Excessive screen time and social media use exacerbate ADHD symptoms and may impact brain development in children with the condition, according to two new studies.

Social media (e.g., Snapchat or Instagram) use gradually increases symptoms of inattention in children with ADHD, with a cumulative four-year effect, a new study published in Pediatrics Open Science found. ADHD symptoms alone, however, did not predict a rise in social media use. Further, playing video games or watching television and videos did not increase the risk of developing ADHD symptoms. The study found the opposite: Children who played video games or watched television and videos experienced reduced hyperactivity and impulsivity. ¹

“We can only speculate about the mechanisms underlying the association between social media use and increased inattention symptoms,” the researchers wrote. “Social media platforms often involve constant messaging and notifications, which can disrupt attention and interfere with current activities. Experimental studies have shown that such interruptions, or even the mere presence of a mobile phone nearby without using it, can impair attention and learning on psychological tests.” ²

In contrast, cognitively engaging exercises (e.g., activities requiring strategy, coordination, and quick decision-making, such as team sports or martial arts) significantly improve sustained attention in children and adolescents with ADHD, according to a new systematic review and meta-analysis published in the Journal of Autism and Developmental Disorders. ³

The Pediatrics Open Science study examined the longitudinal associations between ADHD symptoms in 8,324 children who participated in the Adolescent Brain Cognitive Development (ABCD) study and various types of digital media. The researchers tracked the children from ages 9 or 10 for 4 years.

Over that time, children spent an average of

• 3 hours/day watching television/videos
• 4 hours/ day on social media
• 5 hours/day playing video games

At age 9, children spent approximately 30 minutes per day using social media. The time spent on social media rose to 2.5 hours by age 13, despite the fact that most platforms, such as Facebook and TikTok, require users to be 13 years or older. While the yearly effect size of 0.15 is considered statistically small for a single child, it can have substantial consequences at the population level.

“Together, these results strengthen the potentially causal link between social media use and changes in inattention symptoms,” the researchers wrote.

Another recent study using advanced MRI imaging and ABCD data from more than 10,000 children in the same age range found similarly negative outcomes when examining the broader effects of screen time. The study, published in Translational Psychiatry, found an association between extended screen exposure and changes in brain structure that may exacerbate ADHD symptoms in children.⁴

The researchers observed that children with high screen use had reduced cortical thickness and volume in the right putamen, an area of the brain involved in reward processing and habit formation, as well as changes in the prefrontal cortex, which is involved in focus, emotional regulation, and decision-making. Such changes in brain structure may make it more difficult for children to pay attention and regulate their behavior, which are two prominent features of ADHD.

“Our results indicate a partial mediating effect of cortical volume in the relationship between screen time and ADHD symptoms,” the researchers wrote. “Specifically, longer screen time was associated with smaller cortical volume, which in turn was linked to more severe ADHD symptoms, suggesting that cortical volume may partially explain this association.”

At the two-year follow-up, screen time remained a significant predictor of ADHD symptoms in children, even after controlling for baseline ADHD symptoms as covariates. However, causality could not be established since the results were derived from cross-sectional analyses of the ABCD baseline data.

Social Media Risks

Both studies align with a 2023 U.S. Surgeon General advisory calling social media a “profound risk of harm” to the mental health of children and teens.

According to an ADDitude survey of 1,187 caregivers, 72% of children aged 10 and older with ADHD use social media. Of those, 35% reported adverse mental health effects, including anxiety, sadness, sleep problems, and depression. These negative outcomes are about 70% higher than those seen in adolescents who don’t use social media. In addition, 15% of adolescents with ADHD who use social media reportedly experience eating problems, and 14% have engaged in self-harm. Those numbers are much higher for girls.

“Neurodivergent people, especially those with the focus and self-regulation challenges associated with ADHD, could have a harder time regulating their emotions and unplugging from screens,” said Linda Charmaraman, Ph.D., during the ADDitude Mental Health Out Loud episode “The Mental Health Fallout from Social Media Use.”

Charmaraman recommends that caregivers talk openly with their children about their online experiences to help them become more mindful of their social media use and its effects.

“Avoid judgmental, disproportionate responses when your child comes to you with a social media-related issue,” she said. “Often, tweens and teens will keep things to themselves, afraid that their parents will tell them to deactivate their social media profiles or take away their devices altogether at the first hint of a problem. Should an issue come up, approach with curiosity and collaborate with your teen on a solution.”

Sources

¹Nivins, S., Mooney, M.A., Nigg, J., Klingberg, T. (2026). Digital media, genetics, and risk for ADHD symptoms in children: a longitudinal study. Pediatrics Open Science. https://doi.org/10.1542/pedsos.2025-000922

² Van Der Schuur, W.A., Baumgartner, S.E., Sumter, S.R., Valkenburg, P.M. (2015). The consequences of media multitasking for youth: a review Comput Human Behav. https://doi.org/10.1016/j.chb.2015.06.035

³Zhao, M., Li, J., Xu, R.H. et al. (2025). The impact of exercise interventions on sustained attention for children and adolescents with ADHD: A systematic review and meta-analysis. J Autism Dev Disord. https://doi.org/10.1007/s10803-025-07187-y

⁴Shou, Q., Yamashita, M. & Mizuno, Y. (2025). Association of screen time with attention-deficit/hyperactivity disorder symptoms and their development: the mediating role of brain structure. Transl Psychiatry. https://doi.org/10.1038/s41398-025-03672-1

Some psychiatric disorders commonly co-exist because they share genes, according to a large study published in Nature that analyzed the genetic data of more than 6 million people worldwide.¹

International researchers examined and traced genetic connections among 14 conditions, including ADHD, anxiety disorders, autism spectrum disorder, bipolar disorder, major depression, schizophrenia, obsessive-compulsive disorder, Tourette syndrome, post-traumatic stress disorder (PTSD), and substance use disorders, such as opioid-use disorder, cannabis-use disorder, and nicotine dependence.

They identified 428 genetic variants linked to more than one disorder, along with 101 regions, or “hot spots,” on chromosomes with high concentrations of shared genetic variants.

Using statistical modeling, the researchers determined that the 14 studied conditions clustered into five groups of conditions that shared high genetic overlap:

1. compulsive disorders: obsessive-compulsive disorder, anorexia nervosa, and, to a lesser extent, Tourette disorder and anxiety disorders
2. internalizing disorders: major depressive disorder, anxiety disorders, and PTSD
3. neurodevelopmental disorders: ADHD, autism spectrum disorder, and, to a lesser extent, Tourette disorder
4. schizophrenia and bipolar disorder
5. substance use disorders: opioid use disorder, cannabis use disorder, alcohol use disorder, nicotine dependence, and, to a lesser extent, ADHD

The internalizing and substance use disorder groups demonstrated particularly high levels of shared genetic risk: Major depression, anxiety disorders, and PTSD shared about 90% of their genetic risk; schizophrenia and bipolar disorder shared roughly two-thirds of their genetic markers.

ADHD and autism spectrum disorder showed a strong genetic correlation, suggesting the two conditions share many of the same genetic risk factors. A separate study published in October 2025 found that later-diagnosed autism (after age 10) had a more significant genetic correlation to ADHD, as well as mental health conditions like depression and PTSD, compared to autism diagnosed at age 6 or younger. ²

The researchers also found that disorders with shared genetic risk often exhibit similar biological patterns in the specific genes active during development and the types of brain cells they affect. For example, genes active in oligodendrocytes (brain cells responsible for maintaining neuronal health in the central nervous system) were more strongly associated with internalizing disorders. In contrast, genes active in excitatory neurons, which stimulate other neurons, were more closely associated with schizophrenia and bipolar disorder.

About half of all people who meet the criteria for one psychiatric disorder will be diagnosed with a second or third condition in their lifetime.^{3, 4} According to a 2023 ADDitude survey of 1,500 readers, anxiety and depression are the two most common co-occurring conditions diagnosed alongside ADHD in adults, with co-diagnosis rates of 72% and 70%, respectively.

According to the researchers, this study represents the largest and most comprehensive analysis to date of genetic overlap among 14 psychiatric conditions. Findings from the study may help researchers and clinicians better understand the biological connections among psychiatric conditions and lead to more tailored treatments for patients.

Source

¹Grotzinger, A.D., Werme, J., Peyrot, W.J. et al. (2026). Mapping the genetic landscape across 14 psychiatric disorders. Nature. https://doi.org/10.1038/s41586-025-09820-3

²Zhang, X., Grove, J., Gu, Y., Buus, C. K., Nielsen, L. K., Neufeld, S. A., Koko, M., Malawsky, D. S., Wade, E. M., Verhoef, E., Gui, A., Hegemann, L., Geschwind, D. H., Wray, N. R., Havdahl, A., Ronald, A., St Pourcain, B., Robinson, E. B., Bourgeron, T., Warrier, V. (2025). Polygenic and developmental profiles of autism differ by age at diagnosis. Nature. https://doi.org/10.1038/s41586-025-09542-6

³ Kessler, R.C. et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry. https://doi.org/10.1001/archpsyc.62.6.593

⁴Kessler, R.C., Chiu, W.T., Demler, O. & Walters, E.E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry. https://doi.org/10.1001/archpsyc.62.6.617

ADHD traits in childhood predict physical health problems in midlife, but early exercise interventions may offset this risk, suggest two new studies.

A cohort study of 10,930 participants published in JAMA found that adults with severe childhood ADHD traits had more physical health problems and greater physical health-related disability by age 46 compared to those with less severe ADHD symptoms by age 10.¹

The researchers reported that 42.1% of participants with higher ADHD traits in childhood developed multimorbidity (two or more co-occurring physical health conditions) by age 46. In comparison, just 37.5% of participants with fewer ADHD traits experienced the same health outcomes. Notably, the link between ADHD traits and physical health-related disability appeared much larger in women than it did in men.

Cumulative exposure to health risk factors, such as smoking, alcohol use, psychological distress, low educational attainment, and high body mass index, explains part of the association between ADHD, multimorbidity, and physical disability. However, the researchers emphasized that the direct association between ADHD and physical health outcomes remained significant.

“Clinicians should be aware of the increased rates of physical health problems and associated disability in people with ADHD and should proactively address potential contributing health risk factors,” they wrote. “Integrated interventions addressing mental health, physical health, and key health risk factors may help to reduce chronic conditions in this population.”

The JAMA study analyzed data from the population-based 1970 British Cohort Study, which included people born in England, Scotland, and Wales during the same week in 1970, with follow-up data collected over 46 years.

Increased Mortality Risk for People with ADHD

Untreated physical health problems and co-occurring conditions could reduce the life expectancy of people with ADHD at a higher rate than seen in the general population. A January 2025 study published in The British Journal of Psychiatry comparing the mortality rates of people diagnosed with ADHD to people without ADHD found that the life expectancy for women with ADHD is 8.6 years shorter than that of women without ADHD, while the life expectancy of men with ADHD is 6.8 years shorter. ²

“Adults with diagnosed ADHD are living shorter lives than they should,” the study’s authors wrote. “We believe that is likely caused by modifiable risk factors and unmet support and treatment needs in terms of both ADHD and co-occurring mental and physical health conditions.”

Exercise Interventions Improve Long-Term Mental Health

A 2023 treatment survey of 11,000 ADDitude readers reported positive benefits of exercise. About half of the respondents who exercise regularly rate this ADHD treatment as “extremely” or “very” effective. A staggering 94% of caregivers and 95% of adults recommend exercise to treat ADHD symptoms. However, only 13% said a doctor had recommended exercise to reduce symptoms, and just 37% said physical activity was part of their treatment plan.

“When I get into a good stride with routine exercise, it almost always goes hand-in-hand with better eating habits, better focus, energy levels, mental clarity, and stronger relationships and productivity,” said one adult with ADHD. “Exercise is undoubtedly a crucial piece of the (treatment) puzzle.”

“Depression can really take hold of my 10-year-old son,” one parent said. “We see great improvements after physical activity. He enjoys the elliptical, rower, spin bikes, automatic stepper, and treadmill.”

A new meta-analysis including 18 studies further explores the potential of exercise as an effective adjunctive approach for improving mental health in individuals with ADHD when it is integrated into a multimodal treatment plan that includes pharmacotherapy, behavioral therapy, or psychoeducation.
Exercise interventions produced small-to-moderate improvements in depressive symptoms, anxiety, and emotion regulation in individuals with ADHD, according to the study published in Frontiers in Psychology.

Mind-body integrated exercises, such as yoga and tai chi, significantly improved both depression and anxiety symptoms compared to physical exercises (e.g., structured fitness or sports without a mindfulness component), which did not show significant improvements across outcomes.

The researchers suggest that this advantage may stem from the “mind-body integration” of activities like yoga. By combining physical movement with breath awareness, focused attention, and present-moment acceptance, mind-body exercises directly target emotional dysregulation and attentional control, which are core components of ADHD.

Results from the meta-analysis found that adolescents with anxiety who practiced mind-body exercises experienced the greatest improvements. While children showed moderate improvement, the results were not statistically significant. These discrepancies could be due to developmental differences: Adolescents may be better able to engage with and benefit from the psychological components of exercise, while younger children may require more play-based or gamified approaches.

In addition, the most statistically significant reduction in depressive symptoms occurred from moderate-intensity exercise, whereas low-intensity and high-intensity exercises did not demonstrate measurable benefits for depression, anxiety, or emotion regulation.

While intervention length varied widely (from single sessions to 20-week programs), with no clear differences emerging across durations, single sessions demonstrated immediate short-term anxiety-reducing effects. However, to sustain benefits, longer-term participation may be necessary, the researchers suggest.

They emphasized that the study’s overall findings should be viewed as hypothesis-generating rather than definitive. “Because study designs and exercise protocols varied considerably, the results should be interpreted cautiously, and more rigorous research is needed before definitive clinical guidelines can be established,” they wrote.

Sources

¹Stott, J., O’Nions, E., Corrigan, L., Cotton, J., Donnellan, W.J., et al. (2026). Attention-Deficit/Hyperactivity Disorder Traits in Childhood and Physical Health in Midlife. JAMA Netw Open. https://doi.org/10.1001/jamanetworkopen.2025.54802

²O’Nions, E., El Baou, C., John, A., Lewer, D., Mandy, W., McKechnie, D.G.J. et al. (2025). Life expectancy and years of life lost for adults with diagnosed ADHD in the UK: matched cohort study. The British Journal of Psychiatry. https://doi.org/10.1192/bjp.2024.199

³Shenning, Z., Yaoqi, H., Wenying, S., and Xiangqin, S. (2026). The effect of exercise interventions on mental health in children and adolescents with attention-deficit/hyperactivity disorder: a meta-analysis. Front. Psychol. https://doi.org/10.3389/fpsyg.2026.1748777

Chronic stress, high rates of co-occurring conditions, and unhelpful school and clinical interventions are common among individuals living with pathological demand avoidance (PDA), according to the first-ever comprehensive survey exploring the lived experience of PDA.¹ The survey found that failure to meet the needs of children and adults with PDA results in difficulties at school, at work, and in relationships, often leading to family breakdown and estrangement, school refusal, underemployment, and mental health struggles.

The 2,000 survey respondents comprised three groups: caregivers of children and teens with PDA; caregivers of adults with PDA; and adults with PDA themselves. Though the ripple effects of PDA on education, work, and family life varied across these groups, the core characteristic of PDA remained strikingly stable, with the “resistance to being told what to do” emerging as the most commonly reported trait across all groups.

For children, school was one of the realms most dramatically impacted by PDA; 88% of children with PDA experienced school avoidance or refusal at some point, and 40% struggled to attend school most days. While 70% of children with PDA had IEPs/ 504 Plans, only 17% of caregivers found these to be “very helpful.”

For adults with PDA, family life and mental health were major areas of struggle, with almost a quarter of adults with PDA, and/or their caregivers, reporting family estrangement. Nearly 60% of adults with PDA reported experiencing thoughts of suicide.

Understanding PDA

In a recent ADDitude webinar, “Don’t Tell Me What to Do: Pathological Demand Avoidance in Neurodivergent Kids,” Diane Gould, LCSW, founder and executive director of PDA North America, discussed the degree to which PDA is misunderstood. She explained that core features for children include:

• Resisting and avoiding ordinary demands of life
• Difficulty complying with the requests or rules of others
• Difficulty making themselves do the things they want to do
• A fundamental need for control

Because of this difficulty with compliance, Gould said: “PDA individuals are so often undiagnosed or misdiagnosed. Adults and teens are often misdiagnosed as having bipolar or borderline personality disorder. Children are misdiagnosed with oppositional defiant disorder or conduct disorder.”

As the report’s authors write: “PDA is not about ‘refusing to cooperate,’ but about the need for autonomy, safety and survival.”

A Dearth of Effective Interventions

This lack of awareness about PDA has resulted in a notable dearth of effective interventions.

“Across surveys, no single intervention was consistently rated as helpful, highlighting the need for better tailored approaches for PDA individuals,” write the report’s authors. Moreover, the report found that encounters with affirming, informed providers were rare, and that caregivers and adults with PDA infrequently received helpful, validating guidance. According to survey results:

• The most helpful interventions were medication management and occupational therapy
• The least helpful interventions were Applied Behavior Analysis (ABA) and emergency room visit
• 94% of caregivers reported that punishment can worsen behaviors

“Probably the hardest thing for parents to talk about was how hard they tried to follow all the advice that they were given from therapists, psychiatrists, pediatricians, teachers, and even parenting books,” Gould said. “But those strategies didn’t work, and often made things worse.”

The report’s authors explain that PDA-informed care involves “respecting autonomy at any age, reducing pressure and unnecessary demands, planning for sensory needs, and using relationship-based, responsive approaches.”

Common Co-Occurring Conditions

PDA commonly co-occurs with neuropsychiatric conditions, most frequently autism, ADHD, or both.

The Impact of PDA on Education

Chronic, severe difficulty attending school is the norm for children and teens with PDA. The survey revealed the following:

As Reported by Caregivers of Kids

• 88% of children with PDA experienced school avoidance or refusal at some point
• 4 in 10 children struggled to attend school most days
• 1 in 5 reported suspensions
• 1 in 10 was not currently accessing any education
• 70% had an IEP or 504 Plan
• Just 1 in 6 found their IEP/ 504 Plan to be “very or extremely helpful”

Despite these consistent difficulties, adults with PDA overwhelmingly report having received a high school diploma, with the majority also earning a four-year college degree.

As Reported by Adults

• 96% completed an education equivalent to a high school diploma
• 83% had a four-year college degree<

The Impact of PDA on Work

While adults with PDA struggle to attend work regularly, and experience episodes of under- or unemployment, the vast majority are employed. A high percentage of PDA adults are self-employed, which helps alleviate work-based challenges:

As Reported by Caregivers of Adults

• Two-thirds reported employment at some point
• More than half reported periods of unemployment or underemployment

As Reported by Adults

• 97% of adults reported employment at some point
• Among these, 55% had a history of self-employment
• 80% reported challenges with workplace attendance
• Two-thirds reported periods of unemployment or underemployment

The Impact of PDA on Family

Family life is strained for those with PDA, whether adults or children. This finding is vividly illustrated by Lisa McKay’s experience, as described in the ADDitude article, A Parent’s Guide to Navigating Pathological Demand Avoidance.

“During his early years, Max would frequently refuse to do what was asked of him and insist everything be done his way,” McKay writes. “He would inexplicably melt down or erupt in anger over seemingly minor issues.”

The survey measured the extent to which these areas of life are affected by PDA:

As families navigate these turbulent, murky waters, validation and accurate information about what works for PDA — and what doesn’t — is key.

“Commonly suggested behavioral strategies for neurodivergent children — from setting clear rules to using checklists, visual timers, and liberally doling out praise — didn’t help.” McKay says. “In fact, all they seemed to do was set up further power struggles where everyone lost.”

McKay’s experience is echoed over and over again by the findings of the survey. “This report makes clear that the challenges families face are not due to a lack of effort or care, but to systems that are not designed with PDA in mind,” said Ruth Hevelone, PDA North America’s director of Strategic Growth & Marketing. “When supports are aligned with how PDA is actually experienced, outcomes can change dramatically.”

Research Team Lead for the PDA report, Michele Kleinmann, added: “We hope this data helps shift conversations away from ‘fixing behavior’ and toward building environments where PDA individuals can feel safe, understood, and supported.”

Sources

¹McKenzie, M., Kleinmann, M., Hevelone, R., & Gould, D. (2026). The PDA Experience Report. PDA North America. https://learn.pdanorthamerica.org/products/digital_downloads/key-findingsPDA-Experience-Report

Prenatal exposure to acetaminophen (brand name: Tylenol), also known as paracetamol, does not increase the likelihood of autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), or intellectual disability in children when used as directed, according to a new systematic review and meta-analysis published in The Lancet Obstetrics, Gynaecology & Women’s Health.¹

These findings contradict recent unfounded assertions by the White House and Food and Drug Administration (FDA) that acetaminophen use by mothers in pregnancy causes autism and other neurological conditions in their children.

The Lancet study analyzed databases from Embase, ClinicalTrials.gov, and the Cochrane Library from inception to Sept 30, 2025, and identified 43 studies for inclusion in the systematic review and 17 for inclusion in the meta-analysis. A primary analysis of sibling comparison studies revealed that acetaminophen exposure during pregnancy was not associated with an elevated incidence of ASD, ADHD, or intellectual disability. These results remained stable across subgroups, low-bias studies, and studies restricted to more than 5 years of follow-up.

At a press conference on September 22, 2025, President Donald Trump cited a review linking acetaminophen use in pregnancy to neurodevelopmental outcomes.² This association, however, was not shown to be causal. In addition, the researchers who worked on the Lancet study found that the review was limited by variability in the data and significant differences in how studies defined exposure and outcomes.

To date, no studies show that acetaminophen use in pregnancy causes ASD.

“There is no scientific evidence supporting a causal link between prenatal acetaminophen use and autism,” says Gloria Han, Ph.D., assistant professor at Vanderbilt University Medical Center. “Observational studies have reported correlations, but larger sibling-comparison studies suggest these associations are likely confounded by genetic or familial factors rather than a direct effect of acetaminophen.”

Findings from The Lancet concur. “Explaining the potential causal relationship between paracetamol [acetaminophen] and conditions such as autism, ADHD, or intellectual disability is challenging,” the study’s authors wrote. “Earlier meta-analyses suggested increased likelihood of autism spectrum disorder and ADHD, but these were characterized by high heterogeneity and by reliance on conventional observational designs susceptible to residual confounding.”

More plausible explanations for previously observed associations between acetaminophen use and autism, ADHD, and intellectual disorders, the researchers explained, include familial and genetic factors, and other pre-existing conditions.

“Paracetamol [acetaminophen] is typically used only intermittently, and its prolonged use raises questions about whether the underlying health condition prompting extended use might be more important in shaping neurodevelopmental outcomes rather than the drug itself,” they wrote.

In contrast, large, methodologically rigorous studies provide strong evidence against a causal link. For example, a 2024 Swedish cohort study including 2.47 million births found no association between acetaminophen and autism, ADHD, or intellectual disability after comparing full siblings who were exposed to acetaminophen during pregnancy to those who were not exposed. ³

Acetaminophen is widely regarded as the preferred first-line therapeutic option for pain relief and fever reduction, and both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) state that the over-the-counter medication is safe for use during pregnancy.

The researchers cautioned that avoiding acetaminophen use in pregnancy might increase the risk of maternal fever or severe pain, both of which can contribute to adverse outcomes.

“Untreated maternal fever has been linked to miscarriage, congenital defects, and preterm birth,” they wrote. “For this reason, discouraging the appropriate use of paracetamol [acetaminophen] has the potential to cause greater harm than the drug itself.” ⁴, ⁵

Sources

¹D’Antonio F, Flacco ME, Della Valle L, et al. (2026) Prenatal paracetamol exposure and child neurodevelopment: a systematic review and meta-analysis. Lancet Obstet Gynaecol Women’s Health. https://doi.org/10.1016/S3050-5038(25)00211-0

²Prada, D., Ritz, B., Bauer, A.Z. et al. (2025). Evaluation of the evidence on acetaminophen use and neurodevelopmental disorders using the Navigation Guide methodology. Environ Health. https://doi.org/10.1186/s12940-025-01208-0

³ Ahlqvist, V.H., Sjöqvist, H., Dalman, C., Karlsson, H., Stephansson, O., Johansson, S., Magnusson, C., Gardner, R.M., & Lee, B.K. (2024). Acetaminophen use during pregnancy and children’s risk of autism, ADHD, and intellectual disability. JAMA. https://doi.org/10.1001/jama.2024.3172

⁴Dreier, J.W., Andersen, A.M., Berg-Beckhoff, G. (2014). Systematic review and meta-analyses: fever in pregnancy and health impacts in the offspring. Pediatrics. https://doi.org/0.1542/peds.2013-3205

⁵Antoun, S., Ellul, P., Peyre, H. et al. (2021). Fever during pregnancy as a risk factor for neurodevelopmental disorders: results from a systematic review and meta-analysis. Molecular Autism. https://doi.org/10.1186/s13229-021-00464-4

New research has identified distinct genetic profiles linked to different behavioral and developmental patterns in autistic individuals, reinforcing the understanding that autism is highly complex and not driven by a single cause or influence.

In one study, researchers at the University of Cambridge discovered that individuals who were diagnosed with autism in early childhood, usually before age six, appeared to have a different genetic makeup and lower risk of developing co-occurring mental health conditions than did those who were diagnosed in late childhood and beyond.

Children with an early autism diagnosis were more likely to demonstrate challenges with social interactions from infancy to early childhood, the study showed. Children with a later diagnosis were more likely to experience social and behavioral struggles in adolescence, plus higher rates of comorbid ADHD, depression, PTSD, and self-harm. The study was published in October 2025 in the journal Nature.¹

“Understanding how the features of autism emerge not just in early childhood but later in childhood and adolescence could help us recognize, diagnose, and support autistic people of all ages,” senior study author Varun Warrier, Ph.D., assistant professor of neurodevelopmental research at Cambridge University’s Department of Psychiatry, said.

In a separate study from Princeton University and the Simons Foundation, researchers identified four clinically distinct subtypes of autism, setting the stage and establishing the potential for specialized care. They used data from more than 5,000 children to analyze combinations of traits, looking at social interactions, repetitive behaviors, and developmental milestones, rather than studying genetic links to single traits. The study was published in July 2025 in Nature Genetics.²

The four autism subtypes defined in the Princeton/Simons Foundation study included:

1. Social and Behavioral Challenges

Children in this group face more difficulties with social communication, attention, and repetitive and disruptive behaviors than do participants in other subtypes. This group also has the highest genetic predisposition for ADHD, anxiety, obsessive-compulsive disorder, and depression. Its members do not experience significant developmental delays.

2. Moderate Challenges

In this subtype, children exhibit traits that manifest as social challenges or stimming, but they usually reach developmental milestones at ages similar to their neurotypical peers. They generally do not experience co-occurring psychiatric conditions.

3. Mixed ASD and Developmental Delays

Gene variations identified in this subtype lead to early developmental challenges, as with walking and talking, in many, but not all, children. Members in this group tend to receive an autism diagnosis at an early age, and usually do not show signs of anxiety, depression, or disruptive behaviors.

4. Broadly Affected

Children in this subtype present with the most severe and wide-ranging difficulties, including ADHD, anxiety, depression, and mood dysregulation. The researchers observed impulsivity, hyperactivity, and aggressive behaviors only in this subtype.

Diagnosing Autism and Comorbid Conditions

In the University of Cambridge study, researchers analyzed genetic data from more than 45,000 autistic individuals in the U.S. and Europe, and behavioral data across childhood and adolescence from the U.K. and Australia. The team then linked the genetic data to the age at diagnosis, and found that the genetic profiles differed between those diagnosed with autism earlier vs. later in life, with only a modest overlap.

They also found that the average genetic profile of autism diagnosed later in life was closer to that of ADHD, and co-occurring disorders like depression and PTSD, than it was to autism diagnosed in early childhood. A lack of support in early childhood, however, may potentially increase the risk for mental health issues in the later-diagnosed group, the researchers pointed out.

“The presence of clear behavioral signs helps to facilitate diagnoses in younger children, but the umbrella of core features — social-communication differences and restricted interests and repetitive behaviors — can be more subtle and look different by age, sex, and sociocultural context,” says Gloria T. Han, Ph.D., assistant professor in the Department of Anesthesiology, Division of Pain Medicine, at Vanderbilt University Medical Center.

She says the Cambridge University study helps explain why some individuals, including females, children without language delays, and those who are highly verbal, are often identified later — sometimes after ADHD, anxiety, or other mood concerns are diagnosed. She says autism can be missed or overshadowed when differences in attention, executive functioning, or social difficulties are attributed only to ADHD or social anxiety.

Cambridge University’s Warrier summed up his research: “For the first time, we have found that earlier- and later-diagnosed autism have different underlying biological and developmental profiles. An important next step will be to understand the complex interaction between genetics and social factors that lead to poorer mental health outcomes among later-diagnosed autistic individuals.”

Carole Fleck is Editor-in-Chief at ADDitude magazine.

Sources

¹Zhang, X., Grove, J., Gu, Y., Buus, C. K., Nielsen, L. K., Neufeld, S. A., Koko, M., Malawsky, D. S., Wade, E. M., Verhoef, E., Gui, A., Hegemann, L., Geschwind, D. H., Wray, N. R., Havdahl, A., Ronald, A., St Pourcain, B., Robinson, E. B., Bourgeron, T., Warrier, V. (2025). Polygenic and developmental profiles of autism differ by age at diagnosis. Nature. https://doi.org/10.1038/s41586-025-09542-6

²Litman, A., Sauerwald, N., Green Snyder, L. et al. Decomposition of phenotypic heterogeneity in autism reveals underlying genetic programs. Nat Genet 57, 1611–1619 (2025). https://doi.org/10.1038/s41588-025-02224-z

Women with ADHD who report significant negative mood symptoms just before and during menstruation tend to experience similar-magnitude increases in ADHD symptoms at this time, found a new study in Journal of Attention Disorders.¹ Building upon a modest foundation of previous research that found ADHD symptoms vary across the menstrual cycle, the researchers studied women of reproductive age with ADHD treated with amphetamine salts, the most commonly used medication among members of this demographic, 60% of whom use Adderall of Mydalis.²

The 30 study participants were required to complete daily surveys measuring their ADHD symptoms as well as the severity of 17 mood symptoms. Participants reported their total daily dose of amphetamine salts, as well as use of other medications, alcohol, tobacco, or cannabis.

The study found:

• ADHD symptoms were most severe in the menstruation phase of the monthly cycle
• Negative mood symptoms were most severe in the menstruation and luteal phases
• The magnitude of increase in ADHD symptoms and negative mood was similar, leading researchers to conclude that mood and ADHD symptoms co-vary between menstrual cycle phases

These findings validate the anecdotal experience of many women with ADHD.  “Fluctuating estrogen and progesterone across the menstrual cycle invariably impact ADHD symptoms, emotions, and functioning. We know this to be true, but there is almost no research validating this relationship,” explained Lotta Skoglund Ph.D., in her recent ADDitude article, “The Menstrual Cycle Impacts ADHD Symptoms in Disparate Ways.”

“The entire week leading up to my period is where my ADHD symptoms get even more intrusive than usual,” says Chloe, an ADDitude reader. “My executive functioning dips even lower, distractibility and difficulty focusing is increased, and my mood/energy level is much lower, causing me to feel badly about all the things I’m not being successful at that week.”

Charlie, a reader in Australia, echoes this experience: “A week before I am due for my period, my brain goes to complete peanut butter. It is an utter mission to focus and stay on task. Sensory overload is at its peak. Impatience rules the days, and I get so overwhelmed.”

In addition, many women report lower efficacy of ADHD medication during the luteal and menstrual phase. One ADDitude reader shares “My ADHD meds are significantly less efficacious for about 10 days per month; two days before menstruation I am a barely functional zombie.” Norma, an ADDitude reader in Wisconsin, describes a similar experience, “The week leading up to my cycle, I might as well not even take my ADHD meds. It’s like my body overrides them.”

Based on similar anecdotal reports, the study’s researchers sought to uncover whether women with ADHD were exploring cycle syncing, increasing their dose of stimulants during the late luteal and menstruation phases to address intensified ADHD symptoms. They found, however, that women maintained constant daily medication dosing throughout their menstrual cycles.

“This may reflect prescribing practices for stimulant medications, which often do not encourage ‘flexible’ or ‘symptom-based’ dosing regimens, as well as potential inexperience of providers or patients regarding the effects of menstrual cycle phase on medication metabolism and efficacy,” the researchers reflect. The authors refer to an earlier study that found many women with ADHD were hesitant to ask doctors about the effect of their menstrual cycle on ADHD medication and often reported invalidating responses from their practitioners when they did inquire.³

Skoglund advises women to use a menstrual cycle tracking log to record and report specific data to aid these conversations with doctors: “Tracking your cycle will give you powerful insights into how hormonal fluctuations influence your ADHD symptoms, medication effectiveness, and overall functioning. With this data, you’ll be in a better position to talk to your doctor about enhancements to your treatment plan to improve your health and wellbeing.”

The study had several limitations, including its small sample size; 16 of the 46 initial participants were excluded for failure to complete daily surveys, leaving 30 participants, and the authors note it is possible the individuals who successfully completed the surveys had milder ADHD symptoms. In addition, unlike other studies,⁴ the researchers did not measure ovarian hormone levels, relying on participants’ reporting of menstruation for this information. Individuals who were taking other psychiatric medications were excluded, thus excluding women who receive medication for mood disorders and/or Premenstrual Dysphoric Disorder, both of which are significantly more likely in people with ADHD.

Sources

¹Zaritsky, R., Reed, S. C., & Evans, S. M. (2025). Changes in ADHD Symptoms and Mood Across the Menstrual Cycle in Females Treated With Stimulants: A Pilot Study. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547251400038

²Anderson K. N., Ailes E. C., Danielson M., Lind J. N., Farr S. L., Broussard C. S., Tinker S. C. (2018). Attention-deficit/hyperactivity disorder medication prescription claims among privately insured women aged 15-44 years – United States, 2003-2015. Morbidity and Mortality Weekly Report, 67(2), 66–70. https://doi.org/10.15585/mmwr.mm6702a3

³Bürger I., Erlandsson K., Borneskog C. (2024). Perceived associations between the menstrual cycle and attention deficit hyperactivity disorder (ADHD): A qualitative interview study exploring lived experiences. Sexual & Reproductive Healthcare, 40, Article 100975. https://doi.org/10.1016/j.srhc.2024.100975

⁴Roberts B., Eisenlohr-Moul T., Martel M. M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015

Stimulant medications target brain areas that control reward and wakefulness, not attention, suggests new research in the journal Cell that challenges prior thinking about ADHD treatment.¹

For decades, doctors have prescribed stimulant medications — methylphenidate and amphetamine — under the assumption that the drugs directly improve attention and concentration in individuals with ADHD.^{2, 3, 4} However, the new study led by a team of researchers at Washington University School of Medicine in St. Louis posits that prescription stimulants increase alertness and motivation in children with ADHD.

The researchers compared the resting-state functional MRI (fMRI) data of 5,795 children aged 8 to 11 years who participated in the Adolescent Brain Cognitive Development (ABCD) Study. They found that children who took stimulants the day of the fMRI scan showed increased activity in brain regions related to arousal and reward, but no notable changes in regions connected to attention.

“Essentially, we found that stimulants pre-reward our brains and allow us to keep working at things that wouldn’t normally hold our interest — like our least favorite class in school, for example,” lead author Nico U. Dosenbach, M.D., Ph.D., said in a statement.

According to parent reports in the ABCD study, children with ADHD who took a stimulant medication received better grades in school and performed better on cognitive tests than did children with ADHD who were not taking stimulants.

The study’s findings also offer a new understanding of ADHD hyperactivity. In essence, ADHD hyperactivity may be less about having an abundance of energy and more about seeking stimulation and reward.

“Whatever kids can’t focus on — those tasks that make them fidgety — are tasks that they find unrewarding,” Dosenbach said. “On a stimulant, they can sit still because they’re not getting up to find something better to do.”

Stimulant Medications Benefit Sleep-Deprived Children

Another key finding from the study is that stimulant medications may mimic the benefits of a good night’s sleep.

“We saw that if a participant didn’t sleep enough, but they took a stimulant, the brain signature of insufficient sleep was erased, as were the associated behavioral and cognitive decrements,” Dosenbach said.

The ABCD Study reported that children who got less than the recommended nine hours or more of sleep per night and took a stimulant received better grades in school than children who got insufficient sleep and did not take a stimulant. They also received the same grades as well-rested children who did not take a stimulant.

Children with poor sleep may have shown improved academic performance when taking stimulants, but the researchers caution that stimulants do not cure the effects of chronic sleep deprivation.

“While our results appear to show that the cognitive performance of sleep-deprived children benefited from stimulants, we caution that mounting evidence points to cumulative health consequences of long-term sleep deprivation, including increased risk of depression, cellular stress, and neuronal loss,” the researchers wrote.^{5, 6}

Signs of sleep deprivation, such as difficulty paying attention or poor working memory, overlap with ADHD symptoms and may lead to children being misdiagnosed with ADHD when the actual problem is insufficient sleep.

The researchers stress that findings from the study shouldn’t undermine clinicians’ confidence in the effectiveness of stimulants for ADHD. However, it’s important to rule out factors like sleep deprivation before turning to medication.

“Sleep disturbance is a common comorbidity of ADHD and a common complication of stimulant treatment; therefore, clinicians should screen for sleep disturbance in children with ADHD both before and after prescribing a stimulant,” they wrote.⁷

Nearly three-quarters of children with ADHD experience a sleep disorder.⁸ Sleep problems last into adolescence and can aggravate ADHD symptoms during the day for many children.

“We know that teens with ADHD are more likely than their peers without ADHD to get insufficient sleep on school nights,” said Stephen Becker, Ph.D., in his ADDitude webinar, “Why Am I Always So Tired? The Latest Science on Improving Sleep in Children and Teens with ADHD.”

“We’ve also shown that poor sleep impacts academics, including academic performance, organization, and lower grades based on report cards that we’ve acquired from schools and college institutions,” Becker said. “In some of our work with young teens, even after we account for a teen’s initial levels of depressive symptoms or oppositional behaviors, those teens who had sleep problems went on to experience an increase in depressive symptoms and oppositional behaviors.”

The researchers recommend that future long-term studies evaluate whether stimulant users are less likely to get adequate sleep and measure the cumulative effects of sleep loss over the lifespan. In addition, further research is needed into the long-term effects of stimulant use on brain function and whether stimulants increase task-fMRI activation in response to smaller anticipated rewards.

“The ABCD cohort includes a mix of children taking different stimulant medications and diagnosed with different ADHD subtypes; however, it is not powered to investigate the effects of specific medications or ADHD subtypes,” they wrote. “Variability in scan duration and the lack of precise data on timing and formulation (e.g., immediate vs. delayed release) of stimulant administration limited our ability to account for pharmacokinetic effects in the ABCD cohort, potentially leading to an underestimation of stimulant effects on fMRI connectivity.”

Sources

¹Kay, B.P., Wheelock, M.D., Siegel, J.S., Barch, D.M., et al. (2025). Stimulant medications affect arousal and reward, not attention networks. Cell. https://doi.org/10.1016/j.cell.2025.11.039

²Braga, R.M., Wilson, L.R., Sharp, D.J. (et al). (2013). Separable networks for top-down attention to auditory non-spatial and visuospatial modalities. Neuroimage. https://doi.org/10.1016/j.neuroimage.2013.02.023

³Berridge, C.W., Devilbiss, D.M. (2011). Psychostimulants as cognitive enhancers: The prefrontal cortex, catecholamines, and attention-deficit/hyperactivity disorder. Biol. Psychiatry. https://doi.org/10.1016/j.biopsych.2010.06.023

⁴Farr, O.M., Zhang, S., Hu, S., et al. (2014). The effects of methylphenidate on resting-state striatal, thalamic and global functional connectivity in healthy adults. Int. J. Neuropsychopharmacol. https://doi.org/10.1017/S1461145714000674

⁵Yang, F.N., Xie, W., Wang, Z., et al. (2022). Effects of sleep duration on neurocognitive development in early adolescents in the USA: a propensity score matched, longitudinal, observational study. Lancet Child Adolesc. Health. https://doi.org/10.1016/S2352-4642(22)00188-2

⁶Jan, J.E., Reiter, R.J., Bax, M.C.O., et al. (2010). Long-term sleep disturbances in children: A cause of neuronal loss. Eur. J. Paediatr. Neurol. https://doi.org/10.1016/j.ejpn.2010.05.001

⁷Stein, M.A, Weiss, M., Hlavaty, L. (2012). ADHD treatments, sleep, and sleep problems: Complex associations. Neurotherapeutics. https://doi.org/10.1007/s13311-012-0130-0

⁸Sung, V., Hiscock, H., Sciberras, E., Efron, D. (2008). Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch. Pediatr. Adolesc. Med. https://doi.org/10.1001/archpedi.162.4.336

Digital mental health treatments like LumosityRx, a new prescription digital therapeutic (PDT) for ADHD, and interventions like digital cognitive behavioral therapy (DCBT) for anxiety have been shown to be safe and effective adjunct therapies, according to new research.

“Harnessing digital therapeutics to expand working memory and improve focus and concentration is at the forefront of clinical development and research,” says Greg Mattingly, M.D., an associate clinical professor at Washington University School of Medicine who has been a principal investigator in trials for Akilli Interactive, Lumos Labs, and other digital therapeutic manufacturers.

FDA Clears LumosityRX

Lumos Labs obtained 510(k) clearance from the U.S. Food and Drug Administration (FDA) for LumosityRx on December 10, 2025. The brain training app guides patients through 13 clinically validated games targeting attention, working memory, and cognitive control; it is indicated for use in adults ages 22 to 55 with primarily inattentive or combined-type ADHD. According to the manufacturer, LumosityRx targets attention but does not aim to treat all behavioral symptoms of ADHD, such as hyperactivity.¹

LumosityRx is not intended to be a standalone treatment but part of a broader treatment plan that may include clinician-directed therapy, medication, and/or educational programs. Research confirms that “stimulant medications are most effective, and combined medication and psychosocial treatment is the most beneficial treatment option for most adult patients with ADHD.” ² In addition, the PDT may not be appropriate for users with photo-sensitive epilepsy, color blindness, or physical limitations that restrict the use of a mobile device.

FDA clearance was based on results from the GAMES Study, a randomized, double-blind, sham-controlled clinical trial that included 560 unmedicated participants aged 22 to 55 years with an ADHD diagnosis across 13 U.S. clinical sites. Participants were randomly assigned to use LumosityRx or sham game-play therapy for approximately 15 minutes daily for 9 weeks.

Participants using LumosityRx improved their sustained and selective attention by 1.1 points compared to 0.3 points in the control group on the Test of Variables of Attention (TOVA) Attention Comparison Score (ACS); 44.2% demonstrated “clinically meaningful” gains in attention, defined as improvements of greater than 1.4 points. Users also reported a “clinically meaningful” increase of 8.7 points on the Adult ADHD Quality of Life (AAQoL) questionnaire.

Blinded clinician assessments rated approximately 1 in 3 participants in the PDT group as “much improved” or “better” compared to the controls on the Clinical Global Impression–Improvement (CGI-I) scale.

No serious adverse events were reported, and fewer than 1% of participants experienced treatment-related adverse events.

“Adult ADHD is often misunderstood, and many patients still struggle to find treatment options that fit into their lives,” said Ann Childress, M.D., principal investigator of the trial and president of the Center for Psychiatry and Behavioral Medicine, Inc., in Las Vegas. “Digital therapeutics like LumosityRx open up new possibilities: clinically validated, highly engaging, and accessible from a mobile device.”

DCBT for Anxiety

Digital therapeutics gained further validation in a new study published in JAMA Network Open that found smartphone-delivered digital cognitive behavioral therapy (DCBT) provided significant and sustained benefits to adults with general anxiety disorder (GAD).³

Symptom remission occurred in 71% of participants receiving DCBT at 10 weeks and increased to 77.7% at 24 weeks, according to the study. In comparison, remission occurred in 34.6% of the control group at week 10 and increased to 52% at week 24. The DCBT group reported significant reductions in depressive symptoms and sleep disturbance at weeks 10 and 24 compared to the control group.

Participants in the DCBT intervention group received access to DaylightRx, a mobile digital therapeutic for generalized anxiety that received FDA clearance in September 2024. DaylightRx uses CBT techniques, such as cognitive restructuring, applied relaxation, stimulus control, avoidance reduction, mindfulness, problem-solving, and imaginal exposure, and delivers them through interactive lessons and guided practices.

Members of the psychoeducation (control) group received online access to evidence-based psychoeducation for anxiety self-management, which included education on the symptoms, prevalence, causes, and consequences of GAD, as well as advice on lifestyle changes (e.g., increased sleep and exercise) that individuals could make to reduce anxiety.

The randomized clinical trial took place between March 8, 2023, and February 28, 2024, and it involved 351 adults aged 22 years or older diagnosed with GAD. Participants completed online self-report questionnaires at 6, 10, and 24 weeks, and they participated in video visits with a blinded independent evaluator at 10 and 24 weeks.

Why Consider Digital Therapeutics?

Cognitive behavioral therapy (CBT) and pharmacotherapy are first-line interventions for GAD.⁴

However, the study’s authors explained, systematic barriers, such as an inadequate number of trained therapists, the burden of in-person therapy, and stigma, may make CBT inaccessible for patients.^{5, 6}

“Digital CBT programs may have the potential to overcome barriers to effective treatment and expand therapist reach and impact,” they wrote. “The consistent evidence for the efficacy of this smartphone-accessible DCBT suggests it is a scalable, first-line treatment option for adults with GAD.”⁷

For the first time, the 2025 Medicare Physician Fee Schedule (MPFS) issued a final rule that includes reimbursement opportunities for FDA-cleared digital mental health treatments, potentially easing access to digital therapeutics in clinical settings.

EndeavorRx, developed by Akili Interactive (now part of Virtual Therapeutics), was the first FDA-approved game-based digital therapeutic device for the treatment of primarily inattentive or combined-type ADHD in children ages 8 to 12. Akili used its proprietary technology to develop EndeavorOTC, the first FDA-authorized over-the-counter digital therapeutic treatment designed to treat symptoms of inattentive ADHD in adults 18 and older. Neither EndeavorRx nor EndevaorOTC are intended to be used as a stand-alone therapeutic or a substitute for ADHD medication.

All ADHD treatment decisions should be made in consultation with a licensed medical provider.

Sources

¹Lumosity announces FDA clearance of LumosityRx, a prescription digital therapeutic for adults with ADHD. News release. Lumos Labs. December 10, 2025. Accessed December 15, 2025. https://www.businesswire.com/news/home/20251210648945/en/Lumosity-Announces-FDA-Clearance-of-LumosityRx-a-Prescription-Digital-Therapeutic-for-Adults-with-ADHD

²Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., Hechtman, L. (2008). Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatr Dis Treat. https://doi.org/10.2147/ndt.s6985

³Parsons, E.M., Ball, T., Carl, J. (2025). Digital cognitive behavioral treatment for generalized anxiety disorder. A randomized Clinical trial. JAMA Network Open.
https://doi.org/10.1001/jamanetworkopen.2025.48884

⁴National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. NICE clinical guideline No. 113. Published January 26, 2011. Updated June 15, 2020. Accessed January 23, 2025. https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-pdf-35109387756997

⁵Wolitzky-Taylor, K., Fenwick, K., Lengnick-Hall, R., et al. (2018). A preliminary exploration of the barriers to delivering (and receiving) exposure-based cognitive behavioral therapy for anxiety disorders in adult community mental health settings. Community Ment Health J. https://doi.org/10.1007/s10597-018-0252-x

⁶Gunter, R.W., Whittal, M.L. (2010). Dissemination of cognitive-behavioral treatments for anxiety disorders: overcoming barriers and improving patient access. Clin Psychol Rev. https://doi.org/10.1016/j.cpr.2009.11.001

⁷Carl, J.R., Miller, C.B., Henry, A.L., et al. (2020). Efficacy of digital cognitive behavioral therapy for moderate-to-severe symptoms of generalized anxiety disorder: a randomized controlled trial. Depress Anxiety. https:/doi.org/10.1002/da.23079

Circadian health interventions may improve ADHD symptoms for a significant group of individuals with attention deficit disorder, according to a new perspective review published in Frontiers in Psychiatry.¹ For some, circadian misalignment may play a role in ADHD pathophysiology, and targeted circadian interventions may supplement ADHD treatment for these individuals, concluded the study’s authors following a review of existing research.

Another narrative review in PLOS Mental Health explored the neurobiological mechanisms of psychiatric conditions including depression, anxiety and ADHD, and the bidirectional relationship they have with sleep. That research also found that sleep is an essential element of symptom management for these disorders.²

“Sleep disturbances, including insomnia, hypersomnia, and circadian misalignment, are highly prevalent and clinically significant across various psychiatric disorders. Sleep problems are transdiagnostic features, impacting diagnostic presentation, prognostic trajectories, and underlying pathology,” the authors of the PLOS review write. “Sleep is a tractable factor in mental health, offering a potent intervention leverage point.”

Circadian Rhythm Disorder and ADHD

The authors of the Frontiers in Psychiatry review, Brandon Luu, M.D., and Nicholas Fabiano, M.D., point to several established facts linking circadian rhythm dysfunction to ADHD, including:

• 73-78% of people with ADHD have delayed sleep-wake cycles.³
• Cortisol rhythms, especially in the morning, are decreased and delayed in ADHD patients.⁴Another recent study that investigated the association between morning cortisol variability and ADHD through genomic approaches found ADHD and cortisol levels reflect “a complex interplay involving arousal regulation.”⁵
• Dim-light melatonin onset (DLMO) occurs 90 minutes later in adults with ADHD, and 45 minutes later in children with ADHD, compared to controls.⁶ A study conducted by J.J. Sandra Kooij, Ph.D, found that, in neurotypical populations, melatonin is secreted at 9:30 p.m. (leading to an estimated 11:30 p.m. sleep onset), whereas melatonin is secreted at 11 p.m. for people with ADHD.⁷

Kooij explored her research in detail during her recent ADDitude webinar titled, “How Sleep Disorders Impact Every Aspect of Life with ADHD.

“Each of us has an internal clock that determines our sleep rhythm. This clock, located in the mid-brain, is heritable and it starts ticking in childhood.” she said. “Because it directs the rhythms of all bodily organs, it has far-reaching influence.”

Luu, who has ADHD himself, writes about his personal connection to this research in his newsletter. “When I started implementing circadian interventions for sleep optimization, my ADHD symptoms improved noticeably. When I began digging into the literature, I was struck by how strong the link was, and by how little attention circadian-based interventions have received in ADHD treatment discussions.”

Chronotherapy Interventions

The Frontiers in Psychiatry review found that circadian-targeted interventions, including melatonin supplementation and bright light therapy, both of which advanced DLMO, improved sleep as well as ADHD symptoms.

Melatonin Supplementation

• A small study found that taking 0.5 mg of melatonin nightly moved up melatonin onset by 88 minutes and reduced ADHD symptoms by 14% for adults.⁸
• For children, taking 3-6 mg nightly moved up DLMO by 44 minutes.⁹ After several weeks of melatonin use, 71% of parents reported improvements in behavior and 61% noted improvements in their children’s mood.

Bright Light Therapy

• A pilot study found that, for adults with ADHD, two weeks of bright light therapy in the morning (10,000 lux lamp) advanced DLMO by 31 minutes.¹⁰
• Another small study found that, during winter months, bright light therapy offered particular benefit for individuals with ADHD.¹¹

Multimodal Approaches

While not specific to those with ADHD, multimodal behavioral approaches have resulted in advancement of sleep-wake phases for those with late chronotypes.

• In one study, the multimodal behavioral approach lasted three weeks and involved consistent earlier wake time, morning light exposure, restricted nighttime light exposure, avoiding naps and caffeine in the late afternoon and eating late at night. The intervention group shifted their DLMO, wake time, and peak cortisol time by approximately 2 hours; self-reported depression scores decreased by 58% and stress scores by 40%.¹²

A Low-Risk Adjunctive Approach to Addressing ADHD

“The safety profile, accessibility, and potential for synergy with existing treatments make circadian interventions an attractive addition to the ADHD treatment,” write Luu and Fabiano, who propose that individuals with ADHD receive routine screening for sleep or circadian disturbances, so that potential delayed sleep phase disorder can be more easily identified and addressed.

“This is not a universal cure for ADHD, but a potential adjunctive approach,” Luu writes. “While the evidence is still emerging, these interventions are generally low risk, offer broad health benefits, and are relatively easy to implement.”

Sources

¹Luu, B., & Fabiano, N. (2025). ADHD as a circadian rhythm disorder: Evidence and implications for chronotherapy. Frontiers in Psychiatry, 16, 1697900. https://doi.org/10.3389/fpsyt.2025.1697900

²Hyndych A, Koval K, Dzeruzhynska N, Mader EC. Sleep and psychiatric disorders: Bidirectional interactions and shared neurobiological mechanisms. PLOS Ment Health. 2025;2(12):e0000531. doi:10.1371/journal.pmen.0000531

³Wajszilber D, Santiseban JA, and Gruber R. Sleep disorders in patients with ADHD: impact and management challenges. Nat Sci Sleep. (2018) 10:453–80. doi: 10.2147/nss.s163074

⁴Baird AL, Coogan AN, Siddiqui A, Donev RM, and Thome J. Adult attention-deficit hyperactivity disorder is associated with alterations in circadian rhythms at the behavioural, endocrine and molecular levels. Mol Psychiatry. (2012) 17:988–95. doi: 10.1038/mp.2011.149

⁵Ramos, J. K. N., Grevet, E. H., Junger-Santos, I., Ciochetti, N. P., Bandeira, C. E., de Araujo Tavares, M. E., de Oliveira, V. F., Vitola, E. S., Rohde, L. A., Grassi-Oliveira, R., da Silva, B. S., Dotto Bau, C. H., & Rovaris, D. L. (2025). Shared biological pathways linking ADHD and cortisol variability are related to externalizing behaviors. Psychoneuroendocrinology, 181, Article 107587. https://doi.org/10.1016/j.psyneuen.2025.107587

⁶Lunsford-Avery JR, Scott H, and Kollins SH. Editorial Perspective: Delayed circadian rhythm phase: a cause of late-onset attention-deficit/hyperactivity disorder among adolescents? J Child Psychol Psychiatry. (2018) 59:1248–51. doi: 10.1111/jcpp.12956

⁷Van Veen MM, Kooij JJS, Boonstra AM, Gordijn MCM, and Van Someren EJW. Delayed circadian rhythm in adults with attention-deficit/hyperactivity disorder and chronic sleep-onset insomnia. Biol Psychiatry. (2010) 67:1091–6. doi: 10.1016/j.biopsych.2009.12.032

⁸van Andel E, Bijlenga D, Vogel SWN, Beekman ATF, and Kooij JJS. Effects of chronotherapy on circadian rhythm and ADHD symptoms in adults with attention-deficit/hyperactivity disorder and delayed sleep phase syndrome: a randomized clinical trial. Chronobiology Int. (2020) 38:260–9. doi: 10.1080/07420528.2020.1835943

⁹van der Heijden KB, Smits MG, Van Someren EJW, Ridderinkhof KR, Gunning WB., et al. Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. . J Am Acad Child Adolesc Psychiatry. (2007) 46:233–41. doi: 10.1097/01.chi.0000246055.76167.0d

¹⁰Rybak YE, McNeely HE, Mackenzie BE, Jain UR, Levitan RD, et al. An open trial of light therapy in adult attention-deficit/hyperactivity disorder. J Clin Psychiatry. (2006) 67:1527–35. doi: 10.4088/jcp.v67n1006

¹¹Wynchank DS, Bijlenga D, Lamers F, Bron TI, Winthorst WH, Vogel SW, et al. ADHD, circadian rhythms and seasonality. . J Psychiatr Res. (2016) 81:87–94. doi: 10.1016/j.jpsychires.2016.06.018

¹²Facer-Childs ER, Middleton B, Skene DJ, and Bagshaw AP. Resetting the late timing of ‘night owls’ has a positive impact on mental health and performance. Sleep Med. (2019) 60:236–47. doi: 10.1016/j.sleep.2019.05.001

A wealth of detailed, data-driven information on the efficacy and side effects of ADHD interventions now exists in a free, interactive platform called Evidence Based Interventions-ADHD (EBI-ADHD), the product of a massive umbrella review published in the British Medical Journal.¹

EBI-ADHD was created to satisfy the need for accessible information about a wide array of ADHD interventions, and its findings were drawn from 221 meta-analyses of randomized controlled trials that explore ADHD treatments in adults and kids, as well as from the ADHD community itself.

“The platform is made to be user-friendly, and to help people make informed choices about what they really care about,” said Samuele Cortese, M.D., Ph.D., senior author on the study, in a recent ADDitude webinar titled “Heart Health and ADHD Treatment: Implications of Stimulant Use for Adults.” “It is based on a huge analysis of the literature — we analyzed data from more than 50,000 people — but it is also based on the experience and the recommendation of people with lived experience.”

Information on the EBI-ADHD platform is extensive and can be sorted according to various filters, including the following:

• Age group
  • Preschoolers
  • Children
  • Adults
• Treatment type
  • Medication (12 types, including stimulants and non-stimulants)
  • Psychosocial (8 types)
  • Lifestyle (9 types)
  • Brain stimulation (3 types)

The platform contains data on the impact of the various treatment types on ADHD symptoms, as rated by:

• Clinicians
• Teachers
• Parents
• Patients
• A combination of the above

The database also contains information about side effects such as:

• Sleep disruption
• Appetite suppression

Also included are measures of:

• Acceptability (discontinuation for any reason)
• Tolerability (discontinuation due to side effects)

For each measurement, evidence quality (very low to high) is given.

Most Effective ADHD Medication: Findings

Most Effective ADHD Medication for Children

The researchers found moderate- to high-certainty evidence that the following medications had medium to large effect sizes for ADHD symptoms in children:

• Alpha-2 agonists
• Amphetamines
• Atomoxetine
• Methylphenidate
• Viloxazine

On average, methylphenidate was found to be the most tolerable for children (better than placebo). Amphetamine showed worse tolerability than placebo, with moderate-certainty evidence.

This finding was supported by another recent study which focused on the efficacy and mechanism of action of methylphenidate.² Participants were stimulant-naïve 8- to 12-year-old children with ADHD. They received an MRI while completing tasks that measured attentional control and impulsivity — once without medication and once after a dose of methylphenidate. The MRIs revealed that methylphenidate decreased variability and increased stability in the brain.

“We found that whole brain flexibility decreased on methylphenidate,” the study’s authors wrote. “Further, individuals with greater decreases in whole brain flexibility on methylphenidate exhibited greater improvements in task performance.”

According to the most recent ADDitude treatment survey, which recorded responses from more than 11,000 participants:

• 52% of children taking medication for ADHD use methylphenidate, and their caregivers rate it 3.09 out of 5 for efficacy
• 34% take a form of amphetamine and their caregivers rated it 3.06 out of 5

Most Effective ADHD Medication for Adults

The researchers found moderate-certainty evidence of medium effect sizes for the following ADHD treatments for adults:

• Atomoxetine
• Methylphenidate

Though other medications, including alpha 2 agonists, showed large effect sizes, the evidence was low or very low certainty.

The ADDitude treatment survey found that, among adults taking medication for ADHD symptoms:

• 30% take a form of methylphenidate, and they rate it 2.96 out of 5 for efficacy
• 62% take a form of amphetamine, and they rate it 2.96 out of 5

Most Effective Non-Medication Interventions

Only one non-medication intervention, cognitive behavioral therapy, had moderate-certainty evidence of efficacy in managing ADHD symptoms in adults, according to clinicians.

The ADDitude survey found that 46% of adults have tried cognitive behavioral therapy, and 81% of those recommend it to others.

Acupuncture, mindfulness, and physical training showed large effect sizes on both ADHD symptoms and secondary outcomes, such as academic performance and quality of life, however the evidence certainty was low or very low, because of small sample sizes, trial limitations, and lack of data on acceptability, tolerability, and side effects. Mindfulness was the only intervention to show large effects at extended follow-up; the efficacy of all other interventions was short term.

Effect of Interventions on Other Outcomes

In children and adolescents, moderate-certainty evidence found that

• Amphetamines showed medium improvements in academic performance
• Atomoxetine showed small to medium improvements on quality of life

In adults, moderate- or high-certainty evidence found that:

• Atomoxetine showed small improvements on emotional dysregulation
• Methylphenidate showed small improvements on executive functions

The international team of researchers behind EBI-ADHD hopes the free, user-friendly tool will empower patients with information about the diverse breadth of treatment options available today, so they can actively participate in shared decision making with their providers.

“Long waiting lists for mental health services are a major issue. Having incorrect information about treatments can make people’s journeys even more difficult, by wasting time and money on non-evidence-based approaches,” said Corentin Gosling, Ph.D., an associate professor at the Paris Nanterre University and first lead author of the study, in a press release. “Taking the time to review all treatment options within a shared decision-making process using the web app we developed can empower people with ADHD, leading to better treatment adherence, improved outcomes, and an overall better patient experience.”

Sources

¹Gosling C J, Garcia-Argibay M, De Prisco M, Arrondo G, Ayrolles A, Antoun S et al. Benefits and harms of ADHD interventions: umbrella review and platform for shared decision making BMJ 2025; 391 :e085875 doi:10.1136/bmj-2025-085875

²Nugiel, T., Fogleman, N.D., Lyons, M.G. et al. Methylphenidate stabilizes dynamic brain network organization during tasks probing attention and reward processing in stimulant-naïve children with ADHD. Transl Psychiatry 15, 488 (2025). https://doi.org/10.1038/s41398-025-03694-9

Self-regulation difficulties are a strong predictor of both hyperactive-impulsive and inattentive ADHD in adulthood, according to a new study published in the Journal of Attention Disorders.¹

The study challenges the dual-pathway model of ADHD, which proposes that separate, independent traits explain the two main sets of ADHD symptoms. That model proposes that inattention links to low effortful control (e.g., difficulties with emotional regulation, inhibitory control, and focus), while hyperactivity/impulsivity links to reactive traits, such as high surgency (increased activity levels, impulsivity) and negative affect (strong negative emotions, such as fear, frustration, or discomfort).²

This theoretical framework does not fully account for ADHD that persists into adulthood. For example, it suggests that effortful control should exclusively explain the variance in inattentive symptoms in adults. However, when researchers analyzed the results from the German Adult Temperament Questionnaire of 158 adults (79 with ADHD and 79 controls), they found that low effortful control predicted both inattentive and hyperactive-impulsive symptoms in adults with ADHD.

Likewise, while reactive traits reliably predict ADHD in childhood, they become less relevant for the persistence of ADHD symptoms in adulthood. In the dual-pathway model, high surgency and negative affect exclusively explain the variance in hyperactive-impulsive symptoms in childhood and adolescence, but the study found no significant group differences in surgency in adults. A one-unit increase in negative affect was associated with a twofold increase in the odds of belonging to the ADHD group. However, the negative affect’s predictive value for hyperactive-impulsive symptoms was strongly reduced once effortful control was added to the model.

“When considered alongside research on ADHD in childhood and adolescence, our findings suggest that elevated restrictive traits (surgency and negative effect), although considered central risk factors for the development of ADHD in childhood, may be less relevant for the persistence of clinically significant ADHD symptoms into adulthood,” the researchers wrote. “In contrast, self-reported deficits in effortful control appear to be strongly associated with sustaining a clinical diagnosis of adult ADHD. However, this strong association does not imply that effortful control and ADHD should be equated.”

Cumulative Effects of Low Effortful Control

The researchers also found a strong reciprocal relationship between low effortful control and high negative affect. In this case, deficits in effortful control may intensify negative affective states, which, in turn, impair an individual’s use of self-regulation strategies.

“The emotional consequences of impaired effortful control may become more pronounced with age, as cumulative exposure to adverse life events increases self-perceived negative affect,” the researchers wrote.

A recent study, published in the Journal of Child Psychology and Psychiatry, supports this idea. The study found that the risk of autistic and ADHD children developing comorbid depression or anxiety in adulthood is driven largely by emotional exposures in childhood and how intensely they are experienced. ³

Temperament-based assessments could help clinicians better understand and individualize treatment plans for adult patients, according to the researchers. Interventions focused on strengthening regulatory skills, such as mindfulness, cognitive behavioral training (CBT), or executive function training, may improve executive function and reduce emotional distress in adults with ADHD.

Several limitations of the study exist, including the cross-sectional design and use of self-reported data. The researchers recommend future longitudinal studies spanning various developmental stages.

Sources

¹Teuchert, C., Kerner auch Koerner, J., Daseking, M., & Heinze, H. (2025). How does adult temperament relate to ADHD symptom domains? Testing the dual-pathway model. Journal of Attention Disorders. 0(0). https://doi.org/10.1177/10870547251393062

²Sonuga-Barke EJ. (2003). The dual pathway model of AD/HD: an elaboration of neuro-developmental characteristics. Neurosci Biobehav Rev. https://doi.org/10.1016/j.neubiorev.2003.08.005

³Lukito, S., Chandler, S., Kakoulidou, M., Griffiths, K., Wyatt, A., Funnell, E., Pavlopoulou, G., Baker, S., Stahl, D., & Sonuga-Barke, E. Emotional burden in school as a source of mental health problems associated with ADHD and/or autism: Development and validation of a new co-produced self-report measure. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.70003

Among autistic and ADHD children, the risk of developing comorbid depression or anxiety in adulthood is driven largely by emotional exposures in childhood and how intensely they are experienced, suggests a new study published in the Journal of Child Psychology and Psychiatry.¹ In other words, it’s not the ADHD and autistic traits alone that increase the risk for comorbidities, but the emotional load and regulation problems that often come with trauma.

The study found that emotional burden (EB) and emotional regulation difficulty (ERD) independently predicted higher rates of depression or anxiety in autistic youth with and without ADHD, as well as among teens with ADHD alone. Adolescents within these groups also experienced greater frequency and intensity of common upsetting events (CUEs) and substantially higher overall EB, especially during unstructured or socially complex situations at school, compared to their neurotypical peers. The frequency and intensity of CUEs, and higher EB, were uniquely associated with depression or anxiety.

The researchers identified distinctive sets of CUEs with discriminating burden among the ADHD, autistic, and ADHD-autistic groups.

ADHD-Autistic Group: Burdensome CUEs

• last-minute change of plans
• not allowed self-regulation strategies
• being rushed to move on from task to task

ADHD Group: Burdensome CUEs

• teachers don’t listen
• boring lessons or tasks
• stopped from doing something enjoyable
• losing and forgetting things
• being told to try harder
• being unfairly accused of something

Autistic Group: Burdensome CUEs

• peer gossip
• unexpected wait in a queue
• sensory discomfort
• being rushed to complete work
• not understanding others

Lowering stressors and emotional triggers, the researchers suggest, may be just as important as learning emotion regulation skills.

“The concept of induced EB has the potential to expand, or even to shift, the focus of emotion-related interventions from attempts to reduce ERD within an individual through emotion regulation training alone to ones that incorporate EB reduction — by decreasing CUEs and/or improving ways such provocations might be managed to ameliorate the intensity of emotional reactions they induce,” the researchers wrote.

How Autistic and ADHD Traits Relate to Emotional Burden

The study also revealed that autistic adolescents with ADHD appeared to experience only the same level of burden as those with ADHD or autism alone, rather than the conditions acting additively. “This was a surprising finding, which needs to be replicated in future studies,” the researchers wrote.

One possibility is that there exists a ‘ceiling’ in emotional burden experienced by neurodivergent individuals. “Another possibility,” the researchers wrote, “is that the co-occurrence of ADHD and autism leads to the former cancelling out the latter effect and vice-versa, leading to each contributing to a smaller proportion of emotional burden than each condition alone.”

More longitudinal studies are needed to explore how EB and ERD relate to depression and anxiety in ADHD and/or autistic individuals.

“EB could add significant power to explain the emergence of mental health problems in adolescents with ADHD and/or autism, over and above more traditional measures of emotion dysregulation,” the researchers wrote.

By adulthood, about half of autistic people and 30% of those with ADHD will have a clinical depression and/or anxiety diagnosis. ², ³

“Understanding — not undermining — the lived experiences of those who live with ADHD and/or autism is critical,” explained Karen Saporito, Ph.D., in the ADDitude webinar “AuDHD Guidance: Why Autism is So Difficult to Diagnose in Women and Girls with ADHD.” “The experiences, traits, symptoms, and challenges of our patients do not always align with textbook definitions and available research findings, and firsthand accounts can offer a more accurate and comprehensive understanding of these conditions… When patients feel heard and respected, they are more likely to engage in their care and advocate for themselves, leading to better outcomes.”

Sources

¹Lukito, S., Chandler, S., Kakoulidou, M., Griffiths, K., Wyatt, A., Funnell, E., Pavlopoulou, G., Baker, S., Stahl, D., & Sonuga-Barke, E. Emotional burden in school as a source of mental health problems associated with ADHD and/or autism: Development and validation of a new co-produced self-report measure. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.70003

²Dow, D., Morgan, L., Hooker, J.L., Michaels, M.S., Joiner, T.E., Woods, J., & Wetherby, A.M. (2021). Anxiety, depression, and the interpersonal theory of suicide in a community sample of adults with autism spectrum disorder. Archives of Suicide Research.

³Wilens, T., Nierenberg, A.A., Rostain, A., & Spencer, T.J. (2008). Adult attention-deficit hyperactivity disorder and the role of depression. CNS Spectrums.

Last month, Otsuka Pharmaceutical filed a New Drug Application (NDA) for centanafadine, a first-in-class non-stimulant medication that is a norepinephrine, dopamine, and serotonin reuptake inhibitor (NDSRI). The U.S. Food and Drug Administration (FDA) is now considering centanafadine for the treatment of ADHD in children, adolescents, and adults.¹

Centanafadine is a once-daily, extended-release capsule that increases the availability of three neurotransmitters involved in ADHD (norepinephrine, dopamine, and serotonin) by blocking their reabsorption. While prior research links ADHD with dopamine and norepinephrine dysregulation, rising evidence indicates that serotonin, which influences mood, impulsivity, sleep, and digestion, also contributes to ADHD symptoms and comorbidities.² An August report in Neuroscience & Biobehavioral Reviews concluded that serotonin dysregulation “is likely to generate a broad spectrum of clinical manifestations, which may account for the unique presentation of neuropsychiatric behaviors and comorbidities found in patients with ADHD.”

“Centanafadine represents a new mechanism of action among available ADHD therapies,” says John Kraus, M.D., Ph.D., executive vice president and chief medical officer at Otsuka. “By inhibiting the reuptake of these three key neurotransmitters, the mechanism is designed to address the core symptoms of ADHD and may also help with executive dysfunction and emotional dysregulation.”

Non-stimulant medications are generally considered second- or third-line treatments behind stimulant medications, which are often prescribed to patients who do not respond to or cannot tolerate stimulants. Compared to quick-acting stimulants, non-stimulant ADHD medications may take weeks or longer become fully effective. However, centanafadine demonstrated an earlier onset of action more characteristic of stimulant medications, with clinical benefits emerging by week 1 and maintained through week 6, according to clinical trials.^{3, 4, 5}

“Patients who may be particularly well-suited for centanafadine are those seeking a balanced approach to ADHD management and who may not fully benefit from or tolerate current standard therapies,” Kraus says.

Four Phase 3 clinical trials using extended-release (children and adolescents) and sustained-release (adults) formulations support the NDA submission. Across studies, centanafadine produced statistically significant and clinically meaningful improvements in ADHD symptoms compared with placebo, measured by the ADHD Rating Scale–5 (ADHD-RS-5) in youth and the Adult ADHD Investigator Symptom Rating Scale (AISRS) in adults.^{2, 3, 4}

Adolescent & Pediatric Phase 3 Trial Results

Tim Wilens, M.D., Chief of Child and Adolescent Psychiatry at Massachusetts General Hospital, and a researcher on the centanafadine pediatric and adolescent trials, presented findings from the studies at the American Professional Society of ADHD and Related Disorders (APSARD) conference in January 2025. “Centanafadine had a significant impact on ADHD symptoms,” he said. “It also improves executive functioning — time management, hierarchical thinking, organization, and start/stop/shift transitions.”

A randomized, 6-week, double-blind, placebo-controlled Phase 3 trial involving 480 children (ages 6–12) with ADHD found that high-dose centanafadine significantly improved ADHD symptoms versus placebo. (Footnote 3) Children in the study were assigned to a high-dose, low-dose, or placebo group based on weight. Among those within the high-dose group, 34% achieved an 18-point or greater reduction on the ADHD-RS-5 compared with 23% in the placebo group.

Mean ADHD-RS-5 score reductions (ages 6–12)