December 18, 2024

Understanding ADHD in Older Adults: An Overlooked Concern

ADHD in Older Adults: Challenges, Insights, and the Need for Research

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that persists into adulthood for most individuals, affecting 60% to 90% of those diagnosed as children. However, understanding ADHD in older adults, particularly those over 50, remains limited. With the U.S. population aged 65+ projected to nearly double by 2050, this oversight has critical implications for healthcare.

A recent analysis of 20 studies (sample size: over 20 million) highlights ADHD prevalence in the elderly as 2.18% when community scales are used but only 0.23% when clinical diagnoses are reviewed in medical records. This discrepancy points to underdiagnosis and the need for clinician education. Furthermore, treatment rates are alarmingly low, with just 0.09% of elderly individuals receiving ADHD medications.

Current diagnostic criteria, still rooted in studies of youth, inadequately address age-specific symptoms. Barkley and Murphy’s screening tool is one step forward, but its moderate reliability signals the need for refinement. Diagnostic challenges grow more complex as clinicians must differentiate ADHD from cognitive changes due to aging, medical conditions, or psychiatric disorders like depression or dementia. The concurrent presence of conditions further complicates assessments and treatments.

Treatment hesitancy also hampers care. Concerns about cardiovascular risks, interactions with other medications, and lack of familiarity with ADHD medication dosing in older adults fuel clinician caution. While psychostimulants are generally safe when carefully managed, misconceptions about abuse and addiction persist, creating unnecessary barriers.

Conclusion:

Addressing ADHD in older adults requires dedicated clinician training to overcome biases, refine diagnostic tools, and balance medical risks with the significant quality-of-life benefits ADHD treatment offers. With more research, improved clinical protocols, and better education, older adults with ADHD can receive accurate diagnoses and effective treatment. This will help them maintain cognitive function and independence, significantly enhancing their lives.

Goodman, D. W., Cortese, S., & Faraone, S. V. (2024). Why is ADHD so difficult to diagnose in older adults? Expert Review of Neurotherapeutics, 24(10), 941–944. https://doi.org/10.1080/14737175.2024.2385932

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Reconsidering the Age-of-Onset Criterion in Older Adults Being Evaluated for ADHD

Reconsidering the Age-of-Onset Criterion in Older Adults Being Evaluated for ADHD

The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) requires evidence of symptom onset before age 12 to make a diagnosis of ADHD in adults.

A recently published clinical review questions the appropriateness of this criterion in older adults 50 years old and above. It sets forth several reasons:

  • ADHD was first recognized in the DSM in 1968, just over fifty years ago. Anyone over fifty is highly unlikely to have been diagnosed with ADHD in childhood, or even to have symptoms properly noticed.
  • It is well-established that memories both fade and change with time. Even among young adults, only about half can recall the age at which specific memories occurred. For older adults, the challenge is much greater, and that means questionnaire answers become unreliable.
  • Episodic memory among persons with ADHD is known to be impaired relative to controls, which further limits the reliability of memory, especially over extended periods.

On the other hand, the reason for the early onset criterion is to avoid any confusion with early neurodegenerative diseases such as Alzheimer's or Lewy body dementia, which have overlapping symptoms.

The authors suggest a possible fix:

  • For those over fifty, readjust the under-12 criterion to instead demonstrate the longstanding previous existence of ADHD symptoms, without forcing it to include the first eleven years of life. They call for research to determine how many years of previous symptoms would best distinguish ADHD symptoms from normal aging and the onset of dementia.
  • Establish a family history of ADHD. Heritability estimates suggest that ADHD occurs in roughly half the parents of people with ADHD, and about 15% of grandparents. That means that for persons over 50, having children and/or grandchildren with ADHD would lend greater weight to self-reported ADHD symptoms.
  • Noting that "cognitive functioning rating scales(e.g., the Barkley Deficits in Executive Functioning Scale) have shown to align robustly with ADHD symptoms," they "call for studies investigating the use of these rating scales in older adult samples, and particularly their discriminant validity relative to other late-life disorders affecting cognition."
  • This would be accompanied by careful screening for physical or psychiatric comorbidities, to reduce the risk of false positives.

It is unethical, the authors suggest, to deny care to older, presently undiagnosed adults, given the demonstrated poor outcomes associated with untreated ADHD.

January 16, 2022

CDC: Prescriptions for ADHD Medications in Reproductive Age Women on Rise

CDC Reports increase in prescriptions for ADHD Medications in Reproductive Age Women

The CDC recently reported that ADHD medication use in women ages 15 to 44 increased from 0.9 percent to 4 percent from 2003 to 2015.  The most commonly used medications were formulations of amphetamine or methylphenidate.  

This increase in treatment for ADHD suggests that educational programs such as adhdinadults.com have been effective in teaching clinicians how to identify and treat the disorder.   The 4 percent rate reported by the CDC is encouraging because it is close to what Ron Kessler and colleagues reported as the prevalence of adult ADHD in the population.   CDC correctly points out that little is known about the effects of ADHD medications on pregnancies. Thus, caution is warranted.


Oei et al.'s review of amphetamines concluded: "There is little evidence of amphetamine-induced neurotoxicity and long-term neurodevelopmental impact, as data is scarce and difficult to extricate from the influence of other factors associated with children living in households where one or more parent uses drugs in terms of poverty and neglect. ... We suggest that exposed children may be at risk of ongoing developmental and behavioral impediment, and recommend that efforts be made to improve early detection of perinatal exposure and to increase the provision of early intervention services for affected children and their families"


Bolea-Alamanac et al.'s review of methylphenidate effects concluded: "There is a paucity of data regarding the use of methylphenidate in pregnancy and further studies are required. Although the default medical position is to interrupt any non-essential pharmacological treatment during pregnancy and lactation, in ADHD this may present a significant risk. Doctors need to evaluate each case carefully before interrupting treatment." These words of caution should be heeded by clinicians caring for women of reproductive age.

December 28, 2023

How Effective and Safe are Stimulant Medications for Older Adults?

How effective and safe are stimulant medications for older adults?

Older adults are at greater risk for cardiovascular disease. Psychostimulants may contribute to that risk through side effects, such as elevation of systolic blood pressure, diastolic blood pressure, and heart rate.

On the other hand, smoking, substance abuse, obesity, and chronic sleep loss - all of which are associated with ADHD - are known to increase cardiovascular risk, and stimulant medications are an effective treatment for ADHD.

So how does this all shake out? A Dutch team of researchers sets out to explore this. Using electronic health records, they compared all 139 patients 55 years and older at PsyQ outpatient clinic, Program Adult ADHD, in The Hague. Because a principal aim of the study was to evaluate the effect of medication on cardiovascular functioning after first medication use, the 26 patients who had previously been prescribed ADHD medication were excluded from the study, leaving a sample size of 113.

The ages of participants ranged from 55 from 79, with a mean of 61. Slightly over half were women. At the outset, 13 percent had elevated systolic and/or diastolic blood pressure, 2 percent had an irregular heart rate, 15 percent had an abnormal electrocardiogram, and 29 percent had some combination of these (a "cardiovascular risk profile"), and 21 percent used antihypertensive medication.

Three out of four participants had at least e comorbid disorder. The most common are sleep disorders, affecting a quarter of participants, and unipolar mood disorders (depressive or more rarely manic episodes, but not both), also affecting a quarter of participants.

Twenty-four patients did not initiate pharmacological treatment. Of the 89 who received ADHD medication, 58 (65%) reported positive effects, and five experienced no effect. Thirty-eight (43%) discontinued ADHD medication while at the clinic due to lack of effect or to side effects. The most commonly reported positive effects were enhanced concentration, more overview, less restlessness, more stable mood, and having more energy. The principal reasons for discontinuing medication were anxiety/depression, cardiovascular complaints, and lack of effect.

Methylphenidate raised heart rate and lowered weight, but had no significant effect on systolic and diastolic blood pressure. Moreover, there was no significant correlation between methylphenidate dosage and any of these variables, nor between methylphenidate users taking hypertensive medication and those not taking such medication. There was no significant difference in systolic or diastolic blood pressure and heart rate before and after the use of methylphenidate among patients with the cardiovascular risk profiles.

Systolic blood pressure rose in ten out of 64 patients, with two experiencing an increase of at least 20 mmHg. It descended in five patients, with three having a decrease of at least 20 mmHg. Diastolic blood pressure rose by at least 10 mmHg in four patients, while dropping at least 10 mmHg in five others.

The authors concluded "that the use of a low dose of ADHD-medication is well tolerated and does not cause clinically significant cardiovascular changes among older adults with ADHD, even among those with an increased cardiovascular risk profile. Furthermore, our older patients experienced significant and clinically relevant improvement of their ADHD symptoms using stimulants, comparable with what is found among the younger age group," and that "the use of methylphenidate may be a relatively safe and effective treatment for older adults with ADHD, under the condition that all somatic complaints and especially cardiovascular parameters are monitored before and during pharmacological treatment."

Yet they cautioned that "due to the observational nature of the study and the lack of a control group, no firm conclusions can be drawn as to the effectiveness of the stimulants used. ... Important factors that were not systematically reported were the presence of other risk factors, such as smoking, substance (ab)use, aspirin use, and level of physical activity. In addition, the response to medication was not systematically measured"

December 21, 2021

Network Meta-analysis Explores Long-term Efficacy of Nonpharmacological Treatments for Improving Inhibitory Control in Children and Adolescents with ADHD

Background Info:

Executive functions include inhibitory control, working memory, and cognitive flexibility. Inhibitory control is the ability to suppress distractions and focus on goals, which is the main deficit in ADHD. 

Children and adolescents with ADHD often have off-task, unrelated thoughts and are easily distracted, limiting their sustained attention. This makes it difficult for them to focus on tasks and leads to impulsive behaviors that affect their daily life, academics, and social interactions. Improving inhibitory control in ADHD children and adolescents is essential. 

Stimulant medications are commonly used to treat ADHD. However, side effects like insomnia, loss of appetite, and headaches may make parents hesitant to use these medications for their children. 

Non-pharmacological treatments like cognitive training, behavior therapy, and physical exercise have gained attention for their lack of side effects. Research shows that some non-pharmacological methods can improve cognitive outcomes significantly, underscoring their potential in treating ADHD. 

Study:

A Chinese research team identified four key gaps in current research on non-pharmacological treatments for inhibitory control in children with ADHD: 

  • Existing meta-analyses seldom differentiate between short-term and long-term interventions.  
  • Most studies focus primarily on short-term effects and neglect evaluation of maintenance effects through follow-up assessments.  
  • New treatment methods, such as meditation and board games, have not been systematically assessed in meta-analyses for their impact on inhibitory control in children and adolescents with ADHD, leaving their effectiveness uncertain.  
  • Traditional meta-analysis does not tell us which intervention is most effective. Without this comparative analysis, it is difficult to rank efficacy. 

The team therefore performed a network meta-analysis of long-term randomized controlled trials (RCTs) to assess and rank the effectiveness of various non-pharmacological treatments on inhibitory control in children and adolescents with ADHD. 

The team included only RCTs relying on professional diagnoses of ADHD, excluding those based only on parent and teacher rating scales.  

The included studies measured inhibitory control using objective neurocognitive tasks, such as the Stroop test and the Go/No-Go test, to reduce potential subjective bias. Studies relying on parent- or teacher-reported questionnaires were excluded. 

Controls either received no intervention or placebo, such as watching running videos and attending history classes. 

Meta-analysis of 16 studies combining 546 participants found large short-term effect size improvements in inhibitory control from physical exercise. But the two studies with a total of 110 participants that performed a follow-up test reported only a small-to-medium effect size improvement. 

For cognitive training, a meta-analysis of fifteen studies totaling 674 participants reported a medium effect size of short-term improvement in inhibitory control. The ten studies with 563 participants that performed a follow-up test found only a small effect size improvement since treatment initiation. 

For behavioral therapy, meta-analysis of six studies encompassing 244 individuals likewise found a medium effect size short-term improvement in inhibitory control. In this case, however two studies combining 91 participants that performed a follow-up test reported that the medium effect size improvement was maintained. 

For neurofeedback, meta-analysis of seven studies encompassing 186 individuals found a small-to-medium effect size short-term improvement in inhibitory control. The only study that performed a follow-up test reported a small effect size improvement since treatment initiation. 

The two studies with a combined 44 individuals exploring board games found no significant improvement in inhibitory control. Likewise, the two studies combining 32 participants that explored meditation found no significant improvement in inhibitory control. 

There was no indication of publication bias. 

Conclusion:

The team concluded, “Existing evidence shows that physical exercise, behavior therapy, cognitive training, and neurofeedback can effectively improve the inhibitory control of children and adolescents with ADHD. However, meditation, EMG feedback, and board games did not significantly affect inhibitory control. Physical exercise has the best effect among all non-pharmacological treatments, but its impact will be weakened after intervention. Behavior therapy and cognitive training had a slightly lower effect, but they have a better maintenance effect.” 

Ultimately, the study results suggest that non-drug treatments can help children and teens with ADHD improve their ability to control their actions and stay focused. Some methods, like physical exercise, work well at first but may fade once the activity stops. Other methods, like behavioral therapy and cognitive training, may take a little longer to show results but can last longer and make a bigger difference over time. Ultimately, and most importantly, because this work did not study the symptoms of ADHD or its real-world impairments, it provides no reason to change current treatment practices for ADHD.

July 16, 2025

The Role of Serotonin in ADHD and Its Many Comorbidities

Serotonin is a key chemical in the body that helps regulate mood, behavior, and also many physical functions such as sleep and digestion. It has also been linked to how ADHD (attention-deficit/hyperactivity disorder) develops in the brain. This study looks at how serotonin may be involved in both the mental health and physical health conditions that often occur alongside ADHD.

It is well-established that ADHD is more than just trouble focusing or staying still. For many, it brings along a host of other physical and mental health challenges. It is very common for those with ADHD to also have other diagnosed disorders. For example, those with ADHD are often also diagnosed with depression, anxiety, or sleep disorders. When these issues overlap, they are called comorbidities. 

A new comprehensive review, led by Dr. Stephen V. Faraone and colleagues, delves into how serotonin (5-HT), a major brain chemical, may be at the heart of many of these common comorbidities.

Wait! I thought ADHD had to do with Dopamine–Why are we looking at Serotonin?

Serotonin is a neurotransmitter most often linked to mood, but its role in regulating the body has much broader implications. It regulates sleep, digestion, metabolism, hormonal balance, and even immune responses. Although ADHD has long been associated with dopamine and norepinephrine dysregulation, this review suggests that serotonin also plays a central role, especially when it comes to comorbid conditions.

The Study:

  • Objective: To systematically review which conditions commonly co-occur with ADHD and determine whether serotonin dysfunction might be a common thread linking them.

  • Method: The authors combed through existing literature up to March 2024, analyzing evidence for serotonin involvement in each comorbidity associated with ADHD.

  • Scope: 182 psychiatric and somatic conditions were found to frequently occur in people with ADHD.

Key Findings

  • 74% of Comorbidities Linked to Serotonin: Of the 182 comorbidities identified, 135 showed evidence of serotonergic involvement—91 psychiatric and 44 somatic (physical) conditions.

  • Psychiatric Comorbidities: These include anxiety disorders, depression, bipolar disorder, and obsessive-compulsive disorder—all of which have long-standing associations with serotoninergic dysfunction.

  • Somatic Comorbidities: Conditions like irritable bowel syndrome (IBS), migraines, and certain sleep disorders also showed a significant serotonergic link.

This research suggests that serotonin dysregulation could explain the diverse and sometimes puzzling range of symptoms seen in ADHD patients. It supports a more integrative model of ADHD—one that goes beyond the brain’s attention, reward and executive control circuits and considers broader physiological and psychological health.

future research into the role of serotonin could help develop more tailored interventions, especially for patients who don't respond well to stimulant medications. Future studies may focus on serotonin’s role in early ADHD development and how it interacts with environmental and genetic factors.

The Take-Away: 

This study is a strong reminder that ADHD is a complex, multifaceted condition. Differential diagnosis is crucial to properly diagnosing and treating ADHD. Clinicians' understanding of the underlying link between ADHD and its common comorbidities may help future ADHD patients receive the individualized care they need. By shedding light on serotonin’s wide-reaching influence, this study may provide a valuable roadmap for improving how we diagnose and treat those with complex comorbidities in the future. 

July 14, 2025

Undiagnosed ADHD May Be Undermining Diabetes Control in Adults with Type 1 Diabetes

Our recent study, published in the Journal of Clinical Medicine, aims to shed light on an under-recognized challenge faced by many adults with Type 1 diabetes (T1D): attention-deficit/hyperactivity disorder (ADHD) symptoms.

We surveyed over 2,000 adults with T1D using the Adult Self-Report Scale (ASRS) for ADHD and analyzed their medical records. Of those who responded, nearly one-third met the criteria for ADHD symptoms—far higher than the general population average. Notably, only about 15% had a formal diagnosis or were receiving treatment.

The findings are striking: individuals with higher ADHD symptom scores had significantly worse blood sugar control, as indicated by higher HbA1c levels. Those flagged as "ASRS positive" were more than twice as likely to have poor glycemic control (HbA1c ≥ 8.0%). They also reported higher levels of depressive symptoms.

As expected, ADHD symptoms decreased with age but remained more common than in the general public. No strong links were found between ADHD symptoms and other cardiometabolic issues.

This study highlights a previously overlooked yet highly significant factor in diabetes management. ADHD-related difficulties—such as forgetfulness, inattention, or impulsivity—can make managing a complex condition like T1D more difficult. The researchers call for more screening and awareness of ADHD in adults with diabetes, which could lead to better mental health and improved blood sugar outcomes.

Takeaway: If you or a loved one with T1D struggles with focus, organization, or consistent self-care, it may be worth exploring whether ADHD could be part of the picture. Early identification and support are crucial to managing this common comorbidity. 

July 10, 2025