Understanding ADHD, the Stimulant Shortage and Its Impact on Individuals and Society

The current shortage of stimulant medication has been a significant challenge for individuals with ADHD and their families, as well as healthcare providers. Stimulant medications, such as Adderall and Ritalin, and their longer-acting formulations, are commonly prescribed to manage the symptoms of ADHD. The shortage has been attributed to various factors, including manufacturing and supply chain issues, increased demand due to the pandemic and other unclear reasons, and perhaps changes in regulations related to online prescriptions and drug production. As a result of the shortage, many individuals with ADHD have reported difficulties in obtaining their medications. In the New York metro area where I am located, almost all of my patients are unable to get their medications immediately, having to resort to repeatedly calling their pharmacy to identify the time when a shipment has arrived.

The sad reality of a stimulant shortage will cause immeasurable suffering.

The inability to obtain prescribed stimulant medication has a significant impact on individuals' ability to manage their symptoms and function in daily life. Alternative treatments, such as non-stimulant medications and behavioral therapies, can play a role, but almost uniformly are not as effective as stimulants for individuals with ADHD. Even as a holistic psychiatrist, who regularly utilizes non-medication interventions, such as mindfulness, plant medicines, vitamins, and supplements, the reality is that almost all patients with ADHD need their stimulants to function in their personal and professional lives. Being without their medication comes with profound costs in their work performance, relationships, and often unrecognized and crucially important areas such as the ability to care for their children. It also leads to increased anxiety, depression, and PTSD symptoms, as well as feelings of inadequacy, guilt, and shame due to be negated and dismissed by others who do not understand the way their brains work with the resulting symptoms and challenges.

Clearing Up The Confusion and Reducing The Stigma

ADHD is a profoundly misunderstood medical condition. The last two words are perhaps the most important place to start before moving onto the process of addressing the common misconceptions. The mind-body split is a core distortion in society today that leads to much of the stigma related to this and many other conditions. Biological processes that primarily impact the brain are regarded as less "real" than those that affect other organ systems. This is frankly absurd. There is one organ system that typically, if not functional for more than six minutes, ends our ability to consciously experience life. The brain is called the central nervous system because it is centrally important to our very experience of life. Only in society's perception and people's errant thinking is it less important than other organ systems. How this came to be is a topic for another post. What is important here is to recognize the absurdity of this.

If the stimulant shortage were affecting any other organ system, there would be outrage. If people were unable to get the medication they needed for the treatment of a condition that could lead to the end of a relationship, impact their children, or interfere with their ability to work (with the resulting lost revenue impacting our nation's economy), there would be outrage. People would be screaming from the highest levels of government and media. To this point, the discourse has consisted of only a small number of articles in the media over recent weeks. We need to spread the word of this crisis far and wide.

So let’s start with the reality of what ADHD actually is before addressing the distortions.

What Is ADHD?

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children. Symptoms of ADHD include inattention (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting), and impulsivity (hasty acts that occur in the moment without thought). ADHD is considered a chronic and debilitating disorder and is known to impact the individual in many aspects of their life, including academic and professional achievements, interpersonal relationships, and daily functioning (Harpin, 2005). ADHD leads to poor self-esteem and can impact social function in children when not appropriately treated (Harpin et al., 2016). Adults with ADHD may experience poor self-worth, sensitivity towards criticism, and increased self-criticism, possibly stemming from higher levels of criticism throughout life (Beaton et al., 2022). Of note, ADHD presentation and assessment in adults differ.

An estimated 8.4% of children and 2.5-4.4% of adults in the US population have ADHD. ADHD is often first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork. It is more commonly diagnosed among boys than girls, given differences in how the symptoms present. However, this does not mean that boys are more likely to have ADHD. Boys tend to present with hyperactivity and other externalizing symptoms, whereas girls tend to have inattentiveness. This often leads to girls not being diagnosed, leaving a lasting deleterious impact on their lives due to unrecognized and unaddressed challenges in their academic and professional functioning.

As their symptoms of inattention don't disrupt the classroom girls often go undiagnosed. This creates a deleterious impact on their lives due to unrecognized and unaddressed challenges in their academic and professional functioning.

Brain Function Challenges in AHDD

Whenever discussing brain function, the first thing I am always certain to state is that we don’t know exactly how the brain works. In fact we have much more to learn about the brain than we currently know. We know the most important brain "chemicals" (actually called "neurotransmitters"), part of what the different areas of the brain are responsible for in regards to bodily function, and what patterns of thinking and behavioral connections of neurons (brain cells) between different areas of the brain are involved in. A general model of understanding ADHD is that people with this condition have decreased levels of dopamine and norepinephrine in the frontal lobes of the brain, as these are the parts of the brain responsible for attention and impulse control. When one takes a stimulant, levels of dopamine and norepinephrine are increased. This leads to improved attention, concentration, and impulse control. One of the other primary brain region involved in ADHD is the prefrontal cortex, called by some "The CEO" of the brain. It is the region involved in executive functioning, which is the planning and carrying out of complex tasks. This is the reason for the challenges with avoiding tasks that require sustained mental effort, i.e., procrastination, a major challenge for those with ADHD, and not following through on tasks until complete. People with ADHD will often get through 85% of a task before leaving a string of unfinished tasks. If you want to learn more, simply ask the partner of anyone with ADHD. Only do so if you have hours to spare, however, as the list is going to be pretty long.

Now onto the misconceptions…as stated in the language of distortions that sadly is the commonly held belief in society.

Misconception #1: ADHD is not a real disorder

Some people believe that ADHD is not a real disorder and that individuals who have been diagnosed with it are simply lazy or lack self-control. However, endless studies and decades of clinical experience have demonstrated that ADHD is a valid and impairing disorder that affects brain function and behavior. ADHD is recognized as a real disorder by the American Psychiatric Association and the National Institute of Mental Health, among other organizations per above. Resources:

· "Is ADHD Real?" by CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder) https://chadd.org/for-adults/is-adhd-real/ · "ADHD: Fact vs. Fiction" by the American Psychiatric Association https://www.psychiatry.org/patients-families/adhd/what-is-adhd

Misconception #2: ADHD only affects children

Although ADHD is commonly diagnosed in children, it can persist into adulthood in up to 60% of cases. Many adults with ADHD were not diagnosed as children and may struggle with symptoms such as difficulty with organization, time management, and completing tasks. The incidence of adult ADHD, or the rate at which new cases of ADHD are diagnosed in adults, is not exactly clear due to a lack of large-scale, population-based studies and the sad reality of underdiagnosis due to people not presenting for evaluation due to the above misunderstandings. However, research suggests that ADHD is a common condition among adults, with estimates of the prevalence of ADHD in adults ranging from 2.5% to 4.4% in the general population as stated above.

Resources:

· "ADHD in Adults" by the National Institute of Mental Health https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml#part_145444 · "What Does Adult ADHD Look Like?" by ADDitude Magazine https://www.additudemag.com/what-does-adult-adhd-look-like-symptoms/

Misconception #3: ADHD is caused by bad parenting or lack of discipline

Some people believe that ADHD is caused by bad parenting or a lack of discipline. This is frankly absurd and just plain sad. Research has shown that ADHD has a biological basis and is influenced by genetics and environmental factors. Although parenting strategies can be helpful in managing symptoms, they are simply an intervention that is supportive of the core treatments of medications and cognitive-behavioral therapy for ADHD. They do not cause ADHD.

Resources:

· "What Causes ADHD?" by the National Institute of Mental Health https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml#part_145441 · "ADHD is Not Caused by Bad Parenting" by CHADD https://chadd.org/for-parents/what-is-adhd/causes-of-adhd/

Misconception #4: People with ADHD are always hyperactive and impulsive

Although hyperactivity and impulsivity are common symptoms of ADHD, not all individuals with ADHD exhibit these behaviors. Many individuals with ADHD may struggle with symptoms of inattention, including a lack of sustained attention, being easily distracted/forgetful, and difficulty avoiding or completing tasks that require sustained mental effort. This is particularly true for girls with ADHD and adults, as often the hyperactive/impulsive symptoms resolve in adulthood, with inattentive symptoms persisting. In addition, the symptoms of ADHD can vary in severity and may change over time.

Resources:

· "Types of ADHD" by the ADHD Institute https://www.adhd-institute.com/burden-of-adhd/epidemiology/types-of-adhd/ · "ADHD Symptoms: Inattention, Hyperactivity, and Impulsivity" by WebMD https://www.webmd.com/add-adhd/guide/adhd-symptoms

Millions struggle with symptoms of inattention in the U.S. While hyperactive symptoms disappear in many in adulthood, symptoms of inattention to include poor organization often last, impacting one's life in destructive ways.

Reducing Stigma and Misunderstanding

To reduce stigma and misunderstanding about ADHD, it is important to educate people about the disorder and its impact. Awareness is crucial to help those suffering in silence. There are many resources available for individuals with ADHD, their families, and the general public. Here are some additional website resources:

· CHADD: https://chadd.org/ · ADHD Awareness Month: https://adhdawarenessmonth.org/ · ADDitude Magazine: https://www.additudemag.com

Thankfully social media has become a powerful resource to spread awareness, information, and tools about ADHD. Here are some of the accounts I've found to be incredibly helpful along with their websites as applicable:

@additudemage

@adhd_empowerment_coach www.adhdempowermentcoaching.com

@the_mini_adhd_coach

@adhdhustlers adhdoers.com

@adhddietitian

@mollys_adhd_mayhem

@adhdbrainhealth

Please consider sharing this post with others and on social media platforms to spread the word. We need to raise awareness so that those with the ability to intervene in government, particularly at the FDA, do so to protect those that struggle with ADHD and deserve our support rather than being left to fend for themselves.