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April 12, 2022
A cohort study looked at over five million adults and over 850,000 children between the ages of five and eleven who received care at Kaiser Permanente Northern California during the ten-year period from the beginning of 2007 through the end of 2016. At any given time, KPNC serves roughly four million persons. It is representative of the population of the region, except for the highest and lowest income strata.
The likelihood of being diagnosed with ADHD dropped sharply with age.
(When compared to 18-24-year-olds):
This matches findings from other studies showing that ADHD diagnoses become less common with age.
Other Factors:
Adults with ADHD were more likely to have other mental health conditions:
The authors speculate that rising rates of diagnosis “could reflect increasing recognition of ADHD in adults by physicians and other clinicians as well as growing public awareness of ADHD during the decade under study.” Turning to the notable differences by ethnicity, they note, “Racial/ethnic differences could also reflect differential rates of treatment-seeking or access to care. … Racial/ethnic background is known to play an important role in opinions on mental health services, health care utilization, and physician preferences. In addition, rates of diagnosis- seeking to obtain stimulant medication for non-medical use may be more common among white vs nonwhite patients.” They conclude, “greater consideration must be placed on cultural influences on health care seeking and delivery, along with an increased understanding of the various social, psychological, and biological differences among races/ethnicities as well as culturally sensitive approaches to identify and treat ADHD in the total population.”
The study highlights that many cases of adult ADHD go undiagnosed. Research shows about 3% of adults worldwide have ADHD, but this study found that less than 1% are diagnosed by doctors. This points to the need for better training for clinicians to recognize, diagnose, and treat ADHD in adults. It also emphasizes the importance of understanding cultural factors that affect how people seek and receive care.
Winston Chung, MD, MS; Sheng-Fang Jiang, MS; Diana Paksarian, MPH, PhD; Aki Nikolaidis, PhD; F. Xavier Castellanos, MD; Kathleen R. Merikangas, PhD; Michael P. Milham, MD, PhD, “Trends in the Prevalence and Incidence of Attention-Deficit/Hyperactivity Disorder Among Adults and Children of Different Racial and Ethnic Groups,” JAMA Network Open (2019) 2(11): e1914344. DOI:10.1521/adhd.2019.27.4.8.
A cohort study looked at over five million adults, and over 850,000 children between the ages of five and eleven, who received care at Kaiser Permanente Northern California during the ten-year period from the beginning of 2007 through the end of 2016. At any given time, KPNC serves roughly four million persons. It is representative of the population of the region, except for the highest and lowest income strata.
Among adults rates of ADHD diagnosis rose from 0.43% to 0.96%. Among children the diagnosis rates rose from 2.96% to 3.74%, ending up almost four times as high as for adults.
Non-Hispanic whites had the highest adult rates throughout, increasing from 0.67% in 2007 to 1.42% in 2016. American Indian or Alaska Native (AIAN) had the second highest rates, rising from 0.56% to 1.14%. Blacks and Hispanics had roughly comparable rates of diagnosis, the former rising from 0.22% to 0.69%, the latter from 0.25% to 0.65%. The lowest rates were among Asians (rising from 0.11% to 0.35%) and Native Hawaiian or other Pacific Islanders (increasing from 0.11% to 0.39%).
Odds of diagnosis dropped steeply with age among adults. Relative to 18-24-year-olds, 25-34-year-olds were 1/6th less likely to be diagnosed with ADHD, 35-44-year-olds 1/3rd less likely, 45-54-year-olds less than half as likely, 55-64-year-olds less than a quarter as likely, and those over 65 about a twentieth as likely. This is consistent with other studies reporting and age dependent decline in the diagnosis.
Adults with the highest levels of education were twice as likely to be diagnosed as those with the lowest levels. But variations in median household income had almost no effect. Women were marginally less likely to be diagnosed than men.
ADHD is associated with some other psychiatric disorders. Compared with normally developing adults, and adjusted for confounders, those with ADHD were five times as likely to have an eating disorder, over four times as likely to be diagnosed with bipolar disorder or depression, more than twice as likely to suffer from anxiety, but only slightly more likely to abuse drugs or alcohol.
The authors speculate that rising rates of diagnosis could reflect increasing recognition of ADHD in adults by physicians and other clinicians as well as growing public awareness of ADHD during the decade under study. Turning to the strong differences among ethnicities, they note, Racial/ethnic differences could also reflect differential rates of treatment seeking or access to care. Racial/ethnic background is known to play an important role in opinions on mental health services, health care utilization, and physician preferences. In addition, rates of diagnosis- seeking to obtain stimulant medication for nonmedical use may be more common among white vs nonwhite patients. They conclude, greater consideration must be placed on cultural influences on health care seeking and delivery, along with an increased understanding of the various social, psychological, and biological differences among races/ethnicities as well as culturally sensitive approaches to identify and treat ADHD in the total population.
But the main take home message of this work is that most cases of ADHD in adults are not being diagnosed by clinicians. We know from population studies, worldwide, that about three percent of adults suffer from the disorder. This study found that less than 1 percent are diagnosed by their doctors. Clearly, more education is needed to teach clinicians how to identify, diagnose and treat ADHD in adults.
A transcontinental study team (California, Texas, Florida) used a nationally representative sample – the 2018 National Survey of Children’s Health – to query 26,205 caregivers of youth aged 3 to 17 years old to explore inequities in ADHD diagnosis.
With increasing accessibility of the internet in the U.S., more than 80% of adults now search for health information online. Recognizing that search engine data could help clarify patterns of inequity, the team also consulted Google Trends.
The team noted at the outset that “[d]ocumenting the true prevalence of ADHD remains challenging in light of problems of overdiagnosis (e.g., following quick screening rather than full evaluation incorporating multi-informant and multi-method data given limited resources) and underdiagnosis (e.g., reflecting inequities in healthcare and education systems).” Underdiagnosis is known to be influenced by lack or inadequacy of health insurance, inadequate public health funding, stigma, sociocultural expectations in some ethnic groups, and structural racism, among other factors.
After controlling for poverty status, highest education in household, child’s sex, and child’s age, the team reported that Black youth were a quarter (22%) less likely to receive ADHD diagnoses than their white peers. Latino/Hispanic youth were a third (32%) less likely and Asian youth three-quarters (73%) less likely to receive ADHD diagnoses than their white peers.
The team also found that state-level online search interest in ADHD was positively associated with ADHD diagnoses, after controlling for race/ethnicity, poverty status, highest education in household, child’s sex, and child’s age. However, the odds ratio was low (1.01), “suggesting the need for additional evaluation.” Furthermore, “There was no interaction between individual-level racial/ethnic background and state-level information-seeking patterns. … the state-level online information-seeking variation did not affect the odds that youth of color would have a current ADHD diagnosis over and above other included characteristics.”
That could be due in part to the gap in high-speed broadband access between Black and Hispanic in contrast to white populations, but that would not explain the even larger gaps in diagnosis for Asian youth, who tend to come from more prosperous backgrounds.
The team concluded, “Persistent racial/ethnic inequities warrant systematic changes in policy and clinical care that can attend to the needs of underserved communities. The digital divide adds complexity to persistent racial/ethnic and socioeconomic inequities in ADHD diagnosis …”
Typically, clinicians rely on both subjective and objective observations, patient interviews and questionnaires, as well as reports from family and (in the case of children) parents and teachers, in order to diagnose ADHD.
A group of researchers are aiming to find a diagnostic test that is purely objective and utilizes recent technological advancements. The method they developed involves analyzing videos of children in outpatient settings, focusing on their movements. The study included 96 children, half of whom had ADHD and half who did not.
This new method could potentially provide a more objective way to diagnose ADHD, reducing the reliance on subjective observations and reports. It can help doctors make more accurate diagnoses, ensuring that those who need help get it and that those who don't aren't misdiagnosed.
Oppositional Defiant Disorder (ODD)—a pattern of chronic irritability, anger, arguing, or defiance—is one of the most challenging behavioral conditions families and clinicians face.
A new study involving 2,400 children ages 3–17 offers one of the clearest pictures yet. Using parent-reported data from the Pediatric Behavior Scale, researchers compared how often ODD appears in Autism spectrum disorder (ASD), ADHD-Combined presentation (ADHD-C), ADHD-Inattentive presentation (ADHD-I), and those with both ASD and ADHD.
Results:
Children with ADHD-Combined presentation show both hyperactivity/impulsivity and inattention. They had the highest ODD rates of any single diagnosis: 53% of kids with ADHD-Combined met criteria for ODD.
But when autism was added to ADHD-Combined, the prevalence jumped to 62%. This group also had the highest overall ODD scores, suggesting more severe or more impairing symptoms.
This synergy matters: while autism alone increases ODD risk, the presence of ADHD-Combined is what pushes prevalence into the majority range. Other groups showed lower, but still significant, rates of ODD:
These findings echo what clinicians often see: children with inattentive ADHD, while struggling significantly with attention and learning, tend to show fewer behavioral conflict patterns than those with hyperactive/impulsive symptoms.
It is important to note that ODD is considered to have two main components. Across all diagnostic groups, ODD consistently broke down into these two components: either Irritable/Angry (emotion-based) or Oppositional/Defiant (behavior-based). But the balance between these components differed depending on diagnosis. Notably, Autism + ADHD-Combined showed higher levels of the irritable/angry component than ADHD-Combined alone. The oppositional/defiant component did not differ much between groups. This suggests that autism elevates the emotional side of ODD more than the behavioral side, which is important for clinicians to note before tailoring interventions.
The study notes that autism, ADHD, and ODD often cluster together, with 55–90% comorbidity in some combinations.
As the authors explain, “The high co-occurrence of ADHD-Combined in autism (80% in our study) largely explains the high prevalence of ODD in autism.”
Clinical Implications: Why This Study Matters
The researchers point to a straightforward recommendation: clinicians shouldn’t evaluate these conditions in isolation. A child referred for autism concerns might also be struggling with ADHD. A child referred for ADHD might have undiagnosed ODD. And ignoring one disorder can undermine treatment for the others.
Evidence-based interventions (behavioral therapy, parent training, school supports, and/or medication) can reduce symptoms across all three diagnoses while improving long-term outcomes, including overall quality of life.
Background:
Sleep is more than simple rest. When discussing sleep, we tend to focus on the quantity rather than the quality, how many hours of sleep we get versus the quality or depth of sleep. Duration is an important part of the picture, but understanding the stages of sleep and how certain mental health disorders affect those stages is a crucial part of the discussion.
Sleep is an active mental process where the brain goes through distinct phases of complex electrical rhythms. These phases can be broken down into non-rapid eye movement (NREM) and rapid eye movement (REM). The non-rapid eye movement phase consists of three stages of the four stages of sleep, referred to as N1, N2(light sleep), and N3(deep sleep). N4 is the REM phase, during which time vivid dreaming typically occurs.
Two of the most important measurable brain rhythms occur during non-rapid eye movement (NREM) sleep. These electrical rhythms are referred to as slow waves and sleep spindles. Slow waves reflect deep, restorative sleep, while spindles are brief bursts of brain activity that support memory and learning.
The Study:
A new research review has compiled data on how these sleep oscillations differ across psychiatric conditions. The findings suggest that subtle changes in nightly brain rhythms may hold important clues about a range of disorders, from ADHD to schizophrenia.
The Results:
People with ADHD showed increased slow-spindle activity, meaning those brief bursts of NREM activity were more frequent or stronger than in people without ADHD. Why this happens isn’t fully understood, but it may reflect differences in how the ADHD brain organizes information during sleep. Evidence for slow-wave abnormalities was mixed, suggesting that deep sleep disruption is not a consistent hallmark of ADHD.
Among individuals with autism spectrum disorder (ASD), results were less consistent. However, some studies pointed to lower “spindle chirp” (the subtle shift in spindle frequency over time) and reduced slow-wave amplitude. Lower amplitude suggests that the brain’s deep-sleep signals may be weaker or less synchronized. Researchers are still working to understand how these patterns relate to sensory processing, learning differences, or daytime behavior.
People with depression tended to show reduced slow-wave activity and fewer or weaker sleep spindles, but this pattern appeared most strongly in patients taking antidepressant medications. Since antidepressants can influence sleep architecture, researchers are careful not to overinterpret the changes. Nevertheless, these changes raise interesting questions about how both depression and its treatments shape the sleeping brain.
In post-traumatic stress disorder (PTSD), the trend moved in the opposite direction. Patients showed higher spindle frequency and activity, and these changes were linked to symptom severity which suggests that the brain may be “overactive” during sleep in ways that relate to hyperarousal or intrusive memories. This strengthens the idea that sleep physiology plays a role in how traumatic memories are processed.
The clearest and most reliable findings emerged in psychotic disorders, including schizophrenia. Across multiple studies, individuals showed: Lower spindle density (fewer spindles overall), reduced spindle amplitude and duration, correlations with symptom severity, and cognitive deficits.
Lower slow-wave activity also appeared, especially in the early phases of illness. These results echo earlier research suggesting that sleep spindles, which are generated by thalamocortical circuits, might offer a window into the neural disruptions that underlie psychosis.
The Take-Away:
The review concludes with a key message: While sleep disturbances are clearly present across psychiatric conditions, the field needs larger, better-standardized, and more longitudinal studies. With more consistent methods and longer follow-ups, researchers may be able to determine whether these oscillations can serve as reliable biomarkers or future treatment targets.
For now, the take-home message is that the effects of these mental health disorders on sleep are real and measurable.
Many studies have shown that ADHD is associated with increased risks of suicidal behavior, substance misuse, injuries, and criminality. As we often discuss in our blogs, treatments for ADHD include medication and non-medication options, such as CBT (Cognitive Behavioral Therapy). While non-drug approaches are often used for young children or mild cases of ADHD, medications – both stimulants and non-stimulants – are common for adolescents and adults.
Global prescriptions for ADHD drugs have risen significantly in recent years, raising questions about their safety and effectiveness. Randomized controlled trials have demonstrated that medication can help reduce the core symptoms of ADHD. However, research from these trials still offers limited or inconclusive insights into wider and more significant clinical outcomes, such as suicidal behavior and substance use disorder.
An international study team conducted a nationwide population study using the Swedish national registers. Sweden has a single-payer national health insurance system, which covers nearly every resident, enabling such studies. The researchers examined all Swedish residents aged 6 to 64 who received their first ADHD diagnosis between 2007 and 2018. Analyses of criminal behavior and transport accidents focused on a subgroup aged 15 to 64, since individuals in Sweden must be at least 15 years old to be legally accountable for crimes or to drive.
The team controlled for confounding factors, including demographics (age at ADHD diagnosis, calendar year, sex, country of birth, highest education (using parental education for those under 25), psychiatric and physical diagnoses, dispensations of psychotropic drugs, and health care use (outpatient visits and hospital admissions for both psychiatric and non-psychiatric reasons).
Time-varying covariates from the previous month covered diagnoses, medication dispensations, and healthcare use. During the study, ADHD treatments licensed in Sweden included amphetamine, atomoxetine, dexamphetamine, guanfacine, lisdexamphetamine, and methylphenidate.
After accounting for covariates, individuals diagnosed with ADHD who received medication treatment showed better outcomes than those who did not. Specifically:
-Suicidal behaviors dropped by roughly 15% in both first-time and recurrent cases.
-Initial criminal activity decreased by 13%, with repeated offences falling by 25%.
-Substance abuse initiation declined by 15%, while recurring substance abuse was reduced
by 25%.
-First automotive crashes were down 12%, and subsequent crashes fell by 16%.
There was no notable reduction in first-time accidental injuries, and only a marginally significant 4% decrease in repeated injuries.
The team concluded, “Drug treatment for ADHD was associated with beneficial effects in reducing the risks of suicidal behaviours, substance misuse, transport accidents, and criminality, but not accidental injuries when considering first event rate. The risk reductions were more pronounced for recurrent events, with reduced rates for all five outcomes.”
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