adhd topics for research paper

162 ADHD Essay Topics & Examples

Looking for ADHD topics to write about? ADHD (attention deficit hyperactivity disorder) is a very common condition nowadays. It is definitely worth analyzing.

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In your ADHD essay, you might want to focus on the causes or symptoms of this condition. Another idea is to concentrate on the treatments for ADHD in children and adults. Whether you are looking for an ADHD topic for an argumentative essay, a research paper, or a dissertation, our article will be helpful. We’ve collected top ADHD essay examples, research paper titles, and essay topics on ADHD.

• ADHD and its subtypes
• The most common symptoms of ADHD
• The causes of ADHD: genetics, environment, or both?
• ADHD and the changes in brain structures
• ADHD and motivation
• Treating ADHD: the new trends
• Behavioral therapy as ADHD treatment
• Natural remedies for ADHD
• ADD vs. ADHD: is there a difference?
• Living with ADHD: the main challenges
• Learning Disabilities: Differentiating ADHD and EBD As for the most appropriate setting, it is possible to seat the child near the teacher. It is possible to provide instructions with the help of visual aids.
• Everything You Need to Know About ADHD The frontal hemisphere of the brain is concerned with coordination and a delay in development in this part of the brain can lead to such kind of disorder.
• ADHD and Its Effects on the Development of a Child In particular, this research study’s focus is the investigation of the impact of household chaos on the development and behavior of children with ADHD.
• The History of ADHD Treatment: Drug Addiction Disorders Therefore, the gathered data would be classified by year, treatment type, and gender to better comprehend the statistical distribution of the prevalence of drug addiction.
• Attention Deficit Hyperactivity Disorder and Recommended Therapy The condition affects the motivational functioning and abnormal cognitive and behavioural components of the brain. Dysfunction of the prefrontal cortex contributed to a lack of alertness and shortened attention in the brain’s short-term memory.
• Rhetorical Modes Anthology on Attention Deficit Disorder It clearly outlines the origin and early symptoms of the disorder and the scientist who discovered attention deficit hyperactivity disorder. Summary & Validity: This article describes the causes of hyperactivity disorder and the potential factors […]
• Attention-Deficit Hyperactivity Disorder in a Young Girl The particular objective was to assist Katie in becoming more focused and capable of finishing her chores. The patient received the same amount of IR Ritalin and was required to continue taking it for an […]
• Similarities and Differences: SPD, ADHD, and ASD The three disorders, Sensory Processing Disorder, Attention Deficit Hyperactivity Disorder, and Autism Spectrum Disorder, are often confused with each other due to the connections and similarities that exist.
• Attention Deficit Hyperactivity Disorder Awareness According to Sayal et al, ADHD is common in young boys as it is easier to identify the problem. The disorder is well-known, and there is no struggle to identify the problem.
• Assessing the Personality Profile With ADHD Characteristics On the contrary, the study was able to understand significant changes in the emotional states and mood of the children when the observations and the tests ended.
• Aspects of ADHD Patients Well-Being This goal can be achieved through the help of mental health and behavioral counselors to enhance behavioral modification and the ability to cope with challenges calmly and healthily.
• ADHD and Problems With Sleep This is because of the activity of a person in the middle of the day and the condition around them. The downside of the study is that the study group included 52 adults with ADHD […]
• The Attention Deficit Hyperactivity Disorder Treatment It has been estimated that when medicine and therapy are applied as treatment together, the outcomes for children with ADHD are excellent.
• Attention Deficit Hyperactivity Disorder Organization’s Mission Children and Adults with Attention-Deficit/Hyperactivity Disorder is an organization that is determined to handle individuals affected by ADHD. The organization was founded in 1987 following the rampant frustration and isolation that parents experienced due to […]
• Case Conceptualization: Abuse-Mediated ADHD Patient The case provides insight into the underlying causes of James’s educational problems and the drug abuse of his parents. The case makes it evident that the assumption from the first case conceptualization about James’s ADHD […]
• Change: Dealing With Patients With ADHD In the current workplace, the most appropriate change would be the increase in the awareness of nurses regarding the methods of dealing with patients with ADHD.
• Dealing With Attention Deficit Hyperactivity Disorder Although my experience is not dramatic, it clearly shows how untreated ADHD leads to isolation and almost depression. However, the question arises of what is the norm, how to define and measure it.
• Parents’ Perception of Attending an ADHD Clinic The main principles of the clinic’s specialists should be an objective diagnosis of the neurological status of the child and the characteristics of his/her behavior, the selection of drug treatment only on the basis of […]
• ADHD: Mental Disorder Based on Symptoms The DSM-5 raised the age limit from 6 to 12 for qualifying the disorder in children and now requires five instead of six inattentive or hyperactive-impulsive symptoms.
• Understanding Attention-Deficit/Hyperactivity Disorder Thus, the smaller sizes of the reviewed brain structures associated with ADHD result in problems with attention, memory, and controlling movement and emotional responses.
• Effective Therapies for Attention Deficit Hyperactivity Disorder The problem at hand is that there is a need to determine which of the therapies administered is effective in the management of ADHD.
• Participants of “ADHD Outside the Laboratory” Study The participants in the testing group and those in the control group were matched for age within 6 months, for IQ within 15 points and finally for performance on the tasks of the study.
• Variables in “ADHD Outside the Laboratory” Study The other variables are the videogames, matching exercise and the zoo navigation exercise used to test the performance of the boys.
• Different Types of Diets and Children’s ADHD Treatment The last factor is a trigger that can lead to the development of a child’s genes’ reaction. Thus, diet is one of the factors that can help prevent the development of ADHD.
• Attention Deficit Hyperactivity Disorder in Children The consistent utilization of effective praises and social rewards indeed results in the behavioral orientation of the child following the treatment goals.
• Reward and Error Processing in ADHD: Looking Into the Neurophysiological and the Behavioral Measures The study was mainly concerned with looking into the neurophysiological and to some extent the behavioral measures utilized in self regulation particularly in children suffering from attention – deficit hyperactivity disorder and those who are […]
• Vyvanse – ADD and ADHD Medicine Company Analysis It is produced by Shire and New River Pharmaceuticals in its inactive form which has to undergo digestion in the stomach and through the first-pass metabolic effect in the liver into L-lysine, an amino acid […]
• Dealing With the Disruptive Behaviors of ADHD and Asperger Syndrome Students While teaching in a class that has students with ADHD and Asperger syndrome, the teacher should ensure that they give instructions that are simple and easy to follow.
• Behavioral Parenting Training to Treat Children With ADHD These facts considered, it is possible to state that the seriousness of ADHD accounts for the necessity of the use of behavioral parental training as the treatment of the disorder.
• Current Issues in Psychopharmacology: Attention-Deficit Hyperactivity Disorder This is the area that is charged with the responsibility for vision control as well as a regulation of one’s brain’s ability to go to aresynchronize’ and go to rest.
• Cognitive Psychology and Attention Deficit Disorder On top of the difficulties in regulating alertness and attention, many individuals with ADD complain of inabilities to sustain effort for duties.
• ADHD Symptoms in Children However, there are some concerns in identifying the children with ADHD.described in a report that support should be initiated from the parents in, recognizing the problem and seeking the help of the educational professionals.2.
• Adult and Paediatric Psychology: Attention Deficit Hyperactivity Disorder To allow children to exercise their full life potential, and not have any depression-caused impairment in the social, academic, behavioral, and emotional field, it is vital to reveal this disorder as early in life, as […]
• Attention-Deficit Hyperactivity Disorder: Biological Testing The research, leading to the discovery of the Biological testing for ADHD was conducted in Thessaloniki, Greece with 65 children volunteering for the research. There is a large difference in the eye movement of a […]
• Issues in the Diagnosis of Attention-Deficit Hyperactivity Disorder in Children Concept theories concerning the nature of attention-deficit/hyperactivity disorder influence treatment, the approach to the education of children with ADHD, and the social perception of this disease.
• Attention Deficit Hyperactivity Disorder Care Controversy The objective of this study was to assess the efficacy, in terms of symptoms and function, and safety of “once-daily dose-optimized GXR compared with placebo in the treatment of children and adolescents aged 6 17 […]
• Attention Deficit Hyperactivity Interventions The authors examine a wide range of past studies that reported on the effects of peer inclusion interventions and present the overall results, showing why further research on peer inclusion interventions for children with ADHD […]
• Sociodemographic and Cultural Factors of Attention Deficit Hyperactivity Disorder Children at this age have particular difficulties in retaining and concentrating attention and in controlling behavior, and this stage is sensitive to the development of these abilities. The general problem is the increase in prevalence […]
• Attention Deficit Hyperactivity Disorder (ADHD) in a Child A child counselor works with children to help them become mentally and emotionally stable. The case that is examined in this essay is a child with attention deficit hyperactivity disorder.
• Attention Deficit Hyperactivity Disorder: Drug-Free Therapy The proposed study aims to create awareness of the importance of interventions with ADHD among parents refusing to use medication. The misperceptions about ADHD diagnosis and limited use of behavioral modification strategies may be due […]
• Attention Deficit Hyperactivity Disorder: Psychosocial Interventions The mentioned components and specifically the effects of the condition on a child and his family would be the biggest challenge in the case of Derrick.
• The Diagnosis and Treatment of ADHD Cortese et al.state that cognitive behavioral therapy is overall a practical approach to the treatment of the condition, which would be the primary intervention in this case.
• The Attention Deficit Hypersensitivity Disorder in Education Since ADHD is a topic of a condition that has the potential to cripple the abilities of a person, I have become attached to it much.
• Attention Deficit Hyperactivity Disorder: Comorbidities Due to the effects that ADHD has on patients’ relationships with their family members and friends, the development of comorbid health problems becomes highly possible.
• Medicating Kids to Treat ADHD The traditional view is that the drugs for the disorder are some of the safest in the psychiatric practice, while the dangers posed by untreated ADHD include failure in studies, inability to construct social connections, […]
• Attention Deficit Hyperactivity Disorder: Signs and Strategies Determining the presence of Attention Deficit Hyperactivity Disorder in a child and addressing the disorder is often a rather intricate process because of the vagueness that surrounds the issue.
• Cognitive Therapy for Attention Deficit Disorder The counselor is thus expected to assist the self-reflection and guide it in the direction that promises the most favorable outcome as well as raise the client’s awareness of the effect and, by extension, enhance […]
• “Stress” Video and “A Natural Fix for ADHD” Article There certainly are some deeper reasons for people to get stressed, and the video documentary “Stress: Portrait of a Killer” and the article “A Natural Fix for A.D.H.D”.by Dr.
• Attention Deficit Disorder: Diagnosis and Treatment The patient lives with her parents and 12-year-old brother in a middle-class neighborhood. Her father has a small business, and her mother works part-time in a daycare center.
• Bright Not Broken: Gifted Kids, ADHD, and Autism It is possible to state that the book provides rather a high-quality review of the issues about the identification, education, and upbringing of the 2e children.
• Attention Deficit Hyperactive Disorder: Case Review On the other hand, Mansour’s was observed to have difficulties in the simple tasks that he was requested to perform. Mansour’s appears to be in the 3rd phase of growth.
• Treatment of Children With ADHD Because of the lack of sufficient evidence concerning the effects of various treatment methods for ADHD, as well as the recent Ritalin scandal, the idea of treating children with ADHD with the help of stimulant […]
• Attention Deficit Hyperactivity Disorder Medicalization This paper discusses the phenomenon of medicalization of ADHD, along with the medicalization of other aspects perceived as deviant or atypical, it will also review the clash of scientific ideas and cultural assumptions where medicalization […]
• Medication and Its Role in the ADHD Treatment Similar inferences can be inferred from the findings of the research conducted by Reid, Trout and Schartz that revealed that medication is the most appropriate treatment of the symptoms associated with ADHD.
• Children With Attention-Deficit Hyperactivity Disorder The purpose of the present research is to understand the correlation between the self-esteem of children with ADHD and the use of medication and the disorder’s characteristics.
• Psychology: Attention Deficit and Hyperactivity Disorder It is important to pay attention to the development of proper self-esteem in children as it can negatively affect their development and performance in the future.
• Natural Remedies for ADHD The key peculiarity of ADHD is that a patient displays several of these symptoms, and they are observed quite regularly. Thus, one can say that proper diet can be effective for the treatment of attention […]
• Cognitive Behavior Therapy in Children With ADHD The study revealed that the skills acquired by the children in the sessions were relevant in the long term since the children’s behaviors were modeled entirely.
• Is Attention Deficit Hyperactivity Disorder Real? In fact, the existence of the condition, its treatment and diagnosis, have been considered controversial topics since the condition was first suggested in the medical, psychology and education.
• Is Attention Deficit Disorder a Real Disorder? When Medicine Faces Controversial Issues In addition, it is necessary to mention that some of the symptoms which the children in the case study displayed could to be considered as the ones of ADHD.
• Foods That Effect Children With ADHD/ ADD Therefore, it is the duty of parents to identify specific foods and food additives that lead to hyperactivity in their children.
• Toby Diagnosed: Attention Deficit Hyperactivity Disorder The symptoms of the disorder are usually similar to those of other disorder and this increases the risks of misdiagnosing it or missing it all together.
• Identifying, Assessing and Treating Attention Deficit Hyperactivity Disorder For these criteria to be effective in diagnosing a child with ADHD, the following symptoms have to be present so that the child can be labelled as having ADHD; the child has to have had […]
• ADHD Should Be Viewed as a Cognitive Disorder The manifestation of the disorder and the difficulties that they cause, as posited by the American Psychiatric Association, are typically more pronounced when a person is involved in some piece of work such as studying […]
• Attention Deficit Hyperactivity Disorder Influence on the Adolescents’ Behavior That is why the investigation was developed to prove or disprove such hypotheses as the dependence of higher rates of anxiety of adolescents with ADHD on their diagnosis, the dependence of ODD and CD in […]
• Stroop Reaction Time on Adults With ADHD The model was used to investigate the effectiveness of processes used in testing interference control and task-set management in adults with ADHD disorder.
• Attention Deficit Hyperactivity Disorder Causes Family studies, relationship studies of adopted children, twin studies and molecular research have all confirmed that, ADHD is a genetic disorder.
• Diagnosis and Treatment of ADHD The diagnosis of ADHD has drawn a lot of attention from scientific and academic circles as some scholars argue that there are high levels of over diagnosis of the disorder.
• Attention-Deficit Hyperactivity Disorder As it would be observed, some of the symptoms associated with the disorder for children would differ from those of adults suffering from the same condition in a number of ways.
• Working Memory in Attention Deficit and Hyperactivity Disorder (ADHD) Whereas many studies have indicated the possibility of the beneficial effects of WM training on people with ADHD, critics have dismissed them on the basis of flawed research design and interpretation.
• Attention-Deficit Hyperactivity Disorder: The Basic Information in a Nutshell In the case with adults, however, the definition of the disorder will be quite different from the one which is provided for a child ADHD.
• How ADHD Develops Into Adult ADD The development of dominance is vital in processing sensations and information, storage and the subsequent use of the information. As they become teenagers, there is a change in the symptoms of ADHD.
• Medical Condition of Attention Deficit Hyperactivity Disorder A combination of impulsive and inattentive types is referred to as a full blown ADHD condition. To manage this condition, an array of medical, behavioral, counseling, and lifestyle modification is the best combination.
• Effects of Medication on Education as Related to ADHD In addition, as Rabiner argues, because of the hyperactivity and impulsivity reducing effect of ADHD drugs, most ADHD suffers are nowadays able to learn in an indistinguishable class setting, because of the reduced instances of […]
• Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment Generally the results indicate that children with ADHD had a difficult time in evaluating time concepts and they seemed to be impaired in orientation of time.
• The Ritalin Fact Book: Stimulants Use in the ADHD Treatment Facts presented by each side of the critical issue The yes side of the critical issue makes it clear that the drugs being used to control ADHD are harmful as they affect the normal growth […]
• Attention Deficit Hyperactivity Disorder (ADD / ADHD) Some critics maintain that the condition is a work of fiction by the psychiatric and pharmacists who have taken advantage of distraught families’ attempts to comprehend the behaviour of their children to dramatise the condition.
• Behavior Modification in Children With Attention Deficit Hyperactivity Disorder Introduction The objective of the article is to offer a description of the process of behavior modification for a child diagnosed with ADHD.
• What Is ADHD and How Does It Affect Kids
• The Benefits of Physical Activities in Combating the Symptoms of ADHD in Students
• The Effects of Exercise and Physical Activity as Intervention for Children with ADHD
• What Are the Effects of ADHD in the Classroom
• Are Children Being Diagnosed with ADHD too Hastily
• The Effectiveness of Cognitive Behavioral Therapy on ADHD
• Understanding ADHD, Its Effects, Symptoms, and Approach to Children with ADHD
• ADHD Stimulant Medication Abuse and Misuse Among U.S. Teens
• Severity of ADHD and Anxiety Rise if Both Develop
• The Best Approach to Dealing with Attention Deficit/Herpactivity Disorder or ADHD in Children
• An Analysis of the Potential Causes and Treatment Methods for Attention Deficit Hyperactivity Disorder (ADHD) in Young Children
• The Best Way to Deal with Your Child Who Struggles with ADHD
• Response Inhibition in Children with ADHD
• Behavioral and Pharmacological Treatment of Children with ADHD
• Symptoms And Symptoms Of ADHD, Depression, And Anxiety
• Bioethics in Intervention in the Deficit Attention Hyperkinetic Disorder (ADHD)
• The Effects of Children’s ADHD on Parents’ Relationship Dissolution and Labor Supply
• The Effects of Pharmacological Treatment of ADHD on Children’s Health
• The Educational Implications Of ADHD On School Aged Children
• Differences in Perception in Children with ADHD
• The Effects Of ADHD On Children And Education System Child
• Students With ADD/ADHD and Class Placement
• The Advantage and Disadvantage of Using Psychostimulants in the Treatment of ADHD
• How to Increase Medication Compliance in Children with ADHD
• Effective Teaching Strategies for Students with ADHD
• Scientists Probe ADHD Treatment for Long Term Management of the Disease
• Should Stimulants Be Prescribed for ADHD Children
• The Rise of ADHD and the an Analysis of the Drugs Prescribed for Treatment
• The Correlation Between Smoking During Pregnancy And ADHD
• Exploring Interventions Improving Workplace Behavior In Adults With ADHD
• The Promise of Music and Art in Treating ADHD
• The Struggle Of ADHD Medication And Over Diagnosis
• The Problems of Detecting ADHD in Children
• The Harmful Effects of ADHD Medication in Children
• The Symptoms and Treatment of ADHD in Children and Teenagers
• The Impact of Adult ADD/ADHD on Education
• The Experience of Having the ADHD Disorder
• The Young Children And Children With ADHD, And Thinking Skills
• The Use of Ritalin in Treating ADD and ADHD
• The Ethics Of Giving Children ADHD Medication
• The Importance of Correctly Diagnosing ADHD in Children
• The Rise in ADHD Diagnosis and Treatment within the United States of America
• The World of ADHD Children
• The Use of Drug Therapies for Children with ADHD
• What Are the Effects of ADHD in the Classroom?
• Does ADHD Affect Essay Writing?
• What Are the Three Main Symptoms of ADHD?
• How Does ADHD Medication Affect the Brain?
• What Can ADHD Lead To?
• Is ADHD Legitimate Medical Diagnosis or Socially Constructed Disorder?
• How Does Art Help Children With ADHD?
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• Can Sports Affect Impulse Control in Children With ADHD?
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ADHD: Science and Society

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Attention Deficit Hyperactivity Disorder (ADHD) is one of the most frequently diagnosed and medicated childhood psychiatric disorders worldwide. In the past three decades, diagnosis and medication use rates have risen significantly in many countries. However, concerns about the reliability and validity of ...

Keywords : ADHD, Overdiagnosis, Medicalization, Society, Scientism

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Search strategy, data extraction, risk of bias, data synthesis and analysis, medications, youth-directed psychosocial treatments, parent support, school interventions, cognitive training, neurofeedback, nutrition and supplements, complementary, alternative, or integrative medicine, combined medication and behavioral treatments, moderation of treatment response, long-term outcomes, clinical implications, strengths and limitations, future research needs, acknowledgments, treatments for adhd in children and adolescents: a systematic review.

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Bradley S. Peterson , Joey Trampush , Margaret Maglione , Maria Bolshakova , Mary Rozelle , Jeremy Miles , Sheila Pakdaman , Morah Brown , Sachi Yagyu , Aneesa Motala , Susanne Hempel; Treatments for ADHD in Children and Adolescents: A Systematic Review. Pediatrics April 2024; 153 (4): e2024065787. 10.1542/peds.2024-065787

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Effective treatment of attention-deficit/hyperactivity disorder (ADHD) is essential to improving youth outcomes.

This systematic review provides an overview of the available treatment options.

We identified controlled treatment evaluations in 12 databases published from 1980 to June 2023; treatments were not restricted by intervention content.

Studies in children and adolescents with clinically diagnosed ADHD, reporting patient health and psychosocial outcomes, were eligible. Publications were screened by trained reviewers, supported by machine learning.

Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Data were pooled using random-effects models. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards.

In total, 312 studies reported in 540 publications were included. We grouped evidence for medication, psychosocial interventions, parent support, nutrition and supplements, neurofeedback, neurostimulation, physical exercise, complementary medicine, school interventions, and provider approaches. Several treatments improved ADHD symptoms. Medications had the strongest evidence base for improving outcomes, including disruptive behaviors and broadband measures, but were associated with adverse events.

We found limited evidence of studies comparing alternative treatments directly and indirect analyses identified few systematic differences across stimulants and nonstimulants. Identified combination of medication with youth-directed psychosocial interventions did not systematically produce better results than monotherapy, though few combinations have been evaluated.

A growing number of treatments are available that improve ADHD symptoms and other outcomes, in particular for school-aged youth. Medication therapies remain important treatment options but are associated with adverse events.

Attention-deficit/hyperactivity disorder (ADHD) is a common mental health problem in youth, with a prevalence of ∼5.3%. 1 , 2   Youth with ADHD are prone to future risk-taking problems, including substance abuse, motor vehicle accidents, unprotected sex, criminal behavior, and suicide attempts. 3   Although stimulant medications are currently the mainstay of treatment of school-age youth with ADHD, other treatments have been developed for ADHD, including cognitive training, neurofeedback, neuromodulation, and dietary and nutritional interventions. 4   – 7  

This systematic review summarizes evidence for treatments of ADHD in children and adolescents. The evidence review extends back to 1980, when contemporary diagnostic criteria for ADHD and long-acting stimulants were first introduced. Furthermore, we did not restrict to a set of prespecified known interventions for ADHD, and instead explored the range of available treatment options for children and adolescents, including novel treatments. Medication evaluations had to adhere to a randomized controlled trial (RCT) design, all other treatments could be evaluated in RCTs or nonrandomized controlled studies that are more common in the psychological literature, as long as the study reported on a concurrent comparator. Outcomes were selected with input from experts and stakeholders and were not restricted to ADHD symptoms. To our knowledge, no previous review for ADHD treatments has been as comprehensive in the range of interventions, clinical and psychosocial outcomes, participant ages, and publication years.

The review aims were developed in consultation with the Agency for Healthcare Research and Quality (AHRQ), the Patient-Centered Outcomes Research Institute, the topic nominator American Academy of Pediatrics (AAP), key informants, a technical expert panel (TEP), and public input. The TEP reviewed the protocol and advised on key outcomes. Subgroup analyses and key outcomes were prespecified. The review is registered in PROSPERO (#CRD42022312656) and the protocol is available on the AHRQ Web site as part of a larger evidence report on ADHD. The systematic review followed Methods of the (AHRQ) Evidence-based Practice Center Program. 8  

Population: Children or adolescents with a clinical diagnosis of ADHD, age <18 years

Interventions: Any ADHD treatment, alone or in combination, and ≥4 weeks’ treatment

Comparators: No treatment, waitlist, placebo, passive comparators, or active comparators

Outcomes: Patient health and psychosocial outcomes

Setting: Any

Study designs: RCTs for medication; RCTs, controlled clinical trials without random assignment, or cohort studies comparing 1 or more treatment groups for nondrug treatments. Studies either had to be large or demonstrate that they could detect effects as a standalone study (operationalized as ≥100 participants or a power calculation)

Other limiters: English-language (to ensure transparency for a US guideline), published from 1980

We searched the databases PubMed, Embase, PsycINFO, ERIC, and ClinicalTrials.gov. We identified reviews for reference-mining through PubMed, Cochrane Database of Systematic Reviews, Campbell Collaboration, What Works in Education, PROSPERO, ECRI Guidelines Trust, G-I-N, and ClinicalKey. The search underwent peer review; the full strategy is in the Online Appendix. All citations were reviewed by trained literature reviewers supported by machine learning to ensure no studies were inadvertently missed. Two independent reviewers assessed full-text studies for eligibility. Publications reporting on the same participants were consolidated into 1 record so that no study entered the analyses more than once. The TEP reviewed studies to ensure all were captured.

The data abstraction form included extensive guidance to aid reproducibility and standardization in recording study details, outcomes, 9   – 12   study quality, and applicability. One reviewer abstracted data, and a methodologist checked its accuracy and completeness. Data are publicly available in the Systematic Review Data Repository.

We assessed 6 domains 13   : Selection, performance, attrition, detection, reporting, and study-specific biases ( Supplemental Figs 6 and 7 ).

We organized analyses by treatment and comparison type. We grouped treatments according to intervention content and target (eg, youth or parents). The intervention taxonomy differentiated medication, psychosocial interventions, parent support, nutrition and supplements, neurofeedback, neurostimulation, physical exercise, complementary medicine, school interventions, and provider approaches. We differentiated effects versus passive control groups (eg, placebo) and comparative effects (ie, comparing to an alternative treatment). The following outcomes were selected as key outcomes: (1) ADHD symptoms (eg, ADHD Rating Scale 14 , 15   ), (2) disruptive behavior (eg, conduct problems), (3) broadband measures (eg, Clinical Global Impression 16   ), (4) functional impairment (eg, Weiss Functional Impairment Rating Scale 17 , 18   ), (5) academic performance (eg, grade point average), (6) appetite suppression, and (7) number of participants reporting adverse events.

Studies reported on a large range of outcome measures as documented in the evidence table in the Online Appendix. To facilitate comparisons across studies, we converted outcomes to scale-independent standardized mean differences (SMDs) for continuous symptom outcome variables and relative risks (RRs) for categorical reports, presenting summary estimates and 95% confidence intervals (CIs) for all analyses. We used random-effects models performed in R with Metafor_v4.2-0 for statistical pooling, correcting for small numbers of studies when necessary, to synthesize available evidence. 19   We conducted sensitivity analyses for all analyses that included studies without random assignment. We also compared treatment effectiveness indirectly across studies in meta-regressions that added potential, prespecified effect modifiers to the meta-analytic model. In particular, we assessed whether ADHD presentation or cooccurring disorders modified intervention effects. We tested for heterogeneity using graphical displays, documented I 2 statistics (values >50% are highlighted in the text), and explored sources of heterogeneity in subgroup and sensitivity analyses. 20  

We assessed publication bias with Begg and Egger tests 21 , 22   and used the trim-and-fill methods for alternative estimates where necessary. 23   Applicability of findings to real-world clinical practices in typical US settings was assessed qualitatively using AHRQ’s Methods Guide. An overall strength of evidence (SoE) assessment communicating our confidence in each finding was determined initially by 1 researcher with experience in use of specified standardized criteria 24   ( Supplemental Information ), then discussed with the study team. We downgraded SoE for study limitations, imprecision, inconsistency, and reporting bias, and we differentiated high, moderate, low, and insufficient SoE.

We screened 23 139 citations and retrieved 7534 publications as full text against the eligibility criteria. In total, 312 treatment studies, reported in 540 publications (see list of included studies in the Online Appendix), met eligibility criteria ( Fig 1 ).

Literature flow diagram.

Although studies from 1980 were eligible, the earliest study meeting all eligibility criteria was from 1995. All included studies are documented in the evidence table in the Supplemental Information . The following highlights key findings. Results for intervention groups and individual studies, subgroup and sensitivity analyses, characteristics of participants and interventions contributing to the analyses, and considerations that determined the SoE for results are documented in the Online Appendix.

As a class, traditional stimulants (methylphenidate, amphetamines) significantly improved ADHD symptom severity (SMD, −0.88; CI, −1.13 to −0.63; studies = 12; n = 1620) and broadband measures (RR, 0.38; CI, 0.30–0.48; studies = 12; n = 1582) (both high SoE), but not functional impairment (SMD, 1.00; CI, −0.25 to 2.26; studies = 4; n = 540) ( Fig 2 , Supplemental Fig 8 , Supplemental Table 1 ). Methylphenidate formulations significantly improved ADHD symptoms (SMD, −0.68; CI, −0.91 to −0.46; studies = 7; n = 863) ( Fig 2 , Supplemental Table 1 ) and broadband measures (SMD, 0.66; CI, 0.04–1.28; studies = 2; n = 302). Only 1 study assessed academic performance, reporting large improvements compared with a control group (SMD, −1.37; CI, −1.72 to −1.03; n = 156) ( Supplemental Fig 9 ). 25   Methylphenidate statistically significantly suppressed appetite (RR, 2.80; CI, 1.47–5.32; studies = 8; n = 1110) ( Fig 3 ), and more patients reported adverse events (RR, 1.32; CI, 1.25–1.40; studies = 6; n = 945). Amphetamine formulations significantly improved ADHD symptoms (SMD, −1.16; CI, −1.64 to −0.67; studies = 5; n = 757) ( Fig 2 , Supplemental Table 1 ) but not broadband measures (SMD, 0.68; CI, −0.72 to 2.08; studies = 3; n = 561) ( Supplemental Fig 9 ). Amphetamines significantly suppressed appetite (RR, 7.08; CI, 2.72–18.42; studies = 8; n = 1229) ( Fig 3 ), and more patients reported adverse events (RR, 1.41; CI, 1.25–1.58; studies = 8; n = 1151). Modafinil (US Food and Drug Administration [FDA]-approved to treat narcolepsy and sleep apnea but not ADHD) in each individual study significantly improved ADHD symptoms, but aggregated estimates were nonsignificant (SMD, −0.76; CI, −1.75 to 0.23; studies = 4; n = 667) ( Fig 2 , Supplemental Table 1 ) because of high heterogeneity (I 2 = 91%). It did not improve broadband measures (RR, 0.49; CI, −0.12 to 2.07; studies = 3; n = 539) ( Supplemental Fig 9 ), and it significantly suppressed appetite (RR, 4.44; CI, 2.27–8.69; studies = 5; n = 780) ( Fig 3 ).

Medication effects on ADHD symptom severity. S-AMPH-LDX, lisdexamfetamine; S-AMPH-MAS, mixed amphetamines salts; S-MPH-DEX, dexmethylphenidate; S-MPH-ER, extended-release methylphenidate; S-MPH-IR, immediate release methylphenidate; S-MPH-OROS, osmotic-release oral system methylphenidate; S-MPH-TP, dermal patch methylphenidate; NS-NRI-ATX, atomoxetine; NS-NRI-VLX, viloxazine; NS-ALA-CLON, clonidine; NS-ALA-GXR, guanfacine extended-release.

Medication effects on appetite suppression. Abbreviations as in legend for Fig 2 .

As a class, nonstimulants significantly improved ADHD symptoms (SMD, −0.52; CI, −0.59 to −0.46; studies = 37; n = 6065; high SoE) ( Fig 2 , Supplemental Table 1 ), broadband measures (RR, 0.66; CI, 0.58–0.76; studies = 12; n = 2312) ( Supplemental Fig 8 ), and disruptive behaviors (SMD, 0.66; CI, 0.22–1.10; studies = 4; n = 523), but not functional impairment (SMD, 0.20; CI, −0.05 to 0.44; studies = 6; n = 1163). Norepinephrine reuptake inhibitors (NRI) improved ADHD symptoms (SMD, −0.55; CI, −0.62 to −0.47; studies=28; n = 4493) ( Fig 2 , Supplemental Table 1 ) but suppressed appetite (RR, 3.23; CI, 2.40–4.34; studies = 27; n = 4176) ( Fig 3 ), and more patients reported adverse events (RR, 1.31; CI, 1.18–1.46; studies = 15; n = 2600). Alpha-agonists (guanfacine and clonidine) improved ADHD symptoms (SMD, −0.52; CI, −0.67 to −0.37; studies = 11; n = 1885) ( Fig 2 , Supplemental Table 1 ), without (guanfacine) significantly suppressing appetite (RR, 1.49; CI, 0.94–2.37; studies = 4; n = 919) ( Fig 3 ), but more patients reported adverse events (RR, 1.21; CI, 1.11–1.31; studies = 14, n = 2544).

One study compared amphetamine versus methylphenidate, head-to-head, finding more improvement in ADHD symptoms (SMD, −0.46; CI, −0.73 to −0.19; n = 222) and broadband measures (SMD, 0.29; CI, 0.02–0.56; n = 211), but not functional impairment (SMD, 0.16; CI, −0.11 to 0.43; n = 211), 26   with lisdexamfetamine (an amphetamine) than osmotic-release oral system methylphenidate. No difference was found in appetite suppression (RR, 1.01; CI, 0.72–1.42; studies = 2, n = 414) ( Fig 3 ) or adverse events (RR, 1.11; CI, 0.93–1.33; study = 1, n = 222). Indirect comparisons yielded significantly larger effects for amphetamine than methylphenidate in improving ADHD symptoms ( P = .02) but not broadband measures ( P = .97) or functional impairment ( P = .68). Stimulants did not differ in appetite suppression ( P = .08) or adverse events ( P = .35).

One study provided information on NRI versus alpha-agonists by directly comparing an alpha-agonist (guanfacine) with an NRI (atomoxetine), 27   finding significantly greater improvement in ADHD symptoms with guanfacine (SMD, −0.47; CI, −0.73 to −0.2; n = 226) but not a broadband measure (RR, 0.84; CI, 0.68–1.04; n = 226). It reported less appetite suppression for guanfacine (RR, 0.48; CI, 0.27–0.83; n = 226) but no difference in adverse events (RR, 1.14; CI, 0.97–1.34; n = 226). Indirect comparisons did not indicate significantly different effect sizes for ADHD symptoms ( P = .90), disruptive behaviors ( P = .31), broadband measures ( P = .41), functional impairment ( P = .46), or adverse events ( P = .06), but suggested NRIs more often suppressed appetite compared with guanfacine ( P = .01).

Studies directly comparing nonstimulants versus stimulants (all were the NRI atomoxetine and stimulants methylphenidate in all but 1) tended to favor stimulants but did not yield significance for ADHD symptom severity (SMD, 0.23; CI, −0.03 to 0.49; studies = 7; n = 1611) ( Fig 2 ). Atomoxetine slightly but statistically significantly produced greater improvements in disruptive behaviors (SMD, −0.08; CI, −0.14 to −0.03; studies = 4; n = 608) ( Supplemental Fig 10 ) but not broadband measures (SMD, −0.16; CI, −0.36 to 0.04; studies = 4; n = 1080) ( Supplemental Fig 9 ). They did not differ significantly in appetite suppression (RR, 0.82; CI, 0.53–1.26; studies = 8; n = 1463) ( Fig 3 ) or number with adverse events (RR, 1.11; CI, 0.90–1.37; studies = 4; n = 756). Indirect comparisons indicated significant differences favoring stimulants over nonstimulants in improving ADHD symptom severity ( P < .0001), broadband measures ( P = .0002), and functional impairment ( P = .04), but not appetite suppression ( P = .31) or number with adverse events ( P = .12).

Several studies assessed whether adding nonstimulant to stimulant medication (all were alpha-agonists added to different stimulants) improved outcomes compared with stimulant medication alone, yielding a small but significant additional improvement in ADHD symptoms (SMD, −0.36; CI, −0.52 to −0.19; studies = 5; n = 724) ( Fig 4 ).

Combination treatment. CLON, clonidine, GXR guanfacine.

We identified 32 studies evaluating psychosocial, psychological, or behavioral interventions targeting ADHD youth, either alone or combined with components for parents and teachers. Interventions were highly diverse, and most were complex with multiple components (see supplemental results in the Online Appendix). They significantly improved ADHD symptoms (SMD, −0.35; CI, −0.51 to −0.19; studies = 14; n = 1686; moderate SoE) ( Fig 4 ), even when restricting to RCTs only (SMD, −0.36; CI, −0.53 to −0.19; removing high-risk-of-bias studies left 7 with similar effects SMD, −0.38; CI, −0.69 to −0.07), with minimal heterogeneity (I 2 = 52%); but not disruptive behaviors (SMD, −0.18; CI, −0.48 to 0.12; studies = 8; n = 947) or academic performance (SMD, −0.07; CI, −0.49 to 0.62; studies = 3; n = 459) ( Supplemental Fig 11 ).

We identified 19 studies primarily targeting parents of youth aged 3 to 18 years, though only 3 included teenagers. Interventions were highly diverse (see Online Appendix), but significantly improved ADHD symptoms (SMD, −0.31; CI, −0.57 to −0.05; studies = 11; n = 1078; low SoE) ( Fig 4 ), even when restricting to RCTs only (SMD, −0.35; CI, −0.61 to −0.09; removing high-risk-of-bias studies yielded the same point estimate, but CIs were wider, and the effect was nonsignificant SMD, −0.31; CI, −0.76 to 0.14). There was some evidence of publication bias (Begg P = .16; Egger P = .02), but the trim and fill method to correct it found a similar effect (SMD, −0.43; CI, −0.63 to −0.22). Interventions improved broadband scores (SMD, 0.41; CI, 0.23–0.58; studies = 7; n = 613) and disruptive behaviors (SMD, −0.52; CI, −0.85 to −0.18; studies = 4; n = 357) but not functional impairment (SMD, 0.35; CI, −0.69 to 1.39; studies = 3; n = 252) (all low SoE) ( Supplemental Fig 12 ).

We identified 10 studies, mostly for elementary or middle schools (see Online Appendix). Interventions did not significantly improve ADHD symptoms (SMD, −0.50; CI, −1.05 to 0.06; studies = 5; n = 822; moderate SoE) ( Fig 4 ), but there was evidence of heterogeneity (I 2 = 87%). Although most studies reported improved academic performance, this was not statistically significant across studies (SMD, −0.19; CI, −0.48 to 0.09; studies = 5; n = 854) ( Supplemental Fig 13 ).

We identified 22 studies, for youth aged 6 to 17 years without intellectual disability (see Online Appendix). Cognitive training did improve ADHD symptoms (SMD, −0.37; CI, −0.65 to −0.06; studies = 12; n = 655; low SoE) ( Fig 4 ), with some heterogeneity (I 2 = 65%), but not functional impairment (SMD, 0.41; CI, −0.24 to 1.06; studies = 5; n = 387) ( Supplemental Fig 14 ) or disruptive behaviors (SMD, −0.29; CI, −0.84 to 0.27; studies [all RCTs] = 5; n = 337). It improved broadband measures (SMD, 0.50; CI, 0.12–0.88; studies = 6; n = 344; RCTs only: SMD, 0.43; CI, −0.06 to 0.93) (both low SoE). It did not increase adverse events (RR, 3.30; CI, 0.03–431.32; studies = 2; n = 402).

We identified 21 studies: Two-thirds involved θ/β EEG marker modulation, and one-third modulation of slow cortical potentials (see Online Appendix). Neurofeedback significantly improved ADHD symptoms (SMD, −0.44; CI, −0.65 to −0.22; studies = 12; n = 945; low SoE) ( Fig 4 ), with little heterogeneity (I 2 = 33%); restricting to the 10 RCTs yielded the same point estimate, also statistically significant (SMD, −0.44; CI, −0.71 to −0.16). Neurofeedback did not systematically improve disruptive behaviors (SMD, −0.33; CI, −1.33 to 0.66; studies = 4; n = 372), or functional impairment (SMD, 0.21; CI, −0.14 to 0.55; studies = 3; n = 332) ( Supplemental Fig 15 ).

We identified 39 studies with highly diverse nutrition interventions (see Online Appendix), including omega-3 (studies = 13), vitamins (studies = 3), or diets (studies = 3), and several evaluated supplements as augmentation to stimulants. Most were placebo-controlled. Across studies, interventions improved ADHD symptoms (SMD, −0.39; CI, −0.67 to −0.12; studies = 23; n = 2357) ( Fig 4 ), even when restricting to RCTs (SMD, −0.32; CI, −0.55 to −0.08), with high heterogeneity (I 2 = 89%) but no publication bias. The group of nutritional approaches also improved disruptive behaviors (SMD, −0.28; CI, −0.37 to −0.18; studies [all RCTs] = 5; n = 360) ( Supplemental Fig 16 , low SoE), without increasing the number reporting adverse events (RR, 0.77; CI, 0.47–1.27; studies = 8; n = 735). However, we did not identify any specific supplements that consistently improved outcomes, including omega-3 (eg, ADHD symptoms: SMD, −0.11; CI, −0.45, 0.24; studies = 7; n = 719; broadband measures: SMD, 0.04; CI, −0.24 to 0.32; studies = 7; n = 755, low SoE).

We identified 6 studies assessing acupuncture, homeopathy, and hippotherapy. They did not individually or as a group significantly improve ADHD symptoms (SMD, −0.15; CI, −1.84 to 1.53; studies = 3; n = 313) ( Fig 4 ) or improve other outcomes across studies (eg, broadband measures: SMD, 0.03; CI, −3.66 to 3.73; studies = 2; n = 218) ( Supplemental Fig 17 ).

Eleven identified studies evaluated a combination of medication- and youth-directed psychosocial treatments. Most allowed children to have common cooccurring conditions, but intellectual disability and severe neurodevelopmental conditions were exclusionary. Medication treatments were stimulant or atomoxetine. Psychosocial treatments included multimodal psychosocial treatment, cognitive behavioral therapy, solution-focused therapy, behavioral therapy, and a humanistic intervention. Studies mostly compared combinations of medication and psychosocial treatment to medication alone, rather than no treatment or placebo. Combined therapy did not statistically significantly improve ADHD symptoms across studies (SMD, −0.36; CI, −0.73 to 0.01; studies = 7; n = 841; low SoE; only 2 individual studies reported statistically significant effects) ( Fig 5 ) or broadband measures (SMD, 0.42; CI, −0.72 to 1.56; studies = 3; n = 171), but there was indication of heterogeneity (I 2 = 71% and 62%, respectively).

Nonmedication intervention effects on ADHD symptom severity.

We found little evidence that either ADHD presentation (inattentive, hyperactive, combined-type) or cooccurring psychiatric disorders modified treatment effects on any ADHD outcome, but few studies addressed this question systematically (see Online Appendix).

Only a very small number of studies (33 of 312) reported on outcomes at or beyond 12 months of follow-up (see Online Appendix). Many did not report on key outcomes of this review. Studies evaluating combined psychosocial and medication interventions, such as the multimodal treatment of ADHD study, 28   did not find sustained effects beyond 12 months. Analyses for medication, psychosocial, neurofeedback, parent support, school intervention, and provider-focused interventions did not find sustained effects for more than a single study reporting on the same outcome. No complementary medicine, neurostimulation, physical exercise, or cognitive training studies reported long-term outcomes.

We identified a large body of evidence contributing to knowledge of ADHD treatments. A substantial number of treatments have been evaluated in strong study designs that provide evidence statements regarding the effects of the treatments on children and adolescents with ADHD. The body of evidence shows that numerous intervention classes significantly improve ADHD symptom severity. This includes large but variable effects for amphetamines, moderate-sized effects for methylphenidate, NRIs, and alpha-agonists, and small effects for youth-directed psychosocial treatment, parent support, neurofeedback, and cognitive training. The SoE for effects on ADHD symptoms was high across FDA-approved medications (methylphenidate, amphetamines, NRIs, alpha-agonists); moderate for psychosocial interventions; and low for parent support, neurofeedback, and nutritional interventions. Augmentation of stimulant medication with non-stimulants produced small but significant additional improvement in ADHD symptoms over stimulant medication alone (low SoE).

We also summarized evidence for other outcomes beyond specific ADHD symptoms and found that broadband measures (ie, global clinical measures not restricted to assessing specific symptoms and documenting overall psychosocial adjustment), methylphenidate (low SoE), nonstimulant medications (moderate SoE), and cognitive training (low SoE) yielded significant, medium-sized effects, and parent support small effects (moderate SoE). For disruptive behaviors, nonstimulant medications (high SoE) and parent support (low SoE) produced significant improvement with medium effect. No treatment modality significantly improved functional impairment or academic performance, though the latter was rarely assessed as a treatment outcome.

The enormous variability in treatment components and delivery of youth-directed psychotherapies, parent support, neurofeedback, and nutrition and supplement therapies, and in ADHD outcomes they have targeted, complicates the synthesis and meta-analysis of their effects compared with the much more uniform interventions, delivery, and outcome assessments for medication therapies. Moreover, most psychosocial and parent support studies compared an active treatment against wait list controls or treatment as usual, which did not control well for the effects of parent or therapist attention or other nonspecific effects of therapy, and they have rarely been able to blind adequately either participants or study assessors to treatment assignment. 29 , 30   These design limitations weaken the SoE for these interventions.

The large number of studies, combined with their medium-to-large effect sizes, indicate collectively and with high SoE that FDA-approved medications improve ADHD symptom severity, broadband measures, functional impairment, and disruptive behaviors. Indirect comparison showed larger effect sizes for stimulants than for nonstimulants in improving ADHD symptoms and functional impairment. Results for amphetamines and methylphenidate varied, and we did not identify head-to-head comparisons of NRIs versus alpha-agonists that met eligibility criteria. Despite compelling evidence for their effectiveness, stimulants and nonstimulants produced more adverse events than did other interventions, with a high SoE. Stimulants and nonstimulant NRIs produced significantly more appetite suppression than placebo, with similar effect sizes for methylphenidate, amphetamine, and NRI, and much larger effects for modafinil. Nonstimulant alpha-agonists (specifically, guanfacine) did not suppress appetite. Rates of other adverse events were similar between NRIs and alpha-agonists.

Perhaps contrary to common belief, we found no evidence that youth-directed psychosocial and medication interventions are systematically better in improving ADHD outcomes when delivered as combination treatments 31   – 33   ; both were effective as monotherapies, but the combination did not signal additional statistically significant benefits (low SoE). However, it should be noted that few psychosocial and medication intervention combinations have been studied to date. We also found that treatment outcomes did not vary with ADHD presentation or the presence of cooccurring psychiatric disorders, but indirect analyses are limited in detecting these effect modifiers, and more research is needed. Furthermore, although children of all ages were eligible for inclusion in the review, we note that very few studies assessed treatments (especially medications) in children <6 years of age; evidence is primarily available for school-age children and adolescents. Finally, despite the research volume, we still know little about long-term effects of ADHD treatments. The limited available body of evidence suggests that most interventions, including combined medication and psychological treatment, yield few significant long-term improvements for most ADHD outcomes.

This review provides compelling evidence that numerous, diverse treatments are available and helpful for the treatment of ADHD. These include stimulant and nonstimulant medications, youth-targeted psychosocial treatments, parent support, neurofeedback, and cognitive training, though nonmedication interventions appear to have considerably weaker effects than medications on ADHD symptoms. Nonetheless, the body of evidence provides youth with ADHD, their parents, and health care providers with options.

The paucity of head-to-head studies comparing treatments precludes research-based recommendations regarding which is likely to be most helpful and which should be tried first, and decisions need to be based on clinical considerations and patient preferences. Stimulant and nonstimulant NRI medications, separately and in head-to-head comparisons, have shown similar effectiveness and rates of side effects, including appetite suppression, across identified studies. The moderate effect sizes for nonstimulant alpha-agonists, their low rate of appetite suppression, and their evidence for effectiveness in augmenting the effects of stimulant medications in reducing ADHD symptom severity provides additional treatment options. Furthermore, we found low SoE that neurofeedback and cognitive training improve ADHD symptoms. We also found that nutritional supplements and dietary interventions improve ADHD symptoms and disruptive behaviors. The SoE for nutritional interventions, however, is still low, and despite the research volume, we did not identify systematic benefits for specific supplements.

Clinical guidelines currently advise starting treatment of youth >6 years of age with FDA-approved medications, 33   which the findings of this review support. Furthermore, FDA-approved medications have been shown to significantly improve broadband measures, and nonstimulant medications have been shown to improve disruptive behaviors, suggesting their clinical benefits extend beyond improving only ADHD symptoms. Clinical guidelines for preschool children advise parent training and/or classroom behavioral interventions as the first line of treatment, if available. These recommendations remain supported by the present review, given the paucity of studies in preschool children in general, and because many existing studies, in particular medication and youth-directed psychosocial interventions, do not include young children. 31   – 33  

This review incorporated publications dating from 1980, assessing diverse intervention targets (youth, parent, school) and ADHD outcomes across numerous functional domains. Limitations in its scope derive from eligibility criteria. Requiring treatment of 4 weeks ensured that interventions were intended as patient treatment rather than proof of concept experiments, but it also excluded some early studies contributing to the field and other brief but intense psychosocial interventions. Requiring studies to be sufficiently large to detect effects excluded smaller studies that contribute to the evidence base. We explicitly did not restrict to RCTs (ie, a traditional medical study design), but instead identified all studies with concurrent comparators so as not to bias against psychosocial research; nonetheless, the large majority of identified studies were RCTs. Our review aimed to provide an overview of the diverse treatment options and we abstracted findings regardless of the suitability of the study results for meta-analysis. Although many ADHD treatments are very different in nature and the clinical decision for 1 treatment approach over another is likely not made primarily on effect size estimates, future research could use the identified study pool and systematically analyze comparative effectiveness of functionally interchangeable treatments in a network meta-analysis, building on previous work on medication options. 34  

Future studies of psychosocial, parent, school-based, neurofeedback, and nutritional treatments should employ more uniform interventions and study designs that provide a higher SoE for effectiveness, including active attention comparators and effective blinding of outcome assessments. Higher-quality studies are needed for exercise and neuromodulation interventions. More trials are needed that compare alternative interventions head-to-head or compare combination treatments with monotherapy. Clinical trials should assess patient-centered outcomes other than ADHD symptoms, including functional impairment and academic performance. Much more research is needed to assess long-term treatment effectiveness, compliance, and safety, including in preschool youth. Studies should assess patient characteristics as modifiers of treatment effects, to identify which treatments are most effective for which patients. To aid discovery and confirmation of these modifiers, studies should make publicly available all individual-level demographic, clinical, treatment, and outcome data.

We thank the following individuals providing expertise and helpful comments that contributed to the systematic review: Esther Lee, Becky Nguyen, Cynthia Ramirez, Erin Tokutomi, Ben Coughli, Jennifer Rivera, Coleman Schaefer, Cindy Pham, Jerusalem Belay, Anne Onyekwuluje, Mario Gastelum, Karin Celosse, Samantha Fleck, Janice Kang, and Sreya Molakalaplli for help with data acquisition. We thank Kymika Okechukwu, Lauren Pilcher, Joanna King, and Robyn Wheatley from the American Academy of Pediatrics; Jennie Dalton and Paula Eguino Medina from the Patient-Centered Outcomes Research Institute; Christine Chang and Kim Wittenberg from AHRQ; and Mary Butler from the Minnesota Evidence-based Practice Center. We thank Glendy Burnett, Eugenia Chan, MD, MPH; Matthew J. Gormley, PhD; Laurence Greenhill, MD; Joseph Hagan, Jr, MD; Cecil Reynolds, PhD; Le’Ann Solmonson, PhD, LPC-S, CSC; and Peter Ziemkowski, MD, FAAFP; who served as key informants. We thank Angelika Claussen, PhD; Alysa Doyle, PhD; Tiffany Farchione, MD; Matthew J. Gormley, PhD; Laurence Greenhill, MD; Jeffrey M. Halperin, PhD; Marisa Perez-Martin, MS, LMFT; Russell Schachar, MD; Le’Ann Solmonson, PhD, LPC-S, CSC; and James Swanson, PhD; who served as a technical expert panel. Finally, we thank Joel Nigg, PhD; and Peter S. Jensen, MD; for their peer review of the data.

Drs Peterson and Hempel conceptualized and designed the study, collected data, conducted the analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Trampush conducted the critical appraisal; Drs Bolshakova and Pakdaman, and Ms Rozelle, Ms Maglione, and Ms Brown screened citations and abstracted the data; Dr Miles conducted the analyses; Ms Yagyu designed and executed the search strategy; Ms Motala served as data manager; and all authors provided critical input for the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

This study is registered at PROSPERO, #CRD42022312656. Data are available in SRDRPlus.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2024-065854 .

FUNDING: The work is based on research conducted by the Southern California Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00009). The Patient-Centered Outcomes Research Institute funded the research (Publication No. 2023-SR-03). The findings and conclusions in this manuscript are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the AHRQ or the Patient-Centered Outcomes Research Institute, its board of governors or methodology committee. Therefore, no statement in this report should be construed as an official position of the Patient-Centered Outcomes Research Institute, the AHRQ, or the US Department of Health and Human Services.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

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“Being ADHD”: a Qualitative Study

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• Published: 20 January 2022
• Volume 6 , pages 20–28, ( 2022 )

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• Rosalind Redshaw   ORCID: orcid.org/0000-0002-4965-4000 1 &
• Lynne McCormack 1  

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Attention deficit hyperactivity disorder (ADHD) is well recognised as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development; however, little is known about the subjective experience of “being ADHD”. This phenomenological idiographic study explored how nine individuals with ADHD make sense of their life experiences, ability to function, and ideas about self in the context of ADHD.

Semi-structured interviews were used to collect data from nine participants aged 29 to 54. Audio recordings of interviews were then transcribed and analysed according to the protocols of interpretative phenomenological analysis (IPA).

Three themes emerged (1) otherness; (2) pixies, monkeys, and living in the moment; and (3) Challenging “broken”. Themes encompass the experience of being different to others, mechanics of daily functioning, and advantages of being ADHD.

A tendency to live in the moment was consistent across the nine participants in this study and aligns with quantitative research showing differences in the processing of temporal information in ADHD. The effects of this tendency on day-to-day functioning are linked to typical symptoms of ADHD, as well as perceived advantages. Participants attributed an uncommon degree of energy, optimism, adventurousness and curiosity, and novel problem-solving ability to their ADHD, adding to existing literature that suggests there are advantages to this unique mental architecture. Identifying positive aspects to ADHD offers clinicians and educators a pathway for mitigating the negative effects on self that flow from the challenges of ADHD.

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Redshaw, R., McCormack, L. “Being ADHD”: a Qualitative Study. Adv Neurodev Disord 6 , 20–28 (2022). https://doi.org/10.1007/s41252-021-00227-5

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Why It Matters

Despite decades of research, the media and the internet continue to circulate myths, fallacies, and blatant lies about ADHD. This information war on ADHD stigmatizes affected people, reduces the credibility of providers, and delays or prevents access to treatment. In recent years, these problems have worsened with the ascendancy of "fake news" and "alternative facts" in political life.

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We curated the International Consensus Statement on ADHD by systematically reviewing the scientific literature to select studies meeting a very high level of evidence. We limited our curation to two types of evidence: meta-analyses and very large studies. We also provide blogs based on new scientific publications. Keep in mind that novel results, although intriguing, require replication.

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Going forward, we will promote the International Consensus Statement on social media, to professional organizations devoted to ADHD, and to the advocacy groups that help people with ADHD and their families, worldwide. We will continue curating new evidence as it is published so that the International Consensus Statement can become a living document. And we will fight the War on ADHD through our current book project and related social media activities.

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I'm a clinical psychologist researcher who has studied ADHD for three decades. Ask me anything about the nature, diagnosis and treatment of ADHD.

The Internet is rife with misinformation about ADHD.  I've tried to correct that by setting up curated evidence at www.ADHDevidence.org .    I'm here today to spread the evidence about ADHD by answering any questions you may have about the nature , treatment and diagnosis of ADHD.

Do any particular food/food groups exacerbate ADHD?

Artificial food colorants have been shown to be a problem for some people with ADHD. No other foods are know to exacerbate the disorder.

what do you think is the easiest route for adults newly learning they have adhd to help treat themselves without a million steps that will inevitably leave them giving up and never actually helping (asking for a friend definitely not me)

1. Find a prescriber who is experienced in the treatment of ADHD with medications and adhere to the prescribed treatment.

2. If that treatment does not solve all issues, work with them to figure out what could be added, such as CBT.

What is the evidence that a low sugar or sugar free diet improves adhd symptoms?

Surprisingly, data show that sugar consumption does not worsen symptoms of ADHD. No special diet, except removing artificial food colorants, has been shown to help ADHD symptoms.

Do you have any pearls of wisdom that you think managers who manage employees with ADHD should know?

Encourage them to seek out evidence based treatments and to adhere to those treatments. Self help books by Russ Ramsey or Russ Barkley are also useful.

How does caffeine use interact with ADHD and executive functioning more generally?

Research shows that caffeine helps with alertness, vigilance, attention, reaction time and attention. Effects on memory and higher-order executive functions, like decision making are not as clear. But although it helps with some types of attention, it is not effective for treating the inattention of ADHD.

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Using Video Analysis and Machine Learning in ADHD Diagnosis

News tuesday: machine learning and the possible future of diagnosing adhd.

Typically, clinicians rely on both subjective and objective observations, patient interviews and questionnaires, as well as reports from family and (in the case of children) parents and teachers, in order to diagnose ADHD. 

A group of researchers are aiming to find a diagnostic test that is purely objective and utilizes recent technological advancements. The method they developed involves analyzing videos of children in outpatient settings, focusing on their movements. The study included 96 children, half of whom had ADHD and half who did not.

How It Works

• Video Recording: Children were recorded during their outpatient visits.
• Skeleton Detection: Using a tool called OpenPose, the researchers detected and tracked the children's skeletons (essentially a map of their body's movements) in the videos.
• Movement Analysis: The researchers analyzed these movements, looking at 11 different movement features. They specifically focused on the angles of different body parts and how much they moved.
• Machine Learning: Six different machine learning models were used to see which movement features could best distinguish between children with ADHD and those without.

Key Findings

• Movement Differences: Children with ADHD showed significantly more movement in all the features analyzed compared to children without ADHD.
• Thigh Angle: The angle of the thigh was the most telling feature. On average, children with ADHD had a thigh angle of about 157.89 degrees, while those without ADHD had an angle of 15.37 degrees.
• High Accuracy: Using thigh angle alone, the model could diagnose ADHD with 91.03% accuracy. It was very sensitive (90.25%) and specific (91.86%), meaning it correctly identified most children with ADHD and correctly recognized most children without it.

This new method could potentially provide a more objective way to diagnose ADHD, reducing the reliance on subjective observations and reports. It can help doctors make more accurate diagnoses, ensuring that those who need help get it and that those who don't aren't misdiagnosed.

Understanding Attention to Social Images in Children with ADHD and Autism

News tuesday: understanding attention to social images in children with adhd and autism.

In the field of mental health, professionals often use a variety of tools to diagnose and understand neurodevelopmental disorders such as Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD). One such tool is the Autism Diagnostic Observation Schedule (ADOS), which is specifically designed to help diagnose autism. However, the ADOS wasn't originally intended for children who have both autism and ADHD, though this comorbidity is not uncommon.

A recent study aimed to explore how children with ADHD, autism, or both, pay attention to social images, such as faces. The study focused on using eye-tracking technology to measure where children direct their gaze when viewing pictures, and how long they look at certain parts of the image. This is important because differences in visual attention can provide insights into the nature of these disorders.

The researchers included 84 children in their study, categorized into four groups: those with ASD, those with ADHD, those with both ASD and ADHD, and neurotypical (NT) children without these conditions. During the study, children were shown social scenes from the ADOS, and their eye movements were recorded. The ADOS assessment was administered afterward. To ensure that the results were not influenced by medications, children who were on stimulant medications for ADHD were asked to pause their medication temporarily.

The results of the study showed that children with ASD, whether they also had ADHD or not, tended to spend less time looking at faces compared to children with just ADHD or NT children. The severity of autism symptoms, measured by the Social Communication Questionnaire (SCQ), was associated with reduced attention to faces. Interestingly, ADHD symptom severity, measured by Conners' Rating Scales (CRS-3), did not correlate with how children looked at faces.

These findings suggest that measuring visual attention might be a valuable addition to the assessment process for ASD, especially in cases where ADHD is also present. The study indicates that if a child with ADHD shows reduced attention to faces, it might point to additional challenges related to autism. The researchers noted that more studies with larger groups of children are needed to confirm these findings, but the results are promising. They hope that such measures could eventually enhance diagnostic processes and help in managing the complexities of cases involving comorbidity of ADHD and ASD.

This research opens up the possibility of using eye-tracking as a supplementary diagnostic tool in the assessment of autism, providing a more nuanced understanding of how attentional differences in social settings are linked to ASD and ADHD.

NEW STUDY: RASopathies Influences on Neuroanatomical Variation in Children

This study investigates how certain genetic disorders, called RASopathies, affect the structure of the brain in children. RASopathies are conditions caused by mutations in a specific signaling pathway in the body. Two common RASopathies are Noonan syndrome (NS) and neurofibromatosis type 1 (NF1), both of which are linked to a higher risk of autism spectrum disorder (ASD) and attention deficit and hyperactivity disorder (ADHD).

The researchers analyzed brain scans of children with RASopathies (91 participants) and compared them to typically developing children (74 participants). They focused on three aspects of brain structure: surface area (SA), cortical thickness (CT), and subcortical volumes.

The results showed that children with RASopathies had both similarities and differences in their brain structure compared to typically developing children. They had increased SA in certain areas of the brain, like the precentral gyrus, but decreased SA in other regions, such as the occipital regions. Additionally, they had thinner CT in the precentral gyrus. However, the effects on subcortical volumes varied between the two RASopathies: children with NS had decreased volumes in certain structures like the striatum and thalamus, while children with NF1 had increased volumes in areas like the hippocampus, amygdala, and thalamus.

Overall, this study highlights how RASopathies can impact the development of the brain in children. The shared effects on SA and CT suggest a common influence of RASopathies on brain development, which could be important for developing targeted treatments in the future.

In summary, understanding how these genetic disorders affect the brain's structure can help researchers and healthcare professionals develop better treatments for affected children.

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The ADHD Evidence Project disseminates evidence-based information about  Attention-Deficit/Hyperactivity Disorder (ADHD) for educational  purposes.  The content on this website is not intended to be and should  not be construed as personal medical or psychological advice. While we  strive to ensure the accuracy of the information, it is general in  nature and should not substitute for consultation with professional  healthcare providers.  Individuals seeking advice or treatment for ADHD  or related conditions should consult a licensed mental health care  provider or other qualified health care professional. The ADHD Evidence  Project, its creators, contributors, and affiliates are not liable for  any direct, indirect, consequential, special, exemplary, or other  damages arising from the use of information on this website. Users are  responsible for their interpretation and application of any information  obtained from this site.

TOP TEN RESEARCH PRIORITIES FOR ATTENTION DEFICIT/HYPERACTIVITY DISORDER TREATMENT

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• 1 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU)[email protected].
• 2 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU)Faculty of Odontology,Malmö University.
• 3 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU).
• 4 Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU)Faculty of Odontology,Malmö University,Department of Dental Medicine,Karolinska Institutet.
• PMID: 27516379
• DOI: 10.1017/S0266462316000179

Objectives: The aim of this project was to identify the ten most important research questions for attention deficit/hyperactivity disorder (ADHD) treatment as identified by people with ADHD together with personnel involved in the treatment of ADHD in school, health, and correction services.

Methods: A working group consisting of consumers and personnel was established. The method for prioritization was primarily based on James Lind Alliance's guidebook, consisting of an interim priority setting exercise and a workshop.

Results: The top ten list includes the risk of drug dependency later in life when treated with methylphenidate as a child, teacher support, multimodal therapy, comparisons between atomoxetine and methylphenidate, methylphenidate treatment in substance abusers, parental support programmes, supported conversation, computer-aided working memory training, psychoeducative treatment, and melatonin.

Conclusions: We have shown that consumers and personnel can reach consensus on research priorities for treatments for ADHD. We encourage researchers and funders to consider the list for future studies.

Keywords: Attention deficit disorder with hyperactivity; Mental disorders; Patient participation.

• Attention Deficit Disorder with Hyperactivity / drug therapy*
• Central Nervous System Stimulants / therapeutic use
• Patient Participation
• Randomized Controlled Trials as Topic
• Central Nervous System Stimulants

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ADHD Research Roundup: New Studies, Findings & Insights

Adhd research continues to reveal new insights about attention deficit — its relationship to trauma, race, emotional dysregulation, rejection sensitive dysphoria, and treatments ranging from medication to video games. we’ve curated the most significant news of the past year., adhd research continues to reveal new truths.

ADHD research has produced groundbreaking and impactful discoveries in the past year. Our understanding of the relationship between health care and race has deepened. Alternative treatments, like video games and neurofeedback, are showing encouraging promise while ADHD stimulant medication continues to demonstrate benefits for patients of all ages. The connections between comorbid conditions, gender, and ADHD are better understood than ever before. And we are encouraged by the ongoing work coming from the world’s leading research teams.

Read below to catch up on the most significant news and research from 2020, and stay updated on new findings as they are published by subscribing to ADDitude’s free monthly research digest .

General ADHD Research

Study: Long-Term Health Outcomes of Childhood ADHD are Chronic, Severe November 24, 2020 Childhood ADHD should be considered a chronic health problem that increases the likelihood of adverse long-term health outcomes, according to a population-based birth cohort study of children with ADHD and psychiatric disorders. Further research on the impact of treatment is needed.

Study: Living with ADHD Causes Significant Socioeconomic Burden October 21, 2020 Living with ADHD poses a significant economic burden, according to a new study of the Australian population that found the annual social and economic cost of ADHD was $12.76 billion, with per person costs of $15,664 over a lifetime.

Study: Unmedicated ADHD Increases the Risk of Contracting COVID-19 July 23, 2020 The COVID-19 infection rate is nearly 50% higher among individuals with unmedicated ADHD compared to individuals without ADHD , according to a study of 14,022 patients in Israel. The study found that ADHD treatment with stimulant medication significantly reduces the risk of virus exposure among individuals with ADHD symptoms like hyperactivity and impulsivity.

[ Does My Child Have ADHD? Take This Test to Find Out ]

Study: Poverty Increases Risk for ADHD and Learning Disabilities March 23, 2020 Children from families living below the poverty level, and those whose parents did not pursue education beyond high school, are more likely to be diagnosed with ADHD or learning disabilities, according to a new U.S. data brief that introduces more questions than it answers.

ADHD and Children

Study: Diagnosed and Subthreshold ADHD Equally Impair Educational Outcomes in Children December 21, 2020 Children with diagnosed and subthreshold ADHD both experienced impaired academic and non-academic performance compared to controls used in an Australian study examining the two community cohorts.

Study: Children with ADHD More Likely to Bully — and to Be Bullied November 23, 2020 Children with ADHD are more likely than their neurotypical peers to be the bully, the victim of bullying, or both, according to a new study.

Study: ADHD Symptoms in Girls Diminish with Extracurricular Sports Activity October 16, 2020 Consistent participation in organized sports reliably predicted improved behavior and attentiveness in girls with ADHD, according to a recent study of elementary school students active — and not active — in extracurricular activities. No such association was found for boys with ADHD.

[ Do I Have ADHD? Take This Test to Find Out ]

Study: ADHD in Toddlers May Be Predicted by Infant Attentional Behaviors August 12, 2020 Infants who exhibit behaviors such as “visually examining, acting on, or exploring nonsocial stimuli including objects, body parts, or sensory features” may be more likely to demonstrate symptoms of ADHD as a toddler, according to a new study that also found a correlation between this Nonsocial Sensory Attention and later symptoms of executive dysfunction.

Study Shows Gender Disparities in ADHD Symptoms of Hyperactivity and Poor Response Inhibition June 26, 2020 Girls with ADHD are less physically hyperactive than are boys with the condition, and experience fewer problems with inhibition and cognitive flexibility, according to a new meta-analysis that says more accurate screening tools are needed to recognize the subtler manifestations of ADHD in girls.

Study: Raising a Child with ADHD Negatively Impacts Caregivers’ Mental Wellbeing July 27, 2020 Caring for a child with ADHD negatively impacts caregivers’ quality of sleep, relationships, and satisfaction with free time, among other indicators of mental wellbeing, according to a recent study from the United Kingdom. The significant deficit in sleep and leisure satisfaction led researchers to conclude that caregivers may benefit from greater support — for example, coordinated health and social care — that focuses on these areas.

Study: ADHD, Diet, Exercise, Screen Time All Directly or Indirectly Impact Sleep July 27, 2020 A child with ADHD is more likely to experience sleep problems, in part because ADHD symptoms influence diet and physical activity — two factors that directly impact sleep. This finding comes from a new study that also shows how screen time impacts exercise, which in turn impacts sleep. Understanding these interwoven lifestyle factors may help caregivers and practitioners better treat children with ADHD.

ADHD and Adolescents

Teens with ADHD Should Be Regularly Screened for Substance Use Disorder: International Consensus Reached July 17, 2020 Adolescents with ADHD should be regularly screened for comorbid substance use disorder, and vice versa. This was one of 36 statements and recommendations regarding SUD and ADD recently published in the European Research Addiction Journal.

Study: Girls with ADHD Face Increased Risk for Teen Pregnancy February 12, 2020 Teenagers with ADHD face an increased risk for early pregnancy, according to a new study in Taiwan. However, long-term use of ADHD medications does reduce the risk for teen pregnancies. Researchers suggested that ADHD treatment reduces the risk of any pregnancy and early pregnancy both directly by reducing impulsivity and risky sexual behaviors and indirectly by lowering risk and severity of the associated comorbidities, such as disruptive behavior and substance use disorders.

Study: Teens with ADHD Face Increased Risk for Nicotine Addiction January 27, 2020 Young people with ADHD find nicotine use more pleasurable and reinforcing after just their first smoking or vaping experience, and this may lead to higher rates of dependence, according to findings from a new study published in the Journal of Neuropsychopharmacology .

Study: Adolescent Health Risks Associated with ADHD Go Unmonitored by Doctors February 27, 2020 The health risks facing adolescents with ADHD — teen pregnancy, unsafe driving, medication diversion, and more — are well documented. Yet, according to new research, primary care doctors still largely fail to address and monitor these urgent topics during their patients’ transition to young adulthood.

Study: Emotional Dysregulation Associated with Weak, Risky Romantic Relationships Among Teens with ADHD May 20, 2020 Severe emotional dysregulation increases the chances that an adolescent with ADHD will engage in shallow, short-lived romantic relationships and participate in unprotected sex, according to a new study that suggests negative patterns developed in adolescence may continue to harm the romantic relationships and health of adults with ADHD .

ADHD and Adults

Study: Discontinuing Stimulant Medication Negatively Impacts Pregnant Women with ADHD December 17, 2020 Women with ADHD experience negative impacts on mood and family functioning when they discontinue stimulant medication use during pregnancy, according to a new observational cohort study that suggests medical professionals should consider overall functioning and mental health when offering treatment guidance to expectant mothers.

New Study: Adult ADHD Diagnosis Criteria Should Include Emotional Symptoms April 21, 2020 The ADHD diagnosis criteria in the DSM-5 does not currently include emotional symptoms, despite research indicating their importance. Now, a new replication analysis has found that ADHD in adults presents in two subtypes: attentional and emotional. Researchers suggest that this system offers a more clinically relevant approach to diagnosing ADHD in adults than does the DSM-5 .

Study: Stimulant ADHD Medication Relatively Safe and Effective for Older Adults June 30, 2020 Older adults with ADHD largely experience symptom improvement when taking a low dose of stimulant medication, which is well tolerated and does not cause clinically significant cardiovascular changes. This is the finding of a recent study examining the effects of stimulant medication among adults aged 55 to 79 with ADHD, some of whom had a pre-existing cardiovascular risk profile.

ADHD, Race, and Culture

Study Explores Medication Decision Making for African American Children with ADHD June 23, 2020 In a synthesis of 14 existing studies, researchers have concluded that African American children with ADHD are significantly less likely than their White counterparts to treat their symptoms with medication for three main reasons: caregiver perspectives on ADHD and ADHD-like behaviors; beliefs regarding the risks and benefits associated with stimulant medications; and the belief that ADHD represents a form of social control.

Culturally Adapted Treatment Improves Understanding of ADHD In Latinx Families August 31, 2020 Latinx parents are more likely to recognize and understand ADHD after engaging in culturally adapted treatment (CAT) that includes parent management training sessions adapted to be more culturally appropriate and acceptable, plus home visits to practice skills. This recent review of ADHD knowledge among Latinx parents found that CAT outperformed evidence-based treatment (EBT) in terms of parent-reported knowledge of ADHD.

Treating ADHD

Study: New Parent Behavior Therapy Yields Longer ADHD Symptom Control in Children October 6, 2020 ADHD symptom relapse was significantly reduced in children of parents who participated in a new schema-enhanced parent behavior therapy, compared to those whose parents participated in standard PBT.

Research: Physical Exercise Is the Most Effective Natural Treatment for ADHD — and Severely Underutilized January 22, 2020 A new meta-analysis shows that physical exercise is the most effective natural treatment for controlling ADHD symptoms such as inhibition, attention, and working memory . At the same time, a comprehensive study reveals that children with ADHD are significantly less likely to engage in daily physical activity than are their neurotypical peers.

A Video Game Prescription for ADHD? FDA Approves First-Ever Game-Based Therapy for Attention June 18, 2020 Akili Interactive’s EndeavorRx is the first game-based digital therapeutic device approved by the FDA for the treatment of attention function in children with ADHD. The history-making FDA OK followed a limited-time release of the device during the coronavirus pandemic, and several years of testing the device in randomized controlled trials.

Study: Neurofeedback Effectively Treats ADHD April 9, 2020 Neurofeedback is an effective treatment for ADHD , according to a new quantitative review that used benchmark studies to measure efficacy and effectiveness against stimulant medication and behavior therapy. These findings relate to standard neurofeedback protocols, not “unconventional” ones, for which significant evidence was not found.

Study: Mindfulness-Enhanced Behavioral Parent Training More Beneficial for ADHD Families June 29, 2020 Behavioral parent training (BPT) enhanced with mindfulness meditation techniques provides additional benefits to parents of children with ADHD, such as improved discipline practices and parental behavioral regulation. This is the finding of a new randomized control trial conducted by researchers who compared mindfulness-enhanced to standard BPT.

Mapping the ADHD Brain: MRI Scans May Unlock Better Treatment and Even Symptom Prevention March 9, 2020 Brain MRI is a new and experimental tool in the world of ADHD research. Though brain scans cannot yet reliably diagnose ADHD, some scientists are using them to identify environmental and prenatal factors that affect symptoms, and to better understand how stimulant medications trigger symptom control vs. side effects.

New Clinical Guidelines: Holistic Treatment Is Best for Children with ADHD and Comorbidities February 3, 2020 The Society for Developmental and Behavioral Pediatrics (SDBP) says that children and teens with ADHD plus comorbidities should receive psychosocial treatment, such as classroom-based management tools, in addition to ADHD medication.

Study: Mindfulness Exercises Effectively Reduce Symptoms in Boys with ADHD and ODD May 19, 2020 Boys with both ADHD and ODD were less hyperactive and more attentive after attending a multi-week mindfulness training program, according to a new study that finds promise in this treatment as a viable complement or alternative to medication.

ADHD and Comorbid Conditions

Study: Risk for Diabetes 50% Higher for Adults with ADHD October 23, 2020 A diagnosis of ADHD increased the likelihood of diabetes by as much as 50% for adults with ADHD, according to a recent study from the National Health Interview Survey that found the strong correlation independent of BMI.

Study: ADHD Symptoms Associated with More Severe Gambling Disorder and Emotional Dysregulation January 28, 2020 Roughly one-fifth of individuals diagnosed with gambling disorder in the study also tested positive for ADHD symptoms. This population is more likely to experience severe or acute symptoms of gambling disorder, which is tied to higher emotional dysregulation, according to a new study of 98 Spanish men.

ADHD Research: Next Steps

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Center for ADHD Research Projects

Research projects.

The Center for ADHD strives to find new and innovative approaches to treat children with attention deficit hyperactivity disorder.

Current Projects

Current projects and proposed research include:

• Studies Seeking Participants
• ADHD Study For Parents of Children 4 to 11 Years Old
• Study for Children 10 to 12 With Excessive Daydreaming, Mental Confusion, Fogginess, Spaciness and / or Slowed Behavior / Thinking
• ADHD Study for Children 8 to 12 Years Old
• Carboxylesterase 1 Genetic Variation and Methylphenidate in ADHD (CES1) Study Summary
• Down Syndrome and ADHD Study for Children and Teens 6 to 17 Years Old
• A Study for Black and Latino Caretakers of Children Newly Diagnosed with ADHD
• ADHD Medication Effects on Adolescents with ADHD
• Ongoing Studies
• Carboxylesterase 1 Genetic Variation and Methylphenidate in ADHD (CES1) Study Summary 18+
• Evaluating Assessment and Medication Treatment of ADHD in Children with Down Syndrome (TEAM-DS)
• Longitudinal Examination of Sluggish Cognitive Tempo and Internalizing Psychopathology in Adolescence (ALERT study)
• Longitudinal Evaluation of Sluggish Cognitive Tempo: Identifying Mechanisms of Educational Impairment (CASS-2 study)
• Mindful Awareness Practices (MAPs) in Adolescents with ADHD and Sluggish Cognitive Tempo (SCT)
• A Family Navigator Intervention to Improve ADHD- Related Treatment Adherence (I2-ART) for Minority Children
• Parsing Neurobiological Bases of Heterogeneity in ADHD
• Nationwide dissemination of a web-based quality improvement intervention to improve the quality of ADHD care among community-based pediatricians
• Improving ADHD Behavioral Care Quality in Community-Based Pediatric Settings
• Improving Medication Continuity Among Adolescents with ADHD
• Predictors of Stimulant Medication Continuity in Children with ADHD
• Teaching Academic Success Skills to Middle School Students with Autism Spectrum Disorders (ASD) with Executive Functioning Deficits – School Setting

Completed Projects

• Evaluating Assessment and Medication Treatment of ADHD in Children with Down Syndrome
• ADHD Study for Teens With Sleep Problems
• Improving ADHD Driving Study
• The Effects of ADHD Medication (TEAM) Study
• A Multi-Method Feasibility Study Investigating Reaction Time Variability in Autism Spectrum Disorder
• Children’s Attention Problems Study
• Evaluation of the Computerized Progressive Attention Training (CPAT) program for children with ADHD  
• Multisite Study of School-Based Treatment Approaches for ADHD
• Evaluation of an Intervention for Improving Community-Based Pediatric ADHD Care
• Multimodal Treatment Study Follow-Up
• Developing New Technologies to Improve ADHD Medication Continuity
• Shared Decision Making to Improve Care for Children with ADHD
• Medication Continuity in Children Treated for ADHD
• Improving Self-regulation & School Readiness in Preschoolers
• Interventions for Children with ADHD and Reading Difficulties
• Sleep in Teens with ADHD
• Omega-3 fatty acid supplements on ADHD brain function
• ADHD iPAD App study
• Medication Response in Children with Predominantly Inattentive Type ADHD
• Cognitive Training Program for Children with ADHD
• ADHD Collaborative
• Disseminating a Model Intervention to Promote Improved ADHD Care in the Community
• Examining the Effects of Cell Phone Use in an ADHD Population: A Pilot Study
• Organizational Skills Intervention
• Response Variability in Children with ADHD
• A novel intervention to improve the driving performance of ADHD teens
• Impact of COVID-19 in Adolescents with and without ADHD
• Treating Sleep in Adolescents with ADHD and Co-occurring Sleep Problems
• SCT Interview Study
• Phenotypic Correlates Distinguishing Sluggish Cognitive Tempo from ADHD
• Teaching Academic Success Skills to Middle School Students with Autism Spectrum Disorders (ASD) with Executive Functioning Deficits
• Longitudinal Impact of Sleep in Teens (LIST) With and Without ADHD Study
• Concentration at School Study (CASS)

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124 ADHD Essay Topics

🏆 best essay topics on adhd, ✍️ adhd essay topics for college, 👍 good adhd research topics & essay examples, 🎓 most interesting adhd research titles, 💡 simple adhd essay ideas, ❓ adhd research questions.

• The Influence and Effects of Colour on Attention Deficit Hyperactivity Disorder Children
• The Relation Between Attention Deficit Disorder and Colitis
• ADHD & Personality
• ADHD: The Center’s for Disease Control and Prevention Webpage
• Increase in ADHD Diagnoses
• Sugar: Does It Really Cause Hyperactivity?
• Attention Deficit Hyperactivity Disorder and Nursing Intervention
• Theoretical Approach to ADHD: Case Study Analysis The executive function (EF) theory by Russel Barkley applies to understanding and developing strategies to improve the child’s learning process.
• Teaching Students With Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder is a psychiatric disorder characterized by impulsive actions that are not related proportionally to the age of the affected person.
• Characteristics of ADHD Attention deficit hyperactivity disorder refers to disorders of the nervous system. Neurological disorders are based on prerequisites of a neurological nature.
• Relationship Between ADHD-Inattentive and -Hyperactive The cause and effect relationship between ADHD-inattentive and ADHD-hyperactive-impulsive is conditional upon the former’s role in the latter’s emergence.
• Mental Health and ADHD in Universities The issue of mental health in university learners is rarely brought up, yet it has a tangible effect on the target audience’s health and ability to learn.
• ADHD: Treatment and Over Medication When children have ADHD, it is possible to influence their symptoms by forging a special supportive bond between them, parents, and the education system.
• ADHD in Children and Adults: Causes, Symptoms, and Solutions The paper will try to explain why ADHD is serious, how it can damage a person’s quality of life long into adulthood, and how it can interfere with one’s communication ability.
• Hidden Dangers of Attention Deficit Hyperactivity Disorder Medications Many researchers and ordinary people are concerned with the hidden dangers of ADHD medications and doubt that the result is worth the long-term risks.
• Hyperactivity Disorder Symptoms and Sleep Issues The document to be analyzed is “The moderating roles of bedtime activities and anxiety/depression in the relationship between attention-deficit/hyperactivity” by Tong
• Diagnosis and Treatment for Attention Deficit Hyperactivity Disorder I have been having trouble coping with the fact that my son Ryan was recently diagnosed with attention deficit hyperactive disorder (ADHD).
• Is ADHD Genetically Passed Down to Family Members? Genetic correlations between such qualities as hyperactivity and inattention allowed us to define ADHD as a spectrum disorder rather than a unitary one.
• Aspects of Attention Deficit Hyperactivity Disorder The paper discusses attention deficit hyperactivity disorder. It is a neurologic and developmental illness diagnosed in childhood.
• Is Attention Deficit Hyperactivity a Real Disorder? Attention deficit hyperactivity disorder is one of the most prevalent children neurodevelopmental diseases. It is identified during childhood and frequently persists into maturity.
• Stimulant Therapy for Attention Deficit Hyperactivity Disorder Despite the potential for negative consequences, stimulant therapy is an effective treatment for attention deficit hyperactivity disorder signs.
• Pediatric Occupational Therapy for Attention Deficit Hyperactivity Disorder This is a systematic review of quantitative research studies and occupational therapy interventions for children with Attention Deficit Hyperactivity Disorder (ADHD).
• Attention Deficit Hyperactive Disorder Behavior Attention Deficit Hyperactive Disorder is a psychological disorder that causes a person’s brain to be abnormally hyperactive than usual behavior.
• Understanding ADHD: A Comprehensive Case Study The current paper presents a fictional case of hyperactivity disorder that entails diagnosis, problems, and treatment recommendations.
• Attention Deficit and Effective Treatment of Disorder Effective behavioral and pharmaceutical treatments help reduce the symptoms of ADHD. It can assist individuals in doing better at home, school, and in social situations.
• Attention Deficit Hyperactivity Disorder Treatment The Attention-Deficit/ Hyperactivity Disorder Therapy mechanisms include psychoeducation, where parents are encouraged to discuss the condition with their children.
• Learning Disabilities and Attention Deficit Hyperactivity Disorder The discussion explains common learning disabilities and Attention-Deficit/Hyperactivity Disorder to kids attending the after school program.
• Impact of ADHD on Students ADHD (attention deficit hyperactivity disorder) are experience challenges in managing high levels of energy, controlling impulses, and maintaining attention.
• Attention-Deficit/Hyperactivity Disorder (ADHD): Prominent Aspects, Management, and Prevention Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by a pattern of inattention or hyperactivity in a person.
• A Counseling Theory for Child with Attention Deficit Hyperactive Disorder Attention deficit hyperactive disorder (ADHD) is usually spread among children and adolescents. Proper educational counseling can help students with ADHD to cope with the problem.
• ADHD Awareness ADHD is a widespread behavioral disorder, which can be considered a different cognitive ability with its benefits and disadvantages.
• Living with Attention Deficit Hyperactivity Disorder Though ADHD is not a very dangerous illness, it is better not underrate its effects. Many patients may feel rejected by society, and this alienation is likely to worsen the situation.
• The Effects of Food on ADHD The issue of ADHD and its relation to food has been a concern for a while. According to the outcomes of the study, the daily intake of food must be controlled in ADHD patients.
• Evaluation Plan of Research Project on Attention Deficit-Hyperactivity Disorder Formulated in this paper is a constructive and evidence-based plan that the author would use to evaluate the outcomes of his/her applied research project on ADHD.
• Attention Deficit Hyperactivity Disorder Diagnosis Controversy The article provides an overview of the factors that led to an increase in the number of cases of attention deficit hyperactivity disorder.
• ADHD and Socially Constructed Impairment ADHD is responsible for many complications in the life of people suffering from it, including limited educational achievement, and low self-organizational capacity.
• Sleep Disturbance and Neuropsychological Function Within ADHD Sleep disruption is an inherent behavioral feature in childhood attention-deficit/hyperactivity disorder, known as ADHD.
• The Phenomenon of the ADHD Disorder The paper analyzes the facts represented for whether or not attention-deficit/hyperactivity disorder is real.
• Childhood Mental Disorders: Attention Deficit Hyperactivity Disorder Description, causes, symptoms, discussion around possible treatment options for children with attention deficit hyperactivity disorder.
• Attention Deficit Hyperactivity Disorder Stimulants: Research Method The article that highlights the evaluation of study with regard to the Utility of illegal Attention Deficit Hyperactivity Disorder (ADHD) Stimulants among college students.
• Critique of Articles on Parenting, ADHD, Child Psychology, and Development In this work, the author criticized articles on parenting, ADHD, child psychology, early adult romantic relationships and development.
• Attention Deficit Hyperactivity Disorder Symptoms Analysis ADHD, usually starts presenting it self during childhood, and is thought to be a continual chronic condition, and there is no medical cure for this disorder.
• Attention Deficit Hyperactivity Disorder Identification The criteria for identifying students with the ADHD problem required identifying the essential patterns of attention exhibited by the patient.
• Developmental Disorder Overview: Attention Deficit Hyperactivity Disorder One of the developmental disorders often diagnosed in the middle childhood years is attention-deficit/hyperactivity disorder (ADHD).
• Attention-Deficit Hyperactivity Disorder Diagnostic Mood disorders are adjustment problems that come from stressors emanating from inside and which can be triggered by factors that cannot be controlled.
• General Features and Etiology of ADHD Attention Deficit Hyperactivity Disorder (ADHD) is a mental health disorder that is expressed by extensive impulsivity and deficient attentiveness.
• Child Psychiatry: Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder is a childhood disruptive behavioral disorder that manifests in “inattention, impulsivity and hyperactivity” and can persist into adulthood.
• Attention Deficit Hyperactivity Disorder at School This work is observations of Jacob, a child with attention deficit hyperactivity disorder (ADHD), which was made at Cornell Junior Public School.
• Attention Deficit Hyperactivity Disorder in Students This paper reports the observation of a classroom with children with ADHD. It provides a brief overview of ADHD and summarizes articles regarding ADHD in children.
• Diagnostic Assessment of Children and Adolescents With ADHD The purpose of the study is to evaluate current clinical evidence on the value of different diagnostic tests of children and adolescents with ADHD in social and educational contexts.
• Attention Deficit Hyperactivity Disorder in Children: Studies Analysis This paper analyzes five scholarly articles on Attention Deficit Hyperactivity Disorder (ADHD) in children. The authors studied the effects and treatment of the disorder.
• A Special Education Plan: Grade 1 Male Student With ADHD It is important to know the needs of children with Attention Deficit Hyperactivity Disorder and make the necessary modifications to accommodate them in the classroom.
• Co-Occurrence of ADHD and Bipolar Disorder The relationship between Attention Deficit Hyperactivity Disorder (ADHD) and bipolar disorder has received a lot of attention.
• ADHD and Its Effects on the Development of a Child‘s
• How ADHD Medication Affects the Brain?
• The Epidemiological Rates for ADHD
• ADHD and Its Impact on Mainstream Schooling
• Effective Teaching Strategies for Students With ADHD
• The Debate Over Ritalin Use by Children With ADHD
• ADHD Diagnosis, Diagnostic Tools, and Its Cultural and Ethical Implications
• Dealing With Children Suffering From Add and ADHD
• The Link Between ADHD and Electronic Stimulation
• Affordable Non-Drug Solution to ADHD
• Ten Positive Things About ADHD
• ADHD and What Causes the Childhood Behavioral Condition
• Treating ADHD Long Term Can Cause Harm by Creating Thoughts of Suicide
• The Advantage and Disadvantage of Using Psychostimulants in the Treatment of ADHD
• ADHD and Antisocial Behavior Juvenile Delinquency
• Scientists Probe ADHD Treatment for Long-Term Management of the Disease
• The Correlation Between Technology and Adolescent Mental Health Particularly ADHD
• Over Diagnosis and Medication for ADHD
• How Do School Systems Deal With ADHD?
• Resting-State Brain Signal Variability in Prefrontal Cortex Is Associated With ADHD Symptom Severity in Children
• Social-Emotional and Behavioral Difficulties Alongside ADHD Education
• The Diagnosis, Symptoms, and Treatments for ADHD or Attention Deficit Hyperactivity Disorder
• Comorbidity Between Reading Disability and ADHD
• ADHD: Parents Should Use Alternative Treatments for Illness
• Parental Income, Education and the Diagnosis of ADHD in Children and Adolescents: The Case for Germany
• The Good, the Bad, and the Ugly of Treatments of ADHD
• Twice-Exceptional Students With ADHD Characteristics and Strategies
• Psychosocial Academic Interventions for Children With ADHD
• Impact of Misdiagnosis and Overprescribing of ADHD Medications
• The Relation Between Sleep, Memory Enhancement, Causes of Emotional Deficiency Among ADHD Patients
• How Can You Tell if an Adult Has ADHD?
• About the Controversies Between the Existence of ADHD, and the Different Viewpoints
• The Effects of ADHD Pharmacological Treatment on Teens’ Risky Behaviors
• ADHD Children and How Behavior Therapy Is Necessary With the Use of Medication
• Effective Management Techniques for Children With ADHD
• Side Effects ADHD Ritalin Symptoms
• ADHD: The Serious Public Health Problem
• Alcohol Abuse During Pregnancy and ADHD Symptoms
• Should Children Diagnosed With ADHD Be Given Medication to Address Their Symptoms
• The Young Children and Children With ADHD, and Thinking Skills
• What Are the Effects of ADHD in the Classroom?
• What Effect Does Being Identified With ADHD Have on a Child?
• What Are the Nine Symptoms of ADHD?
• What Are the Three Key Symptoms Used to Diagnose ADHD?
• What Are the Seven Types of ADHD?
• Is ADHD on the Autism Spectrum?
• At What Age Can ADHD Be Diagnosed?
• Can You Treat ADHD Without Medication?
• Is ADHD a Serious Mental Illness?
• Can You Have ADHD Without Being Hyper?
• What Is Ring of Fire ADHD?
• At What Age Does ADHD Peak?
• Do ADHD Brains Look Different?
• Is ADHD Classified as Special Needs?
• Can People With ADHD Have Special Interests?
• Can Additional Training Help Close the ADHD Gender Gap?
• Can Sports Affect Impulse Control in Children With ADHD?
• How Does ADHD Affect School Performance?
• Should Children With ADHD Be On Ritilan or Similar Drugs?
• Do People With ADHD Have Sensory Issues?
• What Is the Most Common Treatment for ADHD?
• Can ADHD Be Mistaken for Bipolar?
• Why Is ADHD Not Considered a Disability?
• Can ADHD Cause Panic Attacks?
• Why Is It So Hard to Get Tested for ADHD?
• What Foods Should Be Avoided With ADHD?
• Can ADHD Be Cured or Grown Out Of?
• Does Omega-3 Help ADHD?
• What Is the Mental Age of Someone With ADHD?
• Does ADHD Affect Intelligence?

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ADHD Research Paper

This sample ADHD research paper features: 8200 words (approx. 27 pages), an outline, and a bibliography with 14 sources. Browse other research paper examples for more inspiration. If you need a thorough research paper written according to all the academic standards, you can always turn to our experienced writers for help. This is how your paper can get an A! Feel free to contact our writing service for professional assistance. We offer high-quality assignments for reasonable rates.

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Get 10% off with 24start discount code, i. introduction.

II. Historical Context

III. Description and Diagnosis

A. The Core Symptoms

B. associated cognitive impairments, iv. theoretical framework.

V. Potential Etiologies

VI. Epidemiology of ADHD

Vii. developmental course and adult outcome, viii. diagnostic criteria, ix. conclusion.

X. Bibliography

It is not unusual for young children to be energetic and active, or to become bored quickly and move from one activity to another as they explore their environment. A young child’s desire for immediate gratification is to be expected, rather than the restraint or self-control that would be demanded of someone older. However, some children persistently display levels of activity that are far in excess of their age group. Some are unable to sustain their attention to activities, their interest in tasks assigned to them by others, or their persistence in achieving long-term goals as well as their peers.

When a child’s impulse control, sustained attention, and general self-regulation lag far behind expectations for their developmental level, they are likely to be diagnosed as having ADHD. Children with ADHD have a greater probability of experiencing a number of problems in their social, academic, and emotional development and daily adaptive functioning.

Attention Deficit/Hyperactivity Disorder (ADHD) has captured public commentary and scientific interest for more than 100 years. While the diagnostic labels for disorders of inattention, hyperactivity, and impulsiveness have changed numerous times, the actual nature of the disorder has changed little, if at all, from descriptions provided at the turn of the century. During the past century, and especially during the last 30 years, thousands of published scientific papers have focused on ADHD, making it one of the most wellstudied childhood psychiatric disorders.

II. Historical Context of ADHD

Serious clinical interest in children who have severe problems with inattention, hyperactivity, and poor impulse control is first found in three published lectures by the English physician, George Still, presented to the Royal Academy of Physicians in 1902. Still reported on a group of 20 children in his clinical practice whom he defined as having a deficit in “volitional inhibition” or a “defect in moral control” over their own behavior. Still’s observations described many of the associated features of ADHD that would be supported by research almost a century later, such as an overrepresentation of boys compared to girls, the greater incidence of alcoholism, criminal conduct, and depression among the biological relatives, and a familial predisposition to the disorder.

Initial interest in children with these characteristics arose in North America around the time of the great encephalitis epidemics of 1917 and 1918. Children surviving these brain infections were noted to have many behavioral problems similar to those comprising contemporary ADHD. These cases, as well as others known to have arisen from birth trauma, head injury, toxin exposure, and infections, gave rise to the concept of a “brain-injured child syndrome,” often associated with mental retardation. This term was eventually applied to children without a history of brain damage or evidence of retardation but who manifested behavioral problems such as hyperactivity or poor impulse control. This concept would later evolve into that of “minimal brain damage,” and eventually “minimal brain dysfunction” (MBD), as challenges were raised to the label given the lack of evidence of brain injury in many of these cases.

During the 1950s researchers became increasingly interested in hyperactivity. “Hyperkinetic impulse disorder” was attributed to cortical overstimulation resuiting from ineffective filtering of stimuli entering the brain. These studies gave rise to the notion of the “hyperactive child syndrome” typified by daily motor movement that was far in excess of that seen in normal children of the same age.

By the 1970s research findings emphasized the importance of problems with sustained attention and impulse control in addition to hyperactivity in understanding the nature of the disorder. In 1983 Virginia Douglas proposed that the disorder was comprised of major deficits in four areas: (1) the investment, organization, and maintenance of attention and effort; (2) the ability to inhibit impulsive behavior; (3) the ability to modulate arousal levels to meet situational demands; and (4) an unusually strong inclination to seek immediate reinforcement. Douglas’ work, along with numerous subsequent studies of attention, impulsiveness, and other cognitive factors, eventually led to renaming the disorder “Attention Deficit Disorder” (ADD) in 1980.

Just as significant as the renaming of the condition at that time was the distinction made between two types of ADD: those with hyperactivity and those without it. Little research existed at the time on the latter subtype. However, later research suggested that ADD without hyperactivity might be a separate and distinct disorder of a different component of attention (selective or focused) than was the type of inattention seen in those with ADD with hyperactivity (persistence and distractibility). Thus, rather than being related subtypes of a single disorder with a shared, common impairment in attention, future research may show these subtypes to constitute separate disorders of attention altogether.

Within a few years of the creation of the label ADD, concern was raised by Barkley in 1990 and Weiss and Hechtman in 1993 that problems with hyperactivity and impulse control were features critically important to differentiating the disorder from other conditions and to predicting later developmental risks. In 1987 the disorder was renamed Attention Deficit Hyperactivity Disorder. Diagnostic symptoms were identified from a single list of items incorporating all three constructs: hyperactivity, impulsivity, and inattention. The subtype of ADD without Hyperactivity was now renamed Undifferentiated ADD and relegated to minor diagnostic status until further research could clarify its nature and relationship to ADHD.

Around this same time (mid-1980s to 1990s) reports began to appear that challenged the notion that ADHD was primarily a disturbance in attention. Over the previous decade, researchers studying information-processing capacities in children with ADHD were having difficulty demonstrating that the problems these children had with attending to tasks were actually attentional in nature (i.e., related to the processing of incoming information). Problems in response inhibition and preparedness of the motor control system appeared to be more reliably demonstrated. Researchers, moreover, were finding that the problems with hyperactivity and impulsivity were not separate constructs but formed a single dimension of behavior. All of this led to the creation of two separate lists of symptoms for ADHD when the latest diagnostic manual for psychiatry, The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (also known as the DSM-IV) was published by the American Psychiatric Association in 1994. In the DSM-IV, one symptom list now existed for inattention and another for hyperactive-impulsive behavior. The inattention list once again permitted the diagnosis of a subtype of ADHD that consisted principally of problems with attention (ADHD Predominantly Inattentive Type). But two other subtypes were also identified (Predominantly Hyperactive-Impulsive and Combined Types). As of this writing, debate continues over the core deficit(s) involved in ADHD, with increasing emphasis being given to a central problem specifically with behavioral inhibition and more generally with self-regulation or executive functioning.

III. ADHD Description and Diagnosis

Problems with attention consist of the child’s inability to sustain attention or respond to tasks or play activities as long as others of the same age or to follow through on rules and instructions as well as others. The child appears more disorganized, distracted, and forgetful than others of the same age. Parents and teachers frequently complain that these children do not seem to listen as well as they should for their age, cannot concentrate, are easily distracted, fail to finish assignments, daydream, and change activities more often than others.

Research corroborates that, when compared to normal children, ADHD children are often more “off-task,” less likely to complete as much work as others, look away more from the activities they are requested to do (including television), persist less in correctly performing boring activities, and are slower and less likely to return to an activity once interrupted. Yet objective research does not find children with ADHD to be generally more distracted by most forms of extraneous events occurring during their task performance, although distractors within the task may prove more disruptive to them than to normal children. Research instead documents that ADHD children are more active than other children, are less mature in controlling motor movements, and have considerable difficulties with stopping an ongoing behavior. They frequently talk more than others and interrupt others’ conversations. They are less able to resist immediate temptations and delay gratification and respond too quickly and too often when they are required to wait and watch for events to happen.

Recent research shows that the problems with behavioral or motor inhibition arise first, at age 3 to 4 years, with those related to inattention emerging somewhat later in the developmental course of ADHD, at age 5 to 7 years. Whereas the symptoms of disinhibition seem to decline with age, those of inattention remain relatively stable during the elementary grades. Yet even the inattentiveness may decline by adolescence in some cases.

A number of factors have been noted to influence the ability of children with ADHD to sustain their attention to task performance, to control their impulses to act, to regulate their activity level, and to produce work consistently. They include: time of day or fatigue; increasing task complexity where organizational strategies are required; extent of restraint demanded for the context; level of stimulation within the setting; the schedule of immediate consequences associated with the task; and the absence of adult supervision during task performance.

It has been shown that children with ADHD are most problematic in their behavior when persistence in work-related tasks is required (i.e., chores, homework, etc.) or where behavioral restraint is necessary, especially in settings involving reduced parental monitoring (i.e., in church, in restaurants, when a parent is on the phone, etc.). Such children are least likely to pose behavioral management problems during free play, when little self-control is required. Fluctuations in the severity of ADHD symptoms have also been documented across a variety of school contexts. In this case, classroom activities involving self-organization and task-directed persistence are the most problematic, with significantly fewer problems posed by contexts involving fewer performance demands (i.e., at lunch, in hallways, at recess, etc.), and even fewer problems posed during highly entertaining special events (i.e., field trips, assemblies, etc.).

Although ADHD is defined by the presence of the two major symptom dimensions of inattention and disinhibition (hyperactivity-impulsivity), research indicates that these children often demonstrate deficiencies in many other abilities. These include: motor coordination and sequencing; working memory and mental computation; planning and anticipation or preparedness for action; verbal fluency and confrontational communication; effort allocation; applying organization strategies; the internalization of self-directed speech; adhering to restrictive instructions; the self-regulation of emotions; and self-motivation. Several studies have also demonstrated what both Still (1902) and Douglas (1983) noted anecdotally years ago–ADHD may be associated with less mature or diminished moral reasoning and the moral control of behavior.

The commonality among most or all of these seemingly disparate abilities is that all fall within the neuropsychological domain described as executive functions. The neurologist Joaquim Fuster wrote in 1989 that these executive abilities are probably mediated by the frontal cortex of the brain, and particularly the prefrontal lobes. Barkley has recently defined executive functions as being those neuropsychological processes that permit or assist with human self-regulation. Self-regulation is then defined as any self-directed form of behavior (both overt and covert) that serves to modify the probability of a subsequent behavior by the individual so as to alter the probability of a later consequence. Such behavior may even involve forgoing immediate rewards for the sake of maximizing delayed outcomes or even exposing oneself to immediate aversive circumstances for this same purpose. Self-regulatory behavior, therefore, includes thinking within this realm of private or covert self-directed behavior. By appreciating the role of the frontal lobes and the prefrontal cortex in these executive abilities, it is easy to see why researchers have repeatedly speculated that ADHD probably arises out of some disturbance or dysfunction of this brain region.

Many different hypotheses on the nature of ADHD have been proposed over the past century, such as Still’s (1902) notion of defective volitional inhibition and moral regulation of behavior, and Douglas’ (1983) theory of deficient attention, inhibition, arousal, and preference for immediate reward. Few of these have produced models of the disorder that were widely adopted by both scientists and clinicians or that served to drive further programmatic research initiatives. Some of these theories have suggested that ADHD is a deficit in sensitivity to reinforcement, a more general motivational disorder, or a deficit in rule-governed behavior (i.e., the control of behavior by language). Most recently, several theorists working in this area have proposed that ADHD represents a deficit behavioral inhibition; an assertion for which there is substantial evidence, at least for those subtypes that involve hyperactive-impulsive symptoms.

Consistent with these proposals, Barkley outlined a model of ADHD in 1994 that was based upon an earlier theory by Jacob Bronowski first set forth in 1966 on the evolution of the unique properties of human language and their relationship to response inhibition. Bronowski’s model was subsequently combined with that of Juaquim Fuster published in 1989, which specified that the overarching role of the prefrontal cortex is the cross-temporal organization of behavior. Barkley’s hybrid theoretical model of ADHD places behavioral inhibition at a central point and supportive point in relation to four other executive functions dependent upon it for their own effective execution. These functions are working memory, the self-regulation of emotion/motivation, the internalization of speech, and reconstitution (analysis and synthesis of behavioral structures in the service of goal-directed behavioral creativity). The four functions are believed to permit and subserve human self-regulation, bringing behavior progressively under the control of internally represented information, often about the future, and transferring it at least partially away from the control of behavior by more immediate consequences and external events. The executive control of behavior afforded by these functions is proposed to result in a greater capacity for predicting and controlling one’s self and one’s environment so as to maximize future consequences over immediate ones for the individual. And, more generally, the interaction of these executive functions permits far more organized and effective adaptive functioning.

Several assumptions are important in understanding this model as it is applied to ADHD. First, the capacity for behavioral inhibition begins to emerge first in the child’s development, prior to or corresponding with the emergence of the four executive functions. Second, inhibition does not directly cause the activation of these executive functions but sets the occasion for their occurrence and is necessary for their effective performance. Third, these functions probably emerge at different times in the child’s development and may have relatively independent developmental trajectories, although interactive. Fourth, the sweeping cognitive impairments that ADHD creates across these executive functions are secondary to the primary deficit in behavioral inhibition, implying that if inhibition were to be improved, these executive functions would likewise improve.

The deficit in behavioral inhibition is thought to arise principally from genetic and neurodevelopmental origins, rather than from purely social ones, although its expression is certainly influenced by a variety of social factors. The secondary deficits in the executive functions and self-regulation created by the primary deficit in inhibition feedback to contribute to further deficits in behavioral inhibition because self-regulation is required for self-restraint.

Behavioral inhibition is viewed in the model as comprising three related processes: (1) the capacity to inhibit “prepotent” responses prior to their initiation; (2) the capacity to cease ongoing response patterns once initiated such that both (1) and (2) create delays in responding to events; and (3) the protection of this delay and the self-directed (often private or cognitive) actions occurring within it from interference by competing events and their prepotent responses (interference control). Prepotent responses are defined as those for which immediate reinforcement (both positive and negative) is available for their performance or for which there is a strong history of reinforcement in this context. Through the postponement of the prepotent, automatic responses and the creation of this protected period of delay, the occasion is set for the four executive functions to act effectively in modifying the individual’s eventual initial responding to events or modifying their ongoing responses to those events (creating a sensitivity to feedback or errors). The executive system described here may exist so as to achieve a net maximization of both temporally distant and immediate consequences rather than immediate consequences alone. The chain of goal-directed, future-oriented behaviors set in motion by these acts of self-regulation is then also protected from interference during its performance by this same process of inhibition (interference control). Even if disrupted, the individual retains the capacity or intention (via working memory) to return to the goal-directed actions until the outcome is successfully achieved or judged to be no longer necessary.

Space permits here only a brief description of each of the four executive components of this new model of ADHD. The first of these involves working memory, or the capacity for prolonging and manipulating mental representations of events and using such information to control motor behavior. This particular type of memory can be thought of as remembering so as to do and serves to sustain otherwise fleeting information that will be useful in controlling subsequent responding, such as is seen in privately rehearsing a telephone number in mind so as to later dial it accurately. One component of working memory may be related to self-speech (verbal working memory), while a second component is related to perceptual imagery (visual-spatial) and probably involves self-directed sensing, as in visual imagery or covert audition. This retention of information related to past events (retrospection) gives rise to the conjecturing of future events (prospection), which sets in motion a preparedness to act in anticipation of the arrival of these future events (anticipatory set). Out of this continuous referencing or sensing of past and future probably arises the psychological sense of time. These activities taking place in working memory appear to be dependent upon behavioral inhibition. Such working memory processes have been shown to exist in rudimentary form even in young infants permitting them to successfully perform delayed response tasks to a limited degree. As the capacity for inhibition increases developmentally, it probably contributes to the further efficiency and effectiveness of working memory.

According to this model of ADHD, behavioral inhibition also sets the stage for the development of the second executive component of this model, that being the self-regulation of emotion in children. The inhibition of the initial prepotent response includes the inhibition of the initial emotional reaction that it may have elicited. It is not that the child does not experience emotion; rather, the behavioral reaction to or expression of that emotion is delayed along with any motor behavior associated with it. The delay in responding this creates allows the child time to engage in self-directed behaviors that will modify both the eventual response to the event as well as the emotional reaction that may accompany it. Because emotions are themselves forms of both motivational and arousal states, the model argues that deficits in the self-regulation of emotion should be associated with deficits in self-motivation and the self-control of arousal, particularly in the service of goal-directed behavior.

The internalization of self-directed speech, as originally described by Vygotsky, forms the third executive component of this model of ADHD. During the early preschool years, speech, once developed, is initially employed for communication with others. As behavioral inhibition progresses, language becomes turned on the self. It now is not just a means of influencing the behavior of others but provides a means of reflection as well as a means for controlling one’s own behavior (instruction).

The fourth component of this model involves the capacity to rapidly take apart and recombine units of behavior, including language. The delay in responding that behavioral inhibition permits allows time for information related to the event to be mentally prolonged and then dissassembled so as to extract more information about the event that will aid in preparing a response to it. In a related fashion, previously learned response patterns can also be broken down into smaller units of behavior. This internal decomposition of information and its associated response patterns permits the complementary process to occur, that being synthesis, or the invention of novel combinations of behavioral structures, including words and ideas, in the service of goal-directed action. This gives a highly creative or generative character as well as a hierarchically organized nature to human goal-directed behavior.

Finally, the internally represented information and motivation generated by these four executive functions is used to control a separate unit within the model, that being motor behavior itself. Such information serves to program, execute, and sustain behavior directed toward goals and the future, giving human behavior an intentional or purposive quality. Task-irrelevant movement is now more effectively suppressed, goal-directed behavior better sustained, and this pattern of behavior more efficiently reengaged should disruption of the behavioral pattern occur because of the control afforded by the internal information being generated from the four executive functions.

The impairment in behavioral inhibition occurring in ADHD is hypothesized to disrupt the efficient execution of these executive functions, thereby limiting the capacity of these individuals for self-regulation. The result is an impairment in the cross-temporal organization of behavior, in the prediction and control of one’s own behavior and environment, and inevitably in the maximization of long-term consequences for the individual.

How does this model account for the problems with attention believed to exist in ADHD? According to this model, it is critical to distinguish between two forms of sustained attention that are traditionally confused in the research literature on ADHD. The first is called contingency-shaped attention. This refers to continued responding in a situation or to a task as a function of the immediate available contingencies of reinforcement provided by the task or its context. Responding that is maintained under these conditions then is directly dependent on the immediate environmental contingencies. Many factors affect this form of sustained attention or responding: the novelty of the task, the intrinsic interest the activity may hold for the individual, the immediate reinforcement it provides for responding in the task, the state of fatigue of the individual, and the presence or absence of an adult supervisor (or other stimuli which signal other consequences for performance that are outside the task itself). The model predicts that this type of sustained attention relatively unaffected by ADHD as it is behavior under the control of external events.

As children mature, however, a second form of sustained attention emerges described in the model as goal-directed persistence. This form of sustained responding arises as a direct consequence of the development of self-regulation or the control of behavior by internally represented information. Such persistence derives from the development of a progressively greater capacity by the child to hold events, goals, and plans in mind (working memory), to adhere to rules governing behavior and to formulate and follow such rules, to self-induce a motivational state supportive of the plans and goals formulated by the individual so as to maintain goal-directed behavior, and even to create novel behaviors in the service of the goal’s attainment. The capacity to initiate and sustain chains of goal-directed behavior in spite of the absence of immediate environmental contingencies for their performance is predicted to be the form of sustained attention disrupted by ADHD.

Apart from this heuristically valuable distinction in forms of sustained attention, this theoretical model of ADHD makes numerous predictions about the cognitive and behavioral deficits likely to be found in those with the disorder (i.e., impaired working memory and sense of time, delayed internalization of speech, etc.), many of which have received little or no attention in research on ADHD. It also provides a framework by which to better organize and understand the numerous cognitive deficits identified in previous studies of children with ADHD than does the current view of ADHD as being chiefly an attention deficit.

V. Potential Etiologies of ADHD

The precise causes of ADHD are unknown at the present time. Numerous causes have been proposed, but evidence for many has been weak or lacking entirely. However, a number of factors have been shown to be associated with a significantly increased risk for ADHD in children.

The vast majority of the potentially causative factors associated with ADHD that are supported by empirical research seem to be biological in nature; that is, they are factors known to be related to or to have a direct effect on brain development and/or functioning. The precise causal pathways by which these factors lead to ADHD, however, are simply not known at this time.

Even so, far less evidence is available to support any purely psychosocial etiology of ADHD. In the vast majority of cases where such psychosocial risks have been found to be significantly associated with ADHD or hyperactivity, more careful analysis has shown these to be either the result of ADHD in the child or, far more often, to be related to aggression or conduct disorder rather than to ADHD. For instance, the child management methods used by parents, parenting stress, marital conflict, or parental psychopathology have now been shown to be far more strongly associated with aggressive and antisocial behavior than with ADHD. The strong hereditary influence in ADHD may also contribute to an apparent link between ADHD and poor child management by a parent — a link that may be attributable to the parent’s own ADHD. The environment in which the child is raised and schooled probably plays a larger role in determining the outcomes of children with the disorder and a much lesser role in primary causation.

Throughout the century, investigators have repeatedly noted the similarities between symptoms of ADHD and those produced by lesions or injuries to the frontal lobes of the brain, particularly the prefrontal cortex. Both children and adults suffering injuries to the certain regions of prefrontal cortex demonstrate deficits in sustained attention, inhibition, working memory, the regulation of emotion and motivation, and the capacity to organize behavior across time.

Numerous other lines of evidence have been suggestive of a neurological origin to the disorder. Several studies have examined cerebral blood flow in ADHD and normal children. They have consistently shown decreased blood flow to the prefrontal regions of the brain and the striatum with which these regions are richly interconnected, particularly in its anterior portion. More recently, studies using positron emission tomography (PET) to assess cerebral glucose metabolism have found diminished metabolism in adults and adolescent females with ADHD although not in adolescent males with ADHD. However, significant correlations have been noted between diminished metabolic activity in the left anterior frontal region of the brain and severity of ADHD symptoms in adolescent males with ADHD. This demonstration of an association between the metabolic activity of certain brain regions and symptoms of ADHD is critical in demonstrating a connection between the findings pertaining to brain activation and the behavior comprising ADHD.

More detailed analysis of brain structures using high resolution magnetic resonance imaging (MRI) devices has also suggested differences in some brain regions in those with ADHD. Initial studies that focused on reading-disabled children and used ADHD children as a contrast group examined the region of the left and right temporal lobes (the planum temporale). These regions are thought to be involved with auditory detection and analysis and, therefore, with certain subtypes of reading disabilities. For some time, researchers studying reading disorders have focused on these brain regions because of their connection to the rapid analysis of speech sounds. Children with ADHD and children with reading disabilities were found to have smaller right hemisphere plana temporale than the control group, while only the reading disabled children had a smaller left plana temporale. In another study, the corpus callosum was examined in subjects with ADHD. This structure assists with the interhemispheric transfer of information. Those with ADHD were found to have a smaller callosum, particularly in the area of the genu and splenium and that region just anterior to the splenium. An attempt to replicate this finding, however, failed to show any differences between ADHD and control children in the size or shape of the entire corpus callosum with the exception of the posterior portion of the splenium, which was significantly smaller in subjects with ADHD. Two additional studies examining the corpus callosum, however, documented smaller anterior (rostral) regions in children with ADHD; findings more consistent with prior studies of brain anatomy and functioning in children with ADHD. Most recently, two studies using larger samples of ADHD and normal children and MRI technology have both documented a smaller right prefrontal cortex and smaller right striatum and right basal ganglia (of which the striatum is a part) in ADHD children. Thus, despite some inconsistencies in findings across some of the earlier studies of brain morphology and functioning in ADHD, more recent studies are increasingly identifying the prefrontal regions of the brain and certain regions of the basal ganglia, such as the striatum, as probably being involved in the disorder.

None of these studies found evidence of frank brain damage in any of these structures in those with ADHD. This is consistent with past reviews of the literature conducted by Michael Rutter in 1983 suggesting that brain damage was related to less than 5% of those with hyperactivity. It is also consistent with more recent studies of twins suggesting that nonshared environmental factors, such as pre-, peri-, and postnatal neurological insults, among other factors, account for approximately 15 to 20% of the differences among individuals in the behavioral pattern associated with ADHD (inattention and hyperactive-impulsive behavior). Where differences in brain structures are found, they are probably the result of abnormalities that arise in brain development (embryology) within these particular regions, the causes of which are not known but may have to do with particular genes responsible for the construction of these brain regions.

No evidence exists to show that ADHD is the result of abnormal chromosomal structures (as in Down’s Syndrome), their fragility (as in Fragile X) or transmutation, or of extra chromosomal material (as in XXY syndrome). Children with such chromosomal abnormalities may show greater problems with attention, but such abnormalities are very uncommon in children with ADHD.

By far, the preponderance of research evidence suggests that ADHD is a trait that is highly hereditary in nature, making heredity one of the most well substantiated among the potential etiologies for ADHD. Multiple lines of research support such a conclusion. For years, researchers have noted the higher prevalence of psychopathology in the parents and other relatives of children with ADHD. In particular, higher rates of ADHD, conduct problems, substance abuse, and depression have been repeatedly observed in these studies. Research such as that by Joseph Biederman and colleagues at the Harvard Medical School (Massachusetts General Hospital) shows that between 10 and 35% of the immediate family members of children with ADHD are also likely to have the disorder, with the risk to siblings of the ADHD children being approximately 32%. More recent studies even suggest that if either parent has ADHD, the risk to offspring for the disorder may be as high as 50%.

Another line of evidence for genetic involvement in ADHD has emerged from studies of adopted children, which have found higher rates of hyperactivity in the biological parents of hyperactive children than in adoptive parents of hyperactive children. Biologically related and unrelated pairs of international adoptees also identified a strong genetic component to the behavioral dimension underlying ADHD.

Studies of twins conducted in the United States, Australia, and the United Kingdom provide a third avenue of evidence for a genetic contribution to ADHD. In general, these studies suggest that if one twin is diagnosed with ADHD, the concordance for the disorder in the second twin may be as high as 81 to 92% in monozygotic twins but only 29 to 35% in dizygotic twins.

Quantitative genetic analyses of a large sample of families studied in Boston by Joseph Biederman and his colleagues suggest that a single gene may account for the expression of the disorder. The focus of research recently has been on the dopamine type 2 gene, given findings of its increased association with alcoholism, Tourette’s Syndrome, and ADHD. However, difficulties have arisen in the replication of this finding. More recent studies have implicated the dopamine transporter gene as being involved in ADHD as might the D4D repeator gene, which has shown an association with novelty-seeking and risk-taking personality traits. Clearly, research into the genetic mechanisms involved in the transmission of ADHD across generations will prove an exciting and fruitful area of research endeavor over the next decade as the human genome is mapped and better understood and as more sophisticated genetic technologies arising from this project come to be applied to the study of the genetics of ADHD.

Pre-, peri-, and postnatal complications, and malnutrition, diseases, trauma, and other neurologically compromising events may occur during the development of the nervous system before and after birth. Among these various biologically compromising events, several have been repeatedly linked to risks for inattention and hyperactive behavior. Elevated body lead burden has been shown to have a small but consistent and statistically significant relationship to the symptoms comprising ADHD. However, even at relatively high levels of lead, less than 38% of these children are rated as hyperactive on teacher rating scales, implying that most lead-poisoned children do not develop symptoms of ADHD. Other types of environmental toxins found to have some relationship to inattention and hyperactivity are prenatal exposure to alcohol and tobacco smoke.

The prevalence of ADHD, as reviewed by Peter Szatmari in 1992, using large epidemiological studies ranges from a low of 2 % to a high of 6.3 %, with most falling within the range of 4.2 to 6.3 %. Most studies have found similar prevalence rates in elementary school-aged children. Differences in prevalence rates are due in part to different methods of selecting these populations, to the criteria used to define a case of ADHD, and to the age range of the samples. For instance, prevalence rates may be 2 to 3% in females but 6 to 9% in males during the 6 to 12-year-old age period, but fall to 1 to 2% in females and 3 to 4.5 % in males by adolescence.

While the declining prevalence of ADHD with age may reflect real recovery from the disorder, it may also involve, at least in part, an artifact of methodology. This artifact results from the use of items in the diagnostic symptom lists across the life span that are were developed upon and chiefly applicable to young children. These items may reflect the underlying constructs of ADHD very well at younger ages but may be increasingly less appropriate for older age groups. This could create a situation where individuals remain impaired by ADHD characteristics as they mature, but outgrow the diagnostic symptom list for the disorder, resulting in an illusory decline in prevalence over development. Until more age-appropriate symptoms are studied for adolescent and adult populations, this issue remains unresolved.

Gender appears to play a significant role in determining prevalence of ADHD within a population. On average, males are between 2 and 6 times more likely than females to be diagnosed with ADHD in epidemiological samples of children, with the average being roughly 3:1. Within clinic-referred samples, the sex ratio can rise to 6:1 to 9:1, suggesting that males with ADHD are far more likely to be referred to clinics than females, especially if they have an associated oppositional or conduct disorder. It is unclear at this time why males should be more likely to have ADHD than females. This could result partly from an artifact of the relationship between male gender and more aggressive and oppositional behavior; such behavior is known to increase the probability of referral to mental health centers. Because such behavior is often associated with ADHD, clinic-referred males are also more likely to have ADHD. The greater preponderance of males might also, in part, be an artifact of applying a set of diagnostic criteria developed primarily on males to females. Using a predominantly male population to set diagnostic criteria as was done for the DSM-IV (see below) could create a higher threshold for diagnosis for females relative to other females than for males relative to other males. Such a circumstance argues for the eventual examination of whether separate diagnostic criteria (symptom thresholds) ought to be considered for each gender.

ADHD occurs across all socioeconomic levels. Where differences in prevalence rates are found across levels of social class, they may be artifacts of the source used to define the disorder or of the association of ADHD with other disorders known to be related to social class, such as aggression and conduct disorder. No one, however, has made the argument that the nature or qualitative aspects of ADHD differ across social classes.

Hyperactivity or ADHD is present in all countries studied so far, such as New Zealand, Japan, Italy, Germany, India, and Australia. While it may not receive the same diagnostic label in each country, the behavior pattern comprising the disorder appears to be present internationally. ADHD arises also in all ethnic groups studied so far.

Major follow-up studies of clinically referred hyperactive children have been ongoing during the last 25 years at five sites: Montreal, New York City, Iowa City, Los Angeles, and Milwaukee. Follow-up studies of children identified as hyperactive during epidemiological screenings of general populations have also been conducted in the United States, Australia, New Zealand, and England.

The onset of ADHD symptoms has been found to be generally in the preschool years, typically by age 3 or 4, and usually by entry into formal schooling. First to arise in many cases is the pattern of hyperactive-impulsive behavior and, in some cases, oppositional and aggressive conduct. Preschool-aged children with significant degrees of inattentive and hyperactive behavior who are difficult to manage for their parents or teachers and whose pattern of such behavior is persistent for at least a year or more are highly likely to have ADHD and to retain their symptoms into the elementary school years.

By the time ADHD children move into the age range of 6 to 12 years, the problems with hyperactive-impulsive behavior are increasingly associated with difficulties with the form of sustained attention referred to above as goal-directed persistence and distractibility (poor interference control). These symptoms of inattention appear to arise by the age of 5 to 7 years and may emerge out of the increasing difficulties ADHD children are having with self-regulation. The inattentiveness evident in children having ADD without Hyperactivity (Predominantly Inattentive Type of ADHD) may be of a qualitatively different form (focused or selective attention) and may not emerge or be impairing of the child’s school performance until even later, such as mid-to-late childhood.

When ADHD is present in clinic-referred children, the likelihood is that 50 to 80% will continue to have their disorder into adolescence. Although severity levels of symptoms are declining over development, this does not mean hyperactive children are necessarily outgrowing their disorder relative to normal children; like mental retardation, the disorder of ADHD is defined by a developmentally relative deficiency, rather than an absolute one, that persists in many children over time.

The persistence of ADHD symptoms across childhood as well as into early adolescence appears to be associated with the initial degree of hyperactive/impulsive behavior in childhood, the co-existence of conduct problems or oppositional/hostile behavior, poor family relations and conflict in parent-child interactions, as well as maternal depression. These predictors have also been associated with the development and persistence of oppositional and conduct disorder into adolescence.

The Montreal follow-up study of Weiss and Hechtman reported in 1993 that at least half of their subjects were still impaired by some symptoms of the disorder in adulthood. The New York City longitudinal study by Salvatore Mannuzza and Rachel Klein suggested that 18 to 30% of hyperactive children continue to have significant symptoms of ADHD into adulthood. Most recently, the Milwaukee follow-up study by Barkley and Fischer suggests that the source of information about the symptoms may be a significant factor in establishing the persistence of the disorder into adulthood. Less than 25 % of ADHD children reported having significant symptom levels of the disorder in adulthood when asked about themselves as young adults while their parents indicated that more than 60% of these subjects continued to have clinically significant degrees of the disorder as young adults. Until more studies report adult outcomes for ADHD children using clinical diagnostic criteria appropriate for adults and collecting information not only from the adult but from a parent or an immediate family member who knows them well, the true persistence of the disorder into adulthood will remain a matter of some controversy. At the very least, current research suggests it may be 30 to 50%, although the percentage may be higher among clinic-referred children followed to adulthood.

The most recent diagnostic criteria for ADHD are defined in the DSM-IV (1994). They stipulate that individuals have had their symptoms of ADHD for at least 6 months, that these symptoms exist to a degree that is developmentally deviant, and that they have developed by 7 years of age. From the Inattention item list, six of nine items must be endorsed as developmentally inappropriate. Likewise, from the Hyperactive-Impulsive item list, six of nine items must be endorsed as deviant. Depending upon whether criteria are met for either or both symptom lists will determine the type of ADHD that is to be diagnosed: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, or Combined Type.

These diagnostic criteria are empirically derived and are the most rigorous ever available in the history of clinical diagnosis for this disorder. They were developed by a committee of some of the leading experts in the field, a literature review of research on ADHD, an informal survey of rating scales assessing the behavioral dimensions related to ADHD by the committee, and from statistical analyses of the results of a field trial of the items using a large sample of children from 10 different sites in North America.

Controversy continues over whether ADHD-Predominantly Inattentive Type represents a true subtype of ADHD. It is unclear if these children share a common attentional disturbance with the Combined Type and are distinguished simply by the relative absence of significant hyperactivity-impulsivity or whether they have a qualitatively different impairment in attention from that seen in the Combined Type. Several recent reviews of the literature have suggested that this is not in fact a true subtype but actually a separate, distinct disorder having a different attentional disturbance than the one present in ADHD-Combined Type. However, evidence for this subtype’s existence was at least strong enough to place it within the DSM-IV while awaiting more research on its course and treatment responsiveness to help clarify its status. The very limited research available to date suggests that Predominantly Inattentive ADHD children have more problems in the focused or selective component of attention, appear sluggish in their speed of information processing, and may have memory retrieval problems; in contrast, those with ADHD-Combined Type have more problems with persistence and distractibility as well as with poor inhibition.

The research criteria from the International Classification of Diseases (ICD-10) for Hyperkinetic Disorders closely resemble the DSM-IV in stressing two lists of symptoms related to inattention and overactivity and in requiring that pervasiveness across settings be demonstrated. The specific item contents, manner of presenting these symptoms lists within the home and school setting, requirement for office observation of the symptoms, and the earlier age of onset (age 6 years) clearly differs from the DSM-IV, as does the specification of a lower bound of IQ below which the diagnosis should not be given.

Social critics have charged that professionals have been too quick to label energetic and exuberant children as having this mental disorder and that educators also may be using these labels simply as an excuse for poor educational environments. This would imply that children who are hyperactive or are diagnosed with ADHD are actually normal but are being labelled as mentally disordered because of parent and teacher intolerance. If this were actually true, then we should find no differences of any cognitive, behavioral, or social significance between ADHD children and normal children. We should also find ADHD is not associated with any significant later risks in development for maladjustment within any domains of adaptive functioning, social, or school performance. Furthermore, research on potential etiologies for the disorder should also come up empty-handed. This is hardly the case. It should become clear from the totality of information on ADHD presented here and elsewhere in reviews such as those by Barkley in 1990 and Hinshaw in 1994 that those with ADHD have significant deficits in behavioral inhibition and associated executive functions that are critical for effective self-regulation, that these deficits are significantly associated with various biological factors, and particularly genetic and neurodevelopmental ones, and that ADHD symptoms and other associated disorders pose substantial risks for these individuals over the life span.

Future research needs to address the nature of the attentional problems in ADHD given that current research seriously questions whether these problems are actually within the realm of attention at all. Most studies of ADHD point to impairment within the motor, output, or motivational systems of the brain being most closely affiliated with ADHD rather than deficiencies in the sensory processing systems where attention has been traditionally thought to reside. Even the problem with sustained attention may represent a deficiency in a more complex form of goal-directed persistence that arises out of poor self-regulation rather than representing a disturbance in the more primitive form of sustained responding that is contingency shaped. Our understanding of the very nature of the disorder of ADHD is at stake in how research comes to resolve these issues.

Key to understanding ADHD is the notion that it is actually a disorder of behavioral performance and not one of skill; of how and when one’s intelligence comes to be applied in everyday effective adaptive functioning and not in that knowledge itself; of doing what one knows how to do rather than of knowing what to do. The concepts of time, timing, and timeliness are likely to prove increasingly crucial in deepening our understanding of ADHD. In particular, psychological time, how it is sensed, and how it is used in the crosstemporal organizing of complex, goal-directed behavior and in self-regulation may come to be a critical element in models of ADHD. Undoubtedly, research on brain function and structure is likely to further our understanding of the unique role of the prefrontal cortex and the midbrain structures with which it is closely associated in ADHD. But advances in theoretical models must also occur in order to better understand the nature and organization of the executive functions subserved by these brain regions and even the relationship of genetics, which builds these brain regions in embryological development, to ADHD and the deficits it produces in behavioral performance. And the current body of twin studies further suggests that while such genetic influences are important, there exists a lesser but still important role for unique (nonshared) environmental influences on the differences among individuals in symptoms of ADHD and its underlying behavioral traits. Some of these influences are no doubt social in nature while others are likely to be nongenetic pre-, peri-, and postnatal factors affecting brain development. Such studies, not only on the basic psychological nature of ADHD but also on its basic neuroanatomic and neurogenetic origins and the influence of unique social factors upon them, forebode further significant and exciting advances to come in the understanding and treatment of this fascinating developmental disorder.

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June 4, 2024

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Program supporting psychological well-being and parenting skills of mothers of children with ADHD proves effective

by Okinawa Institute of Science and Technology

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder characterized by elevated levels of inattention, impulsivity, and hyperactivity that can impair academic and social functioning. ADHD is also associated with increased levels of parenting stress, less effective parenting practices, and can disrupt the parent-child relationship. The importance of support for parents of children with ADHD is widely acknowledged in Japan, but specialized parent training programs targeting ADHD have not been available.

However, a new program developed at the Okinawa Institute of Science and Technology (OIST) aims to reduce the strain on families of children with ADHD by helping mothers improve their ADHD-specific parenting skills, as well as developing confidence in their own parenting. Dr. Shizuka Shimabukuro, a researcher in the Human Developmental Neurobiology Unit at OIST, has worked to develop and evaluate Well Parent Japan (WPJ).

WPJ is a 13-week group-based parent training program that focuses on enhancing mothers' psychological well-being and teaching culturally tailored parenting skills for ADHD. Dr. Shimabukuro was recently recognized with an award from the Japanese Ministry of Education, Culture, Sports, Science and Technology (MEXT) for her long-standing work with the program. She is the lead author on a recently-published paper in the Journal of Child Psychology and Psychiatry that evaluates the efficacy and cost effectiveness of WPJ compared with treatment as usual for Japanese mothers of children with ADHD.

"We implemented WPJ across three sites in Japan and found that the program was more effective than treatment as usual in these settings, as well as being moderate in cost to deliver," explains Dr. Shimabukuro, and adds that importantly, "the study was conducted in regular hospitals and a developmental support center, not the research lab, as we wanted to test if it worked when delivered in the community."

Finding solace in community

The group-based approach was found to be very effective in providing social support and encouraging shared learning among the participating mothers, who might otherwise feel isolated or hesitate to seek help in dealing with their children's difficulties.

"The primary caregiver in Japan is usually the mother, and because they hesitate to put their own needs ahead of others, they often feel alone with their problems. We wanted to invite them to a comfortable, shared space where everyone is dealing with similar issues and can safely share their struggles and concerns, as well as learn from and support one another," explains Dr. Shimabukuro.

Just as the mothers came together to share and address their parenting difficulties, WPJ is the product of ten years of co-production and collaboration between researchers, clinicians, parents, and children with ADHD, drawing on international literature and the voices of Japanese parents who participated in the studies.

Professor Gail Tripp, head of the unit and another author on the paper, describes the present study as an exercise in crossing divides. "We worked closely with a local hospital here in Okinawa, two university hospitals in other parts of Japan, an economist in Tokyo, and a research colleague in the UK... It's a highly collaborative effort, and I'm glad to see it coming to fruition."

From lockdown to the future

The process of testing the efficacy of WPJ was not without its challenges. The clinical trials began just before the onset of the unexpected coronavirus pandemic, which meant they had to adapt the original research design to the changing social conditions.

"We were trying to coordinate the trials across three sites, with the regulations constantly changing with the nature of the pandemic," says Dr. Shimabukuro. "I'm very grateful and proud of the work that the research group leaders put into first and foremost ensuring the health and safety of our research participants, while also ensuring robust data."

Despite the difficulties faced, the researchers were pleased to see that WPJ was effective in "the real world," with the program outperforming treatment as usual in reducing parenting-specific stress, improving parenting efficacy and reducing family strain.

"Considering the disruptions brought by COVID, we had an extraordinarily high participant retention," explains Prof. Tripp, adding that "comparable studies from abroad in non-pandemic conditions usually report a participant attrition rate—the rate of participants dropping off during the study—of about 15%, but ours was just around 7%."

Dr. Shimabukuro suggests that "our results show how much parents engaged with the program and valued the time and space to talk about their children, even during the height of the COVID crisis."

The high participant retention and the positive results confirm the value of programs like the WPJ in Japan. Dr. Shimabukuro says, "As parents are agents of change for their children, it is very important to take care of them before they can take care of others."

Dr. Shimabukuro is now turning her focus to another environment where children with ADHD spend much of their time—schools. "Teachers are also important agents of change for children, and the children spend so much of their time with them—but like parents, they often face the challenges that ADHD can bring alone. It would be much easier for children with ADHD to establish good behavioral habits if parents and teachers dealt with any problems that arise consistently," explains Dr. Shimabukuro.

The team is now running a feasibility study for implementing an educational video series, a modified version of WPJ, for teachers in schools. Both to educate the teachers about what it means for a child to have ADHD and how to adjust their teaching techniques to accommodate this, but also to—as with the mothers—provide a space for the teachers to share their professional insights and experiences of accommodating children with ADHD, with one another.

As licensed clinical psychologists , Dr. Shimabukuro and Prof. Tripp are working to combine their clinical experience with their research in the lab for the good of the children , their families, and their communities.

Dr. Shimabukuro says, "We are ultimately hoping to help enhance people's understanding of ADHD, improve the quality of support and increase the number of places to receive help in the community—we want to help these families under strain."

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Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women

Susan young.

1 Psychology Services Limited, PO 1735, Croydon, London, CR9 7AE UK

2 Department of Psychology, Reykjavik University, Reykjavik, Iceland

Nicoletta Adamo

3 Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK

4 Service for Complex Autism and Associated Neurodevelopmental Disorders, South London and Maudsley NHS Foundation Trust, Michael Rutter Centre, London, UK

Bryndís Björk Ásgeirsdóttir

Polly branney.

5 Oxford ADHD and Autism Centre, Oxford, UK

Michelle Beckett

6 ADHD Action, Harrogate, North Yorkshire, UK

William Colley

7 CLC Consultancy, Perth, UK

Sally Cubbin

8 Manor Hospital, Oxford, UK

Quinton Deeley

9 National Autism Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Beckenham, UK

10 Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology, and Neuroscience, London, UK

Emad Farrag

11 South London & Maudsley NHS Foundation Trust, Maudsley Health, Abu Dhabi, UAE

Gisli Gudjonsson

12 Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

13 Independent Consultant in Child and Adolescent Psychiatry, Private Practice, London, UK

Jack Hollingdale

14 Michael Rutter Centre, South London and Maudsley Hospital, London, UK

15 Koc University, Istanbul, Turkey

16 ADHD Foundation, Liverpool, UK

Peter Mason

17 ADHD and Psychiatry Services Limited, Liverpool, UK

Eleni Paliokosta

18 Tavistock and Portman NHS Foundation Trust, London, UK

Sri Perecherla

19 St Thomas’ Hospital London, London, UK

Jane Sedgwick

20 Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK

Caroline Skirrow

21 Cambridge Cognition, Cambridge, UK

22 School of Psychological Science, University of Bristol, Bristol, UK

Kevin Tierney

23 Neuropsychiatry Team, National Specialist CAMHS, South London and Maudsley NHS Foundation Trust, London, UK

Kobus van Rensburg

24 Adult ADHD and AS Team & CYP ADHD and ASD Service in Northamptonshire, Northampton, UK

Emma Woodhouse

25 Compass, London, UK

Associated Data

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD.

The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan.

A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them.

Conclusions

This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition described in diagnostic classification systems (ICD-10, DSM-5 [ 1 , 2 ]). It is characterised by difficulties in two subdomains: inattention, and hyperactivity-impulsivity. Three primary subtypes can be identified: predominantly inattentive, hyperactive-impulsive, and combined presentations. Symptoms persist over time, pervade across situations and cause significant impairment [ 3 ].

ADHD is present in childhood and symptoms tend to decline with increasing age [ 4 ], with consistent reductions documented in hyperactive-impulsive symptoms but more mixed results regarding the decline in inattentive symptoms [ 5 – 7 ]. This trajectory does not appear to be different in affected males or females [ 6 , 8 ]. A meta-analysis of longitudinal studies published in 2005 showed that up to one-third of childhood cases continued to meet full diagnostic criteria into their 20s, with around 65% continuing to experience impairing symptoms [ 9 ]. More recent studies in large clinical cohorts indicate that persistence of ADHD into adulthood may be much more common. Two studies from child mental health clinics in the UK and the Netherlands have reported persistence in around 80% of children with the combined type presentation into early adulthood [ 10 , 11 ], potentially relating to the high severity of ADHD in this group and the use of more objective ratings [ 12 ]. The proportion meeting full diagnostic criteria for ADHD then continues to decline in adult samples [ 13 ]. Simultaneously, experiences of ADHD symptoms often change over the course of development: hyperactivity may be replaced by feelings of ‘inner restlessness’ and discomfort; inattention may manifest as difficulty completing chores or work-based activities (e.g. filling out forms, remembering appointments, meeting deadlines) [ 1 ].

Psychiatric comorbidity is very common, which may complicate identification and treatment [ 14 ]. In children with ADHD this includes conduct disorder (CD), oppositional defiant disorder (ODD), disruptive mood dysregulation disorder, autism spectrum disorder (ASD), developmental coordination disorder, tic disorders, anxiety and depressive disorders, reading disorders, and learning and language disorders [ 15 – 17 ]. Comorbid conditions are also extremely common in adults and include ASD, anxiety and depressive disorders, bipolar disorder, eating disorders, obsessive compulsive disorder, substance use disorders, personality disorders, and impulse control disorders [ 18 , 19 ].

Prevalence of ADHD is estimated at 7.1% in children and adolescents [ 20 ], and 2.5-5% in adults [ 4 , 21 ], and around 2.8% in older adults [ 22 ]. Sex differences in the prevalence of ADHD are well documented. Clinical referrals in boys typically exceed those for girls, with ratios ranging from 3-1 to 16-1 [ 23 ]. The discrepancy of ADHD rates in community samples remains significant, although it is less extreme, at around a 3-1 ratio of boys to girls [ 4 ]. Nevertheless the discrepancy in the sex-ratio between clinic and community samples highlights that a large number of girls with ADHD are likely to remain unidentified and untreated, with implications for long-term social, educational and mental health outcomes [ 24 ].

This disparity in prevalence between boys and girls may stem from a variety of potential factors. The contribution of greater genetic vulnerability, endocrine factors, psychosocial contributors, or a propensity to respond negatively to certain early life stressors in boys have been proposed or investigated as potential contributors to sexual dimorphism in prevalence and presentation [ 25 , 26 ]. Whilst in childhood there is a clear male preponderance of ADHD, in adult samples sex differences in prevalence are more modest or absent [ 21 , 27 – 29 ]. This may be due to a variety of factors, with potential contributions from the greater reliance on self-report in older samples, greater persistence in females alongside increased levels of remission in males, and potentially more common late onset cases in females [ 25 , 26 , 28 ].

Comprehensive views of the aetiology of ADHD incorporate biological, environmental and cultural perspectives and influences [ 25 ]. Substantial genetic influences have been identified in ADHD [ 30 ]. Individuals who have ADHD are more likely to have children, parents and/or siblings with ADHD [ 31 , 32 ]. The ‘female protective effect’ theory suggests that girls and women may need to reach a higher threshold of genetic and environmental exposures for ADHD to be expressed, thereby accounting for the lower prevalence in females and the higher familial transmission rates seen in families where females are affected [ 33 , 34 ]. Research suggests that siblings of affected girls have more ADHD symptoms compared with siblings of affected boys [ 33 , 34 ].

There is increasing recognition that females with ADHD show a somewhat modified set of behaviours, symptoms and comorbidities when compared with males with ADHD; they are less likely to be identified and referred for assessment and thus their needs are less likely to be met. It is unknown how often a diagnosis of ADHD is being missed or misdiagnosed in females, but it has become clear that a better understanding of ADHD in girls and women is needed if we are to improve their longer-term wellbeing and functional and clinical outcomes [ 35 , 36 ].

This report provides a selective review the research literature on ADHD in girls and women, and aims to provide guidance to improve identification, treatment and support for girls and women with ADHD across the lifespan, developed through a multidisciplinary consensus meeting according to the clinical expertise and knowledge among attendees. To support medical and mental health practitioners in their understanding of ADHD in females, we provide consensus guidance on the presentation of ADHD in females and triggers for referral. We establish specific advice regarding the assessment, interventions, and multi-agency liaison needs in girls and women with ADHD.

In line with previous definitions, we use the terms sex to identify a biological category (male/female), and gender to define a social role and cultural-social properties [ 37 ]. However, we acknowledge the complex differences between the sexes that occur independently of ADHD status [ 38 ], and discuss both biological differences and social roles in the current consensus.

The consensus aimed to provide practical guidance to professionals working with girls and women with ADHD, drawing on the scientific literature and the professional experience of the authors. To achieve this aim, professionals specialising in ADHD convened in London on 30th November 2018 for a meeting hosted by the United Kingdom ADHD Partnership (UKAP; www.UKADHD.com ). Meeting attendees included experts in ADHD across a range of mental health professions, including healthcare specialists (nursing; general practice; child, adolescent and adult psychiatry; clinical and forensic psychology; counselling), academic, educational and occupational specialists. Service-users and ADHD charity workers were also represented. Attendees engaged in discussions throughout the day, with the aim of reaching consensus.

The meeting commenced with presentations of preliminary data obtained from (1) an ongoing systematic review on the clinical and psychosocial presentation of females in comparison with males with ADHD (currently being led by SY and OK); and (2) epidemiological research on sex differences in self-reported ADHD symptoms in population based adolescent cohorts. Following a question and answer session, attendees then separated into three breakout groups. Each group was tasked with providing practical solutions relevant to their assigned topic. Discussions were facilitated by group leaders and summarized by note-takers. Following the small-group work, all attendees re-assembled. Group leaders then presented findings to all meeting attendees for another round of discussion and debate, until consensus was reached. Group discussions included the following themes:

• 1.1 Presentation in females and what might trigger referral?
• 1.2 Considering sex differences when conducting ADHD assessments
• 2.1 Pharmacological
• 2.2 Non-pharmacological
• 3.1 Educational considerations
• 3.2 Other multi-agency considerations

Taking a lifespan perspective, each theme was explored in relation to specific age groups considered to be associated with pertinent periods for environmental and biological change, and change in clinical needs and presentation. Recommendations that differed between age groups are presented separately.

The consensus group incorporated evidence from a broad range of sources. However, the assessment, pharmacological treatment, and multiagency support features reflect clinical practice and legislature in the United Kingdom (UK), and may differ in other countries.

All consensus proceedings, including group and feedback sessions were video-recorded and transcribed. One note-taker was allocated to each breakout group, and notes were subsequently circulated to each breakout group contributor for review and agreement. All materials were sent to the medical writer, who consolidated the meeting transcription, electronic slide presentations and small-group notes. The lead author worked closely with the medical writer to synthesise the consensus report, which was then circulated to all authors for review and feedback. A final draft was circulated to all authors for agreement and approval.

Results and consensus outcome

Presentation of adhd in females.

Although much of the scientific literature indicates an overlap in the clinical presentation of males and females with ADHD, the available evidence often draws on predominantly male samples [ 39 ] due to the higher prevalence of ADHD in males [ 4 ]. Some sex differences have been reported, which are described below, and briefly summarised in Table ​ Table1 1 .

Summary of key points for detection of ADHD in females

ADHD symptoms

Research in population-based samples indicates that for both sexes the hyperactive-impulsive type predominates in pre-schoolers, whereas the inattentive-type is the most common presentation from mid-to-late childhood and into adulthood [ 4 , 21 ]. By contrast, clinical studies typically report a greater prevalence of combined-type ADHD [ 5 , 12 , 22 ]. Early meta-analyses of gender effects have found lower severity of hyperactivity-impulsivity [ 40 ], or all ADHD symptoms (inattention, hyperactivity, impulsivity) [ 24 ] in girls than boys, although individual studies show more mixed results [ 8 , 35 , 41 , 42 ].

Inconsistent findings may reflect that clinic referral and diagnosis tends to favour combined subtypes equally across genders, whilst community sampling points to greater prevalence of inattentive type ADHD in girls than in boys [ 43 ]. Hyperactive-impulsive symptoms have been linked to higher clinic ascertainment rates [ 4 ], and may be more commonly seen in boys [ 40 ], with inattention symptoms being less obvious and therefore less likely to be detected. These differences may lead to the perception that females with ADHD are less impaired [ 44 ].

People may experience and respond to the same behaviour of males and females in different ways due to gender-related behavioural expectations [ 42 ]. For example in two studies where teachers were presented with ADHD-like vignettes, when simply varying the child’s name and pronouns used from male to female, boys names were more likely to be referred for additional support [ 45 ] and considered more suitable for treatment [ 46 ]. Parents may also underestimate impairment and severity of hyperactive/impulsive symptoms in girls whilst over-rating these same symptoms in boys [ 47 ]. Compensatory behaviours in girls, such as socially adaptive behaviour, compliance, increased resilience [ 47 ] or coping strategies to mask behaviour [ 48 ] may also contribute to differing perceptions that may in turn prevent referral.

Less is known about the presentation of ADHD in older adults but evidence suggests whilst symptoms tend to decline, ADHD may persist into middle and old age, with a more even male-to-female community prevalence and referral rate with increasing age [ 22 , 49 ].

Comorbidity

Externalising problems are more prevalent in males with ADHD [ 24 ], manifesting as higher rates of comorbid oppositional defiant disorder (ODD) and conduct disorder (CD) [ 40 ], characterised by rule-breaking behaviour [ 50 , 51 ] and fights in school [ 36 ]. In adulthood, men with ADHD more commonly show antisocial behaviours characteristic of antisocial personality disorder [ 52 – 54 ]. Whilst these problems are more prevalent in males, they typically remain elevated in individuals with ADHD across both sexes in comparison with the general population. The lower rates of disruptive behavioural problems in females may contribute to lower rates of referral for ADHD assessment and support [ 48 , 55 ].

Compared with males with ADHD, internalising disorders (e.g. emotional problems, anxiety, depression) are more often reported in females [ 24 , 29 , 47 , 51 , 53 , 56 ]. Borderline personality traits in ADHD tend to be associated with women [ 57 ] with hyperactive/impulsive symptoms being associated with self-harming behaviours [ 58 ]. Additionally, women with ADHD have been found to be at higher risk for some adverse outcomes, including greater mental health impairment [ 29 ], severe mental illness (schizophrenia) [ 59 ] and admissions to in-patient psychiatric hospitals in adulthood [ 60 ].

The less overt presentation of ADHD in girls and women may mask the underlying condition due to females not meeting stereotypical expectations of ADHD behaviour. Instead females may be more likely to attract a primary diagnosis of internalising disorders or personality disorders, in turn delaying diagnosis and appropriate treatment [ 45 , 47 , 48 ].

Disordered eating behaviour has been associated with ADHD across both sexes. Whilst individual studies have shown increased disordered eating in girls and women with ADHD [ 53 , 61 ], a meta-analysis of twelve studies identified increased risk of all eating disorder syndromes (bulimia nervosa, anorexia nervosa and binge eating disorder), amongst individuals with ADHD, with similar risk estimates for males and females [ 62 ]. Meta-analysis has also confirmed increased co-occurrence of obesity in children and adults with ADHD [ 63 , 64 ], albeit with no difference between males and females.

Consensus meeting attendees highlighted the co-occurrence of somatic symptoms such as pain and fatigue with ADHD in females, based on clinical observation. There is little available research on sex differences in the prevalence of somatic symptoms such as pain and fatigue in people with ADHD. However, elevated ADHD symptoms have been reported in clinical cohorts with fibromyalgia [ 65 ], and chronic fatigue syndrome [ 66 ].

Young people with ADHD are at greater risk for tobacco and alcohol use in mid adolescence [ 67 ]. In adulthood they are more likely to become smokers [ 68 ], engage in higher rates of substance use [ 69 ] and develop alcohol and drug use disorders [ 70 ]. A prospective follow-up study of a nationwide birth cohort using Danish registry data reported that ADHD increased the risk of all substance use disorder (SUD) outcomes [ 71 ], with comparable risks seen for males and females. Females with ADHD (but without any comorbid conditions) had a higher risk of alcohol and cannabis abuse when compared with males.

Associated features, functional problems and impairments

In both children and adults ADHD is commonly accompanied by emotional lability and emotion dysregulation problems (irritability, low frustration tolerance, mood changes) [ 72 – 74 ]. Difficulties of this nature may be more common or severe in girls and women [ 30 , 56 – 58 ] and emotion dysregulation problems are associated with a broad range of impairments in adulthood, including educational, occupational, social, familial, criminal, driving and financial problems [ 75 , 76 ]. In an Icelandic study of ADHD symptoms in university students, poor social functioning best predicted dissatisfaction with life in males, whereas among females the best predictor of life dissatisfaction was poor emotional control [ 77 ].

Cognitive problems are well established in ADHD [ 78 – 80 ], spanning difficulties with executive dysfunction (such as inhibition, planning, working memory and set shifting) and non-executive cognitive domains (e.g. word reading, reaction times, colour or letter naming, response consistency). However, ADHD may also be associated with general impairments in intellectual functioning, which tends to be more prominent in females [ 24 , 40 ]. Subtle social cognition deficits, including facial and vocal emotion recognition, have also been reported in both males and females with ADHD, with no clear sex-related differences [ 81 ].

A similar level of social impairment has been identified for ADHD males and females [ 24 , 40 , 82 ]. Autistic-like symptoms, including social and communication impairments, are common in both girls and boys with ADHD, and although these present at a higher rate in boys, likely influenced by the higher base incidence of ASD in boys, alongside greater difficulties in detecting ASD in girls [ 16 ]

Children with ADHD are more likely to experience rejection and unpopularity and have fewer friendships than their peers [ 83 ] and social problems can persist into adulthood [ 75 ]. Disruption to relationships with parents, siblings and peers has been reported for females with ADHD [ 84 , 85 ]. Girls with ADHD may apply a range of ineffective strategies to resolve their peer relationship problems [ 86 , 87 ], and experience more bullying than their peers [ 88 ], including physical, social-relational, and cyberbullying victimisation [ 23 , 89 , 90 ], whilst in boys physical victimisation appears to be more common [ 91 ]. Peer victimisation has been associated with reduced self-esteem and self-efficacy, and increased anxiety and depression symptoms in young people with ADHD [ 90 , 91 ]. Adverse outcomes have been associated with interpersonal difficulties in females with ADHD including lower satisfaction with romantic relationships [ 92 ] and lower self esteem [ 48 ].

There is some evidence to suggest that elevated symptoms of ADHD are associated with excessive internet use in children and adolescents [ 93 ], as well as adults [ 94 ], but the causal direction of this association is unclear (i.e. elevated ADHD symptoms could trigger excessive internet use, or excessive internet use could lead to elevated symptoms of ADHD) [ 95 ]. Excessive gaming [ 96 ] has also been reported. It is not clear whether this association is stronger in males or females or if it is equivalent across the sexes [ 93 , 94 , 97 ]. A large web-based survey of adult internet behaviours and psychopathology in Norway found that elevated ADHD symptoms were associated with increased addictive technological behaviours, including social media use and gaming [ 98 ]. Overall however, addictive social media use was more common in women [ 98 ].

Throughout adolescence and the transition into adulthood, there is an increase in risk taking behaviour which may be associated with symptoms of hyperactivity and/or impulsivity [ 48 ]. For example, young people with ADHD become sexually active earlier, have more sexual partners and are more frequently treated for sexually transmitted infections [ 99 ]. Rates of teenage, early or unplanned pregnancies are elevated in girls and women with ADHD [ 100 – 102 ]. Pregnant women with ADHD are more likely to smoke up to the third trimester, or be obese or underweight [ 102 ].

A review of ADHD and driving reported that adults with a history of ADHD may be more likely to be unsafe or reckless drivers and have more frequent or severe crashes [ 103 ], albeit with no specific examination of sex differences. One study with data from the US National Epidemiologic Survey on Alcohol and Related Conditions, showed that reckless driving was significantly more frequent in men compared with women with ADHD, reflecting the same pattern as seen the general population [ 29 ]. This suggests that reckless driving is likely to be similarly proportionally enhanced in women as in men with ADHD.

Studies specifically reporting driving problems in women with ADHD have shown no significant association between ADHD and driving outcomes [ 68 , 100 , 104 ]. However, results from a prospective follow-up study of a nationwide birth cohort in Danish registers, reported increased mortality rate among individuals with ADHD; when compared with males with ADHD, females with ADHD had an increased mortality rate after controlling for comorbid CD, ODD and SUD [ 104 ]. The excess mortality in ADHD was mainly driven by deaths from unnatural causes, especially accidents. The authors speculate that the gender difference may be driven by females being less likely to be diagnosed and receive treatment than males with the disorder, leading to greater risk of accidental death.

Delinquency and criminality in females with ADHD is more common compared with their non-ADHD peers but less severe or prevalent than reported in males with ADHD [ 85 , 105 , 106 ]. A study examining adult criminal outcomes in children with ADHD, showed males were twice more likely to be convicted than females, but convictions in females occurred at eighteen times the rate seen in the general population [ 106 ]. Prevalence of ADHD in prison populations is estimated at 25%, with no significant differences seen in relation to gender or age [ 107 ].

Triggers for referral

There are multiple potential triggers that may prompt the referral of females for assessment, shown in Table ​ Table2. 2 . Some of these triggers are indicative of other associated conditions and it is the clustering of multiple trait-like symptoms that are pervasive and impairing that is informative, rather than state-like symptoms showing situational change. The decision to refer would also be strongly supported if there is a first-degree relative with ADHD.

Co-occurring functional problems, features or conditions commonly seen in girls and women with ADHD

Legend: Co-occurring functional problems, associated features or conditions commonly seen in addition to ADHD symptoms in girls and women with ADHD, presented along with age-ranges for detection. These may serve as triggers to help to identify individuals who may require assessment for ADHD

The stereotype of the ADHD ‘disruptive boy’ [ 47 ] is likely to influence the likelihood of referral and access to diagnosis and treatment. The key message is not to disregard females because they do not present with the externalising behavioural problems, or the disruptive, hard-to-manage presentation (e.g. engaging in boisterous, loud behaviours) commonly associated with males with ADHD. Females with ADHD may be overlooked and/or their symptoms misinterpreted, particularly for those in highly structured environments, receiving a high level of support, and for those who have developed strategies to mask or compensate for their difficulties.

It is important to be mindful that environmental demands (including educational, occupational, financial, familial and social functions and responsibilities) increase in number, scope and complexity with age and level of independence, whilst support resources decline [ 108 ]. Many young peoples’ struggles and impairments become apparent as they lose the family and educational scaffolding that was previously in place. Therefore, young people (both males and females) may be particularly vulnerable at times of transition, when symptoms become exposed. Increased functional demands on transition to secondary school (planning ahead, organising work and juggling assignments) may lead them to feel overwhelmed. This may impact on self-esteem and result in learner anxiety and perfectionism in an attempt to compensate. Periods of transition may therefore unmask unidentified ADHD by exposing or exacerbating symptoms, together with the development of internalising problems leading to increased vulnerability.

These environmental changes often occur at a time when girls undergo changes in their physiological and sexual maturation. There is growing recognition that puberty is a phase of high risk for mental health problems [ 109 ]. The developmental changes that occur during puberty and later in adolescence may lead females with ADHD to be particularly psychologically vulnerable if they are not able to access support.

Difficulty coping with more complex social interactions and resolving interpersonal conflict may also trigger cause for concern. As girls with ADHD move into their teenage years, difficulty maintaining friendships often becomes more marked and they may feel rejected and socially isolated. Some respond with bravado to buffer them from social isolation but a ‘brave face’ is unlikely to prevent them from feeling distressed and developing low mood and anxiety. Dysfunctional coping strategies and the lack of a support network may lead them to express these feelings by self-harming behaviours (e.g. cutting) or changes in eating patterns.

The identification of specific educational or learning problems may also be an important trigger for referral. Children may be diagnosed with specific learning difficulties, such as dyslexia, when a diagnosis of ADHD may be more appropriate. Parents/carers and teachers may note the disparity between educational performance (day-to-day classroom contribution) and achievement (end grades).

Many young people with ADHD do not exceed the mandatory minimum level of schooling, and the problems described above may become even more marked when they enter further education and/or leave home. Research suggests that adolescent school girls with elevated ADHD symptoms make significantly fewer plans for their future than their peers, suggesting that they leave this to chance and opportunistic encounters [ 86 ]. Those who enter the world of work may find that their difficulties evolve into employment impairments and limitations. However, as they mature young people may begin to develop greater awareness of their difficulties, leading to an increase in self-referrals.

For both males and females, a comprehensive assessment should be completed to accurately capture the symptoms of ADHD across multiple settings, their persistence over time and associated functional impairments. High rates of comorbidity are typically present. The assessment process is typically tripartite involving the use of rating scales, a clinical interview and ideally objective information from informants or school reports. Key recommendations for enhancing diagnostic assessment in girls and women are provided in Table ​ Table3 3 .

Enhancing ADHD diagnostic assessment in females: consensus recommendations

Rating Scales

Rating scales can obtain perspectives from different informants (e.g. family, teacher, youth worker, occupational health practitioner) in a consistent, quick and easy way. They are not the sole domain of healthcare practitioners and can be applied (with patient consent) by allied professionals, such as social care providers and those working in educational and occupational establishments, to guide whether referral might be merited.

While rating scales are useful aids for clinical assessment and treatment monitoring, findings should be interpreted cautiously if they are used for screening purposes as they are non-specific markers of potential problems [ 110 ]. Rigid adherence to cut-offs may lead to a high proportion of false positives and negatives. There are many rating scales available with varying merits and limitations and some are yet to be updated to reflect revisions to diagnostic criteria. Where possible both informant- and patient-rated scales should be obtained. Rating scales in common use are presented in Table ​ Table4 4 .

Clinical assessment resources which are in common use for ADHD

Rating scale norms are predominantly from male or mixed samples, which may disadvantage their use in females, although some provide female-specific norms (see Table ​ Table4). 4 ). Where female norms are not available, greater emphasis should be placed on collateral information (e.g. parental and school reports). The Nadeau and Quinn checklists may also be used as indication of possible ADHD in girls and women [ 126 , 127 ], providing structured self-enquiry of ADHD symptoms and associated problems, including a range of difficulties such as learning problems, social/interpersonal and behavioural problems.

Since hyperactive and impulsive behaviours tend to decline as patients move into adulthood and impairments associated with inattention are often sustained, it is helpful to re-administer age appropriate scales as young people with ADHD become adults.

The clinical interview

A clinical diagnostic interview, supplemented by a mental state examination, should consider the extent to which the individual’s functioning is age appropriate and obtain examples of how difficulties interfere with functioning and development in home and education/work environments. For children this is usually carried out in the presence of a person close to the child, has known the child for a long time, and is familiar with their developmental history and functioning in different settings (commonly a parent or carer).

Age-appropriate, common co-occurring conditions in females with ADHD should be explored, including ASD, tics, mood disorders, anxiety, and eating disorders. Fibromyalgia, chronic fatigue syndrome, body dysmorphic disorder and gender dysphoria may also be explored as possible co-occurring conditions. The assessor needs to consider what is primary (i.e. occurring alongside and independently to ADHD) and what is secondary (i.e. caused or exacerbated by ADHD). It will help to determine whether the presenting problem is trait-like or episodic in nature. Clinicians should be alert to signs of self-harming behaviours (especially cutting), which typically peak in adolescence and early adulthood [ 128 , 129 ]. Substance and alcohol use disorders should also be assessed in teenagers and adults. Sleep problems are commonly seen in both males and females with ADHD [ 130 , 131 ], and it is important to determine whether this primarily relates to symptoms of ADHD or co-occurring anxiety.

Since heritability of ADHD is high, ranging between 70-80% in both children and adults [ 132 ], it is important to be mindful that informants who are family members may also have ADHD (possibly undiagnosed) which may affect their judgment of ‘typical’ behaviour. The assessor should therefore obtain specific examples of behaviour from the informant and use these to make clinically informed judgments, rather than relying upon the informants’ perception of what is typical or atypical.

Semi-structured clinical diagnostic interviews are helpful as they guide the healthcare practitioner to complete a comprehensive developmental and clinical interview, whilst allowing for individual differences to be considered. For example, symptoms relating to excessive talking, blurting out answers, fidgeting, interrupting and/or intruding on others have been reported as more frequently endorsed by women than men with ADHD [ 53 , 55 ] and may be more sensitive to the presentation in females. Small modifications may help to capture more female-centric behaviour (e.g. ‘excessive talking and giggling’ instead of ‘excessive talking’) [ 133 ]. Commonly used diagnostic interviews are presented in Table ​ Table4. 4 . There are three clinical interviews that prompt the assessor to consider the presence of co-existing conditions (which may differ between males and females); ACE, ACE+ [ 134 ] and the DAWBA [ 118 ].

When assessing adults, the clinical interview is usually completed with the affected individual but whenever possible collateral information should also be obtained. This may be from a parent or carer or another close member of the family. If a reliable informant cannot be identified who knew (and can recall) the individual well during their childhood, it may be helpful to obtain information from an informant who currently knows the individual well (e.g. a partner or a close friend who has known them for a significant period time, 5 years or more) in order to supplement self-reported information with a secondary perspective. If available, reports from childhood (for example, school, social service and/or previous clinical reports) are likely to be informative. Importantly, however, it may not be possible to rely on school reports when assessing females, as subtle hyperactive-impulsive symptoms may have been missed by teachers and/or they omit to comment on interpersonal or relationship problems. School reports may comment more on attentional problems (such as daydreaming or lacking in motivation and effort).

Some girls and women with ADHD become competent at camouflaging their struggles with compensatory strategies, which may lead to an underestimation of their underlying problems. Often these strategies have an adaptive or functional purpose, for example, enabling them to remain focused or sustain attention, or to disguise stress and distress. However, not all strategies are helpful. Coping strategies may be less overt, such as avoiding specific events, settings or people, not facing up to problems, spending too much time online or not seeking out help when needed. Teenage and adult females with ADHD may turn to alcohol, cannabis and other substances to manage emotional turmoil, social isolation and rejection. Some may seek to obtain a social network by forming damaging relationships (for example, joining a gang, engaging in promiscuous and unsafe sexual practices, or criminal activities). If there is cause for concern, a risk assessment should be included that enquires into suicidal ideation, the use of illicit drugs, substances and alcohol, antisocial attitudes and behaviours, harm to self and others, bullying and assault, excessive internet use, unsafe sexual practices and exploitation of a sexual, financial or social nature. In some cases, a physical health assessment may be warranted.

With older age and persistent inattentive symptoms, there may be an increasing risk that individuals with ADHD are incorrectly diagnosed with mild cognitive impairment. Self- perceived ADHD symptoms, and in particular inattention, are found to increase with age in diagnosed adults and perceived symptom severity appears to be exacerbated by concurrent depressive symptoms [ 49 ]. It is not uncommon that adults with ADHD are treated for anxiety and/or depression in the first instance. Clinicians should be mindful that those with treatment resistant anxiety and/or depression should be screened for possible undiagnosed ADHD. Indeed, careful examination of developmental history will elucidate whether symptoms are longstanding and have been exacerbated by situational or biological changes, or whether they represent new-onset symptoms that are less indicative of ADHD.

Objective assessments

Whenever possible, the assessor should obtain collateral information from independent sources. This may include direct observations in a specific setting (e.g. in clinic, at home or at school). A wealth of useful information may be obtained from observing a child in school and speaking directly with teachers. When assessing adults, perusal of school, college and/or employment reports (if available) can be helpful.

Tests that assess executive dysfunction may help to determine deficits in higher order processing skills such as task switching, perseveration, planning, sequencing and organising information. Some have been specifically developed for ADHD populations and focus on assessing attention, impulsivity and vigilance in children and adults. Neuropsychological tests such as the Test of Everyday Attention (TEA) / Test of Everyday Attention for Children (TEACh), may be helpful supplements to the diagnostic process. Those most commonly used in clinical practice include the Conners’ Continuous Performance Test, third edition (CPT 3 [age 8+]) [ 135 ] and the QbTest [ 136 ], the latter including a measure of hyperactivity. QbTest scales have normative data specific to each sex (age 6-60) and may therefore be more sensitive to ADHD in females. The assessor should be mindful that an individual with ADHD may perform relatively well on novel tasks, especially those presented as computerised games providing immediate gratification via rapid feedback. Moreover, findings may lack ecological validity and not reflect performance in the ‘real world’. Neuropsychological assessments are not specific markers of ADHD and should only be used to augment clinical decision making and not be used as stand-alone diagnostic tools.

Interventions and Treatments

Prompt identification and treatment of ADHD is recommended, as there is evidence of long-term functional benefits associated with treatment [ 137 , 138 ]. ADHD is typically treated with psychoactive medication, psychoeducation and therapeutic interventions at all ages, and a stronger treatment effect has been reported with multi-modal treatment [ 138 ]. A brief summary of treatment recommendations is presented in Table ​ Table5 5 .

Treating ADHD in girls and women: key consensus recommendations

In the context of changes in the presentation of ADHD with development and ageing, regular treatment reviews are advised. These can revisit and optimise current pharmacological and non-pharmacological approaches, or revisit those patients who previously may not have been suitable for specific treatments or who did not show good response.

Pharmacological management

ADHD is commonly treated with psychostimulants, such as methylphenidate and amphetamine. In certain cases, a nonstimulant such as atomoxetine, an extended-release form of guanfacine or clonidine, or bupropion may be prescribed, especially when stimulants are inappropriate or have been unsuccessful. These medications, with the exception of bupropion are recommended by the National Institute of Health and Care Excellence (NICE) guidance [ 139 ]. A systematic review and network meta-analysis recommended methylphenidate for children and adolescents and amphetamines for adults, taking into account both efficacy and safety [ 140 ]. Larger confidence intervals in relation to the tolerability and efficacy of bupropion, clonidine and guanfacine were reported, indicating less conclusive results with regards to the efficacy and tolerability of these oral medications [ 140 ].

Treatment recommendations do not differ by sex and differ only modestly by age (NICE, 2018 [ 139 ]). The overarching opinion in the consensus group was that there are no differences in the medicines used to treat ADHD in girls and boys. Stimulant medications show good efficacy for improving ADHD symptoms in both children [ 141 ] and adults [ 142 ], and response appears comparable in females and males [ 143 , 144 ]. However girls with ADHD tend to be less likely to be prescribed stimulant treatment than boys with ADHD, and are likely to start treatment at an older age [ 145 ].

The potential benefits of treatment must be viewed in the context of lifetime adverse outcomes associated with poorly managed ADHD described previously. Prompt identification and treatment may help to improve longer-term functional, health and mental health outcomes. Reduced rates of comorbidity (including depression, anxiety disorders, and disruptive behaviour disorders) have been noted in stimulant treated ADHD populations [ 146 , 147 ], although the converse effect has also been reported [ 148 ]. Comorbid ADHD is associated with treatment resistant depression [ 149 ] and regular treatment for ADHD may reduce rates of treatment resistance [ 150 ]. Pharmacological treatment of ADHD is also associated with improved educational [ 146 ] and occupational [ 151 ] outcomes, as well reduced rates of criminality [ 152 ]. Pharmacotherapy for ADHD appears to be a protective factor for obesity [ 64 ], and some limited evidence suggests that it may increase efficacy of weight management strategies (reviewed in [ 153 ]). Additionally, there appears to be a benefit of ADHD treatment with regards to substance use disorders. A study of commercial healthcare claims showed reduced emergency department visits related to substance use disorders when patients were prescribed treatment for ADHD [ 154 ].

Whilst pharmacological treatments themselves should not differ by sex, the way in which they are managed and monitored should occur in a sex-sensitive manner. The consensus group observed that prescribers need to consider ADHD presentations and associated problems in females to appropriately target what medication aims to improve. It may be less helpful to strictly adhere to conventional rating scales or focus on behaviour management to identify treatment-related changes. Instead, treatment response may be better captured through individualised targets, such as measures of emotional regulation, participation in education, and academic attainment. In the UK, all government funded schools have attainment ratings for each child, which could be examined by the prescriber prior to commencement of medications and monitored over time in conjunction with prescribing. Girls with emotional regulation difficulties (for whom internalising difficulties are often a key component of their ADHD) could benefit from measuring changes in emotional lability with medication use.

Parents and carers may not be as aware of the benefits of medication in girls, especially those with inattentive presentations in the absence of challenging or disruptive behaviour. Psychoeducation regarding available treatments and what they are targeting, provided for parents and girls with ADHD themselves, may help to ensure engagement in treatment and improve adherence to treatment regimens. Where required, adherence may be improved by using long-acting stimulant medication in place of short-acting medications [ 155 – 157 ].

In early to late adolescence, recommended treatment regimens in ADHD remain the same as in early childhood, and do not differ between girls and boys. The use of medication should be followed up over time to verify if medications are effective and well tolerated, and to manage the effects of related conditions (e.g. anxiety, depression) if they emerge. Side effects of stimulants need to be considered, particularly the side effect of appetite suppression if eating disorders are a concern [ 158 ].

There is some early evidence to suggest that ADHD medications may differentially affect women depending on progression of their menstrual cycle. Two small studies have shown that hormonal changes during the menstrual cycle (oestrogen and progesterone levels) may impact on the subjective euphoric and stimulating effects of d-amphetamine in healthy women who are not affected by ADHD [ 159 , 160 ]. Changes in subjective ratings of stimulation have also been noted in young women unaffected by ADHD in response to d-amphetamine after application of estradiol patches (commonly used to treat problems associated with menopause) [ 161 ]. Cellular and small neuroimaging studies which show early evidence of a link between dopamine systems (implicated in the aetiology of ADHD) and gonadal hormones (reviewed in 49). In a case study, a woman with ADHD showed positive response to treatment adjustment around the menstrual cycle, which included augmentation with an antidepressant (fluoxetine) during the immediate pre-menstrual period to reduce problems with moodiness, irritability and inattention normally well controlled through stimulant medication alone [ 162 ].

Whilst the evidence above does not support treatment adjustment according to the menstrual cycle, anecdotal clinical accounts were given during the consensus meeting supporting that this approach benefits certain patients. The consensus group noted that this type of regular medication adjustment may be easier to manage for adult women who can take more control of their dosing, rather than adolescent girls who tend to respond better to routine. There were also anecdotal accounts of symptom exacerbation in women during the post-menopausal period. During this time physicians may consider the use of hormone replacement therapy, if deemed beneficial.

As hormonal changes take place during puberty, the postpartum period and the menopause, patients may report changes in their symptoms and re-evaluation of treatment regimens may be helpful. It may be advised that women track their symptoms during these periods to establish patterns which may help support changes to the medication regimen when reviewed by their physician.

There is no evidence to indicate that females in either early, middle or later adulthood should be treated any differently with respect to specific medicines for ADHD symptoms. However, given the complex clinical picture of many adults with ADHD, particularly with regards to the presence of comorbid conditions, prescribers need to be mindful of potential interactions with other drugs. If ADHD treatment improves co-morbid conditions, medication regimens could potentially be simplified.

Women with ADHD are highly likely to suffer from mental illness and SUDs. Clinicians need to be mindful of, and discuss with their patients, the risks around alcohol and drug use whilst on ADHD medications. Affective symptoms (most commonly emotional lability or volatility) associated with ADHD, may be misattributed to depressive disorders. For women with ADHD in whom depressive mood symptoms are apparent but not pervasive, it is advisable to treat the ADHD symptoms first and monitor for improvement. A more consistent low mood may be due to demoralization driven by ADHD and its functional impairments, and may improve with ADHD medication.

Symptoms or problems experienced by women with ADHD may also overlap with those indicating a personality disorder, such as BPD. Careful consideration is required to establish the underlying condition(s). This will have follow-on implications for treatments, which differ significantly between personality disorders and ADHD. Biosocial theory suggests that BPD may arise as a function of the interaction of early vulnerabilities (impulsivity and heightened emotional sensitivity) with the environment [ 163 ]. If ADHD symptomatology may predispose individuals to later personality disorders [ 164 ], it is possible that early detection and appropriate treatment could prevent the later development of these conditions [ 165 ]. However, there is no clear empirical evidence supporting this hypothesis at present [ 109 ].

Historically, prescribing ADHD medication during pregnancy or breastfeeding was not advised due to a lack of evidence for safety and risks of unknown adverse effects to the baby. However, a recently published systematic review and meta-analysis reported that exposure to ADHD medication during pregnancy does not appear to be associated with serious adverse maternal or neonatal outcomes [ 166 ]. Nevertheless, the group were cautious regarding this outcome and considered that until these findings have been robustly replicated, prescribing ADHD medication during pregnancy or breastfeeding should be avoided. There may be situations however where risks of not treating ADHD may outweigh potential risks to the foetus and continued prescribing may be necessary subject to more careful obstetric monitoring. In this case, women with ADHD need to be informed of these risks.

Women may find their ADHD symptoms worsen or become particularly difficult to manage while breastfeeding given additional life pressures that occur in the presence of a new baby. Whilst it may be possible to use short acting stimulant medication, timed around breastfeeding to minimise transfer between mother and child [ 167 ], there is minimal scientific evidence to support this approach, and it would be generally safer to advise the cessation of medications during this period altogether. Where ADHD medication is necessary, then an alternative to breastfeeding is needed to minimise any risk to the baby.

Prescribers should be aware that mothers with ADHD may experience difficulties in managing their own symptoms alongside the increased demands from family life, and these difficulties may be augmented by the presence of ADHD in their own children. They may benefit from more frequent evaluations of ancillary support requirements and/or a careful review of medication dosage.

Non-pharmacological management

A number of meta-analyses of data from child and adolescent samples have shown that non-pharmacological interventions targeting cognitive processes show small to moderate effects on ADHD symptom outcomes when rated by individuals who are close to the treatment setting (often parents), but that effects become attenuated or non-significant when outcomes are obtained from individuals who are blinded to the interventions (often teachers) or adequately controlled active or sham conditions [ 168 – 170 ]. Research has documented this effect for specific interventions such as cognitive training (for example, training of attention, memory, inhibitory functions) [ 169 ], and neurofeedback [ 170 ] - although more recent research suggests that effects of neurofeedback are more modest rather than absent when assessed by probably blinded evaluators [ 171 ].

Meta-analyses also show potentially more promising outcomes from non-pharmacological interventions that target behaviours and outcomes beyond ADHD symptoms alone in children and adolescents, with ADHD intervention in children producing a moderate effect on parent stress [ 172 ], and organisational skills interventions which resulted improved ratings from both parents and teachers and with modest improvement in academic function [ 173 ]. Behavioural interventions were found to have a moderate positive effects on a range of outcomes including changes in parenting and conduct problems, even when rated by blinded assessors [ 174 ].

Meta analyses also indicate more promising results from cognitive behavioural therapy, and mindfulness interventions on ADHD symptoms in studies with primarily adult samples, albeit without comparisons from blinded raters [ 175 , 176 ]. Benefits of non-pharmacological treatments in adults are also shown to range beyond improvements in ADHD symptoms, as shown in a recent report from a psychological intervention programme in adults with high levels of ADHD symptoms across three municipalities in Denmark. Participant outcomes were compared with matched controls receiving ‘treatment as usual’ drawn from the Danish Registers at 6 and 12 months post-treatment follow-up. The study showed that participation in the programme was associated with increased employment, education rates and reduced use of cash benefits and social services [ 177 ]

The efficacy of a psychological approach varies across the lifespan and the content of treatment should be tailored to meet the individual presentations and needs of individuals with ADHD [ 178 ]. Regular review of how a person is coping may be especially important at times of key transitions. Since the needs of females with ADHD differ considerably as they mature, the goals of treatment are presented across three age ranges: primary age (5-11 years), secondary age (12-18 years) and adulthood (age 18+).

Primary age

ADHD often places a significant psychological, emotional, and economic burden on families as well as the individual; increased stress and discord in the family unit has been reported [ 179 , 180 ]. Where ADHD affects females, it is also more common in their family members [ 33 , 34 ], resulting in bidirectional effects of ADHD in the mother-child relationship. The aim of non-pharmacological interventions therefore is to support individuals with ADHD and their families to develop and/or improve skills and coping strategies. Psychoeducation and psychological interventions directed at both patient and family are needed to achieve this, as they provide the tools to make helpful changes and achieve positive immediate and long-term functional outcomes.

There are two types of parenting intervention that may be offered to parents/carers in this age-group: (1) parent/carer support interventions, where people can meet and share experiences with others, and (2) parent/carer mediated interventions, sometimes referred to as ‘parent training’. The latter is an indirect intervention as the parent/carer is taught to deliver interventions to their child. Ideally both approaches should integrate a psychoeducational component as this is likely to lead to better outcomes.

Psychoeducation and interventions for girls in this age group should include discussion about the difficulties and challenges they will face at home, in school and in social activities - and how they may respond. At school this may relate to difficulty with sustaining attention, organisation, time management, planning activities, prioritising and organising tasks. They may also require generic skills for coping with interpersonal difficulties and/or social events, conflict management, emotional lability, anxiety and feelings of distress. Some girls may need interventions to address discrete problems, including sleep problems [ 131 ], enuresis [ 181 ], bullying [ 89 , 90 ] and repetitive behaviours such as nail biting [ 182 ]. It is important to emphasise that problems may be less overt in females with ADHD compared with boys due to them being less boisterous and hyperactive, yet their struggles with impulse control may manifest in a different way such as blurting out hurtful things to friends and family in anger, or deliberately self-harming behaviours.

Both group and individual sessions working directly with the child may be helpful additions to parent/carer mediated treatments, although individual treatments may be more appropriate for those with severe symptoms, intellectual limitations and/or those who are unable to tolerate group sessions (e.g. due to lack of confidence, poor social communication). Two specific programmes have been developed for young children with cognitive, emotional, social and/or behavioural problems; one for individual delivery [ 183 ] and the other for group delivery [ 184 , 185 ].

Secondary age

As children mature, they are more likely to receive direct interventions without input from their parents or carers. The best mode of psychological treatment is cognitive behavioural therapy (CBT) together with psychoeducation (which can be provided to both patients and parent/carers together or independently). Parents and carers need to be aware of the elevated risk of deliberate self-harming behaviour (e.g. cutting), eating disorders, substance abuse, risk-taking behaviours, and vulnerability to exploitation in teenage girls with ADHD. Thus psychoeducation should include indicators that problems of this nature may be developing.

The focus of treatment in this age group should include information and guidance on the need for adherence to medication. There is evidence that adherence to pharmacotherapy declines in the teenage years, although adherence appears to be modestly better in girls than in boys [ 155 , 157 , 186 ]. These changes have been attributed to adverse effects, sub-optimal response, reduction in parent supervision, increased need for autonomy, and social stigma associated with ADHD diagnosis and taking medication [ 155 , 156 ]. It is important to provide psychoeducation to encourage young people with ADHD to understand and take ownership of their diagnosis and treatment, rather than feeling it has been imposed on them. Those diagnosed with ADHD for the first time in their teenage years are likely to require different intervention strategies to those who have been treated pharmacologically earlier in childhood. For example, psychoeducation should include information on the purposes and benefits of particular medications, as well as strategies around self-management.

Problems presenting in younger childhood often become more marked with age due to increasing academic and social expectations. These are important years in terms of a young person’s education and interventions can help to support executive function (e.g. improving skills to address problems with time management, focus, sustaining attention, organisation and planning) which may in turn support their coping in secondary schooling. Teenage girls may particularly benefit from treatment aimed at improving self-concept and identity. This may be achieved by unpacking the association between ADHD, lack of achievement, poor self-efficacy, lack of self-confidence, poor self-image and low self-esteem.

Aside from addressing core ADHD symptoms and executive deficits, specific interventions should focus on developing skills and coping strategies for co-occurring conditions, such as managing poor emotional regulation, low mood and anxiety, controlling the impulse to deliberately self-harm (including skin picking and cutting), eating for pleasure or restricting food. Additional support for new skills required in teenage years, such as managing money, may also be helpful.

In adolescence, young people develop a strong focus on peer relationships and a tendency towards social conformity [ 187 ]. For teenage girls with ADHD, the desire to develop robust and supportive social networks can be strong, and the rejection and social isolation experienced by many may mean that family support is especially valued [ 87 ]. Simultaneously interpersonal conflict with family members is not uncommon, and girls may engage with dysfunctional social groups and activities in an attempt to gain a sense of ‘belonging’ and to be accepted. Girls with ADHD are at increased risk of being victims of bullying [ 23 , 90 ], and social media may provide additional challenges since it offers a public platform for victimisation.

Behavioural and oppositional problems remain elevated in teenage girls with ADHD in comparison with their peers, albeit not as elevated as in boys with ADHD. Girls with ADHD may attract detentions, suspensions or exclusions from school for their conduct or oppositional behaviour. Their behaviours may be more socially motivated (e.g. spiteful, manipulative, threatening behaviours and/or lashing out at peers) rather than overt aggression. Social skills and interpersonal relationship interventions become salient at this age. These may aim to develop coping strategies to regulate emotions, build confidence, raise self-esteem and manage peer pressure, deal with rejection and manage conflict.

Interventions to address impulsivity and associated risk-taking behaviour may be helpful. These problems may manifest in early onset of sexual behaviour. The desire to be accepted into a peer network may be a motivating factor. Girls with ADHD are more likely to be pressurised into sex or engage in risky sexual behaviour. They are also more vulnerable to sexual exploitation or perceived exhibitionism (including internet grooming, ‘sexting’ and posting inappropriate content [ 188 ]). This may result in disproportionate social stigma for adolescents and young women with ADHD, in the face of violations of social expectations of female sexuality (where promiscuity may enhance male but damage female reputations). As girls become sexually active, the need for contraception should be discussed.

Impulsive behaviour is also associated with substance misuse. The risks around substance use and interactions with ADHD medication, including risks for addiction, need to be discussed.

Considerations around pregnancy, the post-partum period and parenting may also be required, since rates of early pregnancy are higher in girls with ADHD. Early pregnancy, may load additional stress and impairment on young girls with ADHD. The consensus group noted difficulties in young ADHD mothers not only in relation to child discipline and behaviour management, but also in relation to the organisational demands of parenting (for example, ensuring bottles are washed, medical and other appointments are kept, child’s clothes are cleaned).

Both individual and group CBT interventions will be helpful in this age-group, the latter providing the opportunity to meet and talk to others who have similar experiences as well as acquire and rehearse social skills in a contained environment.

Many of the functional problems experienced by women with ADHD in relation to educational, social, and risk-related behaviours are a continuation of those present in their teenage years. In adulthood, psychoeducation and CBT interventions should continue to address core ADHD symptoms, executive dysfunction, comorbid conditions and dysfunctional strategies (e.g. substance abuse, deliberate self-harm). However, specific attention may be required to address the more complex situations adult females may face, e.g. multitasking occupational demands, home management and family/parenting responsibilities. It is important to encourage the patient to identify and focus on their strengths and positive attributes rather than solely on perceived weaknesses and failures.

Interventions need to address the potential for women with ADHD to be vulnerable in terms of their sexual behaviour and relationships, to support their sexual health and safety. Social stigma associated with risky sexual behaviour in women may augment social problems and limit occupational opportunities. In combination with low self-esteem, this may render women with ADHD vulnerable to sexual harassment, exploitation, and/or abusive or inappropriate relationships. The Adult Psychiatric Morbidity household survey conducted in England found that 27% of females who experienced extensive physical and sexual violence had ADHD traits [ 189 ].

The bulk of household, and parental and caring duties are often borne by women [ 190 – 192 ], reflecting social and cultural constraints and expectations. These may result in increased impairment and anxiety in relation to these roles and duties in women compared with men. The consensus group identified that the demands placed on mothers often differ from those of fathers and that low self-esteem may be related to perceived failure to reach societal expectations. Mothers may lack confidence or experience feelings of guilt over their perceived inadequacy as a parent. Dysfunctional beliefs of this nature may be reinforced if they have a difficult-to-manage child with ADHD and are offered ‘parent training’ interventions. The group acknowledged that the term ‘parent training’ is unhelpful and may be perceived as pejorative.

However, at the same time harsh, lax or negative parenting styles have been identified to be elevated in mothers with ADHD [ 193 ]. Mothers with ADHD may benefit from life skills coaching, guidance and support in parenting, including ancillary support around parenting strategies. This may be particularly helpful for more vulnerable mothers: those that are young, are sole caregivers for their children, and/or are parenting a child with ADHD. Tailored assessments, support plans and social interventions may help to improve outcomes for this vulnerable group.

Women with ADHD may experience problems in the workplace, such as disorganisation, forgetfulness, inattention, accepting constructive criticism and appraisal, and difficulties managing interpersonal relationships with colleagues. This is likely to be exacerbated in the presence of concurrent intellectual dysfunction and/or other comorbidity. For these types of problems, often a group intervention is helpful and cost-effective. However the decision of whether a group or individualised approach is preferable should be based on careful formulation and individual need. Women may also benefit from targeted support in managing feelings of stress and distress, managing and regulating emotions, coping with rejection and/or feelings of isolation, managing interpersonal conflict, assertiveness training, compromise and negotiation steps, which may help to improve their occupational outcomes and their ability to cope with everyday social interactions.

Multi-agency liaison

This section addresses issues that arise at a broader institutional level. Primarily, support for females with ADHD may be improved through the psychoeducation and training of individuals who work within these institutions. Some may act as referral gatekeepers and, as such, they have the potential to support or hinder the referral process and to positively or negatively influence the progress of young people and adults within these institutions. A brief summary of multi-agency liaison recommendations is presented in Table ​ Table6 6 .

Multi-agency liaison for ADHD in girls and women: key recommendations

Educational considerations and adjustments

ADHD is associated with low educational attainment and academic underachievement [ 99 , 146 , 195 ]. Interventions should focus on supporting attendance and engagement with education to avoid early school leaving, diminished educational attainment, and associated vulnerabilities. Since ADHD is classified as a disability under the UK Equality Act [ 196 ], reasonable adjustments to education provision are mandated (examples may include: additional examination time, academic coaching, rest-breaks during examination, or possibility for part-time study [ 197 ]). Research suggests that simple interventions, including physical adjustments (table set-up, creating a time-out corner), and behaviour management techniques, as well as joint goal setting with primary age children, can help to improve ADHD symptoms, social and emotional functioning, and reduce conduct problems in the classroom [ 198 ]. However, adjustments cannot be put in place unless ADHD is first recognised and diagnosed.

Young people affected by ADHD are at increased risk for repeating grades, dropping out of high school, being suspended or expelled, and failing to obtain school or higher education qualifications [ 85 , 99 , 199 ]. Maintaining strong links with school is key to promoting adolescent health and social development [ 110 ]. Whilst early or unplanned pregnancy is associated with a reduction in educational and occupational opportunities, school achievement problems in adolescent girls with ADHD have also been shown to predate and predict risky sexual behaviour and unplanned pregnancy [ 200 ]. The consensus group noted that exclusion, truancy and school phobia are associated with increased vulnerability of teenage girls with ADHD in relation to later substance misuse, antisocial behaviour, criminality, sexual exploitation and early pregnancy. There is a danger that punitive measures may be harsher for girls who display hyperactive or disruptive symptoms, due to this behaviour constituting a greater violation of social norms and expectations. Excessive punitive measures can lead to loss of engagement with education. Disciplinary problems (e.g. suspensions, verbal or written warnings or expulsions) predict earlier discontinuation of education in boys with ADHD [ 201 ], although disciplinary problems are less commonly reported in girls [ 85 ].

Externalising conditions have a stronger impact on behaviour in class, whilst internalising problems may impact on motivation and ability to engage in education. Girls with ADHD may present as easily distracted, disorganised, overwhelmed and lacking in effort or motivation. Inattention is more highly predictive of educational under-achievement compared with hyperactivity [ 202 , 203 ]. Females who are more likely to have the diagnosis missed or misdiagnosed, may be particularly disadvantaged since treatment with ADHD medication has been found to mediate educational outcome. For example, a large-scale study of cross-sectional and longitudinal data in ~10,000 12-year old twins from the Netherlands Twin Register showed the potential efficacy of treatment on academic outcomes [ 203 ]. Children taking ADHD medication scored significantly higher on an educational achievement test than children with ADHD who did not.

Individuals with ADHD and intellectual impairments, both male and female, present with complex needs that make it harder for them to engage in education. Many young people with ADHD will have associated specific learning difficulties such as dyslexia, dyscalculia and dysgraphia. Presenting problems may be attributed solely to these specific learning difficulties and/or ASD because school staff are more familiar with them and have a more limited knowledge about ADHD. It may be helpful for students (at all levels of education) who have or who are suspected of having specific learning difficulties to be screened for ADHD, since young people with ADHD may also present with difficulties in reading and writing.

It is important that both child and adult educational professionals have an understanding of ADHD in girls and young women, recognise its presentation and associated vulnerabilities, and have access to screening tools. Training should be disseminated broadly across school staff, including teachers and special educational needs coordinators, as well as teaching assistants, school lunch aides, and after-school club staff who are more likely to supervise children during less structured periods of the day or during one-to-one work in classrooms. It is important that key personnel avoid over-simplistic causation when assessing individual needs (e.g. focusing on their family situation) and understanding of the bi-directional nature of ADHD difficulties in terms of family relationships.

All educational staff should be trained in how to screen females for ADHD and how to make onward referrals for treatment, if indicated. School staff should be trained on the importance of early detection, educational needs and interventions and support strategies that can improve educational outcomes. Training sessions should raise awareness of the current bias towards males in the clinical referral process. Teaching staff may not be as aware of the benefits of referral and ADHD treatment in girls [ 45 ], and children with the inattentive subtype [ 204 ]. Addressing gender-specific ADHD issues, and gender expectations and stereotypes may help staff to better identify affected females. If ADHD is suspected, schools may consider adopting sensitive screening tools for ADHD (Table ​ (Table4) 4 ) or broader mental health problems (e.g. the SDQ [ 116 ]). These tend to be cost-effective, quick and reliable, and can help to identify vulnerable girls and young women. Difficulties can arise in maintaining medication treatment programmes in school and staff should be mindful that children may find this stigmatising, especially those who require short-acting medications to be dispensed at school.

Many of the training needs for educational staff remain the same in secondary as in primary school. However, transition to secondary school is accompanied by increased academic demands, and increased requirement for self-organisation and personal responsibility against a backdrop of navigating a new social environment. Young people with ADHD are likely to find this shift in self-management and responsibility especially challenging. ADHD symptoms may become exacerbated and more noticeable, triggering referral for the first time. Good learning and teaching practices (i.e. not necessarily ADHD specific) may help to mitigate many of the potential issues in the classroom by promoting engagement, increasing on-task behaviour and reducing social friction.

Efforts toward Technology Enhanced Learning or e-Learning, are likely to be especially helpful for young people with ADHD. With the appropriate content and support, these learning resources have the potential to go beyond improving academic outcomes in secondary school by improving psychosocial functioning (e.g. helping young people to acquire skills to manage risks of exploitation, bullying and/or victimisation in the school environment or online via social media and communication platforms). Although further research is required to determine the efficacy of e-learning methods for improving outcomes in ADHD, specific examples of successful application of these technologies have been reported (reviewed in [ 205 ]).

Careers advice should consider the strengths and weaknesses of female students rather than focus solely on current performance, bearing in mind the relative developmental delay, underachievement, immaturity (and sometimes naivety) of young people with ADHD. Research indicates that occupational ‘fit’ can serve to exacerbate or reduce impairments associated with ADHD. For example, some individuals with ADHD show a preference for more stimulating environments, active, hands-on, or busy and fast-paced jobs [ 206 ]. Career planning that incorporates work experience, non-linear progression towards tertiary education and opportunities to re-sit exams or demonstrate potential may be beneficial for those who have struggled to sustain their engagement in a formal school setting.

Guidance for those wishing to embark in further education should take account of the course demands involved (e.g. level of coursework, method of examination). For those who move away from home, transition is further complicated by the many challenges involved in independent living such as financial management, taking responsibility for domestic and occupational arrangements and healthcare. Moving away from home often escalates social demands, with pressure to integrate with people of different ages, cultural backgrounds and interests. It is essential that young people with ADHD make supportive links within the educational organisation (e.g. disability services or student support services) who can support them to access the help to meet their needs, and coordinate with primary health services. This needs to be planned and thought through in advance because a lack of structure and support at this key stage of transition may unveil or amplify ADHD symptoms, together with associated clinical and functional impairments. Adequate support can help young people with ADHD access additional resources. For example, students with ADHD in further or higher education can apply for Disabled Students Allowance ( https://www.gov.uk/disabled-students-allowances-dsas ), which can fund assistive technology (e.g. speech to text software), specialist mentoring (to help with organisational and planning skills) and “academic coaching”.

In general young people with ADHD reach or complete higher education at a later age than their peers [ 201 ]. This can be due to having to repeat years, re-take modules, and obtain extensions for coursework. Many drop out early due to educational or social problems, or early pregnancy. This emphasises the importance for young people having the opportunity to re-access education in later years. However whilst special educational needs support may be available up to age 25 in the UK, women with unrecognised ADHD may experience difficulties in accessing these provisions or meeting eligibility criteria for learning difficulties. Flexible learning systems and support with childcare are helpful initiatives, e.g. in the UK women with children who wish to return to education can obtain childcare support through government initiatives, such as Care to Learn ( https://www.gov.uk/care-to-learn ), and Childcare Grants ( https://www.gov.uk/childcare-grant ).

Occupational considerations and adjustments

In adulthood, ADHD is associated with unemployment or working in unskilled occupations [ 201 ], difficulty maintaining jobs [ 99 , 201 ], and impaired work performance and financial stress [ 207 ]. A longitudinal study following up girls age from eight until age 30, found that women with childhood ADHD were more likely than their peers to have no or few qualifications, be in poorly paid employment, claim benefits, live in temporary or social housing and have a low income [ 68 ].

ADHD qualifies as a disability under the UK Equality Act 2010 [ 196 ], because it can have a substantial and long-term impact on a person’s ability to perform day-to-day activities. This status can afford women with ADHD certain rights, and access to certain services. For women with ADHD commencing employment, additional support may be required regarding the decision to disclose they have a disability. They may need support in understanding the demands of an organisation, the work-role and personnel structure, how to manage interpersonal conflict, and guidance on how to manage their time, plan and prioritise tasks. Diaries, itineraries, lists, reminder notes and similar scaffolding techniques can be adapted to individual needs through a wide range of digital apps currently available at low or no cost.

Women with ADHD may experience particular difficulty returning to work after having children. This is associated with employment penalties linked to educational problems and potentially having left school early with few or no qualifications. Initiatives such as Specialist Employability Support ( https://www.gov.uk/specialist-employability-support ) are available to provide intensive support and training for unemployed people with a disability.

Occupational difficulties may be further compounded by a difficulty managing the effects of persisting ADHD symptoms on job-related and social performance in the workplace, together with the need to balance occupational demands with childcare. Reasonable adjustments in the workplace may be helpfully put in place [ 208 ] but these may only be achieved if women with ADHD elect to disclose they have a disability. This may not be an easy decision as the individual must balance the need to optimise the environment against their fear of social and occupational stigma, the latter including the possibility they may be held back in promotion and/or other career advancement.

On the other hand, disclosing a disability allows for women with ADHD to be treated more favourably under the UK Equality Act 2010 [ 196 ], and benefit from reasonable adjustments that remove barriers in the workplace that would otherwise disadvantage them. Reasonable adjustments are assessed on a case by case basis and extra support for the costs of making reasonable adjustments in the workplace can come from the Access to Work government initiative (see: https://www.gov.uk/access-to-work ). These rights apply to women with ADHD returning to work, taking up employment or becoming diagnosed at any time during their working lives. Employers who fail to comply with this duty would be liable for disability discrimination.

Health and social care

Research suggests an increased involvement of ADHD children with the social care and foster care systems [ 209 , 210 ]. Equipping social care professionals with tools similar to those used in school settings (e.g. the SDQ) may promote a higher level of insight and understanding. Males may be overrepresented in these systems due to high rates of comorbidity with disruptive behavioural problems. Females with ADHD may be more likely to come into contact with social services if they are young single parents struggling with child-care responsibilities; however their underlying ADHD may be unrecognised.

The overrepresentation of developmental disorders in the care population may be the result of a failure in existing services to recognise the specific contribution of these conditions to family breakdown, and an absence of targeted support in such cases. The group recommends that all children at risk of entering the care system should be systematically screened for developmental disorders. Social care professionals may struggle to identify the parenting potential in undiagnosed women with ADHD, and attribute difficulties more to a chaotic lifestyle choice rather than to any underlying disorder. Given the high heritability rates [ 132 ] it is also helpful to consider that other family members may also share symptoms and suffer with associated impairments, when examining family dynamics.

Social and family services will benefit from training so they can provide specific psychoeducational input to support young mothers of ADHD children and young mothers with ADHD. If deemed appropriate, they might refer mothers with ADHD to mental health services for targeted support that aims to develop skills and coping strategies, and to help them manage their own mental health and personal needs and those of their child.

The early sexual activity, promiscuity and higher risk for sexually transmitted diseases in some females with ADHD is likely to increase contact with sexual health clinics. ADHD training should therefore be extended to include service-providers at these clinics in order to raise awareness of the presentation and needs of females with ADHD. For example this may lead to better understanding of the need for additional sexual health education, including digital health education, which in turn may better support these young women and prevent sexual exploitation.

Criminal justice system

Increased rates of delinquent or criminal behaviour may lead to contact with the criminal justice system [ 107 ]. Prevalence of ADHD in incarcerated populations is high, estimated at around one quarter (25.5%) but with no significant differences overall in relation to gender or age. There is however a lower prevalence in adult women than men (22.1% in female adults v. 31.2%, male adults), whereas female youths have a similar prevalence to male youths (30.8% and 29.5%, respectively) [ 107 ]. One study reported that only 18.8% of male adult offenders diagnosed with ADHD in prison had a prior diagnosis of ADHD [ 211 ]. It is likely that this proportion is even lower for females.

Evidence indicates that ADHD treatment is associated with reduced rates of criminality [ 212 ], is tolerated and effective in prison inmates [ 213 ], and improves their quality of life and cognitive function [ 214 ]. This has led to speculation that effective identification and treatment of ADHD may help to reduce reoffending, albeit with reservations surrounding potential for diversion or misuse of medications, treatment adherence, and discontinuity of ADHD treatment after release [ 215 ]. Current best practice recommendations for screening, identifying, treating and supporting ADHD in prisoners and youth offenders are provided in a previous review and consensus report [ 194 ], with particular recommendations for support provided for female offenders.

Females with ADHD are likely to be perceived to deviate substantially from stereotypical expectations of behaviour. The differential diagnosis between BPD and ADHD may be particularly important for females in forensic settings, where a high rate of comorbidity has been reported [ 216 ]. In the criminal justice system, including prison, there may possibly be a more sympathetic approach toward female offenders but, as for males, their ADHD is unlikely to be recognised. The group noted that ADHD is commonly perceived as ‘bad behaviour’ rather than a vulnerability in this setting, perhaps reflecting high rates of critical incidents (verbal and physical aggression, damage to property, self-injury) being reported in prison [ 217 ]. This may be intensified in female offenders with ADHD due to poor understanding of the condition. Further research regarding the interface between the criminal justice system and females with ADHD is needed.

Over 30 years ago, Berry, Shaywitz and Shaywitz warned that girls constitute a ‘silent minority’ in ADHD, with more internalised behaviour making them less likely to be referred for assessment [ 36 ]. This does not appear to have changed. Females with ADHD remain more likely to be unrecognised or mis-identified leading to lower than expected rates of referral, assessment and treatment for ADHD. Whilst this has been attributed to the higher rate of internalised and inattentive only presentation in girls, this omission is remarkable, given that the predominantly inattentive subtype of ADHD has been endorsed by the Diagnostic and Statistical Manual, a key diagnostic tool, for many years.

There are specific barriers that seem to hinder the recognition of ADHD in girls and women. These include symptomatic differences, gender biases due to stereotypical expectations, comorbidities and compensatory functions, which mask or overshadow the effects of ADHD symptoms. There is strong public perception that ADHD is a behavioural disorder that primarily affects males. Hence the challenge is to raise awareness and provide training on the presence and presentation of ADHD in females to agencies that regularly interface with children, young people and adults.

The current health and social care system appears to be better geared toward identifying and treating ADHD presenting alongside behavioural and externalising problems, in particular those that present as overt, disruptive and aggressive in nature, and are more commonly seen in boys and men. It is erroneous to consider that females do not present with hyperactive and impulsive symptoms – they do. However, these are generally less overt and aggressive in nature than the conduct problems displayed by males and instead seem to relate to more social-relational and psychosexual problems and behaviours. Understanding the expression of ADHD in females is the first step towards improving detection, assessment, and treatment, and ultimately enhancing long-term outcomes for girls and women with ADHD.

One of the most consistent topics discussed at the consensus (and across all breakout groups) related to how social-relational and psychosexual problems seem to be more marked in females with ADHD compared with males. Difficulties in managing and maintaining functional interpersonal relationships hinder some girls and women from developing or maintaining a positive social network or accessing peer support. ADHD symptoms and emotional lability seem to be related to dysfunctional coping strategies and dissatisfaction with life [ 77 ]. Lack of planning for the future [ 86 ] may mean that girls and women with ADHD lack constructive activities and occupations in adulthood. These effects may lead to affected girls and women becoming overwhelmed, anxious and low in mood. In turn they may respond by applying dysfunctional coping strategies, such as self-harm and substance use.

Females with ADHD overall have an earlier onset of sexual activity, more sexual partners, and an increased risk of contracting sexually transmitted infections or having an unplanned pregnancy. They are at risk of sexual exploitation, perceived exhibitionism or being considered promiscuous. Social stigma associated with risky sexual behaviour in women may augment social problems, and render affected women vulnerable to being victimised, bullied, harassed, abused, or entering into unhealthy relationships. Young girls with ADHD may become young mothers with ADHD (and possibly also mothers of children with ADHD). This is associated with a further reduction in educational and occupational opportunities. Research is needed to tease out the motivations and causal mechanisms of these behaviours and outcomes in females with ADHD, and if, how and why they may differ from those of males.

Treatment has been reported to moderate the lifetime risks of ADHD for both males and females. The consensus group identified where adjustments to approaches in treatment are needed to better support girls and women with ADHD. This includes more frequent treatment monitoring and psychoeducation at times of personal transition, with a greater focus on functional and emotional aspects of the disorder. The consensus group considered that multi-agency liaison will also be needed to support some girls and women with ADHD. Furthermore, raising awareness of, and providing training about, ADHD in institutions (e.g. educational, social, family, sexual health and criminal justice services) as well as the key healthcare system (primary health, child and adolescent mental health services and adult general psychiatry) will be helpful to improve detection of girls and women with ADHD, increase understanding and reduce stigma.

The consensus highlighted the relative dearth of research on the life-span experience of females with ADHD. Given the higher prevalence of ADHD in males, it would be helpful if studies reporting sex-mixed cohorts segregated data and results by gender. This would be particularly helpful in large clinical or population-based studies, where information on girls with ADHD would otherwise be buried as variance under the predominant male group. Providing sex-segregated results and data for all studies of ADHD (perhaps under supplementary data) would provide information to inform future meta-analyses.

Future research should investigate the presentation and needs of females with ADHD: how they might better be identified and assessed, and how their treatment response should best be evaluated and monitored to effectively improve outcomes. The most recent meta-analyses of gender differences in ADHD symptom presentation and associated features was reported over 15 years ago. An updated meta-analysis including all recent data is now needed. More research is also required to elucidate the interaction of hormones, ADHD symptoms and stimulant medication on functioning during key times of hormonal change (e.g. during the menstrual cycle, pregnancy and the postpartum period, and menopause), to help inform treatment plans. Factors that are associated with hyperactive/impulsive symptoms in females with ADHD and how these differ to males should be investigated further, including sexual behaviours and their motivations in girls and women with ADHD, as well as vulnerabilities to victimisation, physical and sexual assault and cyberbullying.

This consensus will inform effective identification, treatment and support of girls and women with ADHD. To facilitate identification, it is important to move away from the previously predominating ‘disruptive boy’ stereotype of ADHD and understand the more subtle and internalised presentation that predominates in girls and women. In treatment, it is important to consider a lifespan model of care for females with ADHD, which supports the complex and developmentally changing presentation of ADHD in females. Appropriate intervention is expected to have a positive impact on affected girls and women with ADHD, their families, and more broadly on society leading to increased productivity, decreased resource utilization and, most importantly, better outcomes for girls and women.

Acknowledgements

We are grateful to the assistance of Catherine Coles, Alex Nolan and Hannah Stynes who attended the consensus meeting and made notes during the breakout sessions.

Abbreviations

Authors’ contributions.

SY was responsible for the planning and scientific input of this consensus statement. All authors (except NA and EF) attended the consensus meeting. CS completed the first draft of the manuscript. It was substantially revised by SY with further input from EF and BC. The second draft was circulated to all authors for comment and endorsement of the consensus. Following further amendments, the final draft was circulated once more and all authors have read and approved the final manuscript.

The meeting was funded by the UK ADHD Partnership (UKAP), who has been in receipt of unrestricted educational donations from Takeda. Takeda had no influence or involvement in determining the topic and arrangements of the day, the consensus process and outcomes, or writing the final manuscript. Other than reimbursement of travel expenses to attend the meeting, none of the authors received any financial compensation for attending the meeting or writing the manuscript, aside from CS who received funds for medical writing assistance.

Availability of data and materials

Ethics approval and consent to participate.

The current report reflects a review of the research literature on ADHD in girls and women, and a consensus agreement amongst all authors based on this evidence and their clinical experience. As a result, neither consent for participation, nor ethical approval for this work were required.

Consent for publication

Not applicable

Competing interests

In the last 5 years: SY has received honoraria for consultancy and educational talks years from Janssen, HB Pharma and/or Shire. She is author of the ADHD Child Evaluation (ACE) and ACE+ for adults; and lead author of R&R2 for ADHD Youths and Adults. PH has received honoraria for consultancy and educational talks in the last 5 years from Shire, Janssen and Flynn. He has acted as an expert witness for Lilly. PM has received honoraria for consultancy and educational talks from Shire and Flynn. KvR has received honoraria for educational talks from Shire, Lilly, Janssen, Medici and Flynn. In addition SY, PB, WC, PH, PM and EW are affiliated on a full-time basis with consultancy firms/private practices. CS is employed by Cambridge Cognition. JS has received speakers’ honoraria from Shire, is in receipt of an educational grant from the Royal College of Nursing (RCN) Foundation Trust for a contribution towards PhD tuition & conference fees/ costs and is an Executive Committee Member of the UK Adult ADHD Network ( UKAAN.org ). The remaining authors have no disclosures.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Richardson attracts ADHD tech startup FirstThen with inaugural research grant

The city’s new research award match program builds on the city’s emphasis on innovation, economic growth and collaboration..

By Lilly Kersh

6:00 AM on May 31, 2024 CDT

The city of Richardson picked the first recipient for its business incubator program, an experiment to provide cash to attract budding and innovative companies in the North Texas town.

Dallas-based FirstThen, a digital health startup developing technology for ADHD treatment, will qualify for up to $50,000 under the Research Award Match Program if they open an office in Richardson and maintain a presence.

The Research Award Match Program is a pilot the city launched this year to support startup companies that are “primary job creators,” or that have a high potential for commercial viability, according to program guidelines.

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The program’s funding is intended to develop FirstThen’s technologies in ways that create economic opportunity in Richardson, building on the city’s emphasis on innovation, technology and research.

“We really feel like [the grant program] rounds out those other more traditional components of an economic development strategy by adding this focus on entrepreneurship, startups and research and development,” City Manager Don Magner said.

FirstThen’s founders, Amanda and David Schnetzer, are parents of a child who has ADHD. The Schnetzers saw the challenge of accessing and sticking with non-medication interventions for ADHD treatment. Magner said the founders are not currently located in Richardson but will open operations in the city as part of the grant’s requirements.

Their company is working on family-centered digital solutions for children with ADHD to make behavioral health care for neurodevelopmental disorders in children more accessible and affordable.

Richardson’s incubator grants are available to small businesses that are research-focused, for-profit and privately-owned, and that are located in Richardson or will relocate to Richardson for at least five years, according to the city’s website .

The program complements the federal Small Business Innovation Research and Small Business Technology Transfer programs. Small businesses are eligible for Richardson’s program if they have already received either a Phase I or Phase II grants from one of the two federal programs.

The National Science Foundation awarded FirstThen with a Phase I Small Business Innovation Research award in November 2023. The company was granted more than $273,000 for a caregiver-centered app and artificial intelligence coaching intervention for pediatric ADHD, according to the NSF website .

“We are really creating an ecosystem of innovation around our target industries,” Magner said. “FirstThen, we believe, can … benefit from that at the stage they’re in now, further their research and development, commercialize that eventually, and hopefully be a part of our community for a long time.”

Richardson has approved up to $250,000 a year for companies to operate in the city. Phase I eligible applicants may qualify for up to $50,000 while Phase II eligible applicants may qualify for up to $100,000, according to the city’s guidelines.

Richardson’s economic development group is administering the program.

Richardson’s recent grant funding builds on a growing emphasis on research, technology and innovation in the city.

About 13 miles north of Dallas, Richardson is home to The University of Texas at Dallas, a public research university. The city’s Innovation Quarter is a 1,200-acre office and industrial space that hosts start-ups and scale-ups in technology, corporate research and development and other industries, according to the Richardson IQ website .

Lilly Kersh , Staff Writer

Lost in lockdown: Study reveals feeling isolated from others can warp our perception of time

Feelings of loneliness and social isolation during the pandemic left many people confused about the order of events and struggling to remember what day of the week it was, a new study reveals.

The research, from the University of York, looked at the psychological impact of the pandemic, which spread to the UK in March 2020, through the lens of disorientation.

The researchers asked more than 3,300 French participants nearly 60 questions analysing the psychological effects of lockdowns. The survey took place during an acute phase of restrictions when there was a lockdown followed by a strict curfew.

The findings reveal both social and temporal disorientation -- a sensation of disarray in social interactions and sense of time -- was common.

Many participants in the study described feeling out of place and unsure how to behave in social situations.They also reported experiencing a blurring of time and feeling adrift as they struggled to keep track of events prior to the pandemic as well as what day of the week it was. The difficulty also extended onwards in time. Participants found it harder to imagine what lay ahead, and they felt more anxious and less in control of their future.

The researchers found that people who felt disconnected socially were highly likely to also experience temporal disorientation. Their analysis of the study data suggested a causal relationship between the two, with social isolation leading to disruptions in the experience of time.

Dr Pablo Fernandez Velasco, a British Academy postdoctoral fellow at the University of York, and the lead author of the study, said: "We found that social disorientation was a strong predictor of temporal disorientation and it looks likely that there was a causal relationship between the two. Feeling lonely and isolated from others seems to warp our perception of time, with a sense of feeling lost and confused spanning the past, present and future.

"Many people in our society, across all groups and demographics, suffer from loneliness. The findings of our study reinforce the importance for public authorities to address the compounding effect of feeling isolated both during crises and in day to day life."

The researchers found that young people under 25 were the age group most affected by feelings of disorientation.

The researchers suggest their findings point to a new phenomenon which they call "temporal rupture" which is like a fault line in our minds separating the "before" and "after" of the pandemic.

Dr Fernandez Velasco added: "Our study shows that the sense of a rift separating time before and time after the pandemic was a common experience during the Covid-19 crisis.

"The larger the experienced rift between pre-pandemic and pandemic times, the more disorientated people felt.

"The personal accounts collected in our study help advance the understanding of the potential impacts of feelings of loneliness and isolation via the extraordinary experiences of the pandemic."

• COVID and SARS
• Infectious Diseases
• Social Psychology
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• Spirituality
• Influenza pandemic
• Hallucination
• Environmental impact assessment

Story Source:

Materials provided by University of York . Note: Content may be edited for style and length.

Journal Reference :

• Pablo Fernandez Velasco, Bastien Perroy, Umer Gurchani, Roberto Casati. Social and temporal disorientation during the Covid‐19 pandemic: An analysis of 3306 responses to a quantitative questionnaire . British Journal of Psychology , 2024; DOI: 10.1111/bjop.12704

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