of depression are elevated in children and adolescents with ADHD compared with the general population, but are still relatively low. Roughly, a third of children with ADHD also have a specific learning disability impacting reading, writing, or math.

In adolescents and young adulthood, you see a rise in substance use disorders. Adolescents with ADHD are more likely than their peers to disengage from school. Once disengaged, they are more likely to hang out in groups rather than to participate in extracurricular activities. This is a setup for use of recreational substances. Rates of substance use disorders are minimally elevated in young people whose ADHD symptoms are reduced through effective interventions.

Dr. Daniel Knoepflmacher: You mentioned evaluating for depression and anxiety. And with both of those, those are disorders which can impact someone's concentration and attention. So, I'm wondering what diagnoses can be confused with ADHD when someone's being evaluated.

Dr. Anne McBride: Probably what comes up most commonly is a question of whether the problem is related to anxiety. The question often arises as to whether a child is distractible because he or she is anxious or preoccupied. A person with OCD, obsessive compulsive disorder, might be distracted by obsessional rumination or intrusive thoughts. Individuals who develop bipolar disorder in adolescents or young adulthood often presented as meeting criteria for ADHD combined presentation in childhood. And there is a significant overlap between the symptoms of ADHD and mania. Major depression is uncommon in children before puberty, but certainly does present during adolescence. In evaluating whether or not distractibility is more related to depression, we are really conducting an assessment for depression.

People under the influence of a substance may have disturbances in their cognitive function and/or their capacity for self-regulation. Developmental language disorders impact information processing, especially with oral communication. A comprehensive history and in-depth mental status exam tend to clarify the differential diagnosis when you're doing an evaluation.

Dr. Daniel Knoepflmacher: We've talked a lot about evaluation. I want to turn to treatment, specifically medications. Stimulants are the first line when it comes to medications for ADHD. I'm curious, what percentage of patients you are treating for this diagnosis receive stimulants?

Dr. Anne McBride: There are patients who do not tolerate stimulant medication due to side effects. Stimulants may exacerbate anxiety or obsessive compulsive symptoms. Their effects on focus are not selective. If a person is preoccupied with a concern, he or she may hyperfocus on the concern while on a stimulant. The success rate with stimulant medications is no more than about 80%, even following trials of multiple products. Thus, about 15% of my ADHD patients are taking a non-stimulant medication, FDA-approved for ADHD, sometimes in combination with a stimulant seeking greater symptom relief. Where a range of medications have not proven effective or well-tolerated, the focus of treatment is non-pharmacologic. For example, executive function coaching or parent management training.

Dr. Daniel Knoepflmacher: Can you walk us through the various stimulant medications, distinguishing between the mechanisms and the other differences, specifically between amphetamine options versus methylphenidate formulations? And I'm curious what leads you to choose one over the other.

Dr. Anne McBride: There are only two active compounds among the dozens of brand and generic stimulant products currently on the market. These two compounds are amphetamine and methylphenidate. Amphetamine and methylphenidate are close cousins with highly similar benefits and potential side effects.

As a rule of thumb, about 50% of individuals with ADHD will respond favorably to both amphetamine and to methylphenidate. About 15 to 20% will respond better to amphetamine. And then again, about 15-20% will respond better to methylphenidate. Factors contributing to product selection are the mode of medication delivery and the duration of action.

Releasing systems include dissolving tablets, oral disintegrating chewable tablets, liquid suspensions, and these coated to dissolve at specific times in one case with delayed release. There are also osmotic pumps, enzyme-controlled prodrugs, and a patch. Among the various releasing systems are short-acting immediate release options, delivering active medication for about four hours and long-acting options, delivering medication for as long as 16 hours with a single dose. Most products are a 50/50 mixture of D and L mirror image molecules. There are a few products where the L molecule, which has little benefit and more side effects has been removed during manufacture.

In the absence of a strong family history of stimulant response, it is often a tossup as to whether to start with an amphetamine or a methylphenidate product. In the case of young children, it is generally necessary to use a product that does not require them to swallow an intact pill. Some products are less susceptible to misuse.

For example, products using osmotic releasing systems cannot be ground into a powder for snorting. Enzyme-controlled prodrugs only release stimulant in the gastrointestinal tract. The relatively abuse-proof products for adolescents and adults who may be prone to use recreational drugs. Duration of action is an important consideration in choosing a product. Unfortunately, increasingly, insurance formularies are a big factor in medication selection.

Dr. Daniel Knoepflmacher: You mentioned that there's variation and duration of action with the different formulations. Can you describe how you choose among these options?

Dr. Anne McBride: A starting point is the timeframe for which medication benefit is sought. It is desirable to cover a full school day with one early morning dose. In the case of youth, in grades K through 12, sustained release products eliminate the inconvenient trip to the nurse at lunchtime. Aside from this factor, I tend to start children and adolescents on sustained release medication, because it is typically better tolerated than immediate release products. Blood levels rise and fall less precipitously with sustained release; thus, mitigating side effects. Some middle and high school students benefit from a booster dose of short-acting medication in the late afternoon to aid focus with homework. College students and adults often prefer targeted use of stimulant medication, choosing a short-acting product for times when they need to concentrate intently for a relatively brief period, and then a long-acting one for when they must focus throughout most of a day. They may choose to take no medication on an easygoing day. Even the sustained release products vary widely in the expected duration of action, the range eight to sixteen hours. A child in elementary school will likely take one of the shorter acting sustained release products. A high school student will likely do better with a product lasting 10 to 12 hours. There is one product that is given at bedtime, but does not release medication until morning at about the time when a child would be getting up for school.

Dr. Daniel Knoepflmacher: What about the potential adverse effects of stimulant treatment? How do you address these?

Dr. Anne McBride: The most common side effect in youth is appetite suppression. A lack of adequate calories and nutrients can result in growth retardation. There may be more direct effects of stimulant medication on growth. It is important to measure patients' height and weight on a frequent basis, particularly during the growing years.

Stimulant medications tend to make people more alert; thus, they can be associated with delayed sleep onset. Headaches and stomachaches are common when starting stimulant medication, especially when taken on an empty stomach. Some patients are more likely to feel a rise in anxiety on medication, particularly if they are already anxious. Adolescents often observe they are more subdued, less the life of the party on their medication. Patients with comorbid OCD may show an increase in obsessional rumination. Rebound irritability, impulsivity, or motor restlessness may occur as medication wears off. Stimulus can trigger an exacerbation of tics. Though patients with Tourette's disorder can typically take them if needed, given that exacerbations are temporary.

There is often an increase in heart rate and blood pressure on stimulants, though this is usually modest. Prescribing clinicians should periodically take measurements of blood pressure and pulse while patients are on active medication. There is a risk of cardiac arrhythmia in patients with abnormal cardiac function. A screening ECG and echocardiogram should be obtained in the case of individuals with a personal or a close family history of cardiac structural defect, cardiomyopathy, which is a muscle disease of the heart, or primary arrhythmia. Screening tests are not needed in the case of people without known cardiac risk factors.

And finally, there is a risk of abuse in people taking stimulant medicines above the doses FDA approved. Side effects are typically addressed through counseling and practical problem solving. Parents are provided nutritional counseling. They're encouraged to allow their children the foods they will eat as long as they are not totally lacking in nutritional value. People will often live with nuisance side effects if they understand what they are and are seeing significant benefit from their medication.

Dr. Daniel Knoepflmacher: That makes sense. I'm wondering if you can describe how you approach the treatment of ADHD in patients who are also struggling with substance use.

Dr. Anne McBride: Effective treatment of ADHD has been documented to reduce the long-term risk of substance use disorders in both children and adolescents. It is important to treat ADHD in the case of individuals who already have a substance use disorder. Generally, the clinician will prioritize products that cannot be ground up for snorting or for IV injection. Examples are brand Concerta, which has an osmotic releasing system, and Vyvanse, which is a prodrug, amphetamine released through enzymatic action in the gastrointestinal tract.

In the case of serious substance abuse, it is best for the patient to receive treatment with a psychiatrist with specialty training in substance use disorders. I have referred a few of my patients to a colleague with substance use training with a recognition I do not have the expertise to optimally manage the patient's care. In regions of the country where there are no dual diagnosis psychiatrists with advanced substance use training, the treating clinician may work with a substance use counselor.

Dr. Daniel Knoepflmacher: What about non-stimulant medication options? And can you tell us about the clinical scenarios when you tend to choose them?

Dr. Anne McBride: There are four non-stimulant medications FDA approved to treat ADHD in children, and an additional one for adults. Alpha-2 adrenergic receptor agonist includes sustained release clonidine, the brand name is Kapvay, and sustained release guanfacine, brand name Intuniv; selective norepinephrine reuptake inhibitors include atomoxetine, the brand name's Strattera; and viloxazine, the brand name Qelbree. Bupropion, which is brand name Wellbutrin, an aminoketone, is approved only for adults. Overall, stimulant medications are more effective in treating ADHD than non-stimulant alternatives. But there are circumstances where non-stimulants may be the better choice.

Sustained release guanfacine may work out well in patients with Tourette's disorder because it tends to reduce tics, as well as ADHD symptoms. Stimulants sometimes increased irritability in children who are highly emotionally reactive. And as we've discussed, they can exacerbate obsessional symptoms in OCD; thus, one might choose a non-stimulant at the outset of treatment. People with a substance use disorder may be prescribed a non-stimulant to decrease the odds of stimulant misuse or diversion. Non-stimulants are an alternative for patients who did not tolerate stimulants or where stimulants were ineffective in reducing ADHD symptoms. They are used as augmenting agents in patients with a partial response to stimulant medication. But where there are still significant residual ADHD symptoms, sometimes parents of children and adult patients are uncomfortable with the idea of taking a controlled substance. The stimulants are controlled substances; and thus, they may prefer the option of a non-stimulant.

Dr. Daniel Knoepflmacher: Can you describe the non-pharmacological treatments for ADHD?

Dr. Anne McBride: At the outset of treatment for ADHD, medication alone is rarely a sufficient intervention. By the time students come to medical attention, their academic performance is often below their perceived potential. They may benefit from tutoring to fill in holes in their academic skills or their fund of knowledge. Students with comorbid learning disorders might require specialized learning remediation. Most youth with ADHD will benefit from mentorship in organizational skills. The focus of executive function work in children may be writing down assignments and filing papers in an orderly fashion. High school and college students may need help with organizing their presentation of ideas and information in tight expository writing. Children who are routinely rejected by their peers may benefit from social skills training. Parents of children with ADHD combined presentation often welcome parent management training. A goal of the training is to help them understand that their children are not choosing to misbehave, but rather struggling with inattention and impulse control.

 While ADHD is not caused by poor parenting, there are parenting strategies that help children to listen better and to maintain self-control. Our own Dr. Andrea Tempkin has developed a 10-session parent management training protocol specifically for parents of children with ADHD. Other forms of intervention may be warranted for comorbid mental disorders.

Dr. Daniel Knoepflmacher: You mentioned there the psychological impact that ADHD can have on kids, and I'm wondering if you could speak more about that, how untreated ADHD impacts children's psychological development and their self-esteem.

Dr. Anne McBride: The impact will vary in association with symptoms severity. This said, self-esteem and self-confidence progressively decline when children experience persistent academic stress, rejection by their peers and/or accusations of being lazy and irresponsible. They often give up on school if they lack the skills and/or the fund of knowledge to be successful with the next grade level. This is often an issue even following a positive medication response if academic challenges have not been sufficiently addressed. Academic disengagement and failure are a setup for not only anxiety, despondency and low self-esteem, but for conduct problems and substance use. Parent-child conflict is more common when youth are performing poorly in school, oppositional, and slow to launch.

Dr. Daniel Knoepflmacher: I want to turn to adults with ADHD. What percentage of children diagnosed with ADHD continue to have persistent symptoms in adulthood?

Dr. Anne McBride: Longitudinal studies assessing the persistence of childhood ADHD into adulthood have produced widely varied rates. According to the National Library of Medicine at NIH, persistent rates vary from 5-75%. It is fair to say that a significant proportion of patients have residual symptoms, even if they no longer meet full DSM-5 criteria for ADHD. Older adolescents and young adults often experience some easing of their childhood symptoms. A common scenario is that overt signs of physical overactivity decline, though an internal experience of restlessness persists.

Adults have more discretion than school-aged children over the type of work they do. Those who acquire work in line with their talents and interests often find they sustain focus well enough without medication. It helps. There is typically less need to rapidly master new information than when in school.

 Executive function tends to improve in most individuals as the brain matures. People learn ways to organize themselves, to cope with forgetfulness. However, persistent deficits in executive function may have greater impact as demands for independent, efficient and organized work output increase. A relatively small number of patients may continue to exhibit severe ADHD symptoms into adulthood. Functional consequences include reduced educational and vocational achievement, difficulties managing activities of daily living, low self-esteem, impaired social functioning, mental health comorbidities and, importantly, reduced satisfaction in life.

Dr. Daniel Knoepflmacher: It is interesting, in my practice I actually encounter adults, because I'm an adult psychiatrist who have children that were diagnosed with ADHD. They go through an evaluation and discussions with a psychiatrist like you speaking about their children's ADHD. And then, suddenly, they think about their own childhood and the difficulties they had in school and the difficulties that they continue to have in work and wonder about whether they still meet the criteria for an ADHD diagnosis as an adult. So, I'm wondering how you approach making this diagnosis in an adult. I know you mostly see children. But when you're evaluating for an adult, what are the differences?

Dr. Anne McBride: It is hard to have confidence that a diagnosis of ADHD is warranted in the case of an adult without a documented childhood history of ADHD. We are often in the position of having to make judgements based predominantly on the patient's account. In the case of children, we typically obtain permission for contact with school to obtain collateral. It would be highly unusual to call an adult's employer. I will ask younger adults if they are willing to have a parent participate in the consultation to provide a childhood developmental history. School records are occasionally useful, but really only if they have narrative comments.

I would say it is particularly important to take a comprehensive psychiatric history during the course of the consultation. It is common for adults who believe they have ADHD to instead meet criteria for mood, anxiety, autism spectrums, substance use, and learning disorders. If more information is needed, neuropsychological testing may proof helpful in assessing focus and executive function. There's the problem of adults seeking stimulant prescriptions for misuse and diversion. State-controlled substance prescription registries help spot these individuals.

Dr. Daniel Knoepflmacher: I'll say that anecdotally with adults who have taken stimulants, it's a question, I guess, whether they would meet the criteria for ADHD as an adult. But I've seen people who I've encountered that have received these prescriptions, and they talk about the benefit. They talk about how they're focusing better at work. Their attention is better. They actually feel calmer or have less stress. The question is, is that just a lifestyle improvement by taking the medication or are we really treating ADHD? Do you have any thoughts on that?

Dr. Anne McBride: I think it's important to recognize that stimulants help focus in most individuals. Research was done decades ago that showed stimulants increased focus in both children and adults with and without ADHD. So, the effect of the stimulant medication is not particularly selective. Giving a person a stimulant medication is not a diagnostic test as to whether or not they have ADHD. I think a question you're posing, Daniel, is whether we should not be so strict about the criteria for ADHD and prescribing simulant medications. But I do believe that a number of the people who describe benefit probably don't meet criteria for ADHD and never did.

Dr. Daniel Knoepflmacher: Right. I mean, I'm not sure that we need to be less strict. I think we may need to be more strict, because I think there's a lot of people out there receiving these prescriptions as adults, given what we were just describing. I want to ask you two last questions. The first is, what are the most common misconceptions about ADHD that you observe?

Dr. Anne McBride: The most common misconception is that youth with ADHD are lazy and irresponsible, that they do not want to put out the effort to do their work and to achieve, that they just want to have fun. They just want to play video games or hang out. Another common misconception is that they misbehave on purpose to upset their parents and teachers. A third is that ADHD is a product of poor parenting.

Dr. Daniel Knoepflmacher: Let me end with one last question. What are some of the most useful tips you give to parents whose children are being treated for ADHD?

Dr. Anne McBride: A good starting point is helping parents to understand the nature of ADHD, to have a better grasp of why their children struggle and behave as they do. Parents benefit from coaching on selective attention, giving effective instructions, establishing routines, deescalating conflict, and developing point systems to encourage age-appropriate behavior. It is important to share at the outset of treatment that most children with ADHD will show improvement with adherence to a well-conceived individualized treatment plan. I often speak to the fact I have been in practice long enough to see children pass well into adulthood. Most are doing well vocationally and socially.

For most of the adults I continue to follow, medication is used on a targeted basis, mostly in the workplace. The adult patients generally are quite good at knowing when to use medication and when it is not necessary. It's been one of the real pleasures of my work to follow patients from child into adulthood and see how things turn out.

Dr. Daniel Knoepflmacher: Well, I think that's the perfect place for us to end because with all the controversy about ADHD hearing about your experience as someone who's been doing this for decades and being able to track people into adulthood and seeing how their self-esteem was developed, how they thrived as adults with this treatment, I think, is really important to emphasize. So, thank you so much for coming on the podcast today. I'm just grateful to have someone with your long-term clinical experience and your deep psychopharmacological knowledge to cover the ins and outs of ADHD. This is a topic in psychiatry, which really can be controversial, and I think sometimes misunderstood. So, it was a pleasure delving into this with you. Thank you again so much.

Dr. Anne McBride: Well, thank you, Daniel, so much for inviting me to participate in the On the Mind series. It was a lot of fun.

Dr. Daniel Knoepflmacher: Well, it was fun talking to you. And I also want to thank all who listened to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms, including Spotify, Apple Podcasts, YouTube, iHeartRadio and others. If you like what you heard today, please do give us a rating. They help others learn about us. And be sure to subscribe so you can stay up to date with all of our latest episodes. If you have any friends who you think might enjoy listening, tell them about us. We could use your help getting the word out. We'll be back again next month with another episode. Until then, wishing you good health in body and mind.