ADHD: Then and Now

Over the past 25 years, the landscape of ADHD—Attention-Deficit/Hyperactivity Disorder—has changed dramatically. From evolving diagnostic criteria to advances in neuroscience and greater public awareness, our understanding of ADHD today is far more nuanced than it was in the late 1990s. In this post, we’ll explore how our approach to ADHD has matured, what new insights we’ve gained, and what this means for clinical practice.

1. A Broader and More Nuanced Understanding

Then:

In the late 1990s, ADHD was commonly understood as a childhood disorder characterized by hyperactivity, impulsivity, and inattention—mostly diagnosed in boys who “couldn’t sit still” in class. Girls and inattentive-type individuals were often overlooked.

Now:

We now recognize ADHD as a neurodevelopmental disorder with symptoms that can persist into adulthood. In fact, studies estimate that up to 60–70% of children with ADHD continue to experience symptoms as adults. Clinicians are also more attuned to gender differences and inattentive presentations, which has led to improved diagnosis in girls and women who may have previously gone unnoticed.

2. Diagnostic Criteria and Assessment Tools Have Improved

Then:

The DSM-IV (published in 1994) provided basic criteria that focused heavily on observable behaviors, primarily in school-aged children.

Now:

With the release of the DSM-5 and DSM-5-TR, the criteria have been refined to better capture adult presentations and include more developmentally appropriate language. There’s also greater emphasis on impairment across multiple domains—not just in academic settings, but also in work, relationships, and daily functioning. Assessment tools have become more comprehensive and standardized, including input from multiple informants and settings.

3. Advances in Neuroscience and Genetics

Then:

ADHD was often viewed as a behavioral issue, with less understanding of its biological underpinnings.

Now:

We now understand ADHD as a brain-based condition involving dysfunction in the prefrontal cortex, dopamine regulation, and executive functioning networks. Genetic studies suggest that ADHD is highly heritable, with complex interactions between genes and environment. Functional imaging studies have also highlighted patterns of brain activity unique to ADHD.

4. Expanded Treatment Options

Then:

Treatment was largely pharmacological—primarily stimulant medications like Ritalin and Adderall. Behavioral therapy was sometimes used, often inconsistently.

Now:

While stimulants remain the gold standard, we now have a wider range of non-stimulant medications (e.g., atomoxetine, guanfacine) and a better understanding of how to individualize treatment. Cognitive-behavioral therapy (CBT), executive function coaching, mindfulness, and even digital therapeutics are increasingly part of integrated care plans. There is also more awareness of comorbidities, such as anxiety, depression, and learning disorders, which must be addressed for optimal outcomes. At 21 Reflections Professional Counseling, we are up to date on the latest research and treatments for treating ADHD. 

5. Adult ADHD Is No Longer an Afterthought

Then:

ADHD was considered almost exclusively a childhood disorder. Adults with symptoms were often misdiagnosed or dismissed.

Now:

ADHD in adults is now a recognized and research-backed diagnosis, with distinct clinical guidelines. More adults—particularly women—are being diagnosed later in life, often after their own children receive a diagnosis. This shift has profound implications for identity, mental health, and self-understanding.

Diagnosing ADHD in Adults

A. Why It’s Often Missed

• Symptoms in adults often look different than in children—less hyperactivity, more internal restlessness or executive dysfunction.

• Adults often compensate with coping strategies, masking symptoms.

• Many grew up undiagnosed due to outdated stereotypes (e.g., “only hyperactive boys have ADHD”).

• Comorbid conditions like anxiety, depression, or trauma histories can obscure ADHD symptoms.

B. Key Diagnostic Criteria (DSM-5-TR)

To diagnose ADHD in adults, clinicians look for:

• At least 5 symptoms of inattention and/or hyperactivity-impulsivity (vs. 6 in children)

• Symptoms present before age 12 (even if not diagnosed then)

• Evidence of impairment in two or more settings (e.g., work and home)

• Symptoms must interfere with social, academic, or occupational functioning

C. Comprehensive Diagnostic Process

A full evaluation typically includes:

Clinical Interview

• Explore developmental history, childhood symptoms, family history, and current functioning.

• Inquire about school performance, job history, relationships, self-regulation, time management.

Rating Scales / Self-Reports

Common tools include:

• ASRS (Adult ADHD Self-Report Scale)

• BAARS-IV (Barkley Adult ADHD Rating Scale)

• WRAADDS (Wender-Reimherr Adult Attention Deficit Disorder Scale)

• Conners’ Adult ADHD Rating Scales (CAARS)

Executive Function Screening

• Assess planning, organization, working memory, initiation, and emotional control.

• May include performance-based tests or structured questionnaires.

Collateral Information

• Input from a spouse, partner, parent, or close friend can provide insight, especially for symptoms in earlier life.

Rule Out Other Causes

• Evaluate for mood disorders, anxiety, trauma history, learning disabilities, substance use, sleep disorders, or thyroid dysfunction.

6. Reduced Stigma and Increased Awareness

Then:

Stigma around ADHD was high. Misconceptions such as “bad parenting” or “laziness” were common, and the disorder was frequently minimized.

Now:

Public awareness has increased significantly, thanks to advocacy, social media, and more open conversations around mental health. That said, stigma still exists, especially regarding adult ADHD and medication use. Clinicians continue to play a vital role in education and destigmatization.

   ADHD: Then vs. Now

False/Outdated View (Then)	Current Understanding (Now)
ADHD is just a childhood disorder.	ADHD is a lifelong neurodevelopmental condition that often continues into adulthood.
Only hyperactive boys have ADHD.	ADHD affects all genders and can present as inattentive, hyperactive-impulsive, or combined type. Girls and women often go undiagnosed due to subtler symptoms.
ADHD is caused by bad parenting or lack of discipline.	ADHD has strong genetic and neurobiological roots, not caused by parenting. However, parenting strategies can influence outcomes.
Kids with ADHD just need to try harder.	ADHD involves executive function deficits; willpower is not the issue. Support and structure are essential.
Medication is a quick fix or cure.	Medication is one part of a multimodal treatment plan that may include therapy, coaching, lifestyle adjustments, and educational supports.
ADHD is overdiagnosed and not a real condition.	ADHD is a well-documented, evidence-based diagnosis recognized by major health organizations worldwide. It is often underdiagnosed, especially in adults and marginalized populations.
Kids with ADHD will outgrow it.	Many people with ADHD continue to experience symptoms into adolescence and adulthood—up to 70% remain affected.
ADHD means you’re lazy or not intelligent.	People with ADHD often have average or above-average intelligence. The condition affects attention, not ability. Many are creative, driven, and insightful.
ADHD looks the same in everyone.	ADHD is highly individualized, with varied symptom expression and co-occurring conditions (e.g., anxiety, learning disorders).
ADHD only causes problems in school.	ADHD impacts multiple areas of life: relationships, work, emotional regulation, time management, and more.

Alternative & Complementary Treatments for ADHD

Note: These approaches are best considered as part of a comprehensive, individualized treatment plan, and ideally supervised by a clinician familiar with ADHD. Contact 21 Reflections Professional Counseling to be connected to a counselor for your ADHD needs. 

1. Behavioral Therapy / Cognitive-Behavioral Therapy (CBT)

• Focuses on developing coping strategies, improving executive function, and changing negative thinking patterns.

• Especially effective for older children, teens, and adults.

• Helps manage emotional dysregulation, procrastination, and low self-esteem often tied to ADHD.

2. Parent Training & Behavioral Parent Management

• Educates parents on structure, routines, consistent reinforcement, and communication strategies.

• Evidence-based for improving behavior in young children with ADHD.

• Empowers families to manage symptoms at home.

3. ADHD Coaching & Executive Function Coaching

• Helps with time management, organization, planning, and task initiation.

• Especially useful for teens and adults struggling with school, work, or life skills.

• Coaches are not therapists but can work in collaboration with one.

4. Mindfulness & Meditation

• Improves attention, emotional regulation, and impulse control.

• Practices like mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) have shown positive effects in both kids and adults.

• Apps like Headspace and Smiling Mind offer ADHD-friendly meditations.

5. Diet & Nutrition

• No single diet “cures” ADHD, but certain changes can help:

  • Protein-rich meals can support dopamine production.

  • Omega-3 fatty acids (EPA/DHA from fish oil) may improve attention and reduce hyperactivity.

  • Avoid artificial food dyes, preservatives, and excess sugar—though benefits vary.

• Always consult a dietitian or physician before making significant changes or taking supplements.

6. Exercise & Movement

• Physical activity increases dopamine and norepinephrine, improving focus and mood.

• Activities like martial arts, swimming, yoga, and team sports have shown particular benefits.

• Regular exercise can help regulate sleep and reduce impulsivity.

7. Neurofeedback (EEG Biofeedback)

• Trains individuals to regulate their brain wave activity.

• Some studies show promise, especially for attention and impulsivity, though results are mixed and it remains controversial in terms of clinical efficacy.

• Can be expensive and is not always covered by insurance.

8. Sleep Hygiene Interventions

• Many with ADHD struggle with insomnia or poor sleep quality.

• Behavioral sleep interventions (e.g., bedtime routines, limiting screens, consistent sleep/wake times) can reduce ADHD symptoms significantly.

• In some cases, a sleep study is recommended to rule out sleep disorders.

9. Digital Therapeutics & Apps

• FDA-cleared digital tools like EndeavorRx (for children) use game-based interventions to improve attention.

• Task management and productivity apps (e.g., Todoist, Trello, Focusmate) can support daily functioning.

10. Nature & Green Time

• Regular exposure to natural environments (parks, green spaces) has been associated with reduced ADHD symptoms.

• Even brief outdoor time can help improve focus and reduce stress.

As our understanding of ADHD continues to evolve, so too does our ability to support those who live with it. What was once seen narrowly as a childhood behavior issue is now recognized as a complex, lifelong condition that impacts every facet of life—from relationships to careers to self-esteem. Today, we have more tools, insights, and compassion than ever before. Whether you’re a clinician, parent, educator, or someone navigating your own ADHD journey, the message is clear: with the right support and understanding, people with ADHD can not only manage their symptoms—they can thrive. At 21 Reflections Professional Counseling, we are proud to offer support within this area of treatment today. 

-Lauren Brymer, MA, LCPC, CADC