ADVICE ON MENTAL HEALTH: ADHD: What You Need to Know: A Q&A for Parents, Teachers, and Families

ADVICE ON MENTAL HEALTH - from Brain & Behavior Magazine, July 2025 issue

Q&A by Jeffrey Borenstein, M.D., BBRF President & CEO,
with Stephen P. Hinshaw, Ph.D.
University of California, Berkeley
Distinguished Professor of Psychiatry
Professor of Psychiatry and Behavioral Sciences
2019 BBRF Ruane Prize for Outstanding Achievement in Child & Adolescent Psychiatry Research

A world expert in ADHD, Dr. Stephen Hinshaw advises parents and teachers that ADHD is not an attention deficit per se, but rather, more of a regulatory disorder, often reflected in an inability to shift gears between tasks and to stay focused when that is appropriate. Ultimately, ADHD is a family affair, he says, and a child-school-parent affair. “Everybody needs to work together.”

Dr. Hinshaw, what exactly is ADHD?

The stereotype about ADHD is that it’s all about fidgeting, squirming, and running around the classroom; not following multipart directions, not seeming to listen, making careless mistakes.

In fact, ADHD is extreme levels of two types of behaviors or symptoms. The first type has to do with inattention, distractibility, not following directions. These are the quieter symptoms. All of us have some of them, but if you are on the high end of the spectrum, we say that you’re in the realm of the “inattentive” form of ADHD.

The other domain is about hyperactivity and impulsivity. “Hyperactive-impulsive” symptoms do include fidgeting, squirming, or running when you’re not supposed to be running. Also, acting too far ahead of what the consequences of something would be.

Hyperactive-impulsive symptoms are somewhat more prominent in boys, and inattentive symptoms are somewhat more prominent in girls, but most kids who get referred to a doctor have a high degree of both the inattentive and the hyperactive-impulsive symptoms. Learning and behavior, including classroom deportment, are compromised.

Acting out is very commonplace in young people. How can you distinguish ADHD from normal behavior?

It’s true that many people say, “Well, a lot of young kids are like that.” But while a child typically gets older and develops better self-control, there are some kids who are really on the far end of the continuum.

Kids who get a diagnosis of ADHD are way too likely to experience accidental injuries. In fact, young kids with ADHD have a higher risk of death than young kids without ADHD under the age of 6. Failure in school is also more likely, not necessarily because of a learning disorder but because of the inability to pay attention and follow directions. They’re way too likely to get picked on, bullied by, or rejected by their peers. That’s because they may not read facial cues very well, and may fight back in ways that make them unpopular. And then, later in life—as my group has shown in several longitudinal studies from childhood through adulthood— those affected are too often at risk for substance use disorders and for aggression, particularly boys, and for depression, particularly girls.

There are other issues. As our “Berkeley Girls with ADHD Longitudinal Study” (BGALS) has shown, far too many girls with low self-esteem and depression get involved relatively early in adolescence in what we call self-harm: non-suicidal self-injury, cutting, burning, self-mutilating. And rates of attempted suicide by those in their late teens or early twenties are much higher than in other girls.

Now, many kids with ADHD—in the right conditions and the right settings, and when you find their strengths—can thrive later on. But it’s a serious condition, and an equal-opportunity one. More boys than girls have ADHD, but girls have it too. It’s across all racial and ethnic groups, and all socioeconomic levels.

So, this is serious and needs to be attended to. In the classroom, what would teachers see? What should raise the alarm?

Let’s start with preschool. More often in boys than girls, they’re going to see a child who is running around, can’t sit at circle time, pokes at other kids, disrupts the story that’s being read. Some girls with ADHD at that age are just as disruptive and just as hyperactive, but they are more likely to lapse in their attention and not follow what the story is.

In grade school, these kids are often bright. The bell curve of intelligence scores for kids with ADHD follows pretty much the national norms. But it becomes an issue if the kid hasn’t heard the teacher say, “Open your books to page 12, look at the second paragraph, and answer question two.” They’re thinking, “Wait a minute. Question two? What did she say before that?”

Just as much as these behavioral patterns, ADHD also involves problems with executive function: maintaining your attention for a long period of time, planning what you’re going to do rather than just jumping into it willy-nilly. Also, it affects working memory: holding a string of information together, like the parts of a multipart direction. Early on, that could be going from math to reading, and in middle school, from algebra to history.

ADHD is not really an attention deficit, per se. Many people, especially people with ADHD, can get highly engaged in something they really love. So, if you think of hyperfocus as a symptom, ADHD is more of a regulatory disorder. It’s the inability to do well at shifting gears between tasks, particularly those that are highly engaging vs. those that are rote. This problem with shifting “set” is a hallmark of ADHD. It takes a long time for kids with ADHD to learn self-regulation, partly because levels of dopamine functioning in their brains often don’t do the same things they do in neurotypical brains.

When it comes to treatment, what are some behavioral interventions?

The treatments of choice are really engaged in more by parents and teachers than by the kids themselves. Kids with ADHD struggle to get intrinsically motivated because they’re not hearing the direction and they’re slower to remember the parts of the task they’re supposed to do. Their bodies and brains are going to require smaller steps for success, and very specific rewards in the early part of their learning to motivate that success.

Reward charts can help, but the other kids in the class, or their siblings, don’t need to have one. So, part of the treatment plan for ADHD is to do some psychoeducation about what ADHD really is. What people need to understand is that these kids are not willfully lazy or unmotivated: there are some biological differences that produce these behaviors.

What we need to do is be very positive. Build behavioral goals and academic goals into small, doable steps. Then, you can use things like a reward chart. If a kid isn’t sitting at the dinner table the full time she’s supposed to, and her average— you’ve used a clock—is three minutes, you build it to five minutes and then she gets her check on her chart. Or, if in reading circle, the boy with ADHD can’t last 15 minutes but can last five, then you move to seven and then to nine.

The small steps build in success. They build a good self-esteem. And they do something that’s really important for parents and teachers. All too commonly, adults working with kids with ADHD interact with them by saying things like, “Don’t do that, you shouldn’t be doing that.” It’s negative, and often emotionally loaded. What we try to do is change the ratio of positives to negatives. Where there’s three or four negative comments for every positive, just flip it. For every negative comment, there should be three, four, or five positive comments.

So it helps if you have a reward program. It helps if you build skills into small steps. And it helps if you stop the bickering and arguing that only lead to more misbehavior.

It seems that for professionals who work with ADHD kids, it’s key to coach parents and teachers about what a diagnosis means and what can be done.

Exactly. That’s called PMT, Parent Management Training. Parents learn how to set up a reward chart. They tailor the rewards to the kids, improving success in small steps. Maybe they need a timeout program if the kid’s misbehavior is severe, but they still want many more positive interactions and points than negative ones. If their home chart is in deficit, the parents are doing it wrong. “Billy’s 1,000 points in the hole.” No! They’ve got to have a positive total, so he’s got something to continue to work toward.

With Parent Management Training, the parent says: “Let’s have the meeting with the teacher, and let’s have the therapist (with the parent or parents as well as the teacher) sit down and figure out what some school goals are.” Very behavioral, small steps of improvement from where the child is right now. The teacher can either electronically, or on an index card, make a check: “Yes, Sarah today did this and that,” or, “No, she didn’t live up to that.” That report is shared with the parents, and checks are added to the reward chart at home. This puts parents and teachers on a level playing field. They’re working toward parallel goals and reinforcing one another to be positive.

What about the use of medication to help treat ADHD in kids?

Medications are used more often in the United States than other countries for ADHD, but the rest of the world is gradually catching up. Primary treatments for ADHD are called stimulants, or SDRIs: selective dopamine reuptake inhibitors. They keep dopamine in the synapse a little bit longer to help regulate the five or so pathways in the brain that carry dopamine as a neurotransmitter. Most of those pathways have to do with executive functions, focus, sustained attention, and controlling motor behavior. There is the methylphenidate/ Ritalin class and the amphetamine/ Adderall class.

We can’t predict ahead of time who’s going to respond to which of those types of stimulant meds, or what dose. The stimulant meds are in and out of your bloodstream in a day and night cycle. So, with a good doctor and with a willing teacher, parents can fill out some ratings and change the dose once or twice a week, over a couple of weeks, and find the best dosage. It doesn’t take month after month to assess, the way it does for many medications for other psychiatric conditions in kids.

There are also non-stimulant alternatives, which work on the neurotransmitter norepinephrine, sometimes called noradrenaline. They don’t work quite as quickly as the SDRIs do, but over several weeks they can help reduce impulsivity and improve behavior. They probably, on average, don’t have the same attentional boost that you get with the traditional SDRI medications.

A lot of families that I’ve worked with say, “Why would you medicate a child for behavior problems? Wouldn’t you do therapy with them?” If parents are in doubt, depending on the severity of the child’s behaviors, they can do a trial. Parents and teachers really need to collaborate on this trial, to avoid a situation where the teacher doesn’t know when the dose is switched but still fills out the ratings. You can empirically determine, for example, that a low dose of a Ritalin-type compound didn’t work but a medium dose of an Adderall-type compound did work.

About 15% of kids with ADHD don’t respond well to any form of medication. It’s important to know that, too.

So, you’re saying parents don’t have to commit to a specific medication or dosage for their children, they can do a trial first. What about ADHD and genetics?

Genes play a very strong role. But it’s not one gene or 20 or 100—it’s many hundreds, if not thousands operating together. Also, about 35% to 45% of the biological parents of kids with ADHD have a moderate-to-severe degree of ADHD themselves, whether they’ve been diagnosed or know it or not.

If you as a parent maybe aren’t as on top of your checkbook as you should be, and if you’ve got anger management issues, parenting a kid who provides challenges in attention and impulse control is going to be especially challenging. Research shows that—before starting Parent Management Training—if you help parents with their own ADHD symptoms through cognitive behavioral therapy or through medication, or you help parents with their own moderate to severe depression, their engagement in Parent Management Training goes up appreciably and they do it more reliably and consistently.

Ultimately, ADHD is a family affair, and it’s a child-school-parent affair. Everybody needs to work together.

What is the best approach for teachers to take in their discussions with parents?

The best approach is not to be a psychologist, psychiatrist, or expert, and “know” automatically that the kid has ADHD. Rather, have a parent-teacher conference and discuss what you’re seeing. This allows parents to non- defensively describe some of the issues previous teachers may have mentioned. And, where relevant, it might enable the parent to say, “I was like that as a kid, too.” You’re building familiarity with the topic. You’re building a commitment to work together.

It’s also important to talk about individual differences. Some kids are good artists, and some kids are really good at sports. Some kids can sit calmly, and other kids need to move around a bit more. Different kids have different learning styles and thrive in different kinds of environments.

Another teaching strategy is to have classrooms that are project-based, that allow some parts of the day where you can stand and work at a workstation— not sit with hands folded from 8:30 until 3:30. This approach may allow some energy to get out—and may even help kids without ADHD.

In a flexible classroom, there are real expectations. It’s not the same as an open classroom where everyone’s working at her or his own pace. There are standing periods and there are periods where kids can work in groups. So, structure and some flexibility seem to be, for many kids with ADHD, an ideal combination to get the most out of the native smarts they have.

This is similar to the way in which calm, warm, reasonable, democratic parenting—but parenting with real demands and limits—is probably the optimal approach for families. When parents set limits and stick to them using the positive, reward-based approach I mentioned earlier, that is called authoritative parenting. It’s helpful for a lot of kids, but especially kids with ADHD.

As for resources for parents, they can consult their local mental health center, or maybe their pediatrician is in a group of developmental behavioral pediatricians with a lot of expertise in ADHD. It may also be possible as a family and a school to have accommodations made—under Section 504, for example. You’re going to give your child a fighting chance of not feeling like a failure every year, and it’s never too early. [Editor’s Note: Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of disability in programs or activities receiving federal financial assistance, ensuring equal access to services and opportunities for individuals with disabilities.]

You also recommend looking for the child’s strengths and interests.

All parents have some expectations or ideals for their kids—what they will be when they grow up and what they’re going to be good at. But then they find out that their child or teen has a diagnosis of ADHD. Maybe it comes out in preschool, especially for a boy. For a girl, it’s going to take longer because she’s more likely to have these exclusively inattentive symptoms that may not show up until late in grade school or middle school, or even high school. As genetically based as ADHD is, we know from very good data that when parents change their style to a more authoritative stance, and are warm and limit-setting, their kids improve. Biology is not destiny.

The same thing is true for classrooms and kids with ADHD. Especially in girls but also in boys, you need to radically accept that your kid may not be the kid you expected—or maybe you did because you know about your own ADHD, if you have it. At the same time, though, you can take the blame off yourself. Maybe it was just the genes you passed along. But you also have to radically commit to getting Parent Management Training, getting the teacher involved, and doing a medication trial.

So, it’s cutting a little slack. This kid may not be exactly whom I expected, but you ask, “What are they really good at?” Maybe it’s sample collecting, maybe it’s animal husbandry, maybe it’s a sport that’s not a traditional team sport. If your kid likes something and gets good at it, A, that’s a good reward for the reward program to build at home. And B, maybe that’s going to foster a somewhat non-traditional career that they’re going to thrive at years later. This “strengths” approach gets everybody focusing on the positive, not the negative.

Say parents have spoken to their child’s teacher, and then to their pediatrician. The pediatrician is going to send them to a specialist. What should they look for in that person? And what about the importance of a careful evaluation?

ADHD takes some real time and effort to evaluate well, but not maybe in the way many people think. It’s a low-tech diagnosis. Sure, there are brain scans now—MRIs, fMRIs, etc. That research is progressing. We see some differences in neurotransmission patterns in the brains of kids with ADHD on average compared to neurotypical kids on average. But none of those is good enough yet to say, “You’ve got ADHD and I don’t,” or vice versa. What you’re looking for is the kid’s behavioral and emotional patterns in their everyday world, in that classroom. That’s why teacher ratings and a teacher interview are essential. That’s why parent ratings and an interview with them are essential.

Also, with parents, you want to get a good developmental history. What about early milestones? Maybe there is a speech and language delay. Does the child have a subtle seizure disorder? Because seizure disorders can look like ADHD. Has the child been traumatized? Again, we know from the Berkeley Girls with ADHD Longitudinal Study that one of the very difficult long-term outcomes for too many girls with ADHD is low self-esteem. Another outcome is depression in adolescents, and cutting and self-mutilation, around that time, and then actually attempting their own lives by late adolescence or the early twenties. That risk goes up by about 300% if a girl with ADHD has also experienced physical or sexual abuse and neglect early in life.

ADHD is a really biological thing. We call it a neurodevelopmental disorder. It starts early in life. But trauma on top of that is especially triggering of terribly low self-esteem and self-destructive behavior later in life. So, an evaluation even of younger kids is important. The average girl in our country who starts non-suicidal self-injury, self-harm, starts it now before the age of 11. So, we need pediatricians and specialists to screen for depression, and to screen for learning disorders, and to screen for early self-injury—in addition to getting this deep look at the ADHD symptoms.

The final part of an evaluation is computerized tests of attention, objective tests. They can be helpful, but they’re not definitive. One-on-one in front of a computer screen, many kids with ADHD can pull it together for a short while, but then you put them in a classroom or in their family and things fall apart pretty quickly.

So, what you should look for in a treating professional is someone who doesn’t just write a prescription and say, “go home and come back in three months,” but someone who also includes the behavioral component and other interventions.

I think that’s very important, Steve. And that’s what we need to do much more in our country. The research is clear: kids with moderate to severe ADHD on average do best on the right dose of medication, along with Parent Management Training, teacher consultation, and helping these kids with their social skills. It’s both medication and a behavioral approach together. Medications may re-sculpt the brain a bit to be more receptive to input, but they don’t teach a child academic skills or social skills. As you say, they’ve got to learn those skills from the behavioral treatments.

Click here to read the Brain & Behavior Magazine's July 2025 issue