Attention Deficit Hyperactivity Disorder (ADHD) is a common condition that affects how people focus, manage their energy, and control impulses. It is characterized by a persistent pattern of inattention, hyperactivity, and impulsivity, which can interfere with a person’s ability to function effectively at school, at work, at home, and/or in social settings. The diagnosis is made using the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), which is the gold standard in making any psychiatric diagnoses.
Children with ADHD may struggle to stay focused on tasks, follow instructions, or complete assignments, often appearing forgetful or easily distracted. Additionally, they may exhibit excessive energy, fidgeting, or difficulty sitting still. Impulsivity can manifest as impatience, frequent interruptions, or acting without considering the consequences.
What’s confusing to patients and parents is that parents will often tell me that they are able to focus for hours on things that they like but can’t focus on things that they don’t. Boredom is the hub around which difficulties with mind-wandering, daydreaming, distractibility, procrastination, prioritization, organization, all revolve in those with ADHD.
People with ADHD have an issue with starting and stopping. In psychology, we call this set shifting. They have difficulty with starting tasks especially if they require sustained mental effort (repetitive tasks, memorization, etc) or are boring. Many have trouble stopping once they start doing a task which is often called hyperfocus, particularly on tasks that are interesting. Those without ADHD can attend to important tasks at hand (salience) while tuning out distractions enough so that they can focus while also keeping some awareness to important things in the background that they may need to flexibly shift their focus to, such as keeping an eye on the clock for the next deadline or meeting.
As a child, adolescent, and adult psychiatrist, I work closely with individuals and families to develop personalized treatment plans that address each individual’s unique needs as well as the preferences within the family and cultural system they belong to. My goal is to help those with ADHD reduce their symptoms, learn how to manage them, and be able to live fulfilling lives despite their diagnosis.
What Is ADHD?
ADHD is a brain-based condition that causes ongoing problems with attention, hyperactivity, or impulsiveness. Everyone gets distracted or fidgety once in a while—but with ADHD, these symptoms are more frequent, last for a long time (least six months), and affect daily life at home, school, or work.
ADHD comes in three main types:
- Inattentive Type: Trouble staying focused, following through on tasks, organizing, or remembering details. These individuals may seem distracted, forgetful, or “in their own world.”
- Hyperactive/Impulsive Type: Excessive fidgeting, restlessness, talking too much, or acting without thinking. This can lead to problems with waiting, interrupting, or staying seated.
- Combined Type: A mix of both inattentive and hyperactive/impulsive symptoms.
How Common Is ADHD?
ADHD is one of the most common mental health conditions in children and teens, and it often continues into adulthood. It affects:
- About 9-10% of children and 4-5% of adults in the U.S.
- Boys are more likely to be diagnosed in childhood, especially with hyperactive symptoms, but ADHD is often under-recognized in girls—especially when symptoms are less disruptive.
- Symptoms need to be present before the age of age 12. The average age of diagnosis is 7 years old.
Many adults may not realize they have ADHD until they face challenges with work, relationships, or parenting.
ADHD Isn’t About Intelligence—It’s About Execution
Many of the individuals I evaluate are bright, thoughtful, and highly capable. Often, they didn’t struggle much in early childhood—especially if school came easily or their environment was structured and supportive. But as demands increase—whether in middle school, high school, college, graduate school, or the workplace— or when the environment is less structured or supportive, ADHD symptoms can begin to surface.
Tasks that once felt manageable may suddenly feel overwhelming. What’s happening isn’t a lack of intelligence or motivation—it’s a mismatch between executive functioning skills and rising expectations for organization, time management, and sustained effort.
It’s important to understand: ADHD isn’t about not knowing what to do—it’s about having trouble doing what you know, especially when tasks are repetitive, unstimulating, time-consuming, or don’t offer immediate feedback or reward.
This pattern can lead to confusion, frustration, or feelings of failure—especially in individuals who’ve been praised for their intelligence. My role is to help identify these challenges, validate the experience, and offer concrete support strategies that meet your brain where it is.
What Causes ADHD?
While the exact cause of ADHD is not yet fully understood, research suggests that it is likely influenced by a combination of genetic, environmental, and neurological factors. Here is an overview of the factors involved:
- Genetic factors: ADHD tends to run in families, suggesting a strong genetic component. Studies have identified several genes associated with the disorder, which may affect brain function and neurotransmitter systems related to attention and impulse control. About 20-30% of children with ADHD had at least one other family member with ADHD. Studies show that ADHD has about a 75% estimated heritability, which means that the symptom variability is due to genetic rather than environmental causes. If you take a look at this bar graph below, you will see that ADHD is more heritable than IQ and height and is one of the most heritable psychiatric disorders.
What does this graph mean? It means that genetics contribute more to a person having ADHD than environmental (i.e., parental) factors do. - Environmental factors: Prenatal and early childhood exposures to certain environmental factors have been linked to an increased risk of ADHD. These may include maternal smoking or alcohol use during pregnancy, exposure to lead or other toxins, and premature birth or low birth weight. There is also an overlap with trauma and substance misuse.
- Neurological factors: Differences in brain structure and function have been observed in individuals with ADHD compared to those without the disorder. Longitudinal studies suggest that ADHD-affected groups have parallel but delayed patterns of brain development, with approximately 3-year delays in cortical maturation. Research indicates that certain brain regions related to attention, impulse control, and executive function may be affected, as well as low levels or imbalances in dopamine and norepinephrine. These are the two neurotransmitters that FDA-approved medicines for ADHD work on.
- Dopamine – help decrease attention to “noise” and thus reducing distraction in the prefrontal cortex. Dopamine is also implicated in the natural reward circuitry of the brain in the limbic system. This is probably why those with ADHD are at higher risk of addiction to substances, video games, social media, food, and more.
- Norepinephrine – helps increase attention to “signal” and thus increasing focus in the prefrontal cortex. Norepinephrine is also involved with physiological responses to stress and panic and can increase blood pressure and heart rate. This is why we monitor for blood pressure and heart rate for those on any ADHD medication but particularly stimulants.
- Developmental factors: Age and stage of development has a big impact on how ADHD presents. Hyperactivity and impulsivity tend to be the highest when children are in the preschool and grade-school age years, but then decreases over time. Inattention becomes more of an issue starting in grade school and later, especially as environmental demands such as increasing workload in school or having multiple classes, exceeds a child’s cognitie capacity. During teenage years, we often start seeing the emergence of mood, anxiety, substance use, sleep issues that emerge if ADHD is left untreated as this can have an impact on self-esteem and validation from others.
- Other contributing factors: While not direct causes of ADHD, certain factors may exacerbate symptoms or make the condition more challenging to manage. These can include co-occurring mental health conditions, learning disabilities, or stressful life events including trauma.
It is important to note that ADHD is not caused by poor parenting, excessive sugar intake, or lack of discipline. As our understanding of ADHD continues to evolve, ongoing research aims to uncover more about the complex interplay of factors that contribute to the development of the disorder. By understanding the potential causes of ADHD, healthcare professionals can better tailor treatment strategies to help individuals manage their symptoms and lead fulfilling lives.
Despite demonstrated biological difference in groups with and without ADHD, the disorder remains a behaviorally defined syndrome diagnosed by careful assessment of symptoms and clinical history, not by laboratory tests or brain imaging.
What to Expect from an Evaluation?
The diagnostic evaluation for ADHD is a comprehensive process designed to accurately identify the presence of ADHD symptoms and determine the most appropriate course of treatment. This thorough assessment is essential for ensuring that you or your child receives the right support and resources to help them thrive. There is not one formal, sit down, psychometric testing on a computer or paper that can result in an ADHD diagnosis or not.
The evaluation process for ADHD can include:
- Clinical interview: This is the number one way to diagnose ADHD. I will interview the parents and the child to gather information about the child’s medical history, family background, developmental milestones, and overall functioning at home, school, and in social settings. For adults, I may ask for information from loved ones or old school records. I will evaluate how these symptoms may be affecting the functioning of the individual or whether it could be something else.
- Behavior rating scales: Parents, teachers, and sometimes the child themselves will be asked to complete standardized questionnaires that assess ADHD symptoms, as well as any potential co-occurring conditions such as anxiety, depression, or learning disorders. Adults will be filling out these rating scales to track his/her/their own symptoms.
- Observation: I will observe the child during the appointment and may observe the child in a school setting to gain insight into their behavior and interactions with others.
- Cognitive and educational assessments: These tests help to identify any learning difficulties, intellectual capabilities, or other cognitive factors that may be contributing to the child’s difficulties. However, these are not necessary to make the diagnosis and can delay treatment. If there is any question on other learning disorders or a cognitive profile that is atypical, then I would send for neuropsychological testing where they can assess for a more thorough cognitive profile on memory, thinking patterns, math abilities, writing abilities, reading comprehension, and more.
- Review of records: I will review academic records, previous assessments, and any other relevant documentation to gather further information about the child’s history and performance.
- Rule out other conditions: It’s essential to rule out other medical, psychological, or environmental factors that may mimic or contribute to ADHD symptoms. This may involve coordinating with other healthcare professionals or conducting additional tests as needed. The most common medical conditions that can cause cognitive issues that look like ADHD but aren’t, and that I will rule out include:
• Seizure disorder: absence seizures especially
• Diabetes mellitus
• Thyroid dysfunction such as low or high thyroid hormone levels
• Sleep disorders, such as sleep apnea, sleep deprivation, insomnia, narcolepsy
• Post-concussive syndrome
• Inflammatory bowel disease
• Iron-deficiency
• Anemia whether it’s related to iron deficiency or not - Evaluating for comorbidities: Many people with ADHD have difficulties with other aspects of their mental health. Mood difficulties are common as those with ADHD have major depression or bipolar disorder. Trauma is a common experience for those with ADHD as children with ADHD are more prone to injuries, teenagers more prone to accidents as well as more vulnerable to being victims of violence and sexual assault. Anxiety is a common experience, especially around schoolwork, performance, social interactions, and expectations from family members. During our evaluation, I will assess for these to see if your symptoms fit with ADHD, these other conditions, or both. We can then discuss how to fully address each and every one of these conditions.
Once the diagnostic evaluation is complete, I will analyze the gathered information to determine if the child meets the diagnostic criteria for ADHD. If a diagnosis is confirmed, a personalized treatment plan will be developed in collaboration with the family, focusing on a combination of behavioral interventions, educational support, and, if necessary, medication management.
By undergoing a thorough diagnostic evaluation, you can ensure that your child receives the appropriate support and resources to overcome challenges and achieve success in all aspects of their life.
What are the Treatment Options?
There is no one-size-fits-all approach to ADHD. In my practice, effective treatment for ADHD involves a comprehensive and personalized approach, addressing each individual’s unique needs and challenges. The goal of ADHD treatment is to help manage symptoms, improve overall functioning, and enhance the quality of life for patients and their families.
Here are the key components of a comprehensive plan I use in my practice for ADHD treatment:
- Medication: Stimulant medications, such as methylphenidate (e.g., Ritalin, Concerta) and amphetamine-type (e.g., Adderall, Vyvanse), are often prescribed to help improve focus, attention, and impulse control. I will often start with these because the effect size is higher, the benefit is more immediate, and the side effects are typically manageable. As such, they are often the first-line option unless there’s a reason not to start with them.
Non-stimulant medications include alpha-2 receptor agonists such as guanfacine (Intuniv) or clonidine (Kapvay) and norepinephrine reuptake inhibitors atomoxetine (Strattera) and viloxazine (Qelbree). These may also be considered for patients who do not respond well to stimulants or have specific concerns or contraindications to stimulants. I will tailor the way we trial medications to your specific symptoms and preferences.
Off-label (meaning not FDA approved, but still having scientific evidence) strategies may be implemented should the options above not work out well or there are specific symptoms in your situation that would lead me to believe another agent would work better.
If there are any comorbid conditions or other conditions that might present with concentration difficulties such as depression, anxiety, or trauma, I may recommend treating that first or together with ADHD medications. - Behavioral therapy: Medications can help reduce symptoms of inattention, distractibility, hyperactivity, and impulsivity, but they won’t solve all problems. They will not help more complex tasks such as planning, prioritization, time management, organization, procrastination, or persistence toward goals. This is where behavioral interventions matter. Behavioral interventions can help patients develop skills that will last a lifetime while the medication helps to make learning those strategies easier.
I often will refer to executive functioning coaches to help teach these skills. For those wanting to work on anxiety or self-esteem issues that arises from ADHD, coping with the challenges that come with ADHD, and improving relationships where ADHD often creates problems in, I will recommend a therapist to help with these issues. - Educational support: Collaboration between parents, teachers, and other healthcare providers is vital to ensure that children with ADHD receive appropriate accommodations and support in the classroom. This may involve individualized educational plans (IEPs), 504 plans, or other tailored academic strategies. I often write a letters of support for those who require accommodations for their ADHD in school or at work.
- Family involvement: Parenting a child with ADHD comes with its own set of challenges. Family education and support play a crucial role in the successful management of ADHD. This may involve family therapy, parent training, or psychoeducation to help parents better understand and support their child’s needs. My experience is that the younger a child is, the more likely they are to respond to behavioral interventions by the parents/caregivers.
- Lifestyle modifications: Encouraging healthy habits, such as a balanced diet such as the DASH diet for ADHD, regular exercise, and adequate sleep, can have a positive impact on ADHD symptoms and overall well-being. For example, artificial food colorings has been strongly linked to hyperactivity in children (although the effect of this is small) even in those without ADHD and therefore, eliminating this from the diet could yield a small positive effect in children. We can talk during our session about the different interventions and the scientific evidence behind each one.
- Supplements: While supplements are not considered a first-line ADHD, some individuals may explore these options in addition to a prescription medication or in cases where traditional treatments have been ineffective or poorly tolerated, particularly as most of them are low risk options. Most of these do not have rigorous randomized clinical trial data, which is the gold standard for scientific evidence. I typically recommend those that have at least one clinical trial showing positive effect, and can discuss options that don’t have this. Supplemental options include omega-3 fatty acids which have a small to moderate effect size of 0.31 especially with higher EPA dose although it may take 3 months for the benefit to appear, broad spectrum micronutrients which helps more with emotional dysregulation in ADHD than core ADHD symptoms, Korean red ginseng in children with ADHD and those with subthreshold criteria for ADHD, pycnogenol for children and adults (which didn’t separate from placebo but neither did methylphenidate), saffron for children, zinc sulfate (but not zinc gluconate) although I often get a blood test before recommending this, and more.
- Non-medication FDA cleared interventions:
External trigeminal nerve stimulation (eTNS) is a treatment for pediatric ADHD. It is a non-invasive, small, portable device that delivers mild electrical pulses to stimulate the trigeminal nerve, which is located just beneath the surface of the forehead. The benefit of the Monarch eTNS device is that for kids who respond, which about half of kids are super responders, it’s twice as effective as the most powerful medication for ADHD, but it is a minimal risk intervention. Headaches are the most common side effect and this typically goes away by itself, similar to a medication. The risk is much smaller than with stimulant medications, which is why it is a good option to try for your child if you’d like to avoid medications. See the reference below for the pilot study.
In my clinical experience, there seems to be two categories of people who use the eTNS device: those who respond well and better than medication, and those who don’t respond at all. There doesn’t seem to be a middle ground here as there typically is with medication. I would also want to wait for more data before I more strongly recommend this as a first intervention, but the pilot data is good enough and the risk low enough for me to have this as part of my clinical practice.
EndeavorRx is a novel, FDA-authorized digital therapeutic designed to help improve attention and focus in children with Attention Deficit Hyperactivity Disorder (ADHD). Developed by Akili Interactive Labs, EndeavorRx is the first prescription video game-based treatment for ADHD in kids ages 8-17. The game utilizes a series of engaging tasks that target cognitive functions such as attention, working memory, and processing speed. By adapting to the player’s performance, EndeavorRx provides a personalized and progressively challenging experience, aiming to improve attentional control and cognitive skills over time. Clinical trials have shown that EndeavorRx can lead to improvements in attention and focus in some children with ADHD, with minimal side effects. It is important to note that EndeavorRx is not intended to replace traditional ADHD treatments, such as medication or behavioral therapy, but rather to serve as a complementary tool within a comprehensive treatment plan.
My goal is to have the broadest selection of agents possible that can lead to benefit while minimizing risk in order to maximize choice, personalize it to your specific set of symptoms and preferences, and alternatives if any option is suboptimal. By integrating these various treatment components, I hope to help those with ADHD receive a well-rounded approach that addresses their individual needs and fosters long-term success.
Ready to Take the Next Step?
If you’re concerned that you or your child may have ADHD, I’m here to help. Early evaluation and treatment can make a big difference in how someone functions and feels about themselves.
Please reach out to schedule a free phone call by clicking the button below. Together, we’ll create a thoughtful, supportive plan that fits your life.
Resources for Families
Support Groups
Attention Deficit Disorder Association (ADDA)
Children and Adults with Attention Deficit Disorders (CHADD)
edge Foundation
Learning Disabilities Association of America (LDA)
Informative Websites
American Academy of Child and Adolescent Psychiatry (AACAP): Facts for Families
Healthy Children
National Institute of Mental Health (NIMH)
US Centers for Disease Control and Prevention
Books
Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder by Edward Hallowell, MD
Taking Charge of ADHD, Third Edition: The Complete Authoritative Guide for Parents by Russel Barkley, PhD
Parenting Children With ADHD: 10 Lessons That Medicine Cannot Teach by Vincent Monastra, PhD
Straight Talk About Psychiatric Medications for Kids, Third Edition by Timothy Wilens, MS
References:
- Efficacy and tolerability were first described in an 8-week, open-label, pilot study of eTNS treatment of 24 children diagnosed with ADHD aged 7-14 years.
- Participants were assessed weekly with parent-and physician-completed measures of ADHD symptoms and executive functioning, treatment compliance, adverse events, and side effects.
- After four weeks of nightly use, 64% of the study group were rated as “improved” or “improved very much” on the Clinical Global Impression–Improvement (CGI-I) scale.
- After eight weeks, 71% had achieved that rating.
- ADHD Rating Scale-IV (ADHD-RS-IV) scores showed a 47% decrease, compliance was 100%, and no child withdrew from the study due to adverse events
My Publications Related to ADHD:
Stimulants in Preschool-Age Children in the Carlat Psychiatry Report and it’s accompanying Podcast episode
How Safe is Methylphenidate? in the Carlat Psychiatry Report