NEWS TUESDAY: Decision-making and ADHD: A Neuroeconomic Perspective

What do we mean by expert? In simple terms, an expert possesses in-depth knowledge and specialized training in a particular field. In order to be considered an expert in any field, a person must have both deep knowledge of and competence in their specific area of expertise. Experts have a background that includes education, research, and experience. In the world of mental health and psychology, this typically means formal credentials (a PhD, MD, etc) in addition to years of study, peer-reviewed publications, and/or extensive clinical experience. 

Experts are recognized by their peers (and often by the public) as reliable authorities on a specific topic. Experts usually don’t make big claims without evidence; instead, they cite studies and speak cautiously about what the evidence shows. 

Tip: Those looking for likes and clicks will often speak in absolutes (e.g., “refined sugar makes your ADHD worse, but the Keto Diet will eliminate ADHD symptoms”) while experts will use language that emphasizes evidence (e.g., “research has proven that there is no ‘ADHD Diet’, but some evidence has suggested that certain individuals with ADHD may benefit from such dietary interventions as limiting food coloring or increasing omega fatty acids.”) 

The Double-Edged Sword of Social Media   

Social media has created an incredible opportunity for those with ADHD to gain access to invaluable resources, including the creation of communities by and for those with ADHD. Many people with ADHD report feeling empowered and less alone by connecting with others online. These online social platforms provide a space for those with ADHD to share their own perspectives and their lived experience with the disorder. Both inside and outside of mental health-related communities, social media is a powerful tool for sharing information, reducing stigma, and helping people find community. When someone posts about their own ADHD challenges or tips, it can reassure others that they’re not the only ones facing these issues. This kind of peer support is valuable and affirming.

It is vital for those consuming this media, however, to remember that user-generated content on social media is not vetted or regulated. Short TikTok or Instagram videos are designed to grab attention, not to teach nuance or cite scientific studies. As it turns out, most popular ADHD posts are misleading or overly simplistic, at best. One analysis of ADHD TikTok videos found that over half were found to be “misleading” by professionals. Because social feeds reinforce what we already believe (the “echo chamber” effect, or confirmation bias), we can easily see only content that seems to confirm our own experiences, beliefs, or fears.

Stories aren’t a substitute for expert guidance.

Lived Experience vs. Universal Advice

It’s important to recognize the difference between personal experience and general expertise. Having ADHD makes you an expert on your ADHD, but it does not make you an expert on ADHD for everyone. Personal stories are not scientific facts. Even if someone’s personal journey is true, the same advice or experience may not apply to others. For instance, a strategy that helps one person focus might have no effect– or possibly even a negative effect– on someone else.

Researchers have found that most ADHD content on social media is based on creators’ own experiences, not on systematic research. In one study, almost every TikTok ADHD creator who listed credentials actually just cited their personal story. Worse, about 95% of those videos never noted that their tips might not apply to everyone (journals.plos.org.) In other words, they sound absolute even though they really only reflect one person’s situation. It’s easy to misunderstand the condition if we take those singular experiences as universal facts.

How Real Experts Talk

So how can you tell when someone is speaking from expertise rather than personal experience or hearsay? Experienced professionals usually speak cautiously, rather than in absolutes. They tend to say things like “research suggests,” “some studies show,” or “evidence indicates,” rather than claiming something always or never happens. As one health-communication guide puts it, a sign of a trustworthy source is that they do not speak in absolutes; instead, they use qualifiers like “may,” “might,” or refer to specific studies. For example, an expert might say, “Some people with ADHD may have difficulty with organization,” instead of “ADHD people always lose things.”

Real experts also cite evidence. In science and psychology, experts usually share knowledge through peer-reviewed articles, textbooks, or professional conferences – not just social media posts. Reliable health information is typically backed by references to studies published in reputable journals.

If someone makes a claim online, ask: Do they point to research, or is it just their own testimony? This is why it’s wise to prefer content where the author is a recognized authority (like a doctor or researcher) and where references to scientific studies or official guidelines are provided. In fact, advice from sites ending in “.gov”, “.edu”, or “.org” (government, university, or professional organizations) tends to be more reliable than random blogs. When in doubt, look up who wrote the material and whether it cites peer-reviewed research.

The Take-Away: 

When navigating mental health information online, remember these key points:

• experts rarely claim absolute truths
• experts usually have credentials and publications
• experts speak in precise, cautious language. 

If you see sweeping statements like “This one habit will predict if you have ADHD” or “Eliminating this one food will cure your ADHD symptoms”--- that’s a red flag. Instead, the hallmark of expert advice is a tone of humility (“evidence suggests,” “it appears that,” etc.), clear references to studies or consensus statements, and an acknowledgment that individual differences exist.

At the same time, we need to acknowledge that community voices are incredibly valuable – they help us feel understood and less alone. The goal is not to dismiss personal stories, but to balance them with facts and evidence-based information. Let lived experience spark questions, but verify important advice with credible sources. Follow trusted organizations (for example, the National Institutes of Health, CDC, or ADHD specialist groups) and mental health professionals who communicate carefully. Use the online ADHD community for support and sharing tips, but remember it’s just one piece of the puzzle.

By being a savvy reader (checking credentials, looking for cited evidence, and spotting overgeneralizations), you can make the most of online ADHD content. In doing so, you give yourself both the empathy of community and the accuracy of real expertise. That way, you’ll be well-equipped to separate helpful insights from hype and to keep learning from both personal stories and science-based experts.

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Stimulant medications have long been considered the default first-line treatment for attention-deficit/hyperactivity disorder (ADHD). Clinical guidelines, prescribing practices, and public narratives all reinforce the idea that stimulants should be tried first, with non-stimulants reserved for cases where stimulants fail or are poorly tolerated.

I recently partnered with leading ADHD researcher Jeffrey Newcorn for a Nature Mental Health commentary on the subject. We argue that this hierarchy deserves reexamination. It is important to note that our position is not anti-stimulant. Rather, we call into question whether the evidence truly supports treating non-stimulants as secondary options, and we propose that both classes should be considered equal first-line treatments.

What the Evidence Really Shows

Stimulants have earned their reputation as the go-to drug of choice for ADHD. They are among the most effective medications in psychiatry, reliably reducing core ADHD symptoms and improving daily functioning when properly titrated and monitored. However, when stimulant and non-stimulant medications are compared more closely, the gap between them appears smaller than commonly assumed.

Meta-analyses often report slightly higher average response rates for stimulants, but head-to-head trials where patients are directly randomized to one medication versus another frequently find no statistically significant differences in symptom improvement or tolerability. Network meta-analyses similarly show that while some stimulant formulations have modest advantages, these differences are small and inconsistent, particularly in adults.

When translated into clinical terms, the advantage of stimulants becomes even more modest. Based on existing data, approximately eight patients would need to be treated with a stimulant rather than a non-stimulant for one additional person to experience a meaningful benefit. This corresponds to only a 56% probability that a given patient will respond better to a stimulant than to a non-stimulant. This difference is not what we would refer to as “clinically significant.” 

How The Numbers Can Be Misleading

One reason non-stimulants may appear less effective is the way efficacy is typically reported. Most comparisons rely on standardized mean differences, a method of averages that may mask heterogeneity of treatment effects. In reality, ADHD medications do not work uniformly across patients.

For example, evidence suggests that response to some non-stimulants, such as atomoxetine, is bimodal: this means that many patients respond extremely well, while others respond poorly, with few in between. When this happens, average effect sizes can obscure the fact that a substantial subgroup benefits just as much as they would from a stimulant. In other words, non-stimulants are not necessarily less effective across the board, but that they are simply different in who they help.

Limitations of Clinical Trials

In our commentary, we also highlight structural issues in ADHD research. Stimulant trials are particularly vulnerable to unblinding, as their immediate and observable physiological effects can reveal treatment assignment, potentially inflating perceived efficacy. Non-stimulants, with slower onset and subtler effects, are less prone to this bias.

Additionally, many randomized trials exclude patients with common psychiatric comorbidities such as anxiety, depression, or substance-use disorders. Using co-diagnoses as exclusion criteria for clinical trials on ADHD medications is nonviable when considering the large number of ADHD patients who also have other diagnoses. Real-world data suggest that a large proportion of individuals with ADHD would not qualify for typical trials, limiting how well results generalize to everyday clinical practice.

Considering the Broader Impact

Standard evaluations of medication tolerability focus on side effects experienced by patients, but this narrow lens misses broader societal consequences. Stimulants are Schedule II controlled substances, which introduces logistical barriers, regulatory burdens, supply vulnerabilities, and administrative strain for both patients and clinicians.

When used as directed, stimulant medications do not increase risk of substance-use disorders (and, in fact, tend to reduce these rates); however, as ADHD awareness has spread and stimulants are more widely prescribed, non-medical use of prescription stimulants has become more widespread, particularly among adolescents and young adults. Non-stimulants do not carry these risks.

Toward Parallel First-Line Options

Non-stimulants are not without drawbacks themselves, however. They typically take longer to work and have higher non-response rates, making them less suitable in situations where rapid results are essential. These limitations, however, do not justify relegating them to second-line status across the board.

This is a call for abandoning a one-size-fits-all approach. Instead, future guidelines should present stimulant and non-stimulant medications as equally valid starting points, clearly outlining trade-offs related to onset, efficacy, misuse risk, and practical burden.

The evidence already supports this shift. The remaining challenge is aligning clinical practice and policy with what the data, and patient-centered care, are increasingly telling us.

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Today, most treatment guidelines recommend starting ADHD treatment with stimulant medications. These medicines often work quickly and can be very effective, but they do not help every child, and they can have bothersome side effects, such as appetite loss, sleep problems, or mood changes. Families also worry about long-term effects, the possibility of misuse or abuse, as well as the recent nationwide stimulant shortages. Non-stimulant medications are available, but they are usually used only after stimulants have not been effective.

This stimulant-first approach means that many patients who would respond well to a non-stimulant will end up on a stimulant medication anyway. This study addresses this issue by testing two different ways of starting medication treatment for school-age children with attention-deficit/hyperactivity disorder (ADHD). We want to know whether beginning with a non-stimulant medicine can work as well as the  “stimulant-first” approach, which is currently used by most prescribers.

From this study, we hope to learn:

• Is starting with a non-stimulant medication “good enough” compared with starting with a stimulant?
  In other words, when we look at overall improvement in a child’s daily life, not just ADHD symptoms, does a non-stimulant-first approach perform similarly to a stimulant-first approach?
• Which children do better with which approach?
  Children with ADHD are very different from one another. Some have anxiety, depression, learning problems, or autism spectrum conditions. We want to know whether certain groups of children benefit more from starting with stimulants, and others from starting with non-stimulants.
• How do the two strategies compare for side effects, treatment satisfaction, and staying on medication?
  We will compare how often children stop or switch medications because of side effects or lack of benefit, and how satisfied children, parents, and clinicians are with care under each strategy.
• What are the longer-term outcomes over a year?
  We are interested not only in short-term symptom relief, but also in how children are doing months later in school, at home, with friends, and emotionally.

Our goal is to give families and clinicians clear, practical evidence to support a truly shared decision: “Given this specific child, should we start with a stimulant or a non-stimulant?”

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Who will be in the study?

We will enroll about 1,000 children and adolescents, ages 6 to 16, who:

• Have ADHD and are starting or restarting medication treatment, and
• Are being treated in everyday pediatric and mental health clinics at large children’s hospitals and health systems across the United States.

We will include children with common co-occurring conditions (such as anxiety, depression, learning or developmental disorders) so that the results reflect the “real-world” children seen in clinics, not just highly selected research volunteers.

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How will the treatments be assigned?

This is a randomized comparative effectiveness trial, which means:

• Each child will be randomly assigned (like flipping a coin) to one of two strategies:
  
  
  
  1. Stimulant-first strategy – the clinician starts treatment with a stimulant medication.
  2. Non-stimulant-first strategy – the clinician starts treatment with a non-stimulant medication.
• Within the assigned class, the clinician and family still choose the specific medicine and dose, and can adjust treatment as they normally would. This keeps the study as close as possible to real-world practice.
• The randomization is 1:1, so about half the participants will start with stimulants and half with non-stimulants.

Parents and clinicians will know which type of medicine the child is taking, as in usual care. However, the experts who rate how much each child has improved using our main outcome measure will not be told which treatment strategy the child received. This helps keep their ratings unbiased.

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What will participants be asked to do?

Each family will be followed for 12 months. We will collect information at:

• Baseline (before or just as medication is started)
• Early follow-up (about weeks 3 and 6)
• Later follow-up (about 3 months, 6 months, and 12 months)

At these times:

• Parents will complete questionnaires about ADHD symptoms, behavior, emotions, and daily functioning at home and in the community.
• Teachers will complete brief forms about the child’s behavior and performance at school.
• Children and teens (when old enough) will complete age-appropriate questionnaires about their own mood, behavior, and quality of life.
• A specially trained clinical rater, using all available information but blinded to treatment strategy, will give a global rating of how much the child has improved overall, not just in ADHD symptoms.

We will also track:

• Medication changes (stopping, switching, or adding medicines)
• Reasons for any changes (side effects, lack of benefit, or other reasons)
• Any serious side effects or safety concerns

Data will be entered into a secure, HIPAA-compliant research database. Study staff at each site will work closely with families to make participation as convenient as possible, including offering flexible visit schedules and electronic options for completing forms when feasible.

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How will we analyze the results?

Using standard statistical methods, we will:

• Compare the overall improvement of children in the stimulant-first group versus the non-stimulant-first group after 12 months.
• Look at differences in side effects, discontinuation rates, and treatment satisfaction between the two strategies.
• Examine which child characteristics (such as age, sex, co-occurring conditions, and baseline severity) are linked to better results with one strategy versus the other.
• Analyze long-term outcomes, including functioning at home, school, and with peers, and emotional well-being.

All analyses will follow the “intention-to-treat” principle, meaning we compare children based on the strategy they were originally assigned to, even if their medication is later changed. This mirrors real-world decision-making: once you choose a starting strategy, what tends to happen over time?

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Why is this study necessary now?

This study addresses a critical, timely gap in ADHD care:

• Guidelines are ahead of the evidence.
  Existing guidelines almost always recommend stimulants as the first-line medication, yet careful reviews of the evidence show that direct comparisons of stimulant-first versus non-stimulant-first strategies are limited. We do not have strong data to say that starting with stimulants is clearly superior for all children.
• Real-world children are more complex than those in past trials.
  Most prior medication trials have excluded children with multiple conditions, serious family stressors, or other complexities that are very common in everyday practice. Our pragmatic, multi-site design will include these children and thus produce findings that are directly relevant to front-line clinicians and families.
• Families and clinicians are asking for alternatives.
  Parents often express worries about stimulant side effects, long-term use, and stigma. Clinicians would like clearer guidance about when a non-stimulant is a reasonable first choice. At the same time, stimulant shortages and concerns about misuse and diversion have exposed the risks of relying almost entirely on one class of medications.
• The timing is right to influence practice and policy.
  Our team includes parents, youth advocates, frontline clinicians, and national networks that link major children’s hospitals. These partners have helped shape the study from the beginning and will help interpret and share the results. This means that if starting with non-stimulants is found to be similarly effective and safer or more acceptable for some children, practice patterns and guidelines can change rapidly.

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In short, this study is needed now to move ADHD medication decisions beyond “one-size-fits-all.” By rigorously comparing stimulant-first and non-stimulant-first strategies in real-world settings, and by focusing on what matters most to children and families overall functioning, side effects, and long-term well-being, we aim to give patients, parents, and clinicians the information they need to choose the best starting treatment for each child.

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This project was conceived by Professor Stephen V. Faraone, PhD (SUNY Upstate Medical University, Department of Psychiatry, Syracuse, NY) and Professor Jeffrey H. Newcorn, MD (Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, NY).   It will be conducted at nine sites across the USA.

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