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Attention-deficit/hyperactivity disorder (ADHD) is a treatable pediatric condition, but children with racial-ethnic minority backgrounds often do not receive timely or consistent treatment. Understanding how systemic racism impacts care and learning from families of color about their experiences can provide critical insights for improving clinical practice and engaging patients equitably in ADHD care. We interweave a mother's experience navigating ADHD care for her son with commentary from an interprofessional team about what clinicians can do for families to reduce the impact of systemic racism on care. [ Pediatr Ann . 2025;54(1):e12-e17.] ., Competing Interests: Disclosure: JF has received a grant from Maternal and Child Health Bureau (#T73MC00020-29-00), an internal seed grant from Boston Children's Hospital, time supported for directorship of Leadership Education in Neurodevelopmental and Related Disabilities LEND program at Boston Children's Hospital, and funding of a multisite open trial of “ADHD Bootcamp,” a psychoeducational support group for parents of children ages 5 to 11 years with newly diagnosed ADHD that is indirectly referenced in this paper; has received royalties from SpringerNature and American Psychiatric Press; is a consultant for Substance Abuse and Mental Health Services Administration funded Project ATTAIN: Access to Trauma-Informed Treatment and Assessment for Neurodivergent and/or Gender-Expansive Youth, consulting fees paid to the institution; has received honoraria for lectures from Boston Child Study Center, Annual Edythe Kurz Conference, Westchester Jewish Community Services; has received support for travel from Society for Developmental and Behavioral Pediatrics; and is on the Board of Directors of Society for Developmental & Behavioral Pediatrics. KMS has received a grant from the National Institutes of Health (#K12DA000357); is a consultant for Initium Health, the United States Drug Enforcement Administration, The Baker Center, and Case Esperanza; has received honoraria from Harvard University, Boston Medical Center, Columbia University Irving Medical Center, The University of Texas Health Science Center at Houston, Zucker Hillside Hospital, Thomas Jefferson University, McLean Hospital, Meharry Medical College, New England Region Black Nurses Association, The University of Massachusetts Children's Hospital, University of Massachusetts Chan School of Medicine; Department of Psychiatry, Camden Coalition, Cambridge Health Alliance, The Steve Fund, The Brazelton Touchpoint Center, The Council on Recovery, University of Pittsburgh, Opioid Response Network, Learning Collaborative, Somerville Public School, Alkermes Inc, Cary Lecture Series, and Future of Behavioral Health; and holds a leadership role in Bridge Over Trouble Water. AS-F has received honoraria for lectures from ApplyEBP; has received payment for expert testimony; and is the unpaid President of the Society for Developmental and Behavioral Pediatrics, the unpaid President of the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics Executive Committee, and a member on the American Board of Pediatrics Developmental Behavioral Pediatrics Subboard. AES has received grants from the National Institute of Mental Health (#K23MH118478, #R01MH134050), and funding for ADHD research from the Charles H. Hood Foundation, Klingenstein Third Generation Foundation, and Gordon and Betty Moore Foundation; and has received honoraria for lectures from the American Psychiatric Association and the American Academy of Pediatrics. The remaining author has disclosed no potential conflicts of interest, financial or otherwise.

Engaging children and adolescents in ADHD care is critical for future independent disease management. However, there is a lack of evidence guiding health professionals and parents on how best to engage their children and adolescents in ADHD care. We recruited 41 diverse parents of children and adolescents with ADHD and 11 adolescents with ADHD from an urban, safety-net hospital to participate in in-depth, semi-structured qualitative interviews and then analyzed this data using thematic analysis. Children's level of illness insight about ADHD and self-esteem emerged as two major contributors to engagement of children and adolescents in ADHD care, and their intersection created four styles of engagement: proactive (high insight, high self-esteem), anxious (high insight, low self-esteem), apathetic (low insight, high self-esteem), and resistant (low insight, low self-esteem). This framework can help health professionals engage children and adolescents in care for ADHD and guide development of interventions to improve engagement in care., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Improve detection of Attention Deficit/Hyperactivity Disorder (ADHD) in a safety net, hospital-based, academic pediatric practice by optimizing screening with the Pediatric Symptom Checklist attention score (PSC-AS) and further evaluation with the Vanderbilt ADHD Diagnostic Rating Scale (VADRS)., Methods: We implemented a multi-component intervention by (1) optimizing electronic medical record (EMR) features; (2) adjusting clinic operational workflow; and (3) creating a decision-making algorithm for pediatric primary care clinicians (PPCCs). We extracted 4 outcomes manually from the EMR (pediatrician acknowledgment of a positive PSC-AS, documentation of a plan for further evaluation, distribution of VADRS, and completion of at least 1 VADRS). Outcomes were measured monthly in run charts compared to the pre-intervention control period, and implementation was optimized with Plan-Do-Study-Act cycles., Results: PPCCs were significantly more likely to acknowledge a positive PSC-AS in the intervention versus control (65.3% vs 41.5%; p < 0.001), although this did not change documentation of a plan (70% vs 67.1%; p -value = 0.565). Significantly more children with a positive PSC-AS were distributed a parent or teacher VADRS in the intervention versus control (30.6% vs 17.7%; p -value = 0.0059), but the percentage of returned VADRS rating scales did not improve (12.9% vs 9.2%; p -value = 0.269)., Conclusion: Our ADHD detection quality improvement initiative improved use of the PSC-AS to identify attention problems and distribution of VADRS diagnostic rating scales, but additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care., Competing Interests: A. E. Spencer currently receives grant funding from the Klingenstein Third Generation Foundation, the Charles H. Hood Foundation, and the National Institute of Mental Health (grant K23MH118478). Other authors report no conflicts of interest., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Objective: Attention-Deficit/Hyperactivity Disorder (ADHD) disproportionately affects socioeconomically disadvantaged children, but for unclear reasons. We examined the association between social determinants of health (SDH) and ADHD symptoms in a national sample of preschool-age children., Methods: We conducted exploratory factor analysis (EFA) and exploratory structural equation modeling (ESEM) with a sample of 7,565 preschool-age children from the 2016 National Survey of Children's Health, to examine the association between ADHD symptoms and SDH., Results: EFA indicated a one-factor structure for ADHD symptoms, and three factors for SDH (socioeconomic status, access to basic needs, and caregiver well-being). Independently, all three SDH were significantly associated with higher ADHD symptoms. However, in the ESEM model, only worse caregiver well-being (β = .39, p  < .01) was significantly associated with ADHD symptoms, and fully mediated the relationship between SDH and ADHD symptoms., Conclusion: Addressing caregiver well-being in preschoolers with ADHD symptoms could be an early intervention strategy.

Introduction: Attention deficit/hyperactivity disorder (ADHD) remains underidentified among racial/ethnic minoritized populations. We examined whether parent reported screening questionnaires for attention problems in primary care mitigated these ADHD diagnostic inequities and identified contributing sociodemographic and clinical factors., Methods: We conducted a cross-sectional electronic medical record (EMR) study in an urban, hospital-based primary care pediatric clinic of school age children (N=2212) with a completed Pediatric Symptom Checklist (PSC-17). We examined differences between children with vs. without ADHD diagnoses, adjusting for positive PSC-17 attention score., Results: Adjusting for positive PSC attention score, children had higher odds of an ADHD diagnosis if they were English-speaking and had a documented Vanderbilt ADHD Diagnostic Rating Scale in their medical record., Conclusion: Multilingual, parent-report screening for attention problems in pediatric primary care does not mitigate linguistic inequities in ADHD diagnosis.

Background: Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition in children. Although ADHD is treatable, barriers remain to engagement in treatment, especially among socioeconomically disadvantaged and racial and ethnic minority families. Our goal was to examine the process by which families engage in ADHD treatment and to identify targets for an intervention to improve engagement in care., Methods: We conducted in-depth semistructured qualitative interviews with 41 parents of diverse youth aged 3 to 17 years old in treatment of ADHD at an urban safety net hospital. Parents were asked about their journey through diagnosis and treatment, community attitudes about ADHD, and other factors influencing treatment access and decision-making. Transcripts were analyzed by using thematic analysis., Results: Of children with ADHD, 69.2% were male, 57.7% were Black or African American, and 38.5% were of Hispanic, Latino, or Spanish origin. Parents were 92.7% female, were 75.6% English speaking, and had a median income of $20 000. Parents described 6 stages to the process of engaging in care for their child's ADHD, which unfolded like a developmental process: (1) normalization and hesitation, (2) fear and stigmatization, (3) action and advocacy, (4) communication and navigation, (5) care and validation, and (6) preparation and transition. Barriers often occurred at points of stage mismatch between parents and providers and/or systems. Difficulty resolving an earlier stage interfered with the progression through subsequent stages., Conclusions: The 6 stages framework could be used to develop new strategies to measure engagement and to design family-centered interventions to facilitate engagement in ADHD treatment., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

We tested the accuracy of 2 parent-report tools, the Pediatric Symptom Checklist (PSC-35) and Child Behavior Checklist (CBCL), to identify attention-deficit/hyperactivity disorder (ADHD) and distinguish complex (highly comorbid) cases in an urban, largely Latino pediatric practice. Spanish- and English-speaking parents of children aged 6 to 10 years completed a PSC-35 and CBCL at well visits. Those with CBCL Attention Problems Subscale (CBCL-APS) T scores ≥60 plus controls completed the diagnostic MINI-KID (Miniature International Neuropsychiatric Interview) for Children. Receiver operating characteristic (ROC) curves quantified accuracy of both scales to distinguish ADHD from non-ADHD, and complex from simple ADHD. Two hundred and nine children were screened, and 41 completed diagnostic interviews. Both the CBCL-APS and PSC Attention Scale (PSC-AS) accurately identified ADHD; the CBCL-APS performed best (AUROC CBCL&#95;APS = 0.837; AUROC PSC&#95;AS = 0.728). The PSC Total and Internalizing Scores and the number of CBCL subscale elevations accurately distinguished complex from simple ADHD; the PSC Internalizing Score performed best (AUROC PSC&#95;TOTAL = 0.700; AUROC PSC&#95;INT = 0.817; AUROC CBCL&#95;SUBS = 0.762).

Objective: Supratherapeutic doses of methylphenidate activate μ-opioid receptors, which are linked to euphoria. This study assessed whether naltrexone, a mixed μ-opioid antagonist, may attenuate the euphoric effects of stimulants, thereby minimizing their abuse potential in subjects with attention-deficit/hyperactivity disorder (ADHD)., Methods: We conducted a 6-week, double-blind, placebo-controlled, randomized clinical trial of naltrexone in adults with DSM-IV ADHD receiving open treatment with a long-acting formulation of methylphenidate (January 2013 to June 2015). Spheroidal Oral Drug Absorption System methylphenidate (SODAS-MPH) was administered twice daily, was titrated to ~1 mg/kg/d over 3 weeks, and was continued for 3 additional weeks depending on response and adverse effects. Subjects were adults with ADHD preselected for having experienced euphoria with an oral test dose of 60 mg of immediate-release methylphenidate (IR-MPH). The primary outcome measure was Question 2 (Liking a Drug Effect) on the Drug Rating Questionnaire, Subject version, which was assessed after oral test doses of 60 mg of IR-MPH were administered after the third and sixth weeks of treatment with SODAS-MPH., Results: Thirty-seven subjects who experienced stimulant-induced (mild) euphoria at a baseline visit were started in the open trial of SODAS-MPH and randomized to naltrexone 50 mg/d or placebo. Thirty-one subjects completed through week 3, and 25 completed through week 6. Naltrexone significantly diminished the euphoric effect of IR-MPH during the heightened-risk titration phase (primary outcome; first 3 weeks) (χ² = 5.07, P = .02) but not the maintenance phase (weeks 4-6) (χ² = 0.22, P = .64) of SODAS-MPH treatment., Conclusions: Preclinical findings are extended to humans showing that naltrexone may mitigate stimulant-associated euphoria. Our findings provide support for further studies combining opioid receptor antagonists with stimulants to reduce abuse potential., Trial Registration: ClinicalTrials.gov identifier: NCT01673594., (© Copyright 2018 Physicians Postgraduate Press, Inc.)

Objective: Methylphenidate activates μ-opioid receptors, which are linked to euphoria. μ-Opioid antagonists, such as naltrexone, may attenuate the euphoric effects of stimulants, thereby minimizing their abuse potential. This study assessed whether the combination of naltrexone with methylphenidate is well-tolerated while preserving the clinical benefits of stimulants in subjects with attention-deficit/hyperactivity disorder (ADHD)., Methods: We conducted a 6-week, double-blind, placebo-controlled, randomized clinical trial of naltrexone in adults with DSM-IV ADHD receiving open treatment with a long-acting formulation of methylphenidate from January 2013 to July 2015. Spheroidal Oral Drug Absorption System (SODAS) methylphenidate was administered twice daily, was titrated to approximately 1 mg/kg/d over 3 weeks, and was continued for 3 additional weeks depending on response and adverse effects. Subjects were adults with ADHD preselected for having experienced euphoria with a test dose of immediate-release methylphenidate. The primary outcome measure was the Adult ADHD Investigator Symptom Report Scale (AISRS)., Results: Thirty-seven subjects who experienced stimulant-induced (mild) euphoria at a baseline visit were started in the open trial of SODAS methylphenidate and randomly assigned to naltrexone 50 mg or placebo. Thirty-one subjects completed the study through week 3, and 25 completed through week 6. Throughout 6 weeks of blinded naltrexone and open methylphenidate treatment, the coadministration of naltrexone with methylphenidate did not interfere with the clinical effectiveness of methylphenidate for ADHD symptoms. Additionally, the combination of naltrexone and methylphenidate did not produce an increase in adverse events compared with methylphenidate alone., Conclusions: Our findings provide support for the concept of combining opioid receptor antagonists with stimulants to provide an effective stimulant formulation with less abuse potential., Trial Registration: ClinicalTrials.gov identifier: NCT01673594​., (© Copyright 2017 Physicians Postgraduate Press, Inc.)

We examined whether non-traumatized subjects with Attention Deficit Hyperactivity Disorder (ADHD) have dysfunctional activation in brain structures mediating fear extinction, possibly explaining the statistical association between ADHD and other disorders characterized by aberrant fear processing such as PTSD. Medication naïve, non-traumatized young adult subjects with (N=27) and without (N=20) ADHD underwent a 2-day fear conditioning and extinction protocol in a 3T functional magnetic resonance imaging (fMRI) scanner. Skin conductance response (SCR) was recorded as a measure of conditioned response. Compared to healthy controls, ADHD subjects had significantly greater insular cortex activation during early extinction, lesser dorsal anterior cingulate cortex (dACC) activation during late extinction, lesser ventromedial prefrontal cortex (vmPFC) activation during late extinction learning and extinction recall, and greater hippocampal activation during extinction recall. Hippocampal and vmPFC deficits were similar to those documented in PTSD subjects compared to traumatized controls without PTSD. Non-traumatized, medication naive adults with ADHD had abnormalities in fear circuits during extinction learning and extinction recall, and some findings were consistent with those previously documented in subjects with PTSD compared to traumatized controls without PTSD. These findings could explain the significant association between ADHD and PTSD as well as impaired emotion regulation in ADHD., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Objective: To conduct a systematic review and meta-analysis examining the relationship between attention-deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD)., Data Sources: We reviewed literature through PubMed and PsycINFO without a specified date range, utilizing the search (posttraumatic stress disorder OR PTSD) AND (ADHD OR attention deficit hyperactivity disorder OR ADD OR attention deficit disorder OR hyperkinetic syndrome OR minimal brain dysfunction). References from relevant articles were reviewed., Study Selection: We identified 402 articles; 28 met criteria. We included original human research in English that operationalized diagnoses of ADHD and PTSD, evaluated the relationship between the disorders, and included controls. We excluded articles that failed to differentiate ADHD or PTSD from nonspecific or subsyndromal deficits or failed to compare their relationship., Data Extraction: We extracted sample size, age, diagnostic methods, design, referral status, control type, and number of subjects with and without ADHD and PTSD alone and combined. We computed meta-analyses for 22 studies examining ADHD in PTSD and PTSD in ADHD using a random effects model and meta-analytic regression. We assessed for heterogeneity and publication bias and adjusted for intrastudy clustering., Results: The relative risk (RR) for PTSD in ADHD was 2.9 (P < .0005); in samples using healthy controls, the RR was 3.7 (P = .001); and in samples using traumatized controls, the RR was 1.6 (P = .003). The RR for ADHD in PTSD was 1.7 (P < .0005); in samples using traumatized controls, the RR was 2.1 (P < .0005). The association was not significant in samples using psychiatric controls., Conclusions: Results indicate a bidirectional association between ADHD and PTSD, suggesting clinical implications and highlighting the need for neurobiological research that examines the mechanisms underlying this connection., (© Copyright 2015 Physicians Postgraduate Press, Inc.)

Objective: This study investigated the association between mild traumatic brain injury (mTBI) and ADHD, which increases risk of injuries and accidents., Method: We conducted a systematic review and meta-analysis of studies that examined the relationship between mTBI and ADHD., Results: Five studies, comprising 3,023 mTBI patients and 9,716 controls, fit our a priori inclusion and exclusion criteria. A meta-analysis found a significant association between ADHD and mTBI, which was significant when limited to studies that reported on ADHD subsequent to mTBI and when the direction of the association was not specified, but not for studies that reported mTBI subsequent to ADHD. Heterogeneity of effect size and publication biases were not evident., Conclusion: The literature documents a significant association between mTBI and ADHD. Further clarification of the relationship and direction of effect between mTBI and ADHD and treatment implications could have large clinical, scientific, and public health implications., (© 2014 SAGE Publications.)