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Hi Dr Barkley, Do you have any advice on how to explain ADHD, more specifically late diagnosis (40’s) to friends and family? So many people seem to just think it’s about being distracted or hyperactive without acknowledging all the other symptoms/traits that come along with it. After my diagnosis last fall and reading a lot of books (including some of yours!), etc, I’ve realized a lot of my failures and faults were adhd caused (and I’m now addressing).. I can’t expect them to all read like I have though. Thanks for doing this and helping the community!

I like to explain to others that ADHD is far more than merely a disorder of attention or activity; it is a disorder of self-regulation and of the major executive brain functions that permit us to self-regulate. As we develop, self-regulation becomes increasingly critical to our well being and becoming independent of our families and self-governing in society. Thus, ADHD is disrupting one of the most essential psychological capacities, which is that of self-control. We use self-regulation to organize our actions over time in anticipation of and preparation for future events, goals, assigned tasks, etc. It is, simply put, attention to the future and that is what people with ADHD struggle to attend to. They attend just fine to the now and external environment. But they struggle to attend to the next; to the impending future and what must be done to prepare for its arrival. Viewed this way, ADHD is a very serious disorder as it disrupts a major psychological adaptation that humans use to survive, prosper, and see to their longer-term welfare. When you tell people that, they understand how serious this is and that a cup of Starbuck, a better nights sleep, less screen time with technology, or some nutritional supplement will not address this fundamental problem. ADHD is EFDD (or SRDD), not merely inattention.

Q: Hi Dr Barkley, Do you have any advice on how to explain ADHD, more specifically late diagnosis (40’s) to friends and family? So many people seem to just think it’s about being distracted or hyperactive without acknowledging all the other symptoms/traits that come along with it. After my diagnosis last fall and reading a lot of books (including some of yours!), etc, I’ve realized a lot of my failures and faults were adhd caused (and I’m now addressing).. I can’t expect them to all read like I have though. Thanks for doing this and helping the community! Ans: I like to explain to others that ADHD is far more than merely a disorder of attention or activity; it is a disorder of self-regulation and of the major executive brain functions that permit us to self-regulate. As we develop, self-regulation becomes increasingly critical to our well being and becoming independent of our families and self-governing in society. Thus, ADHD is disrupting one of the most essential psychological capacities, which is that of self-control. We use self-regulation to organize our actions over time in anticipation of and preparation for future events, goals, assigned tasks, etc. It is, simply put, attention to the future and that is what people with ADHD struggle to attend to. They attend just fine to the now and external environment. But they struggle to attend to the next; to the impending future and what must be done to prepare for its arrival. Viewed this way, ADHD is a very serious disorder as it disrupts a major psychological adaptation that humans use to survive, prosper, and see to their longer-term welfare. When you tell people that, they understand how serious this is and that a cup of Starbuck, a better nights sleep, less screen time with technology, or some nutritional supplement will not address this fundamental problem. ADHD is EFDD (or SRDD), not merely inattention.

One of the biggest issues I'm facing is that I want to try out new hobbies or develop new skills in my free time but I can't commit to it. I either jump through hobbies or think about all the hobbies I could do, feel overwhelmed and end up not doing anything. What is the best advice you can give to people with ADHD to really hold on to a hobby and develop it without losing interest?

First, get treatment including considering ADHD medications. Second, commit to doing hobbies with others who share your interest or passion for that activity. We are more likely to do things when we make ourselves socially accountable to others for doing them. Third, engage in the hobby or pastime in a setting, room, or context devoid of competing interests that can pull you off task too quickly. Some people find that headphones, light music, etc. while working also help them maintain their on task focus. Break the hobby or task into smaller time units. Sometimes we can all lose interest in something if we stay at it too long. Just some thoughts here.

Q: One of the biggest issues I'm facing is that I want to try out new hobbies or develop new skills in my free time but I can't commit to it. I either jump through hobbies or think about all the hobbies I could do, feel overwhelmed and end up not doing anything. What is the best advice you can give to people with ADHD to really hold on to a hobby and develop it without losing interest? Ans: First, get treatment including considering ADHD medications. Second, commit to doing hobbies with others who share your interest or passion for that activity. We are more likely to do things when we make ourselves socially accountable to others for doing them. Third, engage in the hobby or pastime in a setting, room, or context devoid of competing interests that can pull you off task too quickly. Some people find that headphones, light music, etc. while working also help them maintain their on task focus. Break the hobby or task into smaller time units. Sometimes we can all lose interest in something if we stay at it too long. Just some thoughts here.

Hi Dr. Barkley, thanks for doing this. What is your elevator pitch for what is going on in the brain due to ADHD? ​ Do you have any tips for someone figuring out which medication regimen works?

In my opinion, ADHD arises from problems with brain maldevelopment especially in the prefrontal executive networks that can arise either from genetic factors (different gene variants and mutations for building and regulating such networks) or from acquired disruptions to the development of these networks and regions. While certain brain regions and gray matter or somewhat smaller during development, this may not be so much the case by adulthood. Nonetheless, we continue to see evidence of reduced connectivity of some regions with others that are part of these executive networks, of excess connectivity with non-executive regions, and especially with more variable functioning in these connections or networks that give rise to the ADHD symptoms and related executive function (EF) networks. So in short its a problem with connectivity and functioning of networks critical for self-regulation and EF, such a inhibition, self-awareness, time management, working memory, emotional self-regulation and motivation, and planning and problem solving. It helps to understand what is happening in ADHD by over simplifying brain activity as being where knowledge is acquired (back part of the brain) and where that knowledge is activated and applied in daily performance (frontal executive brain). ADHD partially disconnects the typical interaction of these brain regions, in a sense. So ADHD is far more a problem of doing what you know, not knowing what to do. Its a performance problem, not a knowledge problem. Adults with ADHD are not ignorant, but they struggle to apply all of what they know in key situations where such knowledge should have guided their actions and decision making, and it didn't.

Q: Hi Dr. Barkley, thanks for doing this. What is your elevator pitch for what is going on in the brain due to ADHD? ​ Do you have any tips for someone figuring out which medication regimen works? Ans: In my opinion, ADHD arises from problems with brain maldevelopment especially in the prefrontal executive networks that can arise either from genetic factors (different gene variants and mutations for building and regulating such networks) or from acquired disruptions to the development of these networks and regions. While certain brain regions and gray matter or somewhat smaller during development, this may not be so much the case by adulthood. Nonetheless, we continue to see evidence of reduced connectivity of some regions with others that are part of these executive networks, of excess connectivity with non-executive regions, and especially with more variable functioning in these connections or networks that give rise to the ADHD symptoms and related executive function (EF) networks. So in short its a problem with connectivity and functioning of networks critical for self-regulation and EF, such a inhibition, self-awareness, time management, working memory, emotional self-regulation and motivation, and planning and problem solving. It helps to understand what is happening in ADHD by over simplifying brain activity as being where knowledge is acquired (back part of the brain) and where that knowledge is activated and applied in daily performance (frontal executive brain). ADHD partially disconnects the typical interaction of these brain regions, in a sense. So ADHD is far more a problem of doing what you know, not knowing what to do. Its a performance problem, not a knowledge problem. Adults with ADHD are not ignorant, but they struggle to apply all of what they know in key situations where such knowledge should have guided their actions and decision making, and it didn't.

Hello Dr. Barkley, thank you so much for doing this Why is it that many people with adhd feel like they don't fit in with their peers, or just society as a whole? Also, are comorbidities more of a nature or nurture type issue? For example, would a kid with adhd already have anxiety or ocd along with it, or would the anxiety develop over time because of the adhd?

I think the answer to this is above - ADHD is really SRDD (EFDD). Social interactions, reciprocity, cooperation, and even intimacy all require appropriate degrees of self-regulation from an individual. When such self-regulation is jeopardized by the disorder, it greatly impacts social acceptance and functioning because it raises problems with making and keeping promises, reciprocating with others (sharing), joining into cooperative team or group activities to accomplish some common goal, repaying favors, managing debts, accomplishing daily social responsibilities -- all are at risk from the disorder. Others can detect these differences in adults with ADHD within minutes of getting to know them. Of all the EF difficulties, it is the impulsive emotional and poor self regulation of emotion that is so harmful to social relationships. Others can tolerate one's distractibility, activity, fizzy personality so to speak, but not someone's quickness to be impatient, frustrated, hostile, angry or even reactively verbally and physically aggressive. That can easily lead to social rejection, being fired from your job, road rage and related citations and license suspensions, intimate partner distress and even violence, etc. So it is the dysregulated emotion more than other symptoms that takes its toll on social relations when ADHD is unmanaged.

Q: Hello Dr. Barkley, thank you so much for doing this Why is it that many people with adhd feel like they don't fit in with their peers, or just society as a whole? Also, are comorbidities more of a nature or nurture type issue? For example, would a kid with adhd already have anxiety or ocd along with it, or would the anxiety develop over time because of the adhd? Ans: I think the answer to this is above - ADHD is really SRDD (EFDD). Social interactions, reciprocity, cooperation, and even intimacy all require appropriate degrees of self-regulation from an individual. When such self-regulation is jeopardized by the disorder, it greatly impacts social acceptance and functioning because it raises problems with making and keeping promises, reciprocating with others (sharing), joining into cooperative team or group activities to accomplish some common goal, repaying favors, managing debts, accomplishing daily social responsibilities -- all are at risk from the disorder. Others can detect these differences in adults with ADHD within minutes of getting to know them. Of all the EF difficulties, it is the impulsive emotional and poor self regulation of emotion that is so harmful to social relationships. Others can tolerate one's distractibility, activity, fizzy personality so to speak, but not someone's quickness to be impatient, frustrated, hostile, angry or even reactively verbally and physically aggressive. That can easily lead to social rejection, being fired from your job, road rage and related citations and license suspensions, intimate partner distress and even violence, etc. So it is the dysregulated emotion more than other symptoms that takes its toll on social relations when ADHD is unmanaged.

Dear Dr. Barkley, Thank you so much for doing this again. For someone who is relatively new to the topic of ADHD there seems to be a proverbial mountain of information out there. Is there a book/podcast/other medium out there that you'd recommend as a guideline for adult ADHD? Also thank you moderators. You are sincerely awesome.

i have many lectures I have given over the years at conferences that got posted to YouTube and viewers tell me those videos changed their life by informing them as to the real nature of ADHD. So start there. There are also now lots of podcasts so I can't name them all but ADHD Talk Radio has some and I am sure you could find others. My new book noted above will also be very up to date and is formatted to be more easily read by adults with ADHD who struggle with lengthy text and comprehension of such material. Other good books out there are by Tom Brown Ari Tuckman, Peg Dawson, Ned Hallowell, Stephanie Sarkis, Craig Surman, J. Russell Ramsay, among others so search for their books. Also, check out the [www.chadd.org](https://www.chadd.org) website which is our US ADHD foundation. In Canada, try [www.caddra.ca](https://www.caddra.ca). Lots of information there on ADHD, not to mention [www.add.org](https://www.add.org), a smaller nonprofit organization focusing more on adult ADHD. For professionals, the [www.apsard.org](https://www.apsard.org) website is very good as its the American Professional Society for ADHD and Related Disoders. Check out the Fact Sheets on my website as well. And the website for the European Network for Adult ADHD.

Q: Dear Dr. Barkley, Thank you so much for doing this again. For someone who is relatively new to the topic of ADHD there seems to be a proverbial mountain of information out there. Is there a book/podcast/other medium out there that you'd recommend as a guideline for adult ADHD? Also thank you moderators. You are sincerely awesome. Ans: i have many lectures I have given over the years at conferences that got posted to YouTube and viewers tell me those videos changed their life by informing them as to the real nature of ADHD. So start there. There are also now lots of podcasts so I can't name them all but ADHD Talk Radio has some and I am sure you could find others. My new book noted above will also be very up to date and is formatted to be more easily read by adults with ADHD who struggle with lengthy text and comprehension of such material. Other good books out there are by Tom Brown Ari Tuckman, Peg Dawson, Ned Hallowell, Stephanie Sarkis, Craig Surman, J. Russell Ramsay, among others so search for their books. Also, check out the [www.chadd.org](https://www.chadd.org) website which is our US ADHD foundation. In Canada, try [www.caddra.ca](https://www.caddra.ca). Lots of information there on ADHD, not to mention [www.add.org](https://www.add.org), a smaller nonprofit organization focusing more on adult ADHD. For professionals, the [www.apsard.org](https://www.apsard.org) website is very good as its the American Professional Society for ADHD and Related Disoders. Check out the Fact Sheets on my website as well. And the website for the European Network for Adult ADHD.

Given how things like trauma can alter brain structure and how brains can restructure themselves after damage, is it plausible that ADHD could be due to environmental factors or even be eliminated in a patient purely due to neuroplasticity? Disclaimer: I say this out of scientific interest, not to suggest that ADHD isn't a real neurological condition or that it can be cured.

it is most unlikely. Present research, which is incredibly abundant, shows that variation in humans in their ADHD symptoms is about 70-80% influenced by genetic variation (differences in genes that build and operate the brain). The remainder is the result of non shared environmental factors, which are things that impacted just that person in their family. This would include pregnancy complications, maternal infections, material use of alcohol when pregnant, premature delivery warranting the infant to go to an NICU, etc. After birth, things like lead poisoning, traumatic brain injuries, and any other factor that adversely impacts brain development in the EF prefrontal brain can lead to ADHD. So its pretty much all biology (neurology and genetics). Rearing environment has not been found to be a contributor to ADHD. That said, people with ADHD are more likely to experience traumatic events, including physical, sexual, and emotional trauma, as a consequence of their lack of foresight, risk taking, and other behaviors as well as the peers they select to associated with. Such things can also arise within families not only from the behavioral difficulties and challenges posed by such children to caregivers, but also by the fact that 25-35% or more of parents have ADHD which can interfere with their own parenting and increase the likelihood for such traumas and victimization. Its possible that some kinds of trauma feedback to worsen the ADHD symptoms (traumatic brain injuries for instance) but less clear that emotional trauma can do this. Regardless, because of their problems with emotional self-regulation, people with ADHD are more prone to develop PTSD if traumatized and find it more difficult to treat such PTSD. So there is some interaction here between ADHD and traumatizing environments but its not a simple or single causal direction of emotional trauma causing ADHD.

Q: Given how things like trauma can alter brain structure and how brains can restructure themselves after damage, is it plausible that ADHD could be due to environmental factors or even be eliminated in a patient purely due to neuroplasticity? Disclaimer: I say this out of scientific interest, not to suggest that ADHD isn't a real neurological condition or that it can be cured. Ans: it is most unlikely. Present research, which is incredibly abundant, shows that variation in humans in their ADHD symptoms is about 70-80% influenced by genetic variation (differences in genes that build and operate the brain). The remainder is the result of non shared environmental factors, which are things that impacted just that person in their family. This would include pregnancy complications, maternal infections, material use of alcohol when pregnant, premature delivery warranting the infant to go to an NICU, etc. After birth, things like lead poisoning, traumatic brain injuries, and any other factor that adversely impacts brain development in the EF prefrontal brain can lead to ADHD. So its pretty much all biology (neurology and genetics). Rearing environment has not been found to be a contributor to ADHD. That said, people with ADHD are more likely to experience traumatic events, including physical, sexual, and emotional trauma, as a consequence of their lack of foresight, risk taking, and other behaviors as well as the peers they select to associated with. Such things can also arise within families not only from the behavioral difficulties and challenges posed by such children to caregivers, but also by the fact that 25-35% or more of parents have ADHD which can interfere with their own parenting and increase the likelihood for such traumas and victimization. Its possible that some kinds of trauma feedback to worsen the ADHD symptoms (traumatic brain injuries for instance) but less clear that emotional trauma can do this. Regardless, because of their problems with emotional self-regulation, people with ADHD are more prone to develop PTSD if traumatized and find it more difficult to treat such PTSD. So there is some interaction here between ADHD and traumatizing environments but its not a simple or single causal direction of emotional trauma causing ADHD.

I’m writing a paper on the benefits and challenges of playing drums with ADHD, and I’m suddenly reading things about how motor deficiencies can be a symptom of ADHD. I’ve neither heard of nor experienced this myself (I was diagnosed 20 years ago), and I’m a bit confused: * Are the deficiencies generally limited to fine or gross motor skills? * I know that handwriting can be an issue, so certainly fine motor, but I want to ask before I dive down a rabbit hole * How common are motor deficiencies in ADHD? * Are they (in your opinion, at least) likely to inhibit learning an instrument? (especially a highly physical one like percussion) Or other physical skills, like drawing, cooking, or sports? My paper uses [Rapport’s working memory model of ADHD (in relation to hyperactivity)](https://doi.org/10.1007/s10802-008-9287-8) as a justification/incentive for students with ADHD to study percussion. I’d love to hear your thoughts on this too, if you're able (though my first questions are more important). Basically... * The ADHD brain needs to move more (than NT brain) to compensate for chronic under-arousal * Percussion requires more movement (fine and gross) than other instruments and can therefore provide some of that compensation, making it ideal for students with ADHD * (I'd love to do a study at some point to justify my theory, perhaps measuring attentiveness in ADHD percussionists during rehearsal or individual practice sessions compared to other instrumentalists with ADHD) Thank you so much for your time!

Great question. its probably not percussion per se that is beneficial to folks with ADHD but, as you noted above, movement. Research is increasingly showing the benefits of exercise in helping people manage and cope with ADHD symptoms. Also, just movement while working studying, or in meetings can be helpful, such as squeezing a tennis ball in one hand while note taking with the other or just listening. Before boring meetings or classes, go for a run, or just walk up and down a flight of stairs. Then try to incorporate smaller movements during that situation. So, yes, activity and movement seem to be helpful whether it is drumming, sports, aerobic workouts, running, whatever. It all seems to help.

Q: I’m writing a paper on the benefits and challenges of playing drums with ADHD, and I’m suddenly reading things about how motor deficiencies can be a symptom of ADHD. I’ve neither heard of nor experienced this myself (I was diagnosed 20 years ago), and I’m a bit confused: * Are the deficiencies generally limited to fine or gross motor skills? * I know that handwriting can be an issue, so certainly fine motor, but I want to ask before I dive down a rabbit hole * How common are motor deficiencies in ADHD? * Are they (in your opinion, at least) likely to inhibit learning an instrument? (especially a highly physical one like percussion) Or other physical skills, like drawing, cooking, or sports? My paper uses [Rapport’s working memory model of ADHD (in relation to hyperactivity)](https://doi.org/10.1007/s10802-008-9287-8) as a justification/incentive for students with ADHD to study percussion. I’d love to hear your thoughts on this too, if you're able (though my first questions are more important). Basically... * The ADHD brain needs to move more (than NT brain) to compensate for chronic under-arousal * Percussion requires more movement (fine and gross) than other instruments and can therefore provide some of that compensation, making it ideal for students with ADHD * (I'd love to do a study at some point to justify my theory, perhaps measuring attentiveness in ADHD percussionists during rehearsal or individual practice sessions compared to other instrumentalists with ADHD) Thank you so much for your time! Ans: Great question. its probably not percussion per se that is beneficial to folks with ADHD but, as you noted above, movement. Research is increasingly showing the benefits of exercise in helping people manage and cope with ADHD symptoms. Also, just movement while working studying, or in meetings can be helpful, such as squeezing a tennis ball in one hand while note taking with the other or just listening. Before boring meetings or classes, go for a run, or just walk up and down a flight of stairs. Then try to incorporate smaller movements during that situation. So, yes, activity and movement seem to be helpful whether it is drumming, sports, aerobic workouts, running, whatever. It all seems to help.

Hi Dr. Barkley, thanks for taking the time to do this AMA! In your experience, how does ADHD affect long term relationships and more specifically, the sex life of relationship ships? Are there any tools, or resources you could suggest for people trying to work on their long term relationships/sex lives? I’m asking from a gay male’s perspective. I know the experience for females can be different, in case there are others on this sub who have a similar question. I also wanted you to thank you for all your work and the resources you’ve created and made available. I’ve found them immensely helpful and useful for explaining to loved ones how my ADHD affects me in terms they can understand.

Thanks, Sarah. You are welcome. I addressed the general social relations problems above. There is far less information on this aspect of intimate social behavior than on social relationships with others more generally. But check out Ari Tuckman's latest book, ADHD After Dark, which specifically focuses on sexual relations. Also, ADHD Roller Coaster website managed by Gina Pera deals with cohabiting, intimate, and marital relationships. There are one or two other books at online booksellers that address marriage and partnering though not as much for the gay male perspective as one might wish. Its all such a new area of research at the moment but these resources might prove informative.

Q: Hi Dr. Barkley, thanks for taking the time to do this AMA! In your experience, how does ADHD affect long term relationships and more specifically, the sex life of relationship ships? Are there any tools, or resources you could suggest for people trying to work on their long term relationships/sex lives? I’m asking from a gay male’s perspective. I know the experience for females can be different, in case there are others on this sub who have a similar question. I also wanted you to thank you for all your work and the resources you’ve created and made available. I’ve found them immensely helpful and useful for explaining to loved ones how my ADHD affects me in terms they can understand. Ans: Thanks, Sarah. You are welcome. I addressed the general social relations problems above. There is far less information on this aspect of intimate social behavior than on social relationships with others more generally. But check out Ari Tuckman's latest book, ADHD After Dark, which specifically focuses on sexual relations. Also, ADHD Roller Coaster website managed by Gina Pera deals with cohabiting, intimate, and marital relationships. There are one or two other books at online booksellers that address marriage and partnering though not as much for the gay male perspective as one might wish. Its all such a new area of research at the moment but these resources might prove informative.

Hello Dr. Barkley, Thank you very much for answering the questions and all the research you have done on the subject of people with adhd and treatment methods. Mostly something I've wondered, I don't have a lot of questions on adhd itself right now, they slip my mind easily, but a bit more of a personal one. What is the reason you have researched adhd as much as you have? what interests you about it?

Thank you! I got into this field in 1972 when I attended UNC and was majoring in psychology and minoring in biology. I wanted to go to graduate school but need to have done extra things besides getting good grades. So I wandered their medical school offering to volunteer 15+ hours per week to anyone who needed a research assistant. By chance, a faculty member had just gotten a grant to study hyperactive (ADHD) children and the role of behavior modification and medication in treating them. I became his assistant, then his honors student, and went on to graduate school where I did all my research on ADHD and have never stopped since. The condition fascinated me as I wanted to understand why these children had such poor behavioral (self) control. As I got older, I also realized that understanding ADHD could teach us a great deal about how people generally develop self regulation, what it is, how the executive functions develop so as to allow self control. And I wrote two books just on my theory of all that (ADHD and the Nature of Self Control, 1997, and The Executive Functions, in 2012). Studying ADHD is like holding a mirror up to ourselves - we can all learn a lot from it about self regulation and how to improve it. As some of you know, ADHD was also in my family and so studying it helped me personally to understand and even deal with and try eo help some family members my fraternal twin brother in particular. Regrettably, his life of impulsivity, risk taking, risky driving, and use of alcohol resulted in his death in a car accident when he was 56. And a year later his son with ADHD committed suicide impulsively after an argument with a girlfriend. So understanding ADHD is also personal for me.

Q: Hello Dr. Barkley, Thank you very much for answering the questions and all the research you have done on the subject of people with adhd and treatment methods. Mostly something I've wondered, I don't have a lot of questions on adhd itself right now, they slip my mind easily, but a bit more of a personal one. What is the reason you have researched adhd as much as you have? what interests you about it? Ans: Thank you! I got into this field in 1972 when I attended UNC and was majoring in psychology and minoring in biology. I wanted to go to graduate school but need to have done extra things besides getting good grades. So I wandered their medical school offering to volunteer 15+ hours per week to anyone who needed a research assistant. By chance, a faculty member had just gotten a grant to study hyperactive (ADHD) children and the role of behavior modification and medication in treating them. I became his assistant, then his honors student, and went on to graduate school where I did all my research on ADHD and have never stopped since. The condition fascinated me as I wanted to understand why these children had such poor behavioral (self) control. As I got older, I also realized that understanding ADHD could teach us a great deal about how people generally develop self regulation, what it is, how the executive functions develop so as to allow self control. And I wrote two books just on my theory of all that (ADHD and the Nature of Self Control, 1997, and The Executive Functions, in 2012). Studying ADHD is like holding a mirror up to ourselves - we can all learn a lot from it about self regulation and how to improve it. As some of you know, ADHD was also in my family and so studying it helped me personally to understand and even deal with and try eo help some family members my fraternal twin brother in particular. Regrettably, his life of impulsivity, risk taking, risky driving, and use of alcohol resulted in his death in a car accident when he was 56. And a year later his son with ADHD committed suicide impulsively after an argument with a girlfriend. So understanding ADHD is also personal for me.

Hi Dr. Barkley - it seems like either my symptoms get worse or my meds work less as I approach that time of the month, i.e. getting my period. What is the cause or correlation between period symptoms and ADHD? Is there anything women can do to reduce these effects?

Yes, there is some interesting recent research on this long neglected topic in women with ADHD and an article will be out in my newsletter in August by Ellen Littman and colleagues summarizing what we know about this, which isn't much but squares with your experience. My newsletter is The ADHD Report. In short, ADHD symptoms in women are affected by the balance their estrogen/progesterone hormones. As they fluctuate during the month and even across life, ADHD symptoms can get markedly worse or better. For instance, a few studies suggest that ADHD in girls may start in childhood, but can also appear at the start of menses in adolescence, and can be worsened by entering peri menopause as well. Clinicians often find helpful to add extra meds or other treatments around the monthly menses and even at menopause to try to cope with the exacerbation of symptoms and emotional dysregulation, not to mention working memory. some clinicians, for instance, add an antidepressant or even mood stabilizer to the usual ADHD medications at these times to help women deal with these fluctuating symptoms. Periodically, check Google Scholar to see what new research might be appearing on this but its clearly an issue worth more research to understand and treat it.

Q: Hi Dr. Barkley - it seems like either my symptoms get worse or my meds work less as I approach that time of the month, i.e. getting my period. What is the cause or correlation between period symptoms and ADHD? Is there anything women can do to reduce these effects? Ans: Yes, there is some interesting recent research on this long neglected topic in women with ADHD and an article will be out in my newsletter in August by Ellen Littman and colleagues summarizing what we know about this, which isn't much but squares with your experience. My newsletter is The ADHD Report. In short, ADHD symptoms in women are affected by the balance their estrogen/progesterone hormones. As they fluctuate during the month and even across life, ADHD symptoms can get markedly worse or better. For instance, a few studies suggest that ADHD in girls may start in childhood, but can also appear at the start of menses in adolescence, and can be worsened by entering peri menopause as well. Clinicians often find helpful to add extra meds or other treatments around the monthly menses and even at menopause to try to cope with the exacerbation of symptoms and emotional dysregulation, not to mention working memory. some clinicians, for instance, add an antidepressant or even mood stabilizer to the usual ADHD medications at these times to help women deal with these fluctuating symptoms. Periodically, check Google Scholar to see what new research might be appearing on this but its clearly an issue worth more research to understand and treat it.

As someone with ADHD and with rejection sensitivity being something that 99% of ADHD people have what can we do to learn more / get better with it as it's something that is semi-new to my knowledge what can I do more to learn about it?

Rejection sensitivity is a clinical concept invented by some practitioners and popularized on the web more than it is a well research condition or one that is an inherent part of ADHD. There is no official diagnosis of this but some practitioners and clients have found the concept useful nonetheless. Nor is there much, if any, solid research on the issue in adults with ADHD. That said, what is increasingly well established is that ADHD is associated with problems with impulsive emotions and poor self-regulation of provoked strong emotions. I refer to both of these related problems as emotional dysregulation. Because people with ADHD have a propensity to respond to emotionally provocative events more quickly and with stronger emotions, they may also react specifically to signals of social rejection from others. But the problem is a general one of emotional impulsivity, especially for negative emotions such as impatience, frustration, hostility, anger, and even at times reactive aggression, rather than one specific only to social rejection. Also keep in mind that about 25-50% of adults with ADHD may develop an anxiety disorder which can also make them more concerned about and hence sensitive to social rejection, especially if it is a social anxiety disorder. The same can occur as a result of co-existing depression with adult ADHD. You can learn more about the role of emotional dysregulation and such comorbid disorders in my trade books on adult ADHD as well as in my ADHD Handbook for Diagnosis and Treatment (2015). You can also use Google Scholar to search the science/medical journals for this term and adult ADHD.

Q: As someone with ADHD and with rejection sensitivity being something that 99% of ADHD people have what can we do to learn more / get better with it as it's something that is semi-new to my knowledge what can I do more to learn about it? Ans: Rejection sensitivity is a clinical concept invented by some practitioners and popularized on the web more than it is a well research condition or one that is an inherent part of ADHD. There is no official diagnosis of this but some practitioners and clients have found the concept useful nonetheless. Nor is there much, if any, solid research on the issue in adults with ADHD. That said, what is increasingly well established is that ADHD is associated with problems with impulsive emotions and poor self-regulation of provoked strong emotions. I refer to both of these related problems as emotional dysregulation. Because people with ADHD have a propensity to respond to emotionally provocative events more quickly and with stronger emotions, they may also react specifically to signals of social rejection from others. But the problem is a general one of emotional impulsivity, especially for negative emotions such as impatience, frustration, hostility, anger, and even at times reactive aggression, rather than one specific only to social rejection. Also keep in mind that about 25-50% of adults with ADHD may develop an anxiety disorder which can also make them more concerned about and hence sensitive to social rejection, especially if it is a social anxiety disorder. The same can occur as a result of co-existing depression with adult ADHD. You can learn more about the role of emotional dysregulation and such comorbid disorders in my trade books on adult ADHD as well as in my ADHD Handbook for Diagnosis and Treatment (2015). You can also use Google Scholar to search the science/medical journals for this term and adult ADHD.

Been interested in the fields of psychology and psychiatry for a while now, and I've been wondering: How is (high functioning) ADHD in gifted people perceived, and how can it be diagnosed at all? With how, in my impression, poor performance in school or education is seen as the most major tip-off for ADHD, not having this symptom could lead to either no diagnosis as no significant impairment can be seen, or one or more misdiagnoses (so far I've found cases including mood disorders, ASD, OCD, PTSD, SPD, and a case of anxiety disorder which wasn't a misdiagnosis but the ADHD was overlooked/overshadowed). Generally, how are disorders and disorders as symptoms of others separated? Please correct me if there's anything factually wrong, and I hope these questions aren't inappropriate or too hard to answer. Thank you so much for your time

ADHD is the same in high IQ people but it may not result in impairment in school or even work until later in life as burdens and responsibilities intros domains increase to a point where one's giftedness no longer protects them from adversities. But IQ is not related to all the other impairments we see in adults with ADHD and those can be clues that a person with high IQ has the disorder. So driving, substance use and abuse, impaired social relationships, managing money, risk taking, etc. are all ways to see if ADHD is there in high IQ people apart from just school and work, as you noted above. So we can usually find impairment but it other domains than work and education. The critical criterion for establishing that any disorder is present is one of harm. Is the individual experiencing personal suffering, functional ineffectiveness, and/or adverse consequences from displaying those symptoms. Symptoms alone do not make a disorder. But should they be frequent and serious enough to lead to harmful consequences (impairment) then that is where a disorder gets diagnosed. No impairment, then no disorder. But impairment can arise in many domains than just school or work.

Q: Been interested in the fields of psychology and psychiatry for a while now, and I've been wondering: How is (high functioning) ADHD in gifted people perceived, and how can it be diagnosed at all? With how, in my impression, poor performance in school or education is seen as the most major tip-off for ADHD, not having this symptom could lead to either no diagnosis as no significant impairment can be seen, or one or more misdiagnoses (so far I've found cases including mood disorders, ASD, OCD, PTSD, SPD, and a case of anxiety disorder which wasn't a misdiagnosis but the ADHD was overlooked/overshadowed). Generally, how are disorders and disorders as symptoms of others separated? Please correct me if there's anything factually wrong, and I hope these questions aren't inappropriate or too hard to answer. Thank you so much for your time Ans: ADHD is the same in high IQ people but it may not result in impairment in school or even work until later in life as burdens and responsibilities intros domains increase to a point where one's giftedness no longer protects them from adversities. But IQ is not related to all the other impairments we see in adults with ADHD and those can be clues that a person with high IQ has the disorder. So driving, substance use and abuse, impaired social relationships, managing money, risk taking, etc. are all ways to see if ADHD is there in high IQ people apart from just school and work, as you noted above. So we can usually find impairment but it other domains than work and education. The critical criterion for establishing that any disorder is present is one of harm. Is the individual experiencing personal suffering, functional ineffectiveness, and/or adverse consequences from displaying those symptoms. Symptoms alone do not make a disorder. But should they be frequent and serious enough to lead to harmful consequences (impairment) then that is where a disorder gets diagnosed. No impairment, then no disorder. But impairment can arise in many domains than just school or work.

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Lots of related and good questions here. And your concerns are very typical of the adults with ADHD we have studied in our clinical research and seen in the centers i used to manage. First, the EF and self-regulation deficits inherent in ADHD make work as much a struggle as they did school, especially if the work is not intrinsically rewarding, and most of work isn't. Second, ADHD delays the typical diurnal rhythm of the brain such that adults with ADHD usually report being more alert and attentive in afternoons and at night than in the morning. Indeed, research shows that the clock gene is different in people with ADHD. All this means that if you have a typical day job, it is to some extent conflicting with your own natural diurnal cycle of alertness. Some adults seek out more flexible work hours, second shifts, or even self-employment to allow them to work when they are most suitable to do so instead of just on the typical work day schedule. As for jobs, Google ADHD Success Stories and you will see the sorts of nontraditional occupations that adults with ADHD have found better suited to their ADHD. Also, my new book has an entire section on this issue. And the new documentary, The Disruptors, is all about this pursuit of nontraditional routes to work and success with lots of cameos by adults with ADHD who succeeded. See if you can find it on Amazon Prime, Netflix, PBS, etc. Not sure who picked it up as it was just released this spring. Its not hopeless but often adults we have known really had to go outside the box of traditional routes of occupations instead of business, medicine, law, desk jobs, etc. They seemed to do better in the trades, as entrepreneurs, in performing arts as noted above, in athletics or teaching physical ed, in home building or destruction (Ty Pennington anyone?), in the culinary arts, as EMTs or in police or fire work, in the military, etc. Notice they all involve movement, working at unusual hours and times, allow for inattention, focus on manual activities rather than extended forethought and planning, frequent social interactions with others (sales), etc. Keep at it. There are many roads to Rome, as they say, you just have to find the one that fits you.

Q: [deleted] Ans: Lots of related and good questions here. And your concerns are very typical of the adults with ADHD we have studied in our clinical research and seen in the centers i used to manage. First, the EF and self-regulation deficits inherent in ADHD make work as much a struggle as they did school, especially if the work is not intrinsically rewarding, and most of work isn't. Second, ADHD delays the typical diurnal rhythm of the brain such that adults with ADHD usually report being more alert and attentive in afternoons and at night than in the morning. Indeed, research shows that the clock gene is different in people with ADHD. All this means that if you have a typical day job, it is to some extent conflicting with your own natural diurnal cycle of alertness. Some adults seek out more flexible work hours, second shifts, or even self-employment to allow them to work when they are most suitable to do so instead of just on the typical work day schedule. As for jobs, Google ADHD Success Stories and you will see the sorts of nontraditional occupations that adults with ADHD have found better suited to their ADHD. Also, my new book has an entire section on this issue. And the new documentary, The Disruptors, is all about this pursuit of nontraditional routes to work and success with lots of cameos by adults with ADHD who succeeded. See if you can find it on Amazon Prime, Netflix, PBS, etc. Not sure who picked it up as it was just released this spring. Its not hopeless but often adults we have known really had to go outside the box of traditional routes of occupations instead of business, medicine, law, desk jobs, etc. They seemed to do better in the trades, as entrepreneurs, in performing arts as noted above, in athletics or teaching physical ed, in home building or destruction (Ty Pennington anyone?), in the culinary arts, as EMTs or in police or fire work, in the military, etc. Notice they all involve movement, working at unusual hours and times, allow for inattention, focus on manual activities rather than extended forethought and planning, frequent social interactions with others (sales), etc. Keep at it. There are many roads to Rome, as they say, you just have to find the one that fits you.

Dr. Barkley, thank you for letting us pick your brain! How far are we from having a physical diagnostic test for ADHD, (i.e. fMRI, genetic testing)? Do you think expansion in this area will help us narrow down where people fall on the spectrum? Do you think having a “concrete” test will help dispel some of the misinformation surrounding ADHD and lead to earlier, faster diagnosis? Like many other adults during quarantine, I was diagnosed at 42. I am still absolutely astonished that it was missed during grade school and absolutely appalled at the hurdles that we have to jump to get treatment. I see new posts daily about someone being told “adults can’t have ADHD” “you can read, you don’t have it” “you got good grades, it’s not affecting you”. I don’t know how some of these people are still allowed to practice. Thank you for being one of the, wait, THE main good guy!

Thanks so much for your support of my work. To date we have no test, despite some neuropsychologists using testing for diagnosis. I have written extensively against this as its very inaccurate and misleading. As for biological or lab tests, there is the chance in the near future that neuroimaging or genetic testing will be found to be sufficiently accurate to diagnose individuals. Now they are just useful for comparing groups of ADHDs to NTs and watching for mean differences. That does not help us with diagnosing individuals even if it can help with discovering some scientifically useful information. So, yes, neurology and genetics might offer us a lab task but not yet. And if someone tells you they have it, like a SPECT scan for diagnosis or genetic testing for risk genes, they don't. Steer clear and save your money.

Q: Dr. Barkley, thank you for letting us pick your brain! How far are we from having a physical diagnostic test for ADHD, (i.e. fMRI, genetic testing)? Do you think expansion in this area will help us narrow down where people fall on the spectrum? Do you think having a “concrete” test will help dispel some of the misinformation surrounding ADHD and lead to earlier, faster diagnosis? Like many other adults during quarantine, I was diagnosed at 42. I am still absolutely astonished that it was missed during grade school and absolutely appalled at the hurdles that we have to jump to get treatment. I see new posts daily about someone being told “adults can’t have ADHD” “you can read, you don’t have it” “you got good grades, it’s not affecting you”. I don’t know how some of these people are still allowed to practice. Thank you for being one of the, wait, THE main good guy! Ans: Thanks so much for your support of my work. To date we have no test, despite some neuropsychologists using testing for diagnosis. I have written extensively against this as its very inaccurate and misleading. As for biological or lab tests, there is the chance in the near future that neuroimaging or genetic testing will be found to be sufficiently accurate to diagnose individuals. Now they are just useful for comparing groups of ADHDs to NTs and watching for mean differences. That does not help us with diagnosing individuals even if it can help with discovering some scientifically useful information. So, yes, neurology and genetics might offer us a lab task but not yet. And if someone tells you they have it, like a SPECT scan for diagnosis or genetic testing for risk genes, they don't. Steer clear and save your money.

Hi Dr. Barkley. What is your opinion on the potential use of psychedelics to treat ADHD?

Needs a lot more research. So nothing definitive or even promising at this time.

Q: Hi Dr. Barkley. What is your opinion on the potential use of psychedelics to treat ADHD? Ans: Needs a lot more research. So nothing definitive or even promising at this time.

Hello Mr. Barkley. Thanks for using your precious time to answer some of our questions. I wanted to ask, what's your input regarding knowledge and acceptance of ADHD (and other mental disorders) in third world nations? I live in Argentina and people either think ADHD is just getting distracted easily or that it's an incredibly crippling condition; it's white or black, and most don't know about it anyway. When I was diagnosed as a child my mother was advised not to medicate me as she was told I'd "grow up out of it". I know that in many other places things like this are similar, and many many people go undiagnosed for their whole lives. Do you think this is due to any particular reason other than the socioeconomic conditions of these places? How do you think the medical standards in these places could be improved and the stigma of ADHD and other disorders in society be reduced? I really hope you have a nice week!

You are correct that less developed countries either don't identify ADHD at all or don't view it or that it the way that more developed or Westernized countries do. While that is changing (such as currently in China) its still a problem. I see it as socioeconomically driven because societies have to solve certain problems of their survival and welfare before psychiatric or neurodevelopmental disorders become a higher priority for them to address. Kenya, for instance, could care less about ADHD, has but one or two psychiatrists for the entire country, and is nearly a failed state so ADHD is no where on their social radar screen so to speak. I think the same operates in South America but even there varies across countries, with more knowledge and resources and support groups for ADHD now existing in Brazil. Less so in Argentina or Chile but that will change as more serious societal problems get addressed.

Q: Hello Mr. Barkley. Thanks for using your precious time to answer some of our questions. I wanted to ask, what's your input regarding knowledge and acceptance of ADHD (and other mental disorders) in third world nations? I live in Argentina and people either think ADHD is just getting distracted easily or that it's an incredibly crippling condition; it's white or black, and most don't know about it anyway. When I was diagnosed as a child my mother was advised not to medicate me as she was told I'd "grow up out of it". I know that in many other places things like this are similar, and many many people go undiagnosed for their whole lives. Do you think this is due to any particular reason other than the socioeconomic conditions of these places? How do you think the medical standards in these places could be improved and the stigma of ADHD and other disorders in society be reduced? I really hope you have a nice week! Ans: You are correct that less developed countries either don't identify ADHD at all or don't view it or that it the way that more developed or Westernized countries do. While that is changing (such as currently in China) its still a problem. I see it as socioeconomically driven because societies have to solve certain problems of their survival and welfare before psychiatric or neurodevelopmental disorders become a higher priority for them to address. Kenya, for instance, could care less about ADHD, has but one or two psychiatrists for the entire country, and is nearly a failed state so ADHD is no where on their social radar screen so to speak. I think the same operates in South America but even there varies across countries, with more knowledge and resources and support groups for ADHD now existing in Brazil. Less so in Argentina or Chile but that will change as more serious societal problems get addressed.

Hello Dr Barkley, An issue I seem unable to come across in the literature is the extent to which ADHD is an impairment in abstract fields such as mathematics and theoretical physics. In one of your talks in which you spoke about the relatively poor performance of neuropsychological test batteries predicting impairment compared to rating scales you mentioned that “cold cognition” is significantly impaired, and mentioned that no one cares a lick about digit span backwards. If someone finds that fields like creative problem solving in math are what really excites them to what extent do you expect them to be impaired in such a field and do you expect pharmacological intervention could normalize performance or ameliorate a large chunk of the disparity? Thanks for all the work you do, having a top flight researcher communicate the current scientific consensus in great detail is enormously helpful.

Great question and for which there is no research on that very specialized group of people. But in general when I mentioned cold cognition I meant the usual working memory type tests that deal with remember digit sequences or spatial locations. And while the average person with ADHD struggles with such tasks the deficit is not so apparent there as it is in real world functioning as detected by rating scales. Hence the problem of low ecological validity of those tests and their poor diagnostic accuracy for ADHD. While I would expect someone so talented in such a complex and abstract field who had ADHD would be superior in their working memory for these ideas compared to neurotypicals, you might still see the deficits compared to others working in the same fields. But not always. There are individual differences in the EF deficits that go along with ADHD such that some may not be so bad at working memory but awful on time management or emotion regulation others may show a different patterning to the deficits.

Q: Hello Dr Barkley, An issue I seem unable to come across in the literature is the extent to which ADHD is an impairment in abstract fields such as mathematics and theoretical physics. In one of your talks in which you spoke about the relatively poor performance of neuropsychological test batteries predicting impairment compared to rating scales you mentioned that “cold cognition” is significantly impaired, and mentioned that no one cares a lick about digit span backwards. If someone finds that fields like creative problem solving in math are what really excites them to what extent do you expect them to be impaired in such a field and do you expect pharmacological intervention could normalize performance or ameliorate a large chunk of the disparity? Thanks for all the work you do, having a top flight researcher communicate the current scientific consensus in great detail is enormously helpful. Ans: Great question and for which there is no research on that very specialized group of people. But in general when I mentioned cold cognition I meant the usual working memory type tests that deal with remember digit sequences or spatial locations. And while the average person with ADHD struggles with such tasks the deficit is not so apparent there as it is in real world functioning as detected by rating scales. Hence the problem of low ecological validity of those tests and their poor diagnostic accuracy for ADHD. While I would expect someone so talented in such a complex and abstract field who had ADHD would be superior in their working memory for these ideas compared to neurotypicals, you might still see the deficits compared to others working in the same fields. But not always. There are individual differences in the EF deficits that go along with ADHD such that some may not be so bad at working memory but awful on time management or emotion regulation others may show a different patterning to the deficits.

ADHD is associated with some sensory processing issues. How does this fit into the current models of ADHD?

Problems with sensory processing can occur at various levels of brain processing of information and can be found in several disorders. For instance, people with ASD often have sensory perceptual problems as you know related to lighting, clothes and their texture, touch, loud noise, etc. This often occurs at very early stages of processing. That is not so typical of ADHD unless it coexists with ASD. Instead, in ADHD, the problem is one of inhibition and gating at higher levels of cognitive activity in which competing forms of sensations distract or disrupt thinking and goal directed actions. So that is not so much a processing problem as a gating and inhibition problem with competing sensory events not relevant to goals still crash into goal directed thinking. NTs would have inhibited such competing information effortlessly but the ADHD brain and its weaker inhibitory systems may not do so as easily, at least by my line of reasoning.

Q: ADHD is associated with some sensory processing issues. How does this fit into the current models of ADHD? Ans: Problems with sensory processing can occur at various levels of brain processing of information and can be found in several disorders. For instance, people with ASD often have sensory perceptual problems as you know related to lighting, clothes and their texture, touch, loud noise, etc. This often occurs at very early stages of processing. That is not so typical of ADHD unless it coexists with ASD. Instead, in ADHD, the problem is one of inhibition and gating at higher levels of cognitive activity in which competing forms of sensations distract or disrupt thinking and goal directed actions. So that is not so much a processing problem as a gating and inhibition problem with competing sensory events not relevant to goals still crash into goal directed thinking. NTs would have inhibited such competing information effortlessly but the ADHD brain and its weaker inhibitory systems may not do so as easily, at least by my line of reasoning.

Dr. Barkley, I was wondering if you know of any research or work being done that aims to make education and technology more accessible to people with various disorders and disabilities? Not just affordable accessibility, but insight into how to create and teach in ways that will allow more people to use and understand the material. I got diagnosed earlier this year and the only reason I was able to persist was because of lectures from professionals such as yourself. I was terrified of finding out that there was nothing wrong with me and everything was my fault for not trying harder. I've made more progress in 2021 than I had in the last decade. Wanted to let you know your work continues to reach the people who need it.

Thank you so much for those kind words. I am not aware of anyone working in that field at the moment. All the focus on high tech seems to be either on developing apps and related hardware (if needed) to either assess ADHD or to create brain training games (often called digital medicine) to try to rehabilitate or overcome some of the EF deficits such as in working memory. To date, despite more than 300 such apps, etc., few have been studied and none have been found to generalize from the game or similar game like tasks to real world situations requiring that EF capacity. We call the latter far transfer and the technology usually fails at that requirement. So I advise against people using websites like Lumosity or games like Endeavor, CogMed, etc. unless you just want to have fun. But don't expect them to change your everyday functioning.

Q: Dr. Barkley, I was wondering if you know of any research or work being done that aims to make education and technology more accessible to people with various disorders and disabilities? Not just affordable accessibility, but insight into how to create and teach in ways that will allow more people to use and understand the material. I got diagnosed earlier this year and the only reason I was able to persist was because of lectures from professionals such as yourself. I was terrified of finding out that there was nothing wrong with me and everything was my fault for not trying harder. I've made more progress in 2021 than I had in the last decade. Wanted to let you know your work continues to reach the people who need it. Ans: Thank you so much for those kind words. I am not aware of anyone working in that field at the moment. All the focus on high tech seems to be either on developing apps and related hardware (if needed) to either assess ADHD or to create brain training games (often called digital medicine) to try to rehabilitate or overcome some of the EF deficits such as in working memory. To date, despite more than 300 such apps, etc., few have been studied and none have been found to generalize from the game or similar game like tasks to real world situations requiring that EF capacity. We call the latter far transfer and the technology usually fails at that requirement. So I advise against people using websites like Lumosity or games like Endeavor, CogMed, etc. unless you just want to have fun. But don't expect them to change your everyday functioning.

Thank you Dr. Barkley for doing this! Could you comment on the prevalence of anxiety among adults with ADHD? Is there a connection between the two, and are there ADHD-specific ways to treat anxiety, and vice-versa?

Glad to. Yes there is a connection both in underlying shared genetics and in causation over time. The risk genes for ADHD are shared with those for anxiety to some extent but not completely. About 20-25% of children with ADHD have one or more anxiety disorders. That figure nearly doubles by adulthood (about age 35-45) to 45-50% if the ADHD goes untreated in adulthood. Even over a typical 4 year period in adulthood, research shows that ADHD at time 1 is linked to increased risk for an anxiety disorder at time 2, even controlling for level of any anxiety at time 1. We aer not sure why but experiencing repeated failure could easily lead to the acquisition of various anxiety disorders, in my opinion. If the anxiety remains rlatively low and related to failure, then ADHD medications have been shown to improve it. If it is greater and related to excess fearfulness, panic, worry over the future, etc. as occurs in anxiety disorders even without ADHD, then adding some anti-anxiety medication along with cognitive behavior therapy for anxiety among other psychological methods would likely be suggested to that person by an informed clinician.

Q: Thank you Dr. Barkley for doing this! Could you comment on the prevalence of anxiety among adults with ADHD? Is there a connection between the two, and are there ADHD-specific ways to treat anxiety, and vice-versa? Ans: Glad to. Yes there is a connection both in underlying shared genetics and in causation over time. The risk genes for ADHD are shared with those for anxiety to some extent but not completely. About 20-25% of children with ADHD have one or more anxiety disorders. That figure nearly doubles by adulthood (about age 35-45) to 45-50% if the ADHD goes untreated in adulthood. Even over a typical 4 year period in adulthood, research shows that ADHD at time 1 is linked to increased risk for an anxiety disorder at time 2, even controlling for level of any anxiety at time 1. We aer not sure why but experiencing repeated failure could easily lead to the acquisition of various anxiety disorders, in my opinion. If the anxiety remains rlatively low and related to failure, then ADHD medications have been shown to improve it. If it is greater and related to excess fearfulness, panic, worry over the future, etc. as occurs in anxiety disorders even without ADHD, then adding some anti-anxiety medication along with cognitive behavior therapy for anxiety among other psychological methods would likely be suggested to that person by an informed clinician.

Hello Dr. Russell Barkley, I have a very hard time following a consistent sleep schedule due to restlessness at night caused by my ADHD, and often find myself dozing off during the day due to not sleeping enough. This is not helped by the medication I’m taking (atomoxetine) which has a side effect of making me sleepy. Do you have any advice on how to keep a consistent sleep schedule (or any kind of schedule) for someone with ADHD?

The things we recommend in situations like this might include evaluation at a sleep lab to evaluate sleep phases and disruptions, using melatonin at bedtime, exploring what else you do before bedtime (screen time? gaming? etc.) to see if it is counter productive to sleep onset, possible using a sleep medication for a few nights at bedtime to reset your sleep cycle, using atomoxetine in split doses (morning then night) to spread out that medications and maybe reduce this side effect, talking to your primary care doctor about possible sleep apnea, obstructive airway during sleep, or restless leg syndrome.

Q: Hello Dr. Russell Barkley, I have a very hard time following a consistent sleep schedule due to restlessness at night caused by my ADHD, and often find myself dozing off during the day due to not sleeping enough. This is not helped by the medication I’m taking (atomoxetine) which has a side effect of making me sleepy. Do you have any advice on how to keep a consistent sleep schedule (or any kind of schedule) for someone with ADHD? Ans: The things we recommend in situations like this might include evaluation at a sleep lab to evaluate sleep phases and disruptions, using melatonin at bedtime, exploring what else you do before bedtime (screen time? gaming? etc.) to see if it is counter productive to sleep onset, possible using a sleep medication for a few nights at bedtime to reset your sleep cycle, using atomoxetine in split doses (morning then night) to spread out that medications and maybe reduce this side effect, talking to your primary care doctor about possible sleep apnea, obstructive airway during sleep, or restless leg syndrome.

Asked another question, but remembered another really important one. Is there any observable difference between a brain that has ADHD "naturally" versus one that "develops" it? That is, if someone receives an injury to the frontal lobe, can changes in behavior be differentiated from someone who has had it their entire life? Is there any difference on a mechanical, chemical, or other such level? I ask because my father had a traumatic brain injury and I suspect my mother is part of the genetic link to my ADHD. Both of my parents had traumatic childhoods, but I don't believe my mother has ever been diagnosed with an injury. I was born after my dad's injury, so I didn't observe the changes others had. I also had a traumatic childhood, so my particular combination of nature and nurture made it hard to realize there was more than just PTSD causing problems.

Briefly, as I noted above, most ADHD arises from genetic sources, though they can certainly interact with biological hazards and other injurious events to the brain such as head trauma. The clinical presentation may be the same, but often the acquired form of ADHD is worse, doesn't respond so well to ADHD medications (50% improve vs. 75-90%), may experience more medication side effects (the drugs don't seem to work as well when damage is present vs. genetic maldevelopment), and of course the onset of the ADHD may be different (any time in life the injury occurs) compared to the developmental-familial form of the disorder. And, yes, they would be different in their neuroanatomy as injuries produce more detectable damage int he brain than would a genetically caused malformation of brain circuitry.

Q: Asked another question, but remembered another really important one. Is there any observable difference between a brain that has ADHD "naturally" versus one that "develops" it? That is, if someone receives an injury to the frontal lobe, can changes in behavior be differentiated from someone who has had it their entire life? Is there any difference on a mechanical, chemical, or other such level? I ask because my father had a traumatic brain injury and I suspect my mother is part of the genetic link to my ADHD. Both of my parents had traumatic childhoods, but I don't believe my mother has ever been diagnosed with an injury. I was born after my dad's injury, so I didn't observe the changes others had. I also had a traumatic childhood, so my particular combination of nature and nurture made it hard to realize there was more than just PTSD causing problems. Ans: Briefly, as I noted above, most ADHD arises from genetic sources, though they can certainly interact with biological hazards and other injurious events to the brain such as head trauma. The clinical presentation may be the same, but often the acquired form of ADHD is worse, doesn't respond so well to ADHD medications (50% improve vs. 75-90%), may experience more medication side effects (the drugs don't seem to work as well when damage is present vs. genetic maldevelopment), and of course the onset of the ADHD may be different (any time in life the injury occurs) compared to the developmental-familial form of the disorder. And, yes, they would be different in their neuroanatomy as injuries produce more detectable damage int he brain than would a genetically caused malformation of brain circuitry.

Is it common for many people with ADHD to suffer extreme work burnout? If so are there any tips for combatting that burnout. I can only seem to manage working part time and even still, getting through a shift is a daily struggle even with medication, and it causes significant financial issues.

Yes, it can be. See if its possible to find a side gig that you enjoy better and might grow into more full time work. Get a vocational assessment to see what your strengths may be and if related occupations might be better for you. Perhaps work with an Adult ADHD Coach to help you with dealing with current work, time management, and organizational demands besides using ADHD medications. Look at the occupations I discussed above and in my book to see if any are more suitable for you to move over to, even if just part time to start. All this tells us that one needs a more ADHD friendly occupation if it can be found.

Q: Is it common for many people with ADHD to suffer extreme work burnout? If so are there any tips for combatting that burnout. I can only seem to manage working part time and even still, getting through a shift is a daily struggle even with medication, and it causes significant financial issues. Ans: Yes, it can be. See if its possible to find a side gig that you enjoy better and might grow into more full time work. Get a vocational assessment to see what your strengths may be and if related occupations might be better for you. Perhaps work with an Adult ADHD Coach to help you with dealing with current work, time management, and organizational demands besides using ADHD medications. Look at the occupations I discussed above and in my book to see if any are more suitable for you to move over to, even if just part time to start. All this tells us that one needs a more ADHD friendly occupation if it can be found.

Thank you Dr Barkley for your time! I'm wondering what you think the future direction of the DSM will be and whether it will eventually include emotional regulation and other criterion and how long this may take?

I can't predict where it will go for DSM6 as that is not even in the panning stages. usually a decade or two goes by before they revise the manual. The DSM is not leading the research, but follows it and often a decade or two behind where the research is at the time. I hope that more items of impulsivity (cognitive, motivational, emotional) get into the next one and fewer symptoms of hyperactivity and a few others added to cover EF better so that the criteria are more sensitive to the adult stage of ADHD than they are now, based entirely on children as they originally were in earlier DSMs. But the decisions made by the APA are also political, not just scientifically based, so its hard to know where this will go. I just think that more emphasis on EF and self-regulation would vastly improve the DSM. And waiving the age of onset of age 12 as its not valid or reliable. Onset is usually during development up to age 18-24 but can arise de novo after an injury to the brain that affects the EF networks. So the age of onset is a problem that needs fixing. I teach clinicians to ignore it and also use 4 symptoms endorsed on either list as the threshold to diagnose as its more science based. Dropping it to 5 for adults (from 6 for children) was a half measure granted by APA. Four is better.

Q: Thank you Dr Barkley for your time! I'm wondering what you think the future direction of the DSM will be and whether it will eventually include emotional regulation and other criterion and how long this may take? Ans: I can't predict where it will go for DSM6 as that is not even in the panning stages. usually a decade or two goes by before they revise the manual. The DSM is not leading the research, but follows it and often a decade or two behind where the research is at the time. I hope that more items of impulsivity (cognitive, motivational, emotional) get into the next one and fewer symptoms of hyperactivity and a few others added to cover EF better so that the criteria are more sensitive to the adult stage of ADHD than they are now, based entirely on children as they originally were in earlier DSMs. But the decisions made by the APA are also political, not just scientifically based, so its hard to know where this will go. I just think that more emphasis on EF and self-regulation would vastly improve the DSM. And waiving the age of onset of age 12 as its not valid or reliable. Onset is usually during development up to age 18-24 but can arise de novo after an injury to the brain that affects the EF networks. So the age of onset is a problem that needs fixing. I teach clinicians to ignore it and also use 4 symptoms endorsed on either list as the threshold to diagnose as its more science based. Dropping it to 5 for adults (from 6 for children) was a half measure granted by APA. Four is better.

Dr. Barkley, thank you for the valuable research you do. And, kudos to you and your ability to articulate this research with such clarity, insight, and humor. For most of my life I’ve wanted to be a writer and have struggled with the rather simple idea of story. Keeping a story idea even in mind (a rather important aspect of writing a novel) feels impossible. Understanding how ADHD impairs our ability to “string behavior together in a proper sequence” was a stunning discovery. My question is related to this. Do you have any specific recommendations in overcoming this particular deficit for a writer? Or, is this one of those things I should accept and move on. Breaking things down into small chunks doesn’t quite work. I still manage to lose my way.

Those ideas can help but I do somethings that might also be helpful to you when I write. If I am writing a commentary or article on something already published, a fist on reading it put notes in the margins to myself about what is important or what issue I see with it. Just free associate to the content but be sure to write it down or that idea will be lost to you later. Then sit down and type all your notes into a Word file. Don't worry about sentence structure or even sequence just get the content in there. Now that it is out of your head and physically represented on in the computer on the screen, you can manipulate it, expand, contract, edit, etc. all outside your head and not lose the pieces. Just keep expanding first, then polishing it later all on the screen and it may help. If you are writing something from scratch, then before you do that keep a bunch of 3x5 cards or paper scraps around you and free associate to the topic. Then as you go about your day jot down any other freely associated ideas that spring to mind on that topic but don't force it. Just capture the as they fly through your mind. When you have enough ideas, take the cards or scraps and try to sequence them into some kind of order. You can do this manually or type them into a Word file as above. The secret here especially for someone with ADHD is to get mental content out of the defective working memory and into some physical external form outside the mind so you can play with it initially with your hands in your visual field and then put it into a computer file also in your visual field and work on it there. In my books I refer to this as externalizing mental content and stop depending so much on working memory. See if that helps.

Q: Dr. Barkley, thank you for the valuable research you do. And, kudos to you and your ability to articulate this research with such clarity, insight, and humor. For most of my life I’ve wanted to be a writer and have struggled with the rather simple idea of story. Keeping a story idea even in mind (a rather important aspect of writing a novel) feels impossible. Understanding how ADHD impairs our ability to “string behavior together in a proper sequence” was a stunning discovery. My question is related to this. Do you have any specific recommendations in overcoming this particular deficit for a writer? Or, is this one of those things I should accept and move on. Breaking things down into small chunks doesn’t quite work. I still manage to lose my way. Ans: Those ideas can help but I do somethings that might also be helpful to you when I write. If I am writing a commentary or article on something already published, a fist on reading it put notes in the margins to myself about what is important or what issue I see with it. Just free associate to the content but be sure to write it down or that idea will be lost to you later. Then sit down and type all your notes into a Word file. Don't worry about sentence structure or even sequence just get the content in there. Now that it is out of your head and physically represented on in the computer on the screen, you can manipulate it, expand, contract, edit, etc. all outside your head and not lose the pieces. Just keep expanding first, then polishing it later all on the screen and it may help. If you are writing something from scratch, then before you do that keep a bunch of 3x5 cards or paper scraps around you and free associate to the topic. Then as you go about your day jot down any other freely associated ideas that spring to mind on that topic but don't force it. Just capture the as they fly through your mind. When you have enough ideas, take the cards or scraps and try to sequence them into some kind of order. You can do this manually or type them into a Word file as above. The secret here especially for someone with ADHD is to get mental content out of the defective working memory and into some physical external form outside the mind so you can play with it initially with your hands in your visual field and then put it into a computer file also in your visual field and work on it there. In my books I refer to this as externalizing mental content and stop depending so much on working memory. See if that helps.

Hello, thanks a lot for doing this. I've watched hours of your lectures, your work is amazing (not just on ADHD, but also to understand how humans develop in general). I've been diagnosed for a over a year now, and now I'm going after an Ehlers-Danlos Syndrome diagnosis. Have you found any significant overlap there? Also, keeping consistent effort towards one thing is honestly exhausting! Trying to finish (one of) my university degree(s). What held me back? Extra curricular activity credits. Even going to the movies counts, for time's sake. X_x That last part isn't a question, just wanted to vent. Thanks once again!

Thank you and you are quite welcome. To date I have not seen any research showing such an overlap of those conditions. It just means they may not be related but a person could still experience both. Good luck with that evaluation.

Q: Hello, thanks a lot for doing this. I've watched hours of your lectures, your work is amazing (not just on ADHD, but also to understand how humans develop in general). I've been diagnosed for a over a year now, and now I'm going after an Ehlers-Danlos Syndrome diagnosis. Have you found any significant overlap there? Also, keeping consistent effort towards one thing is honestly exhausting! Trying to finish (one of) my university degree(s). What held me back? Extra curricular activity credits. Even going to the movies counts, for time's sake. X_x That last part isn't a question, just wanted to vent. Thanks once again! Ans: Thank you and you are quite welcome. To date I have not seen any research showing such an overlap of those conditions. It just means they may not be related but a person could still experience both. Good luck with that evaluation.

Any tips on improving our working memory? Or even just our memorys in general?

I have a variety of tips in my latest book (and even in the earlier first edition) too numerous to go into here. We have found that low tech solutions are better as the person is less likely to lose them and more likely to keep them with them and even see them than high tech. By that I mean journals, sticky notes, week at a glance paper calendars, paper do lists, etc. are superior to using a computer calendar, lists on your phone, a digital memory stick, and so o n. Those have to be charged regularly, power cords must be kept available where needed, and someone has to enter the information to be remembered into them. Losing such devices is not uncommon in people with adult ADHD, such as their smartphone or tablet or charging cords.

Q: Any tips on improving our working memory? Or even just our memorys in general? Ans: I have a variety of tips in my latest book (and even in the earlier first edition) too numerous to go into here. We have found that low tech solutions are better as the person is less likely to lose them and more likely to keep them with them and even see them than high tech. By that I mean journals, sticky notes, week at a glance paper calendars, paper do lists, etc. are superior to using a computer calendar, lists on your phone, a digital memory stick, and so o n. Those have to be charged regularly, power cords must be kept available where needed, and someone has to enter the information to be remembered into them. Losing such devices is not uncommon in people with adult ADHD, such as their smartphone or tablet or charging cords.

Hello, can you please give some advice on ADHD in older adults? A relative of mine is in their 70s, but very active physically (very healthy) as well as sharp mentally for their age, except for the ADHD symptoms that have always been present. They were only diagnosed a few years ago with no follow-up, and we are wondering the treatment options and how to go about getting started with it all. A little wary of medication but considering giving it a try and wanting to know more options. Thank you!

Not much is known about ADHD at this stage of life but what is was summarized in an article in my newsletter by Sandra Kooij, MD who operates an adult ADHD Center in Holland and specializes in older adults with the condition. So as not to clog up this feed, please write me and ask for her article and i will email you a PDF copy. As she notes, ADHD medications can be used effectively in this population with some safeguards used beforehand around possible increases in blood pressure and heart rate in that age group. Such effects are minor but at that age even minor changes can be serious if those problems already exist. (drbarkley@russellbarkley.org)

Q: Hello, can you please give some advice on ADHD in older adults? A relative of mine is in their 70s, but very active physically (very healthy) as well as sharp mentally for their age, except for the ADHD symptoms that have always been present. They were only diagnosed a few years ago with no follow-up, and we are wondering the treatment options and how to go about getting started with it all. A little wary of medication but considering giving it a try and wanting to know more options. Thank you! Ans: Not much is known about ADHD at this stage of life but what is was summarized in an article in my newsletter by Sandra Kooij, MD who operates an adult ADHD Center in Holland and specializes in older adults with the condition. So as not to clog up this feed, please write me and ask for her article and i will email you a PDF copy. As she notes, ADHD medications can be used effectively in this population with some safeguards used beforehand around possible increases in blood pressure and heart rate in that age group. Such effects are minor but at that age even minor changes can be serious if those problems already exist. (drbarkley@russellbarkley.org)

What are your tipps for people who are diagnosed and maybe in treatment for adhd but still second guessing weather or not they have it, because they feel like other people "have it but worse"

ADHD varies along a spectrum or continuum so as with ASD no two cases are the same. Understand that and you can see that it is not wise to compare one's ADHD to anyone else and expect them to be identical. Second, if still in doubt get a second opinion from omeone specializing in ADHD. Third, understand that up to 80% of adults with ADHD can have another disorder and 50% may have a third disorder. Comorbidity is common and this can alter the presentation of an ADHD case. ODD, CD, depression, anxiety, personality disorders, learning disorders, and even bipolar disorder can coexist with adult ADHD and thus alter is clinical presentation. So be careful with the comparisons. As we say with ASAD, if you have seen one case of it, then you have seen one case and nothing more.

Q: What are your tipps for people who are diagnosed and maybe in treatment for adhd but still second guessing weather or not they have it, because they feel like other people "have it but worse" Ans: ADHD varies along a spectrum or continuum so as with ASD no two cases are the same. Understand that and you can see that it is not wise to compare one's ADHD to anyone else and expect them to be identical. Second, if still in doubt get a second opinion from omeone specializing in ADHD. Third, understand that up to 80% of adults with ADHD can have another disorder and 50% may have a third disorder. Comorbidity is common and this can alter the presentation of an ADHD case. ODD, CD, depression, anxiety, personality disorders, learning disorders, and even bipolar disorder can coexist with adult ADHD and thus alter is clinical presentation. So be careful with the comparisons. As we say with ASAD, if you have seen one case of it, then you have seen one case and nothing more.

Hello Dr. Barkley! Thank you for taking the time to answer questions. I was wondering if you could explain how stimulant medication would affect someone with ADHD vs a neurotypical individual? I’m curious if someone could figure out whether or not they had ADHD based on how they reacted to stimulants.

Se used to think several decades ago that the drug response of someone with ADHD was atypical and thus if you gave an ADHD drug to a typical person it wouldmake them worse while it would help someone with ADHD. That turned out to be false. The drugs do the same thing for NTs as for ADHDs. its just that people with ADHD are so much further from the mean or typical level of performance that the improvement they experience can be much more dramatic whereas in an NT its rather minor. But they can improve too on medication, just not much. In short, the further from the mean of typicality you are in some trait or behavior the more dramatic will be a treatment effect. Nothing paradoxical going on here that can help with diagnosis, sorry to say.

Q: Hello Dr. Barkley! Thank you for taking the time to answer questions. I was wondering if you could explain how stimulant medication would affect someone with ADHD vs a neurotypical individual? I’m curious if someone could figure out whether or not they had ADHD based on how they reacted to stimulants. Ans: Se used to think several decades ago that the drug response of someone with ADHD was atypical and thus if you gave an ADHD drug to a typical person it wouldmake them worse while it would help someone with ADHD. That turned out to be false. The drugs do the same thing for NTs as for ADHDs. its just that people with ADHD are so much further from the mean or typical level of performance that the improvement they experience can be much more dramatic whereas in an NT its rather minor. But they can improve too on medication, just not much. In short, the further from the mean of typicality you are in some trait or behavior the more dramatic will be a treatment effect. Nothing paradoxical going on here that can help with diagnosis, sorry to say.

Dr Barkley, Thank you for taking our questions. Have you and your colleagues noticed any differences in the way people with “inattentive” ADHD respond to medications vs the more hyperactive subtype? What are the most promising lines of research in the ADHD field these days?

There is really just one kind of ADHD, which is why we don't use subtypes any longer. The DSM5 uses the term presentations. That is because it is only meant to convey that on any given day, one seton symptoms might have been more prominent than the other - nothing else. And people can change presentations with development and even the context. So there really isn't anything different about those presentations; certainly nothing qualitative. that said, clinicians often use the inattentive presentation diagnosis (or even the outdated term ADD) for a group of people who struggle with attention but have no whiff of impulsivity, hyperactivity, or the other EFs I noted above. We now believe that most of those people have a second attention disorder, currently called sluggish cognitive tempo or SCT. But that term is going to get change this year by a task force I am on of leading SCT researchers as the term is demeaning. You can read more about SCT on my website under Fact Sheets and also using Google Scholar to find journal articles. Briefly, its characterized more by daydreaming, staring, spaciness, mental confusion, underactivity, even slowness to react or respond. We are studying if it is a pathological form of mind wandering or daydreaming or mind blanking or all three. Half of people with SCT also have ADHD and vice versa, but the other half do not. SCT is related to passivity, social withdrawal or even shyness, risk for depression, and can be seen in autism spectrum disorder. A root, we think it involves a decoupling or disengagement of the mind and attention from the ongoing external environment and an over coupling of attention to mental content (daydreaming, mind wandering) or at times no content mind blanking). We have a lot more work to do to understand it but its not ADHD and doesn't seem to respond so well to ADHD medications, but that has barely been studied.

Q: Dr Barkley, Thank you for taking our questions. Have you and your colleagues noticed any differences in the way people with “inattentive” ADHD respond to medications vs the more hyperactive subtype? What are the most promising lines of research in the ADHD field these days? Ans: There is really just one kind of ADHD, which is why we don't use subtypes any longer. The DSM5 uses the term presentations. That is because it is only meant to convey that on any given day, one seton symptoms might have been more prominent than the other - nothing else. And people can change presentations with development and even the context. So there really isn't anything different about those presentations; certainly nothing qualitative. that said, clinicians often use the inattentive presentation diagnosis (or even the outdated term ADD) for a group of people who struggle with attention but have no whiff of impulsivity, hyperactivity, or the other EFs I noted above. We now believe that most of those people have a second attention disorder, currently called sluggish cognitive tempo or SCT. But that term is going to get change this year by a task force I am on of leading SCT researchers as the term is demeaning. You can read more about SCT on my website under Fact Sheets and also using Google Scholar to find journal articles. Briefly, its characterized more by daydreaming, staring, spaciness, mental confusion, underactivity, even slowness to react or respond. We are studying if it is a pathological form of mind wandering or daydreaming or mind blanking or all three. Half of people with SCT also have ADHD and vice versa, but the other half do not. SCT is related to passivity, social withdrawal or even shyness, risk for depression, and can be seen in autism spectrum disorder. A root, we think it involves a decoupling or disengagement of the mind and attention from the ongoing external environment and an over coupling of attention to mental content (daydreaming, mind wandering) or at times no content mind blanking). We have a lot more work to do to understand it but its not ADHD and doesn't seem to respond so well to ADHD medications, but that has barely been studied.

I am unmedicated currently due to my mother's concerns (she saw adhd meds turn my dad into a monster). Are there any tips for us who don't have the option to be medicated?

While there are lots of psychosocial treatments that can help, they are only about 1 third as effective or useful as ADHD medications. So avoiding them is really tying one hand behind your back when it comes to treatment. Maybe it would be better for your parents or others to read about the evidence for the usefulness of these medications, such as the chapter in my new book, or Dr. Wilens book, Straight Talk About Psychiatric Medications for Children. The research on the benefits and safety of the medications is voluminous. Yes, there are annoying side effects but none are life threatening. And you father is hardly a representative case of what stimulants or other ADHD drugs do to help ADHD. As I note above, CBT for adults focusing on EF deficits can help, mindfulness practices perhaps, exercise, adult ADHD coaching, are the major forms of evidence supported treatment. Though helpful for many, they are not equivalent to ADHD medications and the best approach is to combine them.

Q: I am unmedicated currently due to my mother's concerns (she saw adhd meds turn my dad into a monster). Are there any tips for us who don't have the option to be medicated? Ans: While there are lots of psychosocial treatments that can help, they are only about 1 third as effective or useful as ADHD medications. So avoiding them is really tying one hand behind your back when it comes to treatment. Maybe it would be better for your parents or others to read about the evidence for the usefulness of these medications, such as the chapter in my new book, or Dr. Wilens book, Straight Talk About Psychiatric Medications for Children. The research on the benefits and safety of the medications is voluminous. Yes, there are annoying side effects but none are life threatening. And you father is hardly a representative case of what stimulants or other ADHD drugs do to help ADHD. As I note above, CBT for adults focusing on EF deficits can help, mindfulness practices perhaps, exercise, adult ADHD coaching, are the major forms of evidence supported treatment. Though helpful for many, they are not equivalent to ADHD medications and the best approach is to combine them.

What are your top tips for getting reasonable accommodations or adjustments recognised at work?

Be careful in doing so. While ADHD is a protected disability wra=ranting some reasonable accommodations in the workplace under the ADA, employers differ in how willing they are to make them. Some people find that their employers sensitive to and compassionate about helping disabled people. In other cases, disclosing your disorder can lead to more documentation against you for your troubles at work in order to get you dismissed. So you really need to think about your employer and how they may react before disclosing ADHD, documenting its diagnosis, and proposing reasonable accommodations, which a clinician can advise you about. Also keep in mind an employer doesn't have to do so if you are not getting treatment for your disorder. And the key word for accommodations is "reasonable."

Q: What are your top tips for getting reasonable accommodations or adjustments recognised at work? Ans: Be careful in doing so. While ADHD is a protected disability wra=ranting some reasonable accommodations in the workplace under the ADA, employers differ in how willing they are to make them. Some people find that their employers sensitive to and compassionate about helping disabled people. In other cases, disclosing your disorder can lead to more documentation against you for your troubles at work in order to get you dismissed. So you really need to think about your employer and how they may react before disclosing ADHD, documenting its diagnosis, and proposing reasonable accommodations, which a clinician can advise you about. Also keep in mind an employer doesn't have to do so if you are not getting treatment for your disorder. And the key word for accommodations is "reasonable."

The "chemical imbalance" model of depression (too little serotonin/dopamine) has been challenged in the last few years due to many antidepressants being as clinically effective as placebos (they are effective, but so are the placebos). (See the studies by Irving Kirsch, or read his book *The Emperor's New Drugs*.) How does this fit in with models of ADHD and medication? Do you find any validity in Kirsch's claims?

Though there are similar issues between over simplifying depression as merely a neurochemical problem and seeing ADHD as just a dopamine disorder, we have moved way beyond that implication now. While ADHD does impact dopamine regulation, it also impacts norepinephrine (why atomoxetine may work) as well as GABA and even the alpha-2 system (why guanfacine may help). But beyond that, neuroimaging studies and those involving white matter connectivity and functional connectivity all suggest myriad difficulties in the development and functioning of networks, not just chemicals. And the risk genes we are discovering for ADHD implicate even other mechanisms. For example, some of the genes involved in ADHD are responsible for nerve cell growth, migration, and density of connections to other nerves. Others involve nerve cell support and nourishment. So we know now there is a lot more to disputed brain development than just low dopamine or insensitivity to it. That doesn't take away from the fact that dopanine drugs remain the most effective for ADHD most likely because the networks we see maldeveloping are dopamine and norepinephrine mediated ones. But its not just neurochemicals any more in modeling ADHD. Its networks, pathways, and their functional connectivity that is also at issue.

Q: The "chemical imbalance" model of depression (too little serotonin/dopamine) has been challenged in the last few years due to many antidepressants being as clinically effective as placebos (they are effective, but so are the placebos). (See the studies by Irving Kirsch, or read his book *The Emperor's New Drugs*.) How does this fit in with models of ADHD and medication? Do you find any validity in Kirsch's claims? Ans: Though there are similar issues between over simplifying depression as merely a neurochemical problem and seeing ADHD as just a dopamine disorder, we have moved way beyond that implication now. While ADHD does impact dopamine regulation, it also impacts norepinephrine (why atomoxetine may work) as well as GABA and even the alpha-2 system (why guanfacine may help). But beyond that, neuroimaging studies and those involving white matter connectivity and functional connectivity all suggest myriad difficulties in the development and functioning of networks, not just chemicals. And the risk genes we are discovering for ADHD implicate even other mechanisms. For example, some of the genes involved in ADHD are responsible for nerve cell growth, migration, and density of connections to other nerves. Others involve nerve cell support and nourishment. So we know now there is a lot more to disputed brain development than just low dopamine or insensitivity to it. That doesn't take away from the fact that dopanine drugs remain the most effective for ADHD most likely because the networks we see maldeveloping are dopamine and norepinephrine mediated ones. But its not just neurochemicals any more in modeling ADHD. Its networks, pathways, and their functional connectivity that is also at issue.

Hello, Dr. Barkley! Your work is greatly appreciated in the ADHD community. Thank you for everything you do. I'd like to ask: what study, on people with ADHD, yielded the most fascinating or surprising results to you?

If you study something for 49 years as I have since 1973, you will be surprised more than once. So I will give you two that stand out understanding there were others as well. First, that ADHD greatly disrupts the human sense of time and especially the ability to be governed by ones sense of time passing (time management). I came upon the idea to test it by reading an essay on how animal and human minds and language/communication may differ. From it I learned that disinhibition is related to sense of time. So I tested it first in ADHD in children, then later in teens, adults, and my 25 year follow up study. People at any age with ADHD were very impaired in time management and time sense. No one had ever said that or predicted it until then. And it was not a subtle but a massive deficit, especially when we measured it through ratings of time sense and time management, not just lab measures. I was blown away. Now its a rock solid finding in the ADHD literature and led me to coin the term time blind or future myopia for the condition. The second one came in late 2018-2019. I have always suspected that ADHD adversely affects health, and we knew it caused more accidental injuries and even early mortality from them. But in my longitudinal study in Milwaukee we were documenting all kinds of health and medical issues as the kids became adults, from obesity, poor nutrition, impaired sleep, increased smoking, excess alcohol use, poor driving, lousy cholesterol panels, etc. But in that year I found a way to combine all that information into a calculator that can estimate life expectancy based on 14 human factors. No one had studied that before. But we had all 14 of those factors in my study. The results from the calculations were stunning and sobering. I had to run them a second time and check all the data entry to make sure we made no mistakes. We had not. A diagnosis of ADHD in childhood was associated with a 9-10 year reduction in life expectancy and if the condition persisted to age 27 the reduction was 12-13 years. That is huge! Greater than any major health variable we try to change in people these days so they live longer. Why, because ADHD is predisposing to many such adverse lifestyle and health factors that all add up to a considerable reduction in lifespan if not treated. So that was my second surprise. Thanks for asking

Q: Hello, Dr. Barkley! Your work is greatly appreciated in the ADHD community. Thank you for everything you do. I'd like to ask: what study, on people with ADHD, yielded the most fascinating or surprising results to you? Ans: If you study something for 49 years as I have since 1973, you will be surprised more than once. So I will give you two that stand out understanding there were others as well. First, that ADHD greatly disrupts the human sense of time and especially the ability to be governed by ones sense of time passing (time management). I came upon the idea to test it by reading an essay on how animal and human minds and language/communication may differ. From it I learned that disinhibition is related to sense of time. So I tested it first in ADHD in children, then later in teens, adults, and my 25 year follow up study. People at any age with ADHD were very impaired in time management and time sense. No one had ever said that or predicted it until then. And it was not a subtle but a massive deficit, especially when we measured it through ratings of time sense and time management, not just lab measures. I was blown away. Now its a rock solid finding in the ADHD literature and led me to coin the term time blind or future myopia for the condition. The second one came in late 2018-2019. I have always suspected that ADHD adversely affects health, and we knew it caused more accidental injuries and even early mortality from them. But in my longitudinal study in Milwaukee we were documenting all kinds of health and medical issues as the kids became adults, from obesity, poor nutrition, impaired sleep, increased smoking, excess alcohol use, poor driving, lousy cholesterol panels, etc. But in that year I found a way to combine all that information into a calculator that can estimate life expectancy based on 14 human factors. No one had studied that before. But we had all 14 of those factors in my study. The results from the calculations were stunning and sobering. I had to run them a second time and check all the data entry to make sure we made no mistakes. We had not. A diagnosis of ADHD in childhood was associated with a 9-10 year reduction in life expectancy and if the condition persisted to age 27 the reduction was 12-13 years. That is huge! Greater than any major health variable we try to change in people these days so they live longer. Why, because ADHD is predisposing to many such adverse lifestyle and health factors that all add up to a considerable reduction in lifespan if not treated. So that was my second surprise. Thanks for asking

There has been some research showing that children with Autism Spectrum Disorder get less overall sleep and 30-50% less REM sleep than their non-ASD counterparts. As REM sleep is associated with emotional processing and therefore impacts emotional and social intelligence, the link between low REM sleep and abnormal synaptogenesis in ASD is relevant to understanding the causes of autism. To your knowledge, is there a similar relationship between sleep quality/quantity and neurodevelopment in ADHD, and are you aware of any research being done along these lines?

Yes, there is a connection between ADHD disrupted sleep, inefficient sleep, restless leg syndrome during sleep, daytime tiredness, sleep apnea, etc. Its not as obvious on EEG bu studies do show some change in REM. You can find the results including a meta-analysis of all research by Samuel Cortese using Google Scholar.

Q: There has been some research showing that children with Autism Spectrum Disorder get less overall sleep and 30-50% less REM sleep than their non-ASD counterparts. As REM sleep is associated with emotional processing and therefore impacts emotional and social intelligence, the link between low REM sleep and abnormal synaptogenesis in ASD is relevant to understanding the causes of autism. To your knowledge, is there a similar relationship between sleep quality/quantity and neurodevelopment in ADHD, and are you aware of any research being done along these lines? Ans: Yes, there is a connection between ADHD disrupted sleep, inefficient sleep, restless leg syndrome during sleep, daytime tiredness, sleep apnea, etc. Its not as obvious on EEG bu studies do show some change in REM. You can find the results including a meta-analysis of all research by Samuel Cortese using Google Scholar.

How can a woman with ADHD successfully go through pregnancy? Can she still take stimulant medications?

This is an important but tough question. And presently we don't have a lot of research on the possible toxic (teratogenic) effects of ADHD medications on the fetus if used by a pregnant woman. However, this past year or two several large scale population wide studies (Denmark, Sweden, etc.) looked at any risk for major malformations int he babies in women who continued on meds and those who didn't. They found none except both studies found a small increased risk for heart malformations (about 2-3% as I recall) over what was seen in moms not taking the meds. But we have no studies on whether the meds could cause less dramatic developmental problems or disorders. The drug company package inserts advise against taking them when pregnant but that is just to protect them from future liability. The latest approach is for a physician to have a long and sensitive discussion of the risks and benefits. After all, there are considerable risks posed by stopping medication, such as increased risks for accidental injuries, car crashes, suicide, anxiety, depression, early mortality, obesity, impaired employment, difficulties managing a household or other children, etc. All that risk comes back if the medications are ceased. So its really a personal decision based on weighting all these factors in talking with your doctor.

Q: How can a woman with ADHD successfully go through pregnancy? Can she still take stimulant medications? Ans: This is an important but tough question. And presently we don't have a lot of research on the possible toxic (teratogenic) effects of ADHD medications on the fetus if used by a pregnant woman. However, this past year or two several large scale population wide studies (Denmark, Sweden, etc.) looked at any risk for major malformations int he babies in women who continued on meds and those who didn't. They found none except both studies found a small increased risk for heart malformations (about 2-3% as I recall) over what was seen in moms not taking the meds. But we have no studies on whether the meds could cause less dramatic developmental problems or disorders. The drug company package inserts advise against taking them when pregnant but that is just to protect them from future liability. The latest approach is for a physician to have a long and sensitive discussion of the risks and benefits. After all, there are considerable risks posed by stopping medication, such as increased risks for accidental injuries, car crashes, suicide, anxiety, depression, early mortality, obesity, impaired employment, difficulties managing a household or other children, etc. All that risk comes back if the medications are ceased. So its really a personal decision based on weighting all these factors in talking with your doctor.

Hi! I'm so glad you decided to do this, and it came at the best time for me. I've been doing a lot of research on my own, mostly listening to conferences and reading books from specialists such as yourself. I do have some questions. 1) Is there a push for renaming ADD to EFDD or did I misunderstand? Where could I find more information about this initiative if there is one? 2) What would you recommend to someone in a 3rd world country, say Mexico, if psychiatrists still talk about ADD as a condition only displayed in kids who misbehave and fail their classes? How could one get a diagnosis if the professionals on the subject are not updated on their topic and don't even know about the relation between ADD and EFs? 3) Do you have colleagues or know of experts/institutions that are working in Mexico to advance research/awareness of ADD?

I don't know anyone currently working on research or clinical practice on adult ADHD in Mexico. There may be good people there but if they do not publish they would not be visible to me. As for changing ADHD to EFDD, while I would love that to happen I am not making such a push nor is anyone else, even though we want ADHD to be understood as a broader problem with EF and self-regulation. The reason is a legal and political one. It has taken so long to get the term ADHD into various laws and regulations and entitlements, such as IDEA, ADA, Social Security, etc. at the federal and state levels that if you change the name, it won't be in those laws and so those protections, entitlements, and other services will not be available to someone with that new diagnosis until the laws get changed to reflect the new term which can take decades. It's a practical issue, not a scientific or theoretical one but its incredibly important to those with ADHD that they not get disenfranchised by a name change. We worked too hard to get this far to lose it all over a change in terms.

Q: Hi! I'm so glad you decided to do this, and it came at the best time for me. I've been doing a lot of research on my own, mostly listening to conferences and reading books from specialists such as yourself. I do have some questions. 1) Is there a push for renaming ADD to EFDD or did I misunderstand? Where could I find more information about this initiative if there is one? 2) What would you recommend to someone in a 3rd world country, say Mexico, if psychiatrists still talk about ADD as a condition only displayed in kids who misbehave and fail their classes? How could one get a diagnosis if the professionals on the subject are not updated on their topic and don't even know about the relation between ADD and EFs? 3) Do you have colleagues or know of experts/institutions that are working in Mexico to advance research/awareness of ADD? Ans: I don't know anyone currently working on research or clinical practice on adult ADHD in Mexico. There may be good people there but if they do not publish they would not be visible to me. As for changing ADHD to EFDD, while I would love that to happen I am not making such a push nor is anyone else, even though we want ADHD to be understood as a broader problem with EF and self-regulation. The reason is a legal and political one. It has taken so long to get the term ADHD into various laws and regulations and entitlements, such as IDEA, ADA, Social Security, etc. at the federal and state levels that if you change the name, it won't be in those laws and so those protections, entitlements, and other services will not be available to someone with that new diagnosis until the laws get changed to reflect the new term which can take decades. It's a practical issue, not a scientific or theoretical one but its incredibly important to those with ADHD that they not get disenfranchised by a name change. We worked too hard to get this far to lose it all over a change in terms.

[deleted]

Well, many NTs struggle with their morning awakening and routines to get our the door for work or school or what have you. But not as much as many adults with ADHD do so ADHD compounds the problems NTs have. Although only approved for children at the moment by the FDA, the drug Jornay PM is a stimulant (methylphenidate) taken at night that activates 9 hours later to help children with ADHD be on medication as they awaken and deal with their weekday morning routines. You might ask your physician about that option to assist with this type of problem as I know other adults with ADHD are on it for that reason. Apart from that, some adults say making a list of what they need to do that morning before leaving bed and carrying that with them in their field of vision as they get ready helps. Hiring an adult aDHD Coach might also help you stay focused and organized during those times. Just food for thought, not advice.

Q: [deleted] Ans: Well, many NTs struggle with their morning awakening and routines to get our the door for work or school or what have you. But not as much as many adults with ADHD do so ADHD compounds the problems NTs have. Although only approved for children at the moment by the FDA, the drug Jornay PM is a stimulant (methylphenidate) taken at night that activates 9 hours later to help children with ADHD be on medication as they awaken and deal with their weekday morning routines. You might ask your physician about that option to assist with this type of problem as I know other adults with ADHD are on it for that reason. Apart from that, some adults say making a list of what they need to do that morning before leaving bed and carrying that with them in their field of vision as they get ready helps. Hiring an adult aDHD Coach might also help you stay focused and organized during those times. Just food for thought, not advice.

I hope you will allow me more questions, /u/ProfBarkley77 - thank you so much for giving us this opportunity to benefit from your clinical experience! In what ways does ADHD interact with high intelligence (IQ > 130)? Do children/adults with high IQ get diagnosed later in life, due to them being able to go through most of school without having to rely on concentration or having to learn? Does the treatment of these children/adults differ from the treatment of patients with average IQ? Is there any research on this interaction between high IQ and ADHD, particularly on the combined effects of high IQ and ADHD on the self worth / self confidence of patients? In your talks you have stated that medication is by far the most effective form of treatment. Do you have any reason to believe that meditation is able to improve certain functions that are inhibited / delayed in ADHD brains? Medition is often regarded as a way to "train" your concentration and to improve executive function. ADHD is thought to be a physiological issue in the brain. Is there any good research that shows improvement in ADHD patients who use medition to improve concentration or executive function?

I am sorry but there are too many questions here to give detailed answers. So here are very brief replies. ADHD does not interact much with IQ. its the same disorder in intelligent and typical people. High IQ merely protects one from an earlier onset of educational problems. Otherwise, it provides no protection from other nonacademic impairments. Treatment does not differ based on IQ. There is no research on self-worth in high IQ people with ADHD. Evidence for mindfulness based practices is promising but better controlled studies are needed. See the new book on this for adult ADHD by Zylowska and Mitchell ([www.guilford.com](https://www.guilford.com) or Amazon). There review of the available evidence indicates it may be helpful for some aspects of ADHD but even that is inconsistent at the moment. ​ Best wishes,

Q: I hope you will allow me more questions, /u/ProfBarkley77 - thank you so much for giving us this opportunity to benefit from your clinical experience! In what ways does ADHD interact with high intelligence (IQ > 130)? Do children/adults with high IQ get diagnosed later in life, due to them being able to go through most of school without having to rely on concentration or having to learn? Does the treatment of these children/adults differ from the treatment of patients with average IQ? Is there any research on this interaction between high IQ and ADHD, particularly on the combined effects of high IQ and ADHD on the self worth / self confidence of patients? In your talks you have stated that medication is by far the most effective form of treatment. Do you have any reason to believe that meditation is able to improve certain functions that are inhibited / delayed in ADHD brains? Medition is often regarded as a way to "train" your concentration and to improve executive function. ADHD is thought to be a physiological issue in the brain. Is there any good research that shows improvement in ADHD patients who use medition to improve concentration or executive function? Ans: I am sorry but there are too many questions here to give detailed answers. So here are very brief replies. ADHD does not interact much with IQ. its the same disorder in intelligent and typical people. High IQ merely protects one from an earlier onset of educational problems. Otherwise, it provides no protection from other nonacademic impairments. Treatment does not differ based on IQ. There is no research on self-worth in high IQ people with ADHD. Evidence for mindfulness based practices is promising but better controlled studies are needed. See the new book on this for adult ADHD by Zylowska and Mitchell ([www.guilford.com](https://www.guilford.com) or Amazon). There review of the available evidence indicates it may be helpful for some aspects of ADHD but even that is inconsistent at the moment. ​ Best wishes,

Hello Dr. Barkley, I've been reading through your back catalogue, the most popular books are on their second or forth edition; this makes it easier to disregard dated previous editions. For your other books that never receive a updated edition like 'ADHD and the Nature of Self-Control' from 1997 are there any points or conclusions you'd warn against now as out of date or no longer supported by evidence? Thanks, and I appreciate the audiobook releases, it's made reading them easier for me.

Some of my books, like ADHD in Adults: What the Science Says (2008) don't get updated because they reported the results of two huge studies I did and what they all meant along with a review of the relevant literature. So that's a one time thing. The book you noted, which is my initial EF Theory of ADHD, was updated but with a new title, Executive Functions:What they are, how they work, and why they evolved (2012). The theory remains solid to this day so I have no plans to change the book, though I did at a postscript to the paperback edition that came out in 2020. Nearly all my others get updated every 7-10 years, including Taking Charge of Adult ADHD coming out in its second edition in September. Thanks for asking

Q: Hello Dr. Barkley, I've been reading through your back catalogue, the most popular books are on their second or forth edition; this makes it easier to disregard dated previous editions. For your other books that never receive a updated edition like 'ADHD and the Nature of Self-Control' from 1997 are there any points or conclusions you'd warn against now as out of date or no longer supported by evidence? Thanks, and I appreciate the audiobook releases, it's made reading them easier for me. Ans: Some of my books, like ADHD in Adults: What the Science Says (2008) don't get updated because they reported the results of two huge studies I did and what they all meant along with a review of the relevant literature. So that's a one time thing. The book you noted, which is my initial EF Theory of ADHD, was updated but with a new title, Executive Functions:What they are, how they work, and why they evolved (2012). The theory remains solid to this day so I have no plans to change the book, though I did at a postscript to the paperback edition that came out in 2020. Nearly all my others get updated every 7-10 years, including Taking Charge of Adult ADHD coming out in its second edition in September. Thanks for asking

Hi Dr Barkley! In one of your lectures, you described ADHD adolescents as being about 30% behind their age-level peers in terms of emotional maturation. As a teacher, I think this the most useful insight into working with students with ADHD. I'd like to be able to explain it well when I'm talking with colleagues and parents. Can you explain some of the specifics of the research that led to this number? Thank you so much for doing this AMA!

The 30% rule about which I often speak is merely a rough clinically derived approximation for how far behind a typical child with ADHD may be from their more typical peers in their development of self-regulation (SR)(executive functioning, or EF). I developed the concept while writing the first edition of my book for parents (Taking Charge of ADHD) but also while practicing clinically at the University of Massachusetts Medical Center from 1985-2002. I was searching for a means by which to counsel parents and teachers on the extent to which such children were behind others of their age so as to get adults to understand the concept of a delay and the need to adjust one’s expectations down to a more appropriate level for a child so delayed. Even back then, ADHD was considered to be developmental in nature and best considered as a delay in development, not a loss of previously normal functioning as in someone with an injury. That idea was borrowed from two other neurodevelopmental disorders - intellectual disability and learning disorders. For both, we often speak about the functional developmental level of the child in the domain of their delay, in those cases intelligence and learning (reading, math, spelling, language etc.) specifically. Indeed, in the field of intelligence research, the concept of a mental age rather than an IQ was used for years in clinical work with families of such children. The rule is not based on a single scientific study of that issue, which would be far too time consuming and expensive to conduct. Instead, I was searching for a clinical rule or concept, not one of exact scientific specification as derived from a single such study. So I went back into my own published research studies and that of many others and simply wrote down the extent to which the ADHD group's performance differed from that of typical children in the same study and looked at a wide range of children’s ages. I did this for a wide variety of measures of EF, child social behaviors, and others. The range of deficits was from about 25-41% or so. The average was 32% but that is not as good for clinical use as is using a nice round number when speaking to parents. So I rounded it down to 30%. On average, then, a child with ADHD seems to perform about 30% behind others of their age in their EF and self-regulation. Don't let the exact number distract you from the point of this exercise. It is clearly a rough (imprecise) rule based on a back of the envelop type of calculation. But it worked brilliantly in advising families and others about how to understand the concept of a delay in EF, or one’s functional executive age, and start thinking about where their own child might be in that level of delay. The point of the rule is for families to understand not just the concept of a delay but, more important to its purpose, also about the need to lower expectations to better fit with their child’s delayed level of EF/SR. So there is no single scientific paper of mine to send you. And the number itself is a crude approximation. Instead, one views the 30% rule as an imprecise estimate so as to better convey a concept of delayed EF/SR to families and teachers and, most importantly, the need to match expectations to functional levels of EF/SR performance. I am so glad to know that my work has been of value to you in understanding ADHD and its management.

Q: Hi Dr Barkley! In one of your lectures, you described ADHD adolescents as being about 30% behind their age-level peers in terms of emotional maturation. As a teacher, I think this the most useful insight into working with students with ADHD. I'd like to be able to explain it well when I'm talking with colleagues and parents. Can you explain some of the specifics of the research that led to this number? Thank you so much for doing this AMA! Ans: The 30% rule about which I often speak is merely a rough clinically derived approximation for how far behind a typical child with ADHD may be from their more typical peers in their development of self-regulation (SR)(executive functioning, or EF). I developed the concept while writing the first edition of my book for parents (Taking Charge of ADHD) but also while practicing clinically at the University of Massachusetts Medical Center from 1985-2002. I was searching for a means by which to counsel parents and teachers on the extent to which such children were behind others of their age so as to get adults to understand the concept of a delay and the need to adjust one’s expectations down to a more appropriate level for a child so delayed. Even back then, ADHD was considered to be developmental in nature and best considered as a delay in development, not a loss of previously normal functioning as in someone with an injury. That idea was borrowed from two other neurodevelopmental disorders - intellectual disability and learning disorders. For both, we often speak about the functional developmental level of the child in the domain of their delay, in those cases intelligence and learning (reading, math, spelling, language etc.) specifically. Indeed, in the field of intelligence research, the concept of a mental age rather than an IQ was used for years in clinical work with families of such children. The rule is not based on a single scientific study of that issue, which would be far too time consuming and expensive to conduct. Instead, I was searching for a clinical rule or concept, not one of exact scientific specification as derived from a single such study. So I went back into my own published research studies and that of many others and simply wrote down the extent to which the ADHD group's performance differed from that of typical children in the same study and looked at a wide range of children’s ages. I did this for a wide variety of measures of EF, child social behaviors, and others. The range of deficits was from about 25-41% or so. The average was 32% but that is not as good for clinical use as is using a nice round number when speaking to parents. So I rounded it down to 30%. On average, then, a child with ADHD seems to perform about 30% behind others of their age in their EF and self-regulation. Don't let the exact number distract you from the point of this exercise. It is clearly a rough (imprecise) rule based on a back of the envelop type of calculation. But it worked brilliantly in advising families and others about how to understand the concept of a delay in EF, or one’s functional executive age, and start thinking about where their own child might be in that level of delay. The point of the rule is for families to understand not just the concept of a delay but, more important to its purpose, also about the need to lower expectations to better fit with their child’s delayed level of EF/SR. So there is no single scientific paper of mine to send you. And the number itself is a crude approximation. Instead, one views the 30% rule as an imprecise estimate so as to better convey a concept of delayed EF/SR to families and teachers and, most importantly, the need to match expectations to functional levels of EF/SR performance. I am so glad to know that my work has been of value to you in understanding ADHD and its management.

I'm very interested in your theory about the potential second attention disorder, Sluggish Cognitive Tempo/Concentration Deficit Disorder. How is the rate of new research on this going? Are you optimistic about it becoming more widely recognized in the next few years? I really identify with it (alongside my ADHD diagnosis), so I'm hoping we may learn more about it (and potential treatments) sooner rather than later

Research on SCT is going on almost weekly in the journals so lots of new information is accumulating. Our work group on SCT is reviewing it all and publishing a review later this year along with a change in the term as I noted above. But we have a long way to go as there is barely 150 articles on SCT but growing whereas there is several hundred thousand on ADHD (over its 250 year history in medicine). But young professionals wanting to establish a research reputation are gravitating toward SCT as there is so much we don't know that nearly any study is publishable. So stay tuned. And use Google Scholar periodically to update yourself on any new findings. You can set the search dates so you don't keep getting the older studies you have already seen. You can check in with me at the end of the year when that review should be done and published and I can provide it to you. The more that gets published and the more experts speak about it at conferences the more the average clinician will start to become familiar with it, but understand that most clinicians right now don't know of it and its not an official disorder. Even ADHD experts who should know about it are forced to use ADHD Inattentive Presentation to tick a box on a billing form to get paid.

Q: I'm very interested in your theory about the potential second attention disorder, Sluggish Cognitive Tempo/Concentration Deficit Disorder. How is the rate of new research on this going? Are you optimistic about it becoming more widely recognized in the next few years? I really identify with it (alongside my ADHD diagnosis), so I'm hoping we may learn more about it (and potential treatments) sooner rather than later Ans: Research on SCT is going on almost weekly in the journals so lots of new information is accumulating. Our work group on SCT is reviewing it all and publishing a review later this year along with a change in the term as I noted above. But we have a long way to go as there is barely 150 articles on SCT but growing whereas there is several hundred thousand on ADHD (over its 250 year history in medicine). But young professionals wanting to establish a research reputation are gravitating toward SCT as there is so much we don't know that nearly any study is publishable. So stay tuned. And use Google Scholar periodically to update yourself on any new findings. You can set the search dates so you don't keep getting the older studies you have already seen. You can check in with me at the end of the year when that review should be done and published and I can provide it to you. The more that gets published and the more experts speak about it at conferences the more the average clinician will start to become familiar with it, but understand that most clinicians right now don't know of it and its not an official disorder. Even ADHD experts who should know about it are forced to use ADHD Inattentive Presentation to tick a box on a billing form to get paid.

Hi! I hope this question doesn't get asked too often, but something I'm curious about is how psychologists try to figure out how to distinguish whether someone has ADHD, something else with symptoms that emulate ADHD symptoms, or both? I know one of the factors is whether symptoms were present during childhood or not, but that can't be the only thing to consider. So do professionals try to look for any particular clues or do they just make an educated guess for the most part?

ADHD is one of the few if only disorder that is a chronic deficiency in EF, and self regulation that often (though not always) dates back to childhood. Other disorders can produce temporary bouts of disinhibition such as bipolar disorder but that is not chronic unless ADHD is comorbid with it. While nearly all psychiatric disorder adversely affect attention in some form, only ADHD is a disorder of attention to the future, the next, or the later and involves disrupted goal directed attention. Other disorders are more likely to create an SCT pattern of inattention in which the mind decouples from the external environment and overly engages in attention to mental content, as in mind wandering, rumination, daydreaming, rexperiencing as in PTSD. That is not what we see in ADHD.

Q: Hi! I hope this question doesn't get asked too often, but something I'm curious about is how psychologists try to figure out how to distinguish whether someone has ADHD, something else with symptoms that emulate ADHD symptoms, or both? I know one of the factors is whether symptoms were present during childhood or not, but that can't be the only thing to consider. So do professionals try to look for any particular clues or do they just make an educated guess for the most part? Ans: ADHD is one of the few if only disorder that is a chronic deficiency in EF, and self regulation that often (though not always) dates back to childhood. Other disorders can produce temporary bouts of disinhibition such as bipolar disorder but that is not chronic unless ADHD is comorbid with it. While nearly all psychiatric disorder adversely affect attention in some form, only ADHD is a disorder of attention to the future, the next, or the later and involves disrupted goal directed attention. Other disorders are more likely to create an SCT pattern of inattention in which the mind decouples from the external environment and overly engages in attention to mental content, as in mind wandering, rumination, daydreaming, rexperiencing as in PTSD. That is not what we see in ADHD.

Thank you Dr. Barkley! I would like to know tips, tricks, and strategies for adults who want to go back to school. How do we go about picking a field of study when we impulsively dive into an exciting new topic, only to get bored with it before finishing a degree? I have a few core ideas I come back to, but worry they won't lead to a career that would be worth taking on the work and debt of school. Or I'd start a career and burn out five years later. How do we navigate the system of actually applying and getting to the first day of classes? What are the pros and cons of working with student disability services for accommodations? How do we work with professors so we can do well in classes? I'd also like to know more about rejection sensitivity as a concept/symptom vs rejection sensitive dysphoria which seems to be viewed more like a diagnosis. How much of a difference does the word "dysphoria" make when talking about this subject?

Please see my earlier replies on choosing vocations. There are also good books out on ADHD going to college that can be helpful. Replying to this complex question about what to do to find a college specialization and even how to apply will take far too long here so please see the several books about college and ADHD. As for rejection sensitivity vs. dysphoria, it really doesn't matter much. See my post above about this (first question in thread???).

Q: Thank you Dr. Barkley! I would like to know tips, tricks, and strategies for adults who want to go back to school. How do we go about picking a field of study when we impulsively dive into an exciting new topic, only to get bored with it before finishing a degree? I have a few core ideas I come back to, but worry they won't lead to a career that would be worth taking on the work and debt of school. Or I'd start a career and burn out five years later. How do we navigate the system of actually applying and getting to the first day of classes? What are the pros and cons of working with student disability services for accommodations? How do we work with professors so we can do well in classes? I'd also like to know more about rejection sensitivity as a concept/symptom vs rejection sensitive dysphoria which seems to be viewed more like a diagnosis. How much of a difference does the word "dysphoria" make when talking about this subject? Ans: Please see my earlier replies on choosing vocations. There are also good books out on ADHD going to college that can be helpful. Replying to this complex question about what to do to find a college specialization and even how to apply will take far too long here so please see the several books about college and ADHD. As for rejection sensitivity vs. dysphoria, it really doesn't matter much. See my post above about this (first question in thread???).

Is severe picky eating something that is more common amongst folks with ADHD, or is this typically an issue where there is another comorbid condition? I have seen a few articles about picky eating in children with ADHD, but nothing about adults.

Not really. Kids with ADHD show a propensity for consuming sugar containing foods that offer immediate gratification more than other people. Picky eating is likely related to some other issue.

Q: Is severe picky eating something that is more common amongst folks with ADHD, or is this typically an issue where there is another comorbid condition? I have seen a few articles about picky eating in children with ADHD, but nothing about adults. Ans: Not really. Kids with ADHD show a propensity for consuming sugar containing foods that offer immediate gratification more than other people. Picky eating is likely related to some other issue.