CCPR: How do you assess young adults for ADHD?
Dr. Beresin: All that’s inattentive is not ADHD. I use neuropsychological testing to clarify ADHD and other reasons for inattention and co-occurring problems. These include post-traumatic stress disorder (PTSD), depression, anxiety, learning disorders (eg, slow processing speed and dyslexia), substance use, phobias, domestic violence, abuse, and neglect. Once I’ve clarified diagnoses, I look for clinical impacts of ADHD, such as trouble with friends, impulsivity, or executive functioning (time management, procrastination, lack of organization). 

CCPR: How do you plan care for young adults with ADHD?
Dr. Beresin: I use biopsychosocial treatment planning, not just medications. Consider psychological treatments—like executive functioning interventions and tutoring—and address comorbid disorders. For example, for comorbid depression, I use antidepressants, but also cognitive behavioral therapy (CBT). For an anxiety disorder, exposure-response prevention. A thorough assessment and a sound multimodal treatment program has the best shot at making the adult experience more manageable, and the younger you start the better. This is especially the case since 60%–80% of ADHD that begins in childhood will progress to adulthood (Cherkasova MV et al, J Am Acad Child Adolesc Psychiatry 2022;61(3):378–391). 

CCPR: How does ADHD care change as a person moves into adulthood?
Dr. Beresin: ADHD involves problems with executive functioning, independent of intelligence. School through grade 12 is highly structured, but when you go to college, there are maybe 12 hours a week of classes, and you’re told, “Okay, your midterm is in 6 weeks, do such and such, then your finals are at 12 weeks.” Many college students fall by the wayside. For those 40% who don’t go to college, you have a job description with duties and responsibilities, without the monitoring you had in high school. So, whether it’s in college or in the working world, your patient must either create that infrastructure for themselves or have coaches, tutors, or other reliable folks help them monitor what they do. 

CCPR: What are some ways parents can help teens prepare for this transition?
Dr. Beresin: Nobody wakes you up when you’re in college or the working world. Parents can help by getting teens to develop their own sleep infrastructure. This includes going to bed on time, not staying up late, turning off blue screens, avoiding distractions from social media, knowing when to get up, setting the alarm in advance, and having mechanisms to avoid distractions in the morning. College has many distractions—roommates, parties, substance use, clubs, and other extracurricular activities—that can derail students. Comorbid conditions like depression, anxiety, stress, or substance use can make it harder to take care of themselves.

CCPR: How can we help young adults with self-management once they’re out of the house?
Dr. Beresin: Most colleges have learning centers, and most kids who have accommodations in high school can get those services through their university or college as well. See if the institution offers them, and if not, explore online programs that provide executive functioning services. (Editor’s note: To learn more about how to help transition-age patients manage their medication, see CCPR Jul/Aug/Sept 2024.)

CCPR: What is the role of brain maturation in young adults with ADHD?
Dr. Beresin: We must revise our thinking of what it is to be a mature adult. Teenagers and young adults are ruled by impulse and peer pressure, doing what seizes them at the time. The myelination of the connections between the lower structures of pleasure and pain to the orbital frontal cortex, which is the grand integrator, isn’t solidified until age 26. Young people between 14 and 26 need mentorship, skill building, and social-emotional learning while their brains are maturing. This is when they learn how to pause and think before they act, make rational decisions, and learn about leadership and inclusion. Historically, we haven’t provided skilled adult supervision during those critical years. ADHD, neuropsychological problems, and psychiatric disorders can interfere with that myelination, maturation, and learning. 

“I use biopsychosocial treatment planning, not just medications. Consider psychological treatments—executive functioning interventions, tutoring—and address comorbid disorders. A thorough assessment and a sound multimodal treatment program has the best shot at making the adult experience more manageable.”

Gene Beresin, MD

CCPR: How does skilled adult supervision guide the development of young adults with ADHD?
Dr. Beresin: You need to balance structure with freedom. Parents and caregivers (eg, teachers, coaches, clergy, community leaders, professionals) are important in the lives of young people. Inadequate structure and lack of supervision put kids at risk for poor maturation. But excessive scheduling and requirements can be detrimental because kids don’t experience and learn autonomy, separation, independence, and how to make decisions on their own. 

CCPR: How do you help parents or others to balance structure with freedom? 
Dr. Beresin: I typically provide therapy, medication management, and parent guidance or family therapy. Most caregivers need coaching on how to work with a teen who has ADHD and deficits in executive functioning. I ask about a teenager’s daily schedule and home situation. Teens need to balance separation and identity formation with the demands of family, school, sports, or community. I ask teens their priorities for free time—time with friends, sports, video gaming, etc. Then I meet with the family and ask what the parents or caregivers want from their teen. We integrate a teen’s personal time with their commitments; set up a daily structure with days of the week, goals, and responsibilities; and allow for rewards (eg, extra screen time, later curfew) if basic demands are met. I encourage 15-minute family meetings every Sunday night to review the week, count rewards, and plan the following week. I model these conversations in family sessions, helping everyone to maintain civility, resolve conflict, and apologize if they screw up (even a parent). We often brainstorm what helps the young person decrease impulsivity, stay on track, and keep their emotions reasonable. It’s key to allow for conversations about flexibility or modifications, and to use praise and rewards rather than punishments. 

CCPR: Are there generational impacts on the presentation or prevalence of ADHD in young adults?
Dr. Beresin: Gen Zers, ages 12 to 26, are the most socially and globally conscious group of young people since the 1960s, and the most anxious. They worry about climate change, gun control, mass shootings, war, economic ­downturn, and disparities among people of color and LGBTQIA+ people. They are growing up in a world riddled with such insecurity that it affects their social-emotional learning. ADHD, if present, just adds to their stress, anxiety, depression, loneliness, and suicidality. 

CCPR: How do you talk with Gen Zers about ADHD? 
Dr. Beresin: I ask about specific symptoms of depression, anxiety, stress, loneliness, and suicidal thinking. I note that these problems have been increasing steadily since the late 1970s (www.tinyurl.com/mrxms2y2). I also ask what stress factors have contributed to these problems. I begin with open-ended questions, then narrow down, asking about their feelings and the impact of social issues on them personally, or how those issues add to their psychological stress. I ask about adverse childhood experiences (eg, abuse or neglect growing up, domestic violence in their homes, incarceration of parents, substance misuse by parents or caregivers). I ask if they have been subject to or impacted by sexual assault, bullying, or cyberbullying. I also ask about concerns related to feeling overscheduled in school and life; marginalized populations such as immigrants, people of color, or LGBTQIA+ individuals; gun violence; climate change; coping with disabilities; or other stresses in society. 

CCPR: This is a huge inventory! 
Dr. Beresin: It is. I never expect to discuss all of these stress factors in one session, but I have found that Gen Zers want to discuss such issues and how they are personally affected by them. Frank discussions about social-emotional issues are a welcome relief for virtually all of my patients. I ask how each issue affects them, as well as their friends and family, and what can be done. Sometimes this leads to discussions about their participation in social activism. Other times it lends itself to teaching CBT skills, meditation, or the use of creative arts to improve their well-being. I encourage them to talk in group settings about these issues, such as in school, in their community settings, in places of worship, and especially in their families. 

CCPR: Do you see ADHD as a form of neurodiversity?
Dr. Beresin: I do, though in the broadest sense because it’s often coupled with other forms of neuropsychological and psychiatric disability (McGough JJ et al, Am J Psychiatry 2005;162(9):1621–1627; Cuffe SP et al, J Atten Disord 2020;24(9):1345–1354). When you combine ADHD, for example, with depression, anxiety, or OCD, it’s a much more complicated picture. Some societies welcome neurodiversity—in Finland, they look at schizophrenia as an accepted variant, part of the normal range of human experience. So while the increase in ADHD can be a concern, we should also consider the culture and society in which this is embedded.

CCPR: How does a neurodiversity perspective shape clinical care?
Dr. Beresin: It’s about supporting good function in a diverse population vs trying to eliminate ADHD. Ned Hallowell has a welcoming, positive view that says, “There’s something you can do about that.” Young people can learn meditation and learn how to calm themselves down. They can improve their concentration with neurocognitive focusing techniques. There’s CBT and executive functioning skills that they can learn. (Editor’s note: For more, see the “Resources for Assistance With Executive Functioning” table below; you can also hear more from Ned Hallowell about ADHD in CCPR Jan/Feb/Mar 2020.) We’d be even better off if we could identify ways to start earlier in life to maximize function.

CCPR: Can we shift the course of ADHD with early intervention?
Dr. Beresin: Yes. It’s not rocket science. Three Ws from the Clay Center outline prevention and intervention: 1) What to look for, 2) When to worry, 3) What to do (www.tinyurl.com/3zttmdb5). If parents learn these early, they will know what problems need evaluation. Adverse childhood experiences cause psychiatric disorders. It’s not just correlative. Young children who’ve been exposed to domestic violence, to abuse and neglect, to incarceration of parents, to poverty, to racism and discrimination—these factors affect parents and kids (Felitti VJ et al, Am J Prev Med 1998;14(4):245–258). If we intervene early, we have a better shot at better outcomes. 

CCPR: What early intervention programs can improve outcomes?
Dr. Beresin: From Neurons to Neighborhoods (www.tinyurl.com/3s776xjf) and Head Start (www.tinyurl.com/yx39vjaf) are early intervention programs for kids in distressed communities. They demonstrate that prevention and early intervention are the best medicine. Although we are still trying to understand the socioenvironmental, economic, and biological causes of these disorders, we can do something about them.

CCPR: Any final thoughts about what clinicians can do to help people ages 18–22 with ADHD?
Dr. Beresin: Early intervention and prevention is best, but it’s never too late. If you suspect ADHD, take a comprehensive history that includes the DSM-5 diagnostic criteria. Supplement with a standard screening tool such as the Vanderbilt Assessment Scale or a Conners checklist. Refer for a full neuropsychological testing battery if possible to elucidate the diagnosis of ADHD; of co-occurring neuropsychiatric conditions, such as slow processing speed; or of a specific learning disability such as dyslexia. Also refer for psychiatric disorders such as depression, anxiety, OCD, or PTSD. I strongly urge all clinicians to get a comprehensive psychiatric history, as well as family history from parents or caregivers, to determine other biological, psychological, or socioenvironmental issues that must be taken into account to craft a comprehensive formulation and treatment plan. Then it becomes possible to treat the whole person and their associated problems. It’s likely to make a big difference in that person’s life as well as in their friendships, in their family, in their workplace, and more broadly as they participate in society. There’s always hope for change. 

CCPR: Thank you for your time, Dr. Beresin.