Insights from Monte Nido’s Latest Webinar
On March 13th, Monte Nido Vice President of Psychiatry Suki Conrad, MD, CEDS-C and Monte Nido Vice President of Clinical Services Danielle Small, M.S., LMFT, CEDS-C, presented “Attention Needed: Navigating ADHD and Eating Disorders.”
Identifying ADHD
The attention-deficit/hyperactivity disorder (ADHD) DSM 5 criteria for adolescents requires six or more attentive and/or hyperactive-impulsive symptoms that have occurred for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/ occupational activities, while only requiring five symptoms for those 17+. ADHD also has a genetic component, with heritability estimated to be between 60-90% (Grimm O, et al, 2020).
Inattentive ADHD Symptoms
For inattentive symptoms, the key is functional impairments, like losing things, hyperfocus on preferred activities, struggles to engage in non-preferred activities. Hyperactive-impulsive symptoms are typically more aversive symptoms in classrooms that get teachers’ attention, which is why the hyperactive-impulsive subtype tends to get identified at younger ages.
Complications in Diagnosing ADHD
It is necessary to acknowledge barriers in identification and diagnosis of ADHD, including gender and race. Diagnostic criteria is based off of white cis-gendered males, which leads to misdiagnosis in other demographics, such as BiPOC children and cis-gendered females.
Female-identifying individuals may present with more internalized symptoms and be overlooked in diagnosis as male-identifying individuals are more likely to be referred for diagnosis and treatment (Attoe DE, et al, 2023). Diagnosis of black, Hispanic, and other groups tend to be significantly less (46-49%) than white (Ginsberg Y, et al, 2014; Thapar A, 2014). Bilingual individuals are less likely to be diagnosed (Ginsberg Y, et al, 2014; Thapar A, 2014). Lower socioeconomic status less likely to be diagnosed, and less likely to be prescribed medication (Ginsberg Y, et al, 2014; Thapar A, 2014).
Differential, and sometimes co-morbid, diagnoses can complicate the identification of ADHD as symptoms may mimic ADHD. These include mood disorders, anxiety disorders, trauma disorders, substance use disorder, autism spectrum disorder, hearing issues, seizures, learning disabilities, hypoglycemia, and sleep disorders.
Treatment for ADHD
There are various methods to treat ADHD, including stimulants, non-stimulants, behavioral management interventions, and mind-body interventions.
Inattentive symptoms tend to respond at lower doses stimulants, however, there are concerns such as appetite suppression, height suppression, psychosis, cardiac issues, anxiety, insomnia, worsening tics, and misuse. These can be especially important to take into account when treating someone who is struggling with an eating disorder.
Behavioral management interventions include parent training, classroom interventions, organizational skills, cognitive behavioral therapy, and physical activity.
Specific Considerations in ADHD Medication and Eating Disorders
ADHD and eating disorders are often linked, as ADHD may be the primary driver and serves as a high-risk factor for disordered eating mediated through heightened psychological distress and impaired salience networks and impulsivity (Sinita E, Coghill D., 2014). Disordered eating may also present first and contribute to executive dysfunction (Keshen A, et al, 2022).
ADHD and eating disorders can interact, creating worsening outcomes including compensatory behaviors, such as self-induced vomiting, laxative misuse, fasting, or excessive exercise (Viborg, N., Wångby-Lundh, M., & Lundh, L. G., 2014; Bleck J, DeBate RD, 2013).
The Link Between ADHD and Eating Disorders
Current research shows that there may be a link between ADHD and eating disorders, which presents a rationale for trialing stimulant medications in some patients for eating disorder symptoms (Keshen A, et al, 2022). Stimulant misuse is more common in individuals with binge-related disorders compared to anorexia nervosa restricting subtype (Root TL, et al, 2009). Vyvanse is FDA approved for binge eating disorder with moderate to severe symptoms, and there are case reports describing successful treatment of bulimia nervosa with stimulants (no published randomized control trials). There are no published randomized control trials for treating anorexia nervosa with stimulants, but one successful treatment case study of two individuals who maintained weight restoration at a 1-year follow up (Shear, M., 2021).
20% of children with ADHD also develop an eating disorder and individuals with diagnosed ADHD are 3.8 times more likely to present an ED as a comorbid diagnosis (Ravi P, Khan S., 2020; Levin RL, Rawana JS., 2016).
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Citations and additional resources:
Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of attention disorders, 27(7), 645–657. https://doi.org/10.1177/10870547231161533
Biederman, J., Ball, S. W., Monuteaux, M. C., Surman, C. B., Johnson, J. L., & Zeitlin, S. (2007). Are girls with ADHD at risk for eating disorders? Results from a controlled, five-year prospective study. Journal of developmental and behavioral pediatrics : JDBP, 28(4), 302–307. https://doi.org/10.1097/DBP.0b013e3180327917
