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Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Sami Timimi, MD, is a consultant child and adolescent psychiatrist in the National Health Service of the United Kingdom (UK) and a visiting professor of child psychiatry and mental health improvement at the University of Lincoln, UK. He has authored, coauthored, and coedited several books, including his latest, 

. Dr Timimi is among the fiercest critics of psychiatric diagnoses and the medical model in psychiatry, especially child psychiatry. He is a prominent voice of British critical psychiatry, and over the years he and his colleagues have argued that psychiatric conditions in their very nature reach beyond the brain to involve sociocultural dimensions and cannot be adequately understood through the epistemology of biomedicine.

 Dr Timimi’s sweeping critique of and divergence from mainstream views is also illustrated in a 2018 debate with David Foreman, MD, in the 

 on the validity of attention-deficit/hyperactivity disorder (ADHD) as a diagnostic construct.

Your critique of current psychiatric thinking and practices touches on so many conceptual and philosophical issues, that I worry that it would be too easy to get mired in disagreements about abstract questions regarding the nature and goals of psychiatric classification or the medical model. Let’s begin with clinical practice: How would you approach the assessment and management of a child who with a pervasive and persistent pattern of inattention and hyperactivity?

First, many thanks for inviting me to be a part of your conversation series. It is so important for us to continue a discussion on the problems with, and alternatives to, dominant models. I hear the concern in your first question, but I do not think the conceptual and philosophical issues can be separated from clinical ones. How we imagine what we are dealing with, particularly if we are imbued with cultural meaning–making power, has a massive impact on what we show interest in clinically, what questions we ask, what interventions we make, and what impression our patients are given about what is happening in their lives.

This means the question you ask already sends us crashing against the shores of social construction. What do you (or this mythical family) mean by pervasive, persistent, inattention, and hyperactivity, and why have these bits of behavior been brought to the clinical foreground? If, like me, your clinical practice understands that what we do in psychiatry is essentially provide a new story about the stories our patients, or parents, might tell, then we cannot escape the interpretive nature of how we construct our story about them. After all, we have no recourse independent of subjective opinion empirical evidence.

I would be more interested in knowing their broader narrative. What has happened in that child’s and family’s life? Like the vast majority of those who end up in my clinics, many children who present like this have had more than their fair share of adversity. What are the child’s strengths and existing skills? If there were a mythical perfect treatment, what would they like to see change: school? home? relationships? Who is it—parents, teachers, child themselves—who most wants to see what sort of change? A 1-acronym formulation, such as 

, has powerful consequences. It acts as a hypnotic suggestion on those around the child and influences what they might view as important. It has the potential to obscure, or at least render as secondary, the things that might bolster the child’s esteem and the parent’s sense of empowerment.

I may choose an alternative label such as the child is “intense.” They engage with the world with an emotional intensity that provokes powerful emotions in those around them. We could see this as a gift that needs understanding, guidance, and nurturing, rather than using a label that views their behaviors as symptoms that need suppressing. With the cultural pressure to diagnose and medicate, this is not always easy, but maybe easier than we realize.

 Yes, I do not think either conceptual or philosophical issues can be separated from clinical ones—something I strongly try to convey to my trainees as well as colleagues! My hope was that by looking at how our clinical approach is informed by these issues, we may be better able to appreciate your views. And your response is very helpful in this regard. As you mention, you are not a fan of psychiatric diagnoses and you have criticized them extensively. From my perspective, one of the things psychiatric classifications do is to serve a sort of pragmatic function, which allows researchers to conduct studies about causes and treatments and allows clinicians to link the individual in front of them with the existing body of knowledge related to causes and treatments. For instance, the ADHD construct allows clinicians to capitalize on the literature related to stimulant medications. The short-term efficacy of stimulant medications for individuals who meet criteria for ADHD is so robust—and universally endorsed by practice guidelines—that it would be considered below the standard of care not to discuss them as a treatment option for individuals who could benefit from them. However, it is hard for me to imagine how we can determine who could benefit from 

 if we were not making diagnostic distinctions, at the very least in our head—for instance, differentiating between anxiety syndrome vs inattention-hyperactivity syndrome. This does not necessitate that we are forced to consider these diagnoses as natural kinds or as neurobiological disease entities; it only means that we recognize them, at minimum, as pragmatic constructs, more or less helpful given our goals. What is your view on how clinicians and researchers can carry out their pragmatic functions of research and treatment?

 These are great questions, but we need more than this interview to properly unpack them; nevertheless, I will have a go. First, there is an important difference between psychiatric diagnosis and a psychiatric classification. There are many different classification systems, with diagnosis being a particular system based on classification by cause (at least proximal cause). This is why your statement that diagnosis “allows clinicians to link the person in front of them with the existing body of knowledge related to causes and treatments” works when it is shedding light on cause and therefore the development of treatment technologies that address cause, but it does not work when the system of classification is unable to identify, or get close to identifying, proximal causes. Worse, calling it diagnosis leads to (an understandable) assumption that cause and therefore evidence-based useful treatments are known/knowable. Because what we call psychiatric diagnosis is not diagnosis, in that technical sense. Thinking that it is has led to practice that is skewed and patient expectations that are unrealistic.

What about making pragmatic decisions? I do not agree that the construct of 

 allows clinicians to capitalize on the literature for stimulants, for example. It makes them imagine they can, which is far more dangerous. Thus, we end up with vested interests shaping guidelines, which then influence public perception and media reports, and distort doctors’ practice. The result has been catastrophic mass prescribing of stimulants to children and equally catastrophic convincing of children and their caregivers that they have a hardwired condition that makes them incapable of doing certain things and requires that they ingest the same substance that we warn adults about its profound dangers.

 has been known for a long time and is no different if you get the label of ADHD or not. Decades ago, studies found that if you take them, regardless of diagnosis, it improves your ability, in the short term at least, to maintain task concentration. So that is the danger of imagining these are pragmatic groupings: It embeds and reifies ideas, turning an imagined entity into an assumed concrete reality, which when done without realizing that this is what you are doing, has the potential for unhealthy consequences to individuals, the profession, and our culture more broadly.

You have talked about the “McDonaldization” of child development, where the difficulties of growing up are categorized neatly and then addressed with quick fixes. You have also talked about psychiatric diagnoses functioning as “brands” that are sold to consumers and generate lucrative markets around them. Can you tell us more about what you mean by this?

 refers to the way the challenges and uncertainties connected with growing up are placed into neat categories of things wrong with individual children, which can then be fixed with simple, one-size-fits-all interventions. A market economy and culture preys on our desire for the here-and-now satisfaction of our cravings, provided in a fast manner that requires little engagement with the product beyond its consumption. Get your products and messaging right, and you can entice your consumers when they are still young and then have them as potential customers for life. McDonaldization is just a more culturally familiar reference to the process of commodification—in other words, the process of turning something into an object of economic value. Commodification’s overriding value is making money. In this arena, you need to convince a population that all manner of experiences may lead to unpleasant and dangerous consequences if not identified and remedied with your products (a diagnosis, a book, a medication, a therapy, a course, a supplement, etc).

You have argued that the current system of mental health care alienates individuals from the meaning inherent in their own emotional difficulties, undermines their capacities for everyday 

, and by doing so, perpetuates those very difficulties. Can you elaborate on how you think this process of alienation unfolds?

The labeling of our experiences with medicalized language (diagnosis, symptoms, disorder, dysfunction, dysregulation, etc) has spread far and wide. My kids and their friends talk about feeling “depressed,” a medical word. It entrenches a fear of, and alienation from, an appreciation of the ordinariness and understandability of a panoply of human emotional experiences. When we place our emotional experiences in a problematizing framework, we extract the everyday meanings these have and become worried that there is something wrong in us beyond our capacity to comprehend. 

 campaigns have made this dynamic worse. Far from normalizing the diversity of our emotional experiences and helping create an awareness of the variety of reactions to all the things that happen in our life being ordinary and/or understandable, even in those more extreme states, we have instead made more individuals suspicious that their experiences are a signal that there is something deeply wrong in them.

These medicalized frames also undermine our natural resilience, sensitize us to an idea of our vulnerability, and encourage us to transfer our agency to practitioners who are assumed to have some special knowledge about our experiences that we cannot possess.

Medical colonialism—of language and the concepts that flow from this—means that we do not have any other strong culturally available model for emotions beyond banal mechanical ones. As a result, we fear, and are fascinated by, displays of emotions, and we easily slide into an idea that individuals need help to learn how to control and manage how they feel. To me, one of the worst phrases to emerge in modernist mental health practice is the oxymoronic “emotionally dysregulated.” The aspired to neoliberal entrepreneurial individual has to learn how to nourish their ego and use their thoughts to control their emotions. There are too few resources in medicalized Western cultures for learning how to sit with, experience, withstand, and understand emotions as important forces for action and connection. We have imbued our emotional life with a destructive power more than a liberatory one.

 Given that mental health is a multidisciplinary area, a professional space shared by psychiatrists, primary care physicians/general practitioners, psychologists, and social workers, among others, what are your thoughts on the relationship between these disciplines? How would you like this professional space to be reorganized? In what areas should psychiatry be at the forefront and in what areas should it take a backseat and let other professions take the lead?

 It is sad that psychiatrists have been pushed into being primarily viewed as the prescribers in mental health services. Our representative institutions and academics have been complicit in this. The flimsy appeal that our models and practices are biopsychosocial—apart from not really knowing what this looks like in practice—is a smokescreen to what much of practice as a psychiatrist has become.

I consider myself a traditional child psychiatrist. My first placement in child psychiatry in the early 1990s was in a children’s hospital in London. The lead consultant worked in collaboration with the other professionals and the team used primarily systemic models. We had access to 2 beds for in-patients and, as well as outpatient work, we carried out consultation on cases requested by the pediatricians. In those 9 months, I prescribed medication to only 1 individual, and beyond broad formulations, the idea of a diagnosis was nowhere. It all made sense to me and persuaded me that this was the career for me. I felt that child psychiatry’s gift to medicine was understanding that there was a context to individuals’ suffering—they existed in systems of support and meaning—and to the idea of development—that life is dynamic and changes.

As I undertook the 4-year training to become a consultant, I saw, with concern, the tide of 

 sweep across the Atlantic from the United States. It gradually colonized our curriculums.

Potentially, psychiatrists are the only mental health practitioners who can do it all, from prescribing to therapy. We also ought to be
able to identify organic conditions that may cause psychological problems as well as the organic complications that arise from psychological challenges, such as eating issues. If we live up to our promise, we should be leaders in mental health services, helping bring other professions along, as well as not being afraid of becoming embroiled in the politics and politicization of services. If we do not seriously reform and reconnect with our wider roots as a profession (most psychotherapies were originally developed by doctors), which, for example, had historically strong relationships with disciplines such as anthropology, then there are plenty who would come and rightfully take our place. This would be a great loss to the task of humanizing medicine.

The opinions expressed are those of the participants and do not necessarily reflect the opinions of Psychiatric Times™.

is a psychiatrist in Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of the Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

1. Bracken P, Thomas P, Timimi S, et al. 

2. Foreman DM, Timimi S. Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment. 

3. Timimi S. Rebuttal to Foreman’s article ‘Attention-deficit hyperactivity disorder (ADHD): progress and controversy in diagnosis and treatment.’ 

Insane Medicine: How the Mental Health Industry Creates Damaging Treatment Traps and How You Can Escape Them.

Sami Timimi, MD, shares his thoughts on alienation and ADHD, and what role current systems of mental health play.

Upon the Shores of Social Construction

Attention-deficit/hyperactivity disorder (

) is one of the most common neurodevelopmental disorders of childhood.

 This disorder is typically first diagnosed in childhood and can persist into adulthood, with far-reaching implications on academic achievement, employment, finances, peer relationships, and increased accidental injuries and substance abuse.

 Children with ADHD may have difficulty initiating and maintaining attention, concentrating, completing tasks, and controlling impulsive behaviors. According to the American Psychiatric Association, there are 3 types of ADHD: predominantly inattentive presentation; predominantly hyperactive-impulsive presentation, and combined presentation.

ADHD prevalence in the pediatric population has been stable over the past 30 years except in the United States, where cases have increased.

 According to a 2016 parent survey, approximately 6.1 million (9.4%) children received a diagnosis of ADHD in the United States.

 Worldwide, ADHD is the third most common mental health disorder, following depression and anxiety.

 Overall, girls are less likely to be diagnosed with ADHD than boys.

 A 2021 global systematic review and meta-analysis suggested that the prevalence of persistent adult ADHD was 2.58%, and the prevalence of symptomatic adult ADHD was 6.76%, with 139.84 million and 366.33 million affected adults worldwide in 2020, respectively.

 ADHD appears to impact men more than women. In adults, ADHD decreases as an individual ages.

The etiology of ADHD is still not clearly understood; however, combinations of genetic, neurological, and environmental factors contribute to the pathogenesis and symptom expression.

 Genetic factors are implicated in ADHD, but the mechanism of action is not completely clear. Family, twin, and adoption studies have strongly suggested that ADHD is highly inheritable. Moreover, genetic studies have documented the gene sets interfering with neurotransmitter pathways in the brain that implicate rare copy number variants or the collection of higher deletions, as well as the duplications impacting gene transcriptions that are more likely to be found in individuals with ADHD.

Pre-, peri-, and postnatal environmental factors play a significant role in the development of ADHD. Prenatal factors include the mother’s lifestyle during pregnancy.

 For example, prenatal alcohol exposure can lead to hyperactive, disruptive, and impulsive behaviors and increase the risk of psychiatric disorders.

 Maternal smoking during the prenatal developmental period has been linked to increased risk of ADHD

 Perinatal factors such as very low-birthweight children have a twofold increase in ADHD.

ADHD is conceptualized as a disorder of childhood that gradually diminishes over the lifespan.

 However, several prospective longitudinal studies have challenged the prevailing assumption that childhood ADHD and adult ADHD affect the same individuals who share the same neurodevelopmental vulnerabilities.

 These studies suggest that more than two-thirds of individuals with adult ADHD never had childhood ADHD. Adult ADHD is generally neglected in epidemiological studies, and, until recently, many attempts have been made to estimate the prevalence of ADHD in adults. Further, researchers are exploring whether ADHD is solely a neurodevelopmental disorder that is diagnosed in childhood, or whether ADHD can be acquired during other developmental periods. The prevalence of persistent adult ADHD from childhood and that of symptomatic adult ADHD were 2.58% and 6.76% in 2020, respectively.

The diagnostic assessment of ADHD can be complicated, as inattention, impulsivity, and difficulties with concentration can be driven by a myriad of factors. It is well-documented that children and adolescents diagnosed with ADHD have a cooccurring disorder.

 It is estimated that 45% children and adolescents with ADHD have a learning disability; 27% have a conduct disorder diagnosis; 18% have an anxiety disorder; and 15% have a depressive disorder.

 According to a study by Elia and colleagues, oppositional defiance disorder was the most common comorbid disorder at 41%, followed by depression/dysthymia at 22% and general anxiety disorder at 15%.

In adults with ADHD, the most common cooccurring psychiatric disorders are depression, anxiety disorders, bipolar disorder, substance use disorders (SUDs), and personality disorders.

 ADHD has a high cooccurring prevalence with bipolar disorder: Estimates range between 9.5% and 21.2%, with bipolar I disorder being more likely.

 ADHD and depression commonly cooccur at high rates ranging from 18.6% to 53.3%.

 Individuals with ADHD are at higher risk for developing anxiety disorders than the general population with rates approaching 50%.

 SUDS are likely the most common cooccurring condition with ADHD—specifically alcohol and/or nicotine, cannabis, and cocaine use.

Research support for the intersection of ADHD and personality disorders is scant compared to the support of other psychiatric cooccurring conditions. However, reports indicate that personality pathology are present approximately 50% of adults with ADHD—most commonly cluster B and C personality structures—and up to 25% of adults with ADHD have 2 or more personality conditions.

It is important to differentiate if an individual is presenting with any of the above-mentioned conditions to determine if they have comorbid ADHD. Diagnosing ADHD can be a complicated process that goes beyond a checklist. It is imperative to obtain historical information such as academic performance records and previous psychological testing reports, if ever tested. There are several significant barriers to diagnosis and treatment in ADHD, including overlapping symptomology between ADHD and mood, anxiety, SUDS, learning disabilities, information processing disorders, auditory processing disorders, and psychosocial factors. Another key barrier to the accurate diagnosis of ADHD is that some individuals will be able to overcome their deficits by developing and mastering compensating skills that will likely impact the accuracy of ADHD diagnosis and treatment.

Evidenced-based assessment that includes multi-informant/multimethod methods and evidenced-based assessment measures are well-regarded and arguably gold-standard approaches to the assessment of ADHD. This approach should be guided by current research and include test data to support clinical observations and, ultimately, an accurate ADHD diagnosis. 

 highlights several measures used in ADHD assessment conducted by clinical psychologists.

Treatment considerations should be informed by functional outcomes, which include symptom reduction; improved daily, academic, and occupational functioning; and increased quality of life.

 Efficiency at working or studying, maintaining stable relationships, containing or curbing impulsivity, and being satisfied with life overall are indicators of improved functioning. Moreover, adherence to treatment is key to successful management of ADHD.

The first line of ADHD are pharmacologic treatments, which are divided into stimulants and nonstimulants. Stimulant medications include methylphenidate, mixed amphetamine salts, and lisdexamfetamine dimesylate. Nonstimulants used in ADHD treatment include atomoxetine and alpha-2-adrenergic agonists. 

 highlights several medication options for ADHD.

There is a well-established body of evidence highlighting the effectiveness of psychosocial treatments for ADHD in children and adolescents, which include behavioral management interventions (parent training, classroom interventions, and peer-based interventions), training interventions (cognitive training, neurofeedback, and organization), cognitive behavioral therapy (CBT), and physiological treatments (play and other physical activities).

 CBT is the preferred nonpharmacological treatment for adult ADHD, which shows consistent reduction in the core behavioral symptoms of ADHD.

 is an assistant professor and licensed clinical psychologist at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. 

 is a psychology fellow at Baylor College of Medicine.

1. Faraone SV, Banaschewski T, Coghill D, et al. 

The World Federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder

The transition of youth with ADHD into the workforce: review and future directions

3. Polanczyk GV, Willcutt EG, Salum GA, et al. 

ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis

4. Danielson ML, Bitsko RH, Ghandour RM, et al. 

Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016

5. Bélanger SA, Andrews D, Gray C, Korczak D. 

ADHD in children and youth: part 1-etiology, diagnosis, and comorbidity

The prevalence of adult attention-deficit hyperactivity disorder: a global systematic review and meta-analysis

Molecular genetics of attention deficit hyperactivity disorder

8. Stergiakouli E, Hamshere M, Holmans P, et al. 

Investigating the contribution of common genetic variants to the risk and pathogenesis of ADHD

9. Williams NM, Franke B, Mick E, et al. 

Genome-wide analysis of copy number variants in attention deficit hyperactivity disorder: the role of rare variants and duplications at 15q13.3

11. D'Onofrio BM, Van Hulle CA, Waldman ID, et al. 

Causal inferences regarding prenatal alcohol exposure and childhood externalizing problems

Maternal prenatal substance use and behavior problems among children in the U.S.

13. Milberger S, Biederman J, Faraone SV, et al. 

Is maternal smoking during pregnancy a risk factor for attention deficit hyperactivity disorder in children?

14. Kotimaa AJ, Moilanen I, Taanila A, et al. 

Maternal smoking and hyperactivity in 8-year-old children

Practitioner review: early adversity and developmental disorders

16. Moffitt TE, Houts R, Asherson P, et al. 

Is adult ADHD a childhood-onset neurodevelopmental disorder? evidence from a four-decade longitudinal cohort study

17. Agnew-Blais JC, Polanczyk GV, Danese A, et al. 

Evaluation of the persistence, remission, and emergence of attention-deficit/hyperactivity disorder in young adulthood

Attention-deficit/hyperactivity disorder trajectories from childhood to young adulthood: evidence from a birth cohort supporting a late-onset syndrome

 [published correction appears in Lancet. 2006 Jan 21;367(9506):210]. 

20. Larson K, Russ SA, Kahn RS, Halfon N. 

Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007

ADHD characteristics: I. concurrent co-morbidity patterns in children & adolescents

22. Katzman MA, Bilkey TS, Chokka PR, et al. 

Adult ADHD and comorbid disorders: clinical implications of a dimensional approach

A systematic review of rates and diagnostic validity of comorbid adult attention-deficit/hyperactivity disorder and bipolar disorder

24. Torgersen T, Gjervan B, Rasmussen K. 

ADHD in adults: a study of clinical characteristics, impairment and comorbidity

25. Mancini C, Van Ameringen M, Oakman JM, Figueiredo D. 

Childhood attention deficit/hyperactivity disorder in adults with anxiety disorders

26. Braaten EB, Beiderman J, Monuteaux MC, et al. 

Revisiting the association between attention-deficit/hyperactivity disorder and anxiety disorders: a familial risk analysis

27. Kessler RC, Adler L, Barkley R, et al. 

The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication

28. Klassen LJ, Bilkey TS, Katzman MA, Chokka P. 

Comorbid attention deficit/hyperactivity disorder and substance use disorder: treatment considerations

29. Olsen JL, Reimherr FW, Marchant BK, et al. 

The effect of personality disorder symptoms on response to treatment with methylphenidate transdermal system in adults with attention-deficit/hyperactivity disorder

30. Rösler M, Ginsberg Y, Arngrim T, et al. 

Correlation of symptomatic improvements with functional improvements and patient-reported outcomes in adults with attention-deficit/hyperactivity disorder treated with OROS methylphenidate

31. Shrestha M, Lautenschleger J, Soares N. 

Non-pharmacologic management of attention-deficit/hyperactivity disorder in children and adolescents: a review

32. Pliszka S; AACAP Work Group on Quality Issues. 

Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder

Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

Behavior management for school-aged children with ADHD

35. Nimmo-Smith V, Merwood A, Hank D, et al. 

Non-pharmacological interventions for adult ADHD: a systematic review

The importance of understanding diagnosis, assessment, and treatment.

ADHD—or Something Else?

(This is the second part of a 4-part series. The next 2 pieces will discuss addiction and suicide prevention as covered in the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference.—Ed.)

The late Paul H. Wender, MD, once wrote that “ADHD is probably the most common chronic undiagnosed psychiatric disorder in adults.”

 The primary care providers (PCPs) on our planning committee for the “

Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care

” conference unanimously favored covering this topic, and we are thrilled that Jeffrey Newcorn, MD, professor of psychiatry and pediatrics and director of the Division of ADHD and Learning Disorders at Icahn School of Medicine at Mount Sinai, will present a 30-minute lecture titled,“Diagnosis & Treatment of ADHD Across the Lifespan: A Primer for Primary Care Physicians.”

Newcorn shares with us that the main obstacle to the diagnosis and treatment of adults with attention-deficit/hyperactivity disorder (ADHD) is that most PCPs are not trained to consider it in the differential diagnosis.

“Very few physician training programs outside of psychiatry, pediatrics, and family medicine include ADHD in their curricula, yet ADHD is often present in ~4.5% of the adult population,” he said. 

“Adults with ADHD underachieve at work and often have multiple changes in jobs. They earn less money than their non-ADHD peers—across all socioeconomic and social strata.

 Further, ADHD complicates family relationships and is associated with high rates of divorce. Moreover, a missed diagnosis of ADHD is a very common contributor to treatment failure of other disorders. Unfortunately, the vast majority of adults with ADHD who are seen for medical checkups by their primary care providers never come to psychiatric care. So, identifying ADHD in medical settings is extremely important.”

For adults with undiagnosed ADHD, the consequences can have serious implications. The National Comorbidity Survey Replication study reported a significant degree of psychiatric comorbidity among adults with ADHD: 19% had major depressive disorder, compared with 8% of those without ADHD; 47% also had a coexisting anxiety disorder (vs 20%), 38% had a mood disorder (vs 11%), and 15% had a substance use disorder (vs 6%).

Unfortunately, there are not current treatment guidelines for adult ADHD, so extrapolation from guidelines and best practices in treating adolescents is necessary. Treatments can include a combination of medication, environmental modifications, and psychosocial interventions. For medication treatment, whether to use simulants or approved nonstimulant medications, or to use them in combination, of course depends on many factors. Newcorn’s presentation will review ways to choose from among the various medications and nonmedication approaches to care.

We hope you join us and Dr Newcorn on Saturday, March 12, to learn more about how to treat your patients with ADHD. Find conference details, including the schedule, description of presenters, and registration at 

 is professor and department chair of psychiatry at the University of Arizona College of Medicine. He is an expert in the fields of geriatric psychiatry, depression treatment, and suicide prevention. He is committed to educating health care providers about the principles of psychiatry and behavioral medicine. 

 is the communication and marketing specialist for the University of Arizona College of Medicine Department of Psychiatry.

Attention-Deficit Hyperactivity Disorder in Adults

2. Biederman J, Faraone SV, Spencer TJ, et al. 

Functional impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults in the community

3. Kessler RC, Adler L, Barkley R, et al. 

Being able to identify ADHD in medical settings is very important. One doctor will offer some guidelines for diagnosis and treatment.

Psychiatry for Primary Care: An Update on ADHD (Part 2)

(This is the first part of a 4-part series. The following 3 pieces will discuss ADHD, addiction, and suicide prevention as covered in the “Psychiatry for Non-Psychiatrists: The University of Arizona Update in Behavioral Medicine for Primary Care” conference.—Ed.)

Prior to the COVID-19 pandemic, the prevalence of mental illness was rising at an alarming rate. Since March 2020, it has only gotten worse.

 Between the increase in psychiatric conditions and the dearth of mental health care professionals, primary care providers (PCPs) are increasingly confronted with patients who are struggling with behavioral health conditions such as depression, attention-deficit/hyperactivity disorder (ADHD), insomnia, addiction, and suicidal ideation.

In response to this intersecting crisis of limited access to mental health specialists and rising rates of these disorders, the Department of Psychiatry at the University of Arizona College of Medicine in Tucson convened a committee of PCPs and psychiatrists with the charge to organize a fully virtual conference on Saturday, March 12, targeting the educational needs of physicians and allied health professionals working in primary care settings. “

” was created to provide PCPs with new and updated knowledge to enhance their clinical confidence and skills, improve comorbid medical comorbidities, and reduce the stigma of seeking treatment for mental illness.

Because the topics are wide-ranging and packed into 30- to 45-minute presentations, there are plenty of options for physicians, nurses, physician assistants, practicing psychiatrists, and resident physicians to gain valuable and applicable clinical knowledge.

In this series on the conference (for which participants may receive up to 5.5 CME hours), we will cover the presentations in 3 subsequent articles on ADHD in adults, screening for addiction, and suicide prevention.

1. Czeisler MÉ, Lane RI, Petrosky E, et al. 

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic – United States, June 24-30, 2020

Primary care providers are increasingly seeing patients who are struggling with mental illness—how can they effectively assist these patients?

Psychiatry for Primary Care: A Behavioral Medicine Update (Part 1)

Steven Pliszka, MD, chair of The American Professional Society of ADHD [attention-deficit/hyperactivity disorder] and Related Disorders (APSARD) annual program committee, joined Jeffrey Newcorn, MD, APSARD president, in welcoming attendees to their virtual 2022 Annual Meeting, noting the conference was putting attendees “on the ground floor of exciting developments in the field.” Pliszka said the conference would highlight issues in genetics, neuroimaging, psychological variables, and environmental variables. “I think we’re moving to really integrating all these different aspects so we can think much more broadly about where ADHD fits into psychopathology in general,” he added. “And it will get us thinking more about new ways to intervene and to treat people.”

The 4-day meeting was held January 13 to 16, 2022. In-depth coverage can be found online at 

www.psychiatrictimes.com/conferences/apsard

As separate groups, college students with ADHD and college students who identify as a sexuality and gender minority (SGM) have increased risk for functional impairments, psychiatric comorbidities, and risky behaviors.

 According to Destiny Orantes, PhD, from Syracuse University, and colleagues, previous research had not considered if these outcomes are further increased in SGM students who have ADHD. Orantes shared findings from their recent research in a poster presentation.

The study assessed functional impairments, psychiatric comorbidities, and engagement in risky behaviors in 4 groups: (1) SGM students with ADHD, (2) SGM students without ADHD, (3) non-SGM students with ADHD, and (4) non-SGM students without ADHD. Data from the American College Health Association-National College Health Assessment 2019-2021 III were used. The researchers also sought to examine the prevalence of ADHD in SGM college students.

They found ADHD prevalence increased in SGM populations: 15% compared with 8% in non-SGM individuals. Additionally, SGM students with ADHD reported the highest levels of functional impairments, substance use, and psychiatric comorbidities.

The research results suggest, Orantes said, that future studies should consider the underlying reasons for SGM students having high rates of ADHD, and how best to reduce these negative outcomes. Specifically, treatment plans should take into account the separate difficulties students face from their ADHD diagnosis and their SGM identities, as well as how best to target the risky behaviors and comorbidities. 

1. Auerbach RP, Mortier P, Bruffaerts R, et al; WHO WMH-ICS Collaborators. 

Mental disorder comorbidity and suicidal thoughts and behaviors in the World Health Organization World Mental Health Surveys International College Student initiative.

“The [APSARD] task force was launched in relation to the amazing societal changes that are happening...in association with the awareness that equity means creating fair, equitable opportunities for all of us,” Martin Katzman, MD, FRCP(C), APSARD Health Equity Task Force chair, told attendees. “We’re hoping to build connections within the APSARD community, to enhance diversity of the organization, and to reach out across boundaries as well as to partner within all of our communities to raise awareness and to increase opportunities for treatment for populations that may not get the same access to treatment.”

Amy Glasofer, DPN, RN, nurse scientist with Virtua, shared an analysis of 41 studies relating to ADHD, race, ethnicity, and disparity; Catherine Dingley, PhD, RN, FNP, FAAN, associate professor in the Nursing Department of the University of Las Vegas, Nevada, also worked on the project.

They found 66.7% of studies noted Black children were significantly less likely than white children to be diagnosed with ADHD, and 65% of Black children with ADHD were significantly less likely than white children to receive medication. In addition, compared to white children, she noted Black children were more likely to discontinue medication and more likely to experience gaps in treatment; less likely to receive an α2 agonist alone; and more likely to receive significantly lower doses of stimulant. The findings suggest that, although diagnostic disparities have been reduced over time, treatment disparities still exist for minority children with ADHD.

1. Katzman M, Higgins N, Glasofer A, et al. Introducing the APSARD Health Equity Task Force. Presented at 2022 APSARD Conference. January 14, 2022.

“ADHD in preschool children is a valid and reliable condition,” reported Ann Childress, MD, president of the Center for Psychiatry and Behavioral Medicine, Inc, in Las Vegas, Nevada.

According to the 2014 National Survey of Diagnosis and Treatment of ADHD and Tourette’s, 30% of children diagnosed with ADHD receive their diagnosis before age 6; 16% receive the diagnosis at 4 years or younger.

 Impairment can be great for these patients, Childress said. For example, an epidemiological review of preschoolers diagnosed with ADHD found more than 40% had been suspended from school or daycare and about 16% had been expelled.

 In comparison, less than 1% of young children without ADHD were suspended.

The actions of young children with ADHD pose safety risks to themselves due the higher levels of hyperactive impulsivity, she said. “These are kids who are running out in traffic. They’re jumping off of things and breaking bones. They’re doing things that are dangerous, and they really need treatment for their safety,” she explained.

Childress reviewed efficacy and safety data for a number of common medications, noting some small behavior improvements as a result of the study medications. However, medications were associated with adverse events, including insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted not all of these medications have been approved for the youngest patients.

Fortunately, there is good evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD, Childress reported. The New Forest Therapy, Helping the Noncompliant Child, and the Incredible Years series were among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

“You have to carefully consider both developmental aspects and comorbidity when you’re establishing a diagnosis, and the medication efficacy and tolerability profile may not look as good in the little guys as it does in older children,” she concluded.

1. Visser SN, Zablotsky B, Holbrook JR, et al. 

Diagnostic experiences of children with attention-deficit/hyperactivity disorder.

The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder: a review.

Catch up on all the latest in ADHD from the APSARD virtual 2022 Annual Meeting. 

ADHD

Upon the Shores of Social Construction

ADHD—or Something Else?

Psychiatry for Primary Care: An Update on ADHD (Part 2)

Psychiatry for Primary Care: A Behavioral Medicine Update (Part 1)

Spotlight on Issues in ADHD

Reinforcement/Reward Mechanisms: Interventions for Executive Functioning

ADHD, Infections, and the Immune System

Introducing the APSARD Health Equity Task Force

Sex, Drugs, and ADHD

The College Experience for Students with ADHD