My boys squirm around on the couch. Sometimes they stand on their heads in the middle of family scripture study — or randomly wander off from dinner without any explanation.
That’s not because something is wrong with them. It’s because they are boys. Rambunctiousness is one reason boys are two to three times more likely to be diagnosed with “ADHD” — first introduced in 1980 as simply “ADD” (Attention Deficit Disorder).
In an attempt to calm down children, amphetamines had been used experimentally since the 1930s, when one psychiatrist reported “remarkably improved school performance” in half the children he medicated.
By 1988, with the growing use of the stimulant methylphenidate (Ritalin), researchers in a L.A. Times story, “Use of Drug to Calm Children Rises Sharply, Study Reports,” described a rapid shift taking place: “Medication treatment for hyperactive children in the United States has emerged from its minor treatment role in the 1960s to become the dominant child mental health intervention in the late 1980s.”
Reasons more parents have been looking for another way
Some parents of attention-struggling boys and girls have resisted — for at least 3 reasons:
1. Short-term side effects. Officially listed side effects for the most commonly used ADHD medications vary:
For methylphenidate (Ritalin and Concerta) and amphetamine products (Adderall and Vyvanse), short-term effects include decreased appetite, stomach/abdominal discomfort, headaches, insomnia or other sleep disturbance, irritability, anxiety, or mood changes. These medications can also sometimes increase heart rate and blood pressure.
The “nonstimulant” atomoxetine (Strattera) commonly causes decreased appetite, nausea or other gastrointestinal symptoms, headache, dizziness, tiredness or sleepiness, and sometimes other sleep problems. More infrequently, some children can experience suicidal thoughts and liver injury.
Guanfacine (Intuniv) and clonidine (Kapvay) more commonly cause sleepiness/fatigue, dizziness, headache, dry mouth, stomach symptoms, and lowered blood pressure or heart rate.
A 2017 review of ADHD medications for children and adolescents across 5,837 participants found statistically significant increases in blood pressure or heart rate with amphetamines and atomoxetine (Strattera)— emphasizing that the longer-term picture remains unclear. And a 2025 systematic review likewise found ADHD medications can affect blood pressure, pulse, and other cardiovascular measures in the short-term — with the authors again noting that trials were generally too short to paint a settled picture of long-term cardiovascular safety.
2. Long-term, counterintuitive worsening in attention. Longer-term data has been slow in coming. In 1995, for instance, a decade after these medications became more widespread, NIMH researchers in arguably the first long-term study of ADHD medications acknowledged that “long-term efficacy of stimulant medication has not been demonstrated for any domain of child functioning.”
By 2007, a 3-year NIMH follow-up study found that core ADHD symptoms were reduced in children in the first year — as many parents have witnessed. But the surprise came later. At the end of three years, researchers noted that “medication use was a significant marker not of beneficial outcome, but of deterioration. That is, participants using medication in the 24-to-36 month period actually showed increased symptomatology during that interval relative to those not taking medication.”
The same study later reported that counterintuitively, by the end of six years, medication use was “associated with worse hyperactivity-impulsivity and oppositional defiant disorder symptoms,” and with greater “overall functional impairment.”
3. Other long-term concerns. Other questions about the long-term use of ADHD medications center around the emergence of new challenges in children with attention struggles. For instance, medical summaries also acknowledge that ADHD medications taken for years can contribute to slowed growth, which is a well-known challenge on these medications, along with a potential increase in obesity.
A 2022 study found that Ritalin leads to an 18-fold increase in depression, which decreased when kids stopped taking the medication. More concerning, a 1996 bipolar study found that 11% of children treated with stimulants developed bipolar symptoms within four years. A 2001 bipolar depression study likewise found that two-thirds of the adolescent patients hospitalized for mania at the University of Cincinnati Medical Center had been on stimulants “prior to the onset of an affective episode.” Stimulants, the researchers concluded, may “precipitate depression and/or mania in children who would not have otherwise developed bipolar disorder.”
The same medical reports confirm more serious effects that can include psychotic symptoms or significant cardiovascular problems. One study found stimulants leading to hallucinations and other psychotic experiences in 62.5% of kids. (More recent evidence found that teens and young adults taking Adderall were more than twice as likely to develop psychosis or mania, with those on high doses were more than five times as likely).
This helps explain why some parents have been resistant to medicating their child for attention issues.
But wait, don’t the benefits for focus outweigh these risks?
Many parents believe the ADHD medications have benefitted their children with focus, especially in the short term. And there are plenty of clinical studies conducted that demonstrate some short-term benefits behaviorally.
But the picture is a little more mixed when we focus on more systematic studies done without any industry funding. Bob Whitaker, an award-winning journalist I’ve interviewed twice, reviewed in 2013 independent studies from Canada, Oregon and Australia, each of which found worse academic outcomes among children taking the medications.
For instance, a study by the Oregon Health and Science University involving investigators from 13 universities concluded in 2005: “There is no good-quality evidence on the use of drugs to affect outcomes related to global academic performance, consequences of risky behavior, social achievements, etc.”
Another 2010 study in Western Australia followed children on ADHD medications over 10 years, and found that medicated children were much more likely to be identified by teachers as performing at below age level. Their overall conclusion was that: “medication does not translate into long-term benefits to the child’s social and emotional outcomes, school-based performance, or symptom improvement.”
More recent evidence raises similar cautions. For instance, a 2014 study found that ADHD medications may increase school drop-out rates among children. And an impressive 2022 study by scientists at the University of California, San Diego (and Irvine), Florida State University, and Penn State College of Medicine compared medicated and non-medicated children with attention struggles specifically in terms of academic performance, reporting: “Although it has been believed for decades that medication effects on academic seatwork productivity and classroom behavior would translate into improved learning of new academic material, we found no such translation.”
“Medication had no detectable impact on how much children learned from academic units of science, social studies, and vocabulary,” they said, before concluding: “Our failure to find an effect of stimulant medication on the learning of individual academic curriculum units raises questions about how stimulant medication would lead to improved academic achievement over time. This is important given that many parents and pediatricians believe that medication will improve academic achievement; parents are more likely to pursue medication (vs. other treatment options) when they identify academic achievement as a primary goal for treatment.”
Bottom line: Although you may still experience a positive improvement for your child on these medications, that may not be guaranteed.
So, what else can be done for these children?
One of the most formative moments in my graduate education was attending a conference in Chicago where the presenter, an older psychiatrist with decades of experience, had reviewed some of this same disheartening data about the longer-term trajectory of children taking these ADHD medications.
As he finished, a hand shot up in the back: “But hold on, if we’re not putting these kids with ADHD on these medications, what else can we do?”
I’ll never forget the stunned look on this seasoned physician’s face. The question stopped him in his tracks for a moment, but after a pause he said with energy in his voice: “All of life! Nature and relationships and art and play and reading and food and sunlight ….”
The implication was clear: Since when did we decide that stimulant medication was our only option for helping children navigate attention struggles?
The hundreds of factors that shape attention, young and old
Inspired by this presentation, I dove into an in-depth project in 2012 with Jeffrey Lacasse, a social work professor at Florida State University — mapping every risk factor for inattentiveness we could find in the research literature up till that year.
Sorting through thousands of studies, we identified several hundred that were relevant, distilling the findings into themes for an inventory that could be reviewed by parents. You can check that out and download it here:
To be clear, not all of these factors listed are classically defined “risk factors.” We didn’t want our focus to be that narrow, so we also included associations and correlations noted in the literature.
Our purpose, then, was not to establish causal mechanisms claiming “this is why ADHD happens” — as much as to paint the broader picture of the dizzying variety of influences that shape the development of all of our levels of attentiveness over time.
Creating your own family plan to nurture attention
My hope was that with this knowledge, parents and families could create their own plan to nurture attention in the right direction over time. In addition to the risk factor literature itself, there are lots of encouraging studies to guide you. For instance:
A 2008 UCLA study found that adults and adolescents with ADHD who took a meditation class experienced improvements to attention, “cognitive inhibition” (better ability to stay focused despite distractions) and other self-reported ADHD symptoms
Another striking 2009 study by researchers at my alma mater, the University of Illinois, Urbana-Champaign, found that a 20-minute walk in a park improved attention in children with ADHD, with an effect size comparable to those reported in studies of methylphenidate (Ritalin).
Although there’s been some fascinating evidence that CBT therapy can be especially helpful to adults struggling with attention, something else is needed for children aged 4–12. The best research centers on something called “behavioral parent training,” which teaches parents practical strategies — such as consistent routines, positive reinforcement, and clear consequences — to help children struggling with attention function more successfully at home and school.
One 2023 summary of 27 studies of behavioral parent training found “sustained improvements” in various outcomes, including ADHD symptoms — with the authors concluding that “behavioural parent training has longer-term benefits for children’s ADHD symptoms and behavioural problems, and for positive parenting behaviours, parenting sense of competence and quality of the parent-child relationship.”
Stanford researchers pointed out last year that this kind of family/behavioral therapy should be the first thing to try with young children struggling with attention — noting with concern that 42% of 3- to 5-year-olds studied were given stimulant drugs before therapy could even be attempted. As they state, “Clinical practice guidelines recommend medications as second-line treatment in cases with substantial dysfunction or lack of response to behavioral treatment.” Yet, they add, “more than one-third of patients lacked sufficient time for an evidence-based behavioral treatment before starting medications.”
It’s important to remember that even children with ADHD can pay attention in some contexts. For instance, remove that distracted child from a math class and put them in front of a video game. What happens? Attentiveness is just fine. This suggests a socialization problem that can be gradually improved over time, rather than an inherent biological impairment that must be directly intervened with or ultimately just “lived with.”
Related to this, researchers have repeatedly found that the youngest children in a classroom are significantly more likely to receive an ADHD diagnosis and be prescribed stimulants. That highlights an important influence of comparative age — especially of being slightly behind other children developmentally (again, a socialization, experience and training question, rather than a matter of underlying pathology).
My take: If you see your child’s attention as a training ground, rather than a disease to manage, you’ll naturally work towards long-term improvement, instead of just short-term symptom control.
In this way, instead of measuring whether someone is deficient or not, it would be better to think of attention (for all of us) as gradually changing over time on a spectrum. Depending on so many different factors, we could then measure how our attention is shifting over time.
Anything new in the last 15 years of data?
Because it’s been almost 15 years since that review, I did a deep dive this weekend on anything else that’s come up in the years since. What I’m finding is mostly confirmatory of that earlier picture, with a few expansions and clarifications. In chronological order, with key take-aways bolded:
A 2019 meta-analysis of dietary patterns found healthy dietary patterns associated with lower ADHD risk and unhealthy dietary patterns associated with higher ADHD risk — concluding: “a diet high in refined sugar and saturated fat can increase the risk, whereas a healthy diet, characterized by high consumption of fruits and vegetables, would protect against ADHD or hyperactivity.”
A 2022 systematic review/meta-analysis of 70 studies and nearly 4 million participants found children exposed to adverse childhood experiences (abuse, neglect, family violence, household mental illness, household substance abuse, economic adversity, incarceration, bullying, other violence) had approximately 1.68 times the odds of ADHD compared with those without such traumatic exposure. More adversity was associated with greater vulnerability.
A large 2022 CDC systematic meta-analysis across 69 studies found associations between ADHD diagnosis in children and maternal preeclampsia, pregnancy complications, neonatal illness, lower Apgar scores and lack of breastfeeding.
A 2022 CDC systematic review of 59 longitudinal studies found associations between ADHD and negative/harsh parenting, maltreatment, divorce/single parenting, parental incarceration and child media exposure, while sensitivity/warmth was inversely associated with ADHD outcomes.
A 2023 meta-analysis involving 81,234 children found that more than two hours/day of screen time was associated with higher odds of ADHD.
A 2023 analysis of more than 1,800 studies found “evidence of a significant role for some pollutants, in particular heavy metals and phthalates, in the increased risk of developing ADHD symptoms.”
A 2024 Swedish study looked at 2.48 million children, included more than 1.77 million full siblings — and found a small association between prenatal acetaminophen (Tylenol) and ADHD.
A 2024 meta-analysis of 796,157 mother-child pairs found elevated ADHD symptoms among children whose mothers experienced antenatal or postnatal depression — although only a few of the studies examined maternal antidepressant use.
A 2024 systematic review of 28 longitudinal studies found that children with more ADHD symptoms were more likely to develop problematic digital-media use, all of which predict later ADHD symptoms.
Looking for research collaborators
There are hundreds of other, smaller studies out there that I haven’t had time to review — including research in modern media that has evolved well beyond what we found in 2012. That includes a lot more data on problematic digital-media use, gaming, social media, highly stimulating/rapid-switching media, etc.
If there were any others interested in collaborating, it would be nice to review the last 15 years of data more closely to update this ADHD child/adolescent inventory — along with the adult version that we developed separately.
You don’t need to be a “researcher” — just need to have some time, even just a few hours on weekends would work. With the right team, we could probably pull this off by Christmas or springtime.
One more note — so much depends on measurement
In 2002, Eli Lilly released atomoxetine (Strattera), marketed as the first “non-stimulant” treatment for ADHD. This was exciting since many parents don’t like the idea of medicating their child with a stimulant drug in the same class as amphetamines. And this new medication was marketed as “superior” to other ADHD medication in their side-effect profile.
But my colleague Shannon Hughes, in collaboration with the brilliant David Cohen at UCLA, analyzed all 73 industry-funded trials submitted to the FDA as part of the approval process for this and other related medication. What they found was that the number of measures used in the clinical trials to track any positive effects was substantially more comprehensive than those to identify adverse events (often only a self-report from parents).
In other words, much like I’ve written about regarding antidepressant side effects, the official safety profile of this ADHD medication — now represented on packaging, safety insert and clinical reports — comes from studies that appear exceedingly careful to track any possible improvement from the med, and not so much with possible adverse effects.
I end where this began: With hundreds of documented influences on attention, you’ve got many adjustments to consider. Is it time to come up with a more sustainable plan for improving attentiveness in your own family?