Psyched Perspectives: Closing the ADHD Diagnostic Gap for Girls and Minority Youth

Attention-deficit/hyperactivity disorder (ADHD) is frequently missed in girls, who tend to present with quieter, inattentive symptoms rather than overt hyperactivity, and in children from racial and ethnic minority groups, who face delayed diagnosis and treatment even when exhibiting the same symptoms as their peers.¹ Untreated ADHD can affect self-esteem, academic performance, and family relationships, and its impulsivity component raises the risk of accidents, unsafe driving, and substance misuse into adulthood. Screen time does not cause ADHD, but the two share a bidirectional relationship, and lifestyle interventions—sleep, exercise, nutrition, and predictable routines—remain central to nonpharmacologic management. The pharmacologic landscape for ADHD recently expanded with the FDA approval of centanafadine, a first-in-class norepinephrine, dopamine, and serotonin reuptake inhibitor.² Frank Clark, MD, host of Psyched Perspectives, spoke with Paige Walton, MD, a double board-certified child and adolescent and adult psychiatrist, about diagnostic disparities in ADHD, the effects of screen time on the developing brain, the treatment landscape, and practical lifestyle strategies for patients and families.

Frank Clark, MD: I would love for you to talk about why you have such joy and passion when it comes to working with individuals with ADHD.

Paige Walton, MD: This is a population I love working with. What I love most about working with children and adolescents with ADHD is helping them feel understood. Many of these children have spent years hearing that they are not trying hard enough or not living up to their potential, when in reality they are trying so much harder than adults realize, or than it may look like on the outside. When we are able to identify what is really going on and give them the right support, we see improvements not just in school performance but also in their confidence and their relationships with peers and family. Helping families and patients move from a place of frustration and blame—which comes with ADHD so often—toward understanding, and giving them practical support, can be life-changing and so rewarding to see.

Clark: What got you interested in specializing in treating children and adolescents with ADHD?

Walton: It goes back to how misunderstood these patients are, and how often they get missed. Over time, that can have significant consequences. The biggest impact is on self-esteem and how a child views themselves and their self-concept, but there are also academic difficulties and grades, which can affect relationships with peers and within the family. Impulsivity can increase the risk of accidents, unsafe driving, and substance misuse, and if it carries into adulthood, it can affect employment and finances. Early intervention is so important, because a lot of these outcomes can be prevented with appropriate treatment.

Clark: Could you talk about the disparities you’ve seen related to individuals who may be misdiagnosed, undertreated, or undiagnosed with ADHD? I know there is a lot of data about gender disparities and racial disparities.

Walton: When people think about ADHD, they think about the young boy running around creating disruption, and those children are the most likely to get picked up on because they are creating distraction and inconvenience in the classroom, so they are the first to get picked out. But there are certainly groups that get missed. Girls are one group that can experience delayed diagnosis. They tend to be quieter and more on the inattentive side, so they are daydreaming, or they might struggle with disorganization and paying attention, but they are struggling quietly. Over time, they internalize that, and they end up working really hard to compensate, so nobody knows. I hear so many parents say, “She has all As,” but then I ask if she is sleeping, and they say no, she stays up until midnight to do her homework and stays after school working so hard. That compensation can turn into anxiety and perfectionism, and then it becomes, “She is so sensitive, she is always so overwhelmed,” when really the core of that ends up being ADHD. It can be missed in girls because they are working so hard to compensate for it. Certain racial and ethnic minority groups are also more likely to have delayed diagnosis or treatment, even when they are exhibiting the same symptoms as their peers. There are a lot of possible reasons for that: limited access to care, or cultural differences in how people think about mental health or concerns about medication, understandably. But there certainly is a role of bias as well, where one child’s behavior gets labeled as defiant or bad behavior, while another child’s same behavior prompts the question, “Is that ADHD?” It is so important that we are not just looking at the behavior in isolation, but at what is driving it, and that every child gets a quality evaluation where all possibilities—including ADHD and everything else that could be going on—are considered.

Clark: As you were talking about the gender disparities, a lot of the adult women I have treated in my clinic with ADHD tell me they have these perfectionistic characteristics, and what you then find out is that they were overcompensating straight-A students—I think it is so important to highlight that. As it relates to the racial disparities, I am not a child and adolescent psychiatrist, but I do see children and adolescents when they come into the emergency room in a behavioral crisis, and many have a history of ADHD, though sometimes it gets labeled as conduct disorder or oppositional defiant disorder instead, and we are missing a lot of these children. How we treat ADHD is not how we treat conduct disorder or oppositional defiant disorder, and I always think about the downstream effects, like the school-to-prison pipeline—some of these kids are getting suspended when they actually need to go to the counselor and have some screening done to figure out the root of the problem so we can better address it. Along those lines, I am curious—and I am not trying to throw a curveball here—but since we are talking about ADHD and concentration, I know some people feel like they have ADHD when some of their inattentiveness could also be related to screen time. Given that you are a child and adolescent psychiatrist, and our pediatric colleagues have really been advocating for limiting screen time, could you speak a little bit about how too much screen time can impact the developing brain?

Walton: This is something I am so passionate about, and I am glad you brought it up, because it is so important, especially in the time we are living in. It is something you cannot escape, especially now that a lot of schools are doing their work on computers, so it is hard to get away from. Screen time does not necessarily cause ADHD, but there is a bidirectional relationship: we notice that if children are spending more time on screens, they do seem to struggle more with attention and with significant emotional dysregulation, so it can make those symptoms worse. At the same time, children with ADHD are more drawn to screens—to that novelty, to the immediate reward—and they have trouble with impulsivity, so they might really struggle with transitioning away from the screen; it can become a coping strategy for them as well. It is so important that we are talking about limiting screen time, and I would not say there is a perfect number for every child. It is more about what they are looking at on the screens, what they are using it for, how much difficulty they have pulling away from the screens, and whether they can separate from screens at night. It is also important to think about what screen time is taking away—time that could be spent getting adequate sleep, exercise, and in-person socialization with friends and family. I think it is impossible to completely take screens away, but it is important to have those conversations, and I tell parents it is up to them to model appropriate screen behaviors. As parents, we all have to reflect on our own screen time and what our kids are seeing—that is the best thing a parent can do.

Clark: A lot of times our patients will say, “Hey doc, what is new on the pharmaceutical scene?” I know there was a new medication that has been FDA approved for ADHD. What are your thoughts about it, and what would you like to share with our viewers?

Walton: I am glad we are talking about medication, because it is such an important piece—of course, we do not want to forget screen time and the other lifestyle and behavioral modifications for ADHD, but medication is so important. We have our traditional stimulants, methylphenidates, which are so helpful with great evidence but do come with some side effects, as all medications do. Then we have the non-stimulants, which I think of in two families: the alpha agonists, and our other non-stimulants, atomoxetine and viloxazine. But now we also have the new medication, centanafadine, which is exciting—it has a novel mechanism as a triple reuptake inhibitor, primarily norepinephrine but with significant activity at dopamine and serotonin as well. It is exciting to have more options, because there is no one medication that works for everybody, so it is good to have something with a novel mechanism, and it will be interesting to see how it works in the real world and how patients respond to it.

Clark: I did not want to leave this conversation without touching on the nonpharmacologic interventions you mentioned, since we are both big proponents of lifestyle medicine and that holistic approach. What would be three take-home points you would give our listeners and viewers about lifestyle changes that can be implemented in a timely fashion? We know medications can take some time to work—stimulants act pretty quickly, but the non-stimulants can take longer—so what would you recommend for parents who are the primary caregivers for their children with ADHD?

Walton: There are even more than 3—there are so many things to work on, and I sometimes get so excited that I name all of them, but I think picking one or two things to focus on at a time is really helpful. The number one lifestyle modification people should prioritize is sleep. Sleep is so incredibly important, and our children and adolescents are not getting enough of it, and we know people with ADHD struggle with sleep, so that is not surprising. Prioritizing good sleep hygiene and a regular routine—going to sleep and waking up at the same time, which is a big struggle especially in the summer—is so important, because if we are not getting good sleep, it is really hard for the brain to concentrate and function well. We also know the ADHD brain really thrives with exercise and physical activity, so that is important, along with good nutrition. A lot of my patients with ADHD are picky eaters, and while we would love good-quality, healthy food—vegetables, fruits, whole grains—a lot of these kids are not getting enough nutrition or calories in general, so making sure they are getting proper nutrition is really important. If I could add a fourth point, I would say predictability and regular routines are really helpful, not only for the child but also for the parents. As I work with these families over time, a child’s diagnosis can become the lens through which a parent starts to understand their own lifelong struggles with ADHD, so I try to be compassionate toward these parents and recognize that I am asking them to execute structure and consistency when they might be personally struggling with these same things. Using strategies such as alarms, visual calendars, checklists, and automating things as much as possible—rather than relying on memory—can be really helpful, not only for the child but also for the parent, so they are not carrying that mental load.

Clark: You said a lot, and I think it is so important—sleep matters for adults too. I find that a lot of my adult patients with ADHD are quite nocturnal; they have that delayed sleep, so I am glad you mentioned it—our bodies have to recover. The other thing I wanted to ask about: I know a lot of my patients will try to self-medicate their ADHD symptoms with caffeine. What are your thoughts on the amount you would recommend for someone with ADHD, especially if they are also taking a stimulant, since we try to encourage some caffeine but not too much?

Walton: That is a great point, and it is something we sometimes forget to ask about. When I am doing my review of substance use, I always start with caffeine, and you can be surprised by how much people are drinking—not just a cup of coffee, but sometimes energy drinks and other products with really high caffeine levels. It makes sense that patients use caffeine, because it helps with energy and can have some benefit for focus and motivation, but especially if a patient has a stimulant on board, we have to be careful monitoring how much caffeine they are drinking, because it can impact those side effects and carry cardiac risks. It can create worsening anxiety and jitteriness, which can then become more distracting, so it is something to monitor. I would probably say around 200 mg is what I tell most people to stick with, but some people have a higher or lower tolerance than others, so it is also important to monitor how they feel when they drink caffeine.

Clark: I have had patients tell me they drink their last caffeinated beverage around 7:00 pm, and I tell them that is probably why they are not sleeping—it can be hard for people to cut down, but even one fewer caffeinated beverage is progress. And thank you for speaking with us today and sharing your expertise!

Dr Clark is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association's Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for Psychiatric Times.

Dr Walton is a double board-certified child and adolescent psychiatrist and adult psychiatrist practicing at Sweetgrass Psychiatry in Mount Pleasant, South Carolina. She also serves as an affiliate assistant professor at the Medical University of South Carolina.

References

1. Shalaby N, Sengupta S, Williams JB. Large-scale analysis reveals racial disparities in the prevalence of ADHD and conduct disorders. Sci Rep. 2024;14:25123.

2. Walters J. FDA approves centanafadine for ADHD in children, adolescents, and adults. Psychiatric Times. July 24, 2026. https://www.psychiatrictimes.com/view/fda-approves-centanafadine-for-adhd-in-children-adolescents-and-adults