ADHD and Disordered Eating
John Fleming, Ph.D. and Lance Levy, M.B.
Published in Gender Issues and ADHD: Research, Diagnosis, and Treatment Edited by Patricia Quinn, M.D. and Kathleen Nadeau, Ph.D.2002, Advantage Books.
Available at Addvance website www.addvance.com
Reprinted by permission
Anyone who has lived with Attention Deficit Hyperactivity Disorder knows that it can interfere with many different aspects of one’s life: educational and career performance, parenting style, romance, leisure pursuits, and friendships. ADHD may also significantly modify one of the most basic and essential of human concerns, eating behavior. While many practitioners have been aware of the impact of ADHD on eating , there has been little systematic study of this issue. Here, we hope to open the issue for discussion based on our clinical work with disordered eating and a sequential case study of symptoms of ADHD among the severely obese.
Disordered eating is a consequence of a large number of different factors, including genetic, social, medical, psychological, and environmental determinants. We do not propose that ADHD is a universal determinant of disordered eating, but rather that it is a contributing factor which impacts on a subgroup of individuals. In this chapter, we will examine the broader spectrum of disturbed eating behaviors, including obesity, binge eating disorder, and bulimia .
If we knew then what we know now…
Though we did not realize it at the time, our first clue to the possible connection between disordered eating and ADHD came in an unpublished pilot study of obese clients conducted at our Nutritional Disorders Clinic in 1988-90. These 50 self-referred clients were significantly obese, with a Body Mass Index of greater than 32 (BMI, calculated by height in meters squared over weight in kg), they were not bulimic, and their weight was stable. (See Levy, 2000, for complete discussion and results.) One area of interest was the discrepancy between their weekly self-reported dietary intake, and their measured caloric requirements for maintaining their weight (with open circuit indirect calorimetry). We found that 48% of these clients under-reported food intake by 400 to 900 calories per day. This subgroup also showed a lack of awareness of many significant experiences, such as mood states, chronic pain, chronic tiredness, sleep fragmentation, and other medical problems such as gastrointestinal disorders (e.g., irritable bowel syndrome). They also showed a reduced ability to recognize internal signals of hunger, fullness, and thirst, and tended to over-estimate what a normal portion size of food should look like. While we did not recognize the possible relationship to ADHD at the time, we did note that it is well established that individuals with anorexia and bulimia nervosa tend to be deficient in their awareness of emotional states, and states of hunger and satiety . While our study subjects did not meet the criteria for either of these disorders, they clearly had disturbed eating habits, with typically no regularly planned meals or snacks, and an inability to follow dietary plans for any useful length of time. Simply put, half of our subjects were unaware of, or inattentive to, many of the physical and psychological factors that can modify eating behavior and hence weight control.
Our many years of clinical experience has demonstrated that the identification and effective treatment of a variety of psychological and medical conditions is critically important in enabling many clients to correct disordered eating, poor lifestyle choices, and overweight. However, we found that a significant minority of clients (though markedly improved in mood, energy level, pain control, and the like) did not lose weight easily and could not sustain dietary and lifestyle changes beyond a few weeks. This group continued to be very poor reporters of their actual intake. After careful clinical assessment, we were quite sure that these clients were not deliberately resistant to change, nor were they in significant psychological denial. Clearly, something more was going on that caused these intelligent and well-motivated people to be so inconsistent in their efforts. We began to understand that this problem could be related to an attention deficit when a client named “Annie” came for help.
Our Wake-up Call: The Story of Annie
Annie was a 32-year-old woman who had been referred because of a longstanding inability to lose weight. She was successful in her profession, had a good marriage and two young children. At just over five feet, her BMI was 47. She reported that she ate relatively little and was careful in her food choices. Her dietary records showed that she consumed 2000 calories a day on average. Direct measurement of her metabolism with open circuit indirect calorimetry showed that her metabolism was normal. Her calculated energy requirement for weight maintenance indicated that she required approximately 2800 calories to maintain her weight . This means that she was eating the equivalent of a substantial extra meal with no real awareness. This is not what most people would expect from someone with a university degree working as a senior manager in a large business. But, as she sat leaning forward in her chair with her foot tapping rapidly to some unheard song, responding to our questions before we could finish asking them, something clicked. While she was clearly not manic, we did wonder about her “hyper” state. While the thought of hyperactivity and obesity coexisting seemed unlikely at first, the more we learned about ADHD, the more sense it made.
In taking a careful history, it became clear that Annie compensated for her difficulties in concentration by being bright enough to fill in the gaps. Her school performance varied with her interest. She did very well in subjects she liked, and did poorly when a course did not interest her. Essays and various projects were always begun at the 11th hour but successfully completed just in time. Clearly, her quick mind also allowed her to overcome her penchant for procrastination. Her work career was charged by a rapid advancement that allowed her to maintain her interest with new and varied challenges. As long as she was over-committed, adrenaline kept her focused. Over time, she found herself working longer hours since she only felt in control and positive about herself in her professional life. In sharp contrast to this corporate superwoman, the private Annie was binge eating, sleeping poorly, and was clinically depressed. Her home life was chaotic except for those areas that were managed by her highly organized spouse. When we finished our assessment, her response to the diagnosis of ADHD Combined type, was one of absolute recognition and relief. For us, it opened the door to understanding another dimension of the complex etiology of disordered eating.
After recognizing the possible contribution of ADHD to disordered eating and learning more about the variability in its manifestation in adults, we soon found that Annie’s history was not as unusual as we first thought. As we took a fresh look at our clients, we found that roughly one third of the people we were seeing showed compelling evidence of ADHD. We found this to be true for people with binge eating disorder, bulimia, and for the severely obese.
It is quite clear that not all individuals with obesity have major psychological problems , nor do they all have characteristics that would suggest ADHD. We are also quite certain that most people with ADHD never develop serious problems with obesity or other forms of eating pathology. However, we do believe that there is a sub-population of people with disordered eating where undiagnosed ADHD plays a major role in the etiology and maintenance of the disorder.
Unfortunately, literature searches as well as queries to colleagues provided little in the way of research addressing the possible contribution of ADHD to the development of disordered eating. Schweickert, Strober, and Moskowitz published one case study of a college student with bulimia who had been diagnosed with ADHD as a child. She was engaging in frequent episodes of binge eating, but also complained of ongoing problems with distractibility, concentration, organizing schoolwork, and studying and taking tests. Within one week of treatment with methylphenidate, she reported that her ADHD symptoms had much improved and that the eating binges had stopped. At 16week followup, she had still not resumed binge eating.
In a related publication, Sokol, Gray, Goldstein, and Kaye reported the results of their clinical trial with two bulimics with B cluster personality disorders who were successfully treated with methylphenidate. Both showed a significant decrease in bulimic pathology while taking methylphenidate after having had no benefit from trials of SSRI antidepressants. The authors also reported the results of a pilot study looking at the occurrence of ADHD among bulimics. They found that a group of bulimic patients with comorbid B cluster personality disorders reported more symptoms of ADHD than a normal comparison group. Though somewhat difficult to interpret because of the very small sample size of 13, and because the bulimia was confounded with the presence of a personality disorder, the findings are certainly suggestive of a relationship between ADHD and bulimia.
From the obesity literature we found no direct investigations of a possible relationship between disordered eating and ADHD. One recent study found a strong correlation (r= -.84) between dopamine receptor density as measured by PET scan and BMI. That is, individuals with the lowest density of dopamine receptors had the highest BMIs. Given the substantial amount of evidence documenting the role of dopamine in the etiology of ADHD , these results should be considered relevant.
Thus far, little hard data have come from the ADHD literature. A number of authors have raised the clinical issue of problematic patterns of eating among their ADHD clients. Richardson (1997) has discussed the use of food in the context of an analysis of the relationship of ADHD to addictive behaviors. Clinical discussions have suggested that eating might help fulfill the need for high stimulation in ADHD, decrease agitation, or satisfy a need for control . Similarly, Robin (1998) recommends screening for ADHD in bulimia and binge eating disorder because of the prevalence of poor self-control and impulsivity in this population.
As a follow up to clinical observations, a more formal study was undertaken to investigate the prevalence of symptoms of AD/HD among a group of severely obese individuals who were referred to a medical specialty clinic for treatment. Using a sequential case study design, 57 women and 13 men having a BMI of 35 or more were assessed during a one-year period. As a function of the referral process, these people tended to be more chronic than the general population in their struggle with weight, and most had extensive histories of failed attempts at weight management.
To address the DSM-IV (American Psychiatric Association, 1994) diagnostic requirement that symptoms of AD/HD be present before the age of seven, the Wender Utah Scale was used (, a retrospective survey of behavior problems characteristic of childhood AD/HD). Based on clinical experience, a total Wender score of 60 was deemed as reflecting a history consistent with AD/HD. To receive a score of 60 the respondent would have to report significant difficulty across numerous behavioral domains, including problems with concentration, emotionality, school problems, social problems, and disorganization. It was found that 60% of the sample described a childhood history consistent with a diagnosis of childhood AD/HD.
To measure the presence of current symptoms of AD/HD, the long form of the Conners’ Adult ADHD Rating Scale was used. Since the Conners instrument has multiple scales measuring each primary domain (inattentiveness and hyperactivity/impulsivity), it was decided that a positive case would be defined by elevations in at least two subscales (with the exception of the self-esteem scale, which is not specific to AD/HD symptomology). A scale was considered elevated if the T score was 65 or above (at or above the 93rd percentile) on the age and gender specific norms . It was found that 30% of the sample had two or more of the AD/HD scales elevated in addition to having a childhood history consistent with a diagnosis of AD/HD. The percentage of probable AD/HD cases was 23.1% among males, 31.6% among females.
After we had enlisted just over half of the subjects for the study, we decided to have all remaining subjects (n=29) complete a second adult AD/HD instrument; the Brown ADD Scales (Brown, 1996). This scale differs from the Conners’ in that it does not assess hyperactivity and impulsivity, but focuses on problems with executive function (inattention, affect regulation, maintaining effort, activation, and memory). When we looked only at the subsample of subjects that completed the Brown (n=29), 13 (44.8%) had profiles suggestive of the presence of AD/HD, as indicated by a suggestive childhood history and a total Brown T score of 65 or above. Using a very different measure, we again found very high levels of the kind of cognitive impairment that characterizes AD/HD.
The authors do not suggest that self-report tests alone are adequate to diagnose AD/HD. It was also clear from clinical interviews with a number of the study subjects, that these selection criteria failed to identify all cases of AD/HD. Several subjects who were generally quite bright and better adjusted psychologically, did not demonstrate the requisite level of difficulty during childhood, or tended to minimize the extent of their problems on the adult symptom questionnaires. Despite the recognized limitations of this study, on the basis of reported findings it seems clear that there is a clinically significant relationship between AD/HD and the development of dysfunctional patterns of eating in the severely obese that warrants further research.
ADHD and Disordered Eating: Why the connection?
How might ADHD contribute to the development of disordered eating? Several authors have emphasized that ADHD is characterized by problems in self-regulation. These deficiencies in self-regulation include problems with working memory, attention, primary arousal, affect regulation, and organization. Dietary regulation is a complex process and can be quite vulnerable to disruption. One important factor in self-regulation is an ongoing awareness of the cues for hunger and fullness . In order to know when to eat and when to stop eating, it is necessary to be continuously aware of how you feel and the subtle changes in these states. People with ADHD are renowned for their lack of self-awareness . Maintaining a high level of awareness of internal states, particularly in the context of other activities, can be extremely challenging for someone with ADHD. Many of our ADHD/eating disordered clients report that they often miss meals because they never notice being hungry and only know to stop eating when they feel “stuffed”.
Dietary regulation also requires a fairly high degree of organization and planning, another potential area of difficulty for those who struggle with ADHD. Eating nutritious food at appropriate intervals requires a series of actions, including making a shopping list, buying the food, and preparing it. It is also necessary to be sensitive to the passage of time to know that you are due for a refueling. A person who is already feeling overwhelmed by the demands of their life, will not invest the personal resources to manage these dietary fundamentals. It is far easier to “make do”. (See Barkley, 1997, for a discussion of time awareness.)
Generally speaking, self-regulation requires good inhibitory control. People eat for many reasons other than physiological hunger, such as boredom, excitement, anger, sadness, food availability, reward, and stress relief. Surrounded by highly desirable food, we very often have to say “no” to the impulse to eat. Again, it is easy to see how ADHD puts someone at a disadvantage, since difficulties with impulse control are a central defining attribute .
Our clinical experience has shown us that the more ambiguous or contradictory the rules, the more difficult it is for an individual with ADHD to make good decisions. On a daily basis, we are bombarded with a vast quantity of contradictory and confusing advice about how to eat properly. Furthermore, eating provides immediate gratification while the consequences of a poor dietary choice are abstract and delayed. Individuals with ADHD tend to be dominated by the moment, reactive, and regretful for the lack of foresight .
Probably the best way to examine the relationship between disordered eating and ADHD is to look directly at some of the clinical issues involved in its treatment. The following suggestions are intended for health-care providers but also for consumers, who we encourage to take an active role in educating themselves and being a partner in their own care.
Treatment Considerations: ADHD and Disordered Eating
The cognitive and behavioral symptoms of ADHD can exert a significant and negative impact in the area of food regulation. While the pharmacological treatment of the problems of impulsivity and inattentiveness can produce striking improvement, weight loss or the modification of eating behaviors typically require more intensive intervention. Bulimia, binge eating disorder, as well as significant obesity are complex disorders that typically require psychological and medical intervention for resolution. While a full plan for treating the eating disordered client with ADHD is outside of the scope of this chapter, what follows is a brief discussion of some important issues.
Ask your ADHD clients about their eating behavior. It is important to ask directly about issues with weight and eating because many individuals with a pattern of disordered eating feel a great deal of shame over their perceived inadequacies in this area. If such problems seem to be present, ask about their appetite awareness. Do they experience feelings of being out of control with food when they are bored or under-stimulated; do they binge eat? It is very helpful to explore how their ADHD might impact on their eating to help reduce their self-blame and begin the process of regaining control.
Medical problems causing poor weight control must be treated in order to make ADHD recognizable and responsive to treatment. If your client’s eating habits are very disorganized, make sure that she is properly assessed for the following problems, as any of them can make weight management almost impossible if untreated and they may mask the symptoms of ADHD. The medical and psychological problems that underlie an inability to deal effectively with diet and lifestyle changes include: Mood Disorders (depression/anxiety), Chronic Tiredness, Chronic Pain, Chronic Gastrointestinal Disorders (such as irritable bowel syndrome), and Disorders of Impulse Regulation (binge eating disorder, night time eating syndrome, and ADHD) . These medical/psychological problems should be assessed since a number of them, especially Chronic Tiredness, Mood Disorders, and Chronic Pain, can mimic some of the symptoms of ADHD and make it hard to monitor responses to treatment.
Identify problems with meal planning. One of the initial requirements for correcting a disordered pattern of eating is to identify those situations, times of day, interpersonal pressures, and thought patterns that are associated with loss of control over food intake and poor meal planning. This is especially important because many people with ADHD tend to forget about eating when they are fully engaged in an activity. They are more likely to eat during lulls in the action, by which time they may have gone many hours without adequate food intake (and are likely ravenous). This tendency is due to an under-awareness of hunger signals, and is a major problem when a person with ADHD is trying to gain control over their eating. By under-eating, hunger builds up over the day so that control over intake is overwhelmed by the urgent need to eat. ADHD clients require assistance in planning regular food breaks and learning to read internal signals regarding hunger and early satiety. Establishing appropriate portion size also appears to be more difficult when ADHD is present. Many clients find it useful to have visual cues to improve their judgment, such as working with plastic food models, using smaller plates, or using their palm or fingers as measurement guides.
Emphasize the basics. Contrary to what we are constantly being told by the multi-billion-dollar diet industry, the basics of good nutrition are fairly simple and straightforward. People become preoccupied with cutting calories and place an unfortunate emphasis on the value of not eating. Instead, the focus needs to be placed on taking in adequate nutrition by deliberate planning so that one does not become excessively hungry, which tends to cause overeating. Generally, people should not go more than four hours without either a meal or snack if they have difficulty regulating their eating . Their intake should never drop below a level that is adequate to maintain a reasonable body weight (which can often be defined as the lowest adult weight that they had maintained for at least a year without dieting). That is, they should go directly to what the diet industry calls the “maintenance” part of the diet. To the surprise of many, this requires an intake of somewhere between 1800 to 2500 calories for a normally active adult woman . Because people with ADHD are not known for their patience, they often need to be convinced that “slow is the only way to go”. Emphasizing realistic goals is also important. All people are not meant to be thin and it has been well established that as little as a ten percent reduction in weight can substantially reduce many of the health risk factors associated with obesity .
Discourage dieting. Research has consistently demonstrated that the vast majority of individuals who lose weight through low calorie dieting not only regain the weight, but end up at an even higher weight than where they started . Repeated failures to control weight through dieting cause people to see themselves as ineffectual, stupid, out-of-control, and helpless. They blame themselves rather than see that diets simply do not work. Long term adherence to low calorie diets can increase the chance of developing either bulimia or binge eating disorder and creates a tremendous disruption in one's ability to accurately read physical cues for hunger and fullness . On the basis of what we know about clients with ADHD, it would seem likely that they are even more adversely affected by dieting because of their high level of impulsivity and limited abilities for self-awareness. Coaching is needed to devise a deliberate and reasonable plan for eating to replace the bad habits that arose out of ADHD inspired disorganization, impulsiveness, and disturbance in self-awareness.
Medication. Quite strikingly, our clinical experience has shown that medication use alone does not effectively alter the disordered eating habits of individuals with ADHD. While good results are sometimes initially seen because stimulant medication temporarily causes appetite suppression, this side effect is typically short-lived. Improved cognitive functioning, as demonstrated by decreased ADHD symptoms, can set the stage for change, but does not by itself alter strongly ingrained patterns of abnormal eating behavior. It is critical to separate this clinical practice from the debacle that occurred during the ‘50s and ‘60s, where stimulants were commonly used in treatment of obesity. Amphetamines were liberally prescribed to diminish interest in food by using the side effect of appetite suppression. The problem is that, for most adults, the appetite suppressing effect of these medications is temporary and disappears unless the dose is repeatedly increased . This is entirely contrary to the way stimulant medications are used in the treatment of ADHD, where there is no evidence of a tolerance effect .
It is critical that before any trial of stimulant medication is begun with someone with a history of disordered eating, that the possible contribution of ADHD be examined carefully and thoroughly. It is irresponsible to continue prescribing stimulant medication in relation to disordered eating without ongoing supervision and monitoring of dietary compliance, since the potential for abuse is probably higher than in the general ADHD population. While medication can be an effective adjunct to treatment of patterns of disordered eating in someone with ADHD, it should never be used in the absence of ongoing behavioral treatment. In this context, medication is used to improve executive functioning that, in turn, impacts on the ability to control eating behavior. Stimulant medication should never be used for its side effect of appetite suppression.
Adequate medication coverage is also a critical issue when it comes to helping someone manage their eating more effectively. The most difficult time for most individuals is in the evening. Here, it becomes a somewhat tricky business of balancing the need to maintain adequate levels of medication, while still ensuring that these medications do not interfere with sleep. We often have to work hard with clients to establish external structures and routines to ensure consistent dosing schedules.
The importance of stimulation. Perhaps because of our cultural biases and prejudices concerning overweight individuals, we have failed to fully appreciate the importance of adequate stimulation in dietary control. Individuals with ADHD typically require higher levels of stimulation in order to feel focused and emotionally balanced . For many, being under-stimulated creates an uncomfortable feeling of irritability, boredom, or fatigue that is temporarily remedied by turning to food. Since food is so readily available, it can be very difficult for many individuals to resist the urge to eat if they find themselves frequently under-stimulated. We have found that many of our female clients do not appreciate their needs for stimulation or how to best fulfill them. It is critical to plan leisure time that provides adequate challenge and a sense of accomplishment. People seldom treat their own time as something of real value, and instead spend it engaged in activities (such as watching television) that they are not even likely to remember the following day. (For a unique discussion of this issue, see .)
When it comes to satisfying a high need for stimulation, boys and men with ADHD tend to have a real advantage. There are more socially approved outlets for boys who have an inherent need for stimulation. Most social activities for girls are centered around discussion and “chatting” . In contrast, boys have easier access to sports, more activity oriented socializing, and it is generally more socially acceptable for males to do such things as start a rock band, ride a motorcycle, or go on an “adventure”. The double standard is most apparent when it comes to sexual stimulation, where “boys will be boys”, but girls who are more sexually adventurous are judged very harshly.
Our culture has maintained the fairy tale idea that women should be happy and satisfied by maintaining the nest (while working full time and remaining forever young, of course). This expectation just doesn’t work for many women, and especially those with ADHD. Food and eating provide a private and readily available solution to high stimulation needs. By eating alone, women with a high need for stimulation can use food to help hide who they really are. It helps them swallow the arbitrary expectation that they should not crave excitement or new stimulation. Many of our female clients are tremendously relieved when they are encouraged to fulfill their need for adventure and novel experience.
Psychotherapy. It would require a book rather than a chapter to address the important issues of the psychological counseling of individuals with disordered eating. Still, a few comments are indicated. Since there are few people with expertise in both ADHD and disordered eating, a caregiver might consider working in collaboration or consultation with another professional. By keeping communication open between all parties, this can be a highly successful approach. As we have repeatedly mentioned, there is no singular route to the development of a pattern of disordered eating, and therefore, no simple solutions. However, by keeping an open mind and letting the client guide you to those areas where she is struggling the most, a collaborative process of problem solving can produce positive results. While the normalization of eating is generally considered a prerequisite for recovery from binge eating disorder and bulimia , normalizing one’s eating can often cause intense and debilitating anxiety that needs to be recognized and treated.
In our study, over 30% of our seriously overweight clients had significant symptoms of ADHD, which contributed to their difficulty with changing their eating behavior. On the basis of our clinical experience and research, we feel that an adequate assessment of disordered eating should entail the consideration of comorbid ADHD. Furthermore, because of the critical health consequences of obesity and other patterns of disordered eating, we believe it also to be important to enquire about these issues when working with individuals with ADHD.