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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.

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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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 2024; 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, 0.01; 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, −0.26; 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 = 7; n = 866) 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, −0.27; CI, −0.52 to −0.03). 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 not significantly improve ADHD symptoms (SMD, −0.39; CI, −0.81 to 0.03; studies = 9; n = 448; low SoE) ( Fig 4 ), with some heterogeneity (I 2 = 71%), or functional impairment (SMD, 0.52; CI, −0.34 to 1.39; studies = 4; n = 317) ( Supplemental Fig 14 ). It significantly improved disruptive behaviors (SMD, 0.43; CI, 0.00–0.87; studies [all RCTs] = 4; n = 267) and 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, −0.47; CI, −0.72 to −0.22; studies = 11; n = 857; low SoE) ( Fig 4 ), with little heterogeneity (I 2 = 54%); restricting to the 9 RCTs yielded the same point estimate, also statistically significant (SMD, −0.47; CI, −0.79 to −0.15). 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 nutrition or supplements. Cognitive training and school interventions did not significantly improve ADHD symptoms. 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 guanfacine produced small but significant additional improvement in ADHD symptoms over stimulant medication alone (moderate 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, and cognitive training (low SoE) and nutrition or supplements (low SoE) significant small effects. 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 nutritional interventions, 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 does, and cognitive training does not, 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 https://www.pediatrics.org/cgi/doi/10.1542/peds.2024-065854 .

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Altered brain connections in youth with ADHD

At a glance.

Youth with ADHD have elevated brain activity connecting the frontal cortex with the information processing centers deep in the brain.
Understanding the brain regions involved in ADHD symptoms could help point toward directions for new approaches to treatment.

People living with attention-deficit/hyperactivity disorder, or ADHD, can struggle with focus and self-control. The condition’s symptoms may interfere with daily functioning in both children and adults. ADHD can make it hard for kids to succeed in school, and for adults to thrive in the workforce and in personal relationships.

ADHD is a brain condition that requires a professional diagnosis to help guide treatment. Drugs that increase the levels of certain chemicals in the brain help some people with ADHD. But they don’t work for everyone, and can have unacceptable side effects.

To design better treatments for ADHD, scientists need to understand more about how the brain works in people with the condition. Researchers have wondered if differences in the neural connections between the brain’s frontal cortex, which sits in the front of the brain, and regions deep within the brain, called subcortical regions, may underlie some symptoms of ADHD. The frontal cortex plays a role in attention and control of unwanted behaviors. The subcortical regions are involved in learning, movement, reward, and emotion.

Previous studies used a type of brain imaging called functional magnetic resonance imaging (fMRI) to look for such connections in children with symptoms of ADHD. fMRI can measure changes in brain activity in real time. But these studies have been small and returned conflicting results.

An NIH research team re-analyzed fMRI images collected in six previous studies. Altogether, those studies had obtained fMRI images from more than 1,696 youths with ADHD, aged 6 to 18, as well as almost 7,000 without the condition. In addition to using a large number of images, the researchers strictly defined the brain areas being measured. This allowed for more accurate comparisons between individual fMRI scans. Results were published March 13, 2024, in the American Journal of Psychiatry .

The team found that the brains of youth with ADHD had more activity between several subcortical regions and the frontal cortex than those in youth without the condition. The brains of youth with ADHD also showed greater connection between the frontal cortex and part of the brain called the amygdala. The amygdala helps process emotions and had been suspected to play a role in ADHD.

These results were seen regardless of children’s sex, age, race or ethnicity, socioeconomic status, or estimated intelligence. The differences in brain connectivity also didn’t appear to be affected by the presence or absence of other mental health problems, such as anxiety or depression. However, the differences found by the researchers were small and likely capture only part of the processes involved in ADHD.

“The findings from this study help further our understanding of the brain processes contributing to ADHD symptoms. Such understanding is a first step in thinking of new ways to help those who find the symptoms cause difficulties in day-to-day life,” says Dr. Philip Shaw, who helped lead the study. “But these brain changes are only part of the story. ADHD is a complex condition, and many other changes in brain connectivity will play a role.”

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Published: 12 August 2020

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 ORCID: orcid.org/0000-0002-8494-6949 1 , 2 ,
Nicoletta Adamo 3 , 4 ,
Bryndís Björk Ásgeirsdóttir 2 ,
Polly Branney 5 ,
Michelle Beckett 6 ,
William Colley 7 ,
Sally Cubbin 8 ,
Quinton Deeley 9 , 10 ,
Emad Farrag 11 ,
Gisli Gudjonsson 2 , 12 ,
Peter Hill 13 ,
Jack Hollingdale 14 ,
Ozge Kilic 15 ,
Tony Lloyd 16 ,
Peter Mason 17 ,
Eleni Paliokosta 18 ,
Sri Perecherla 19 ,
Jane Sedgwick 3 , 20 ,
Caroline Skirrow 21 , 22 ,
Kevin Tierney 23 ,
Kobus van Rensburg 24 &
Emma Woodhouse 10 , 25

BMC Psychiatry volume 20 , Article number: 404 ( 2020 ) Cite this article

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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.

Peer Review reports

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 , 6 , 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 , 16 , 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 , 28 , 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: Identification and assessment of ADHD in females

Presentation in females and what might trigger referral?

Considering sex differences when conducting ADHD assessments

2: Interventions and treatments for ADHD in females

Pharmacological

Non-pharmacological

3: Multi-agency liaison

Educational considerations

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 1 .

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 , 53 , 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 , 73 , 74 ]. Difficulties of this nature may be more common or severe in girls and women [ 30 , 56 , 57 , 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 , 79 , 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 , 101 , 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 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.

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 3 .

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 4 .

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 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 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 5 .

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 , 156 , 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 , 169 , 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 , 191 , 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 6 .

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 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.

Availability of data and materials

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

Abbreviations

ADHD Child Evaluation

Attention-Deficit/Hyperactivity Disorder

Autism Spectrum Disorder

Adult ADHD Self-report Rating Scale

Borderline Personality Disorder

Conners’ Adult Rating Scales

Cognitive Behavioural Therapy

Conners’ Comprehensive Behavior Rating Scales

Conduct Disorder

Conners’ Continuous Performance Test, third edition

Development and Wellbeing Assessment

Diagnostic Interview of Adult ADHD

Diagnostic Interview for ADHD in Adults with Intellectual Disability

Diagnostic and Statistical Manual of Mental Disorders

Education, Health and Care Plan

International Classification of Diseases

Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version

Learning Disability

Oppositional Defiant Disorder

Personalised Education Plan

The Vanderbilt ADHD Rating Scales

Quantified Behavior Test

Strengths and Difficulties Questionnaire

Swanson, Nolan, and Pelham-IV Questionnaire

Substance Use Disorder

United Kingdom of Great Britain and Northern Ireland

United Kingdom ADHD Partnership

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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.

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.

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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.

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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.

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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.

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Young, S., Adamo, N., Ásgeirsdóttir, B.B. et al. 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. BMC Psychiatry 20 , 404 (2020). https://doi.org/10.1186/s12888-020-02707-9

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Understanding ADHD from a Biopsychosocial-Cultural Framework: A Case Study

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The biopsychosocial-cultural framework is a systemic and multifaceted approach to assessment and intervention that takes into account biological, psychological, and socio-cultural factors that influence human functioning and service delivery. Although originally developed to assess physical health and medical illness, this contemporary model can be used as a framework for school psychologists to address the mental health needs of culturally and linguistically diverse youth with Attention-Deficit/Hyperactivity Disorder (ADHD). School psychologists can apply this model when conceptualizing academic, behavioral, and social-emotional functioning of children and adolescents, while also considering cultural barriers relating to treatment acceptability when working with families. Because it encourages school psychologists to address presenting problems in a culturally sensitive and contextual manner, this model may reduce bias and result in more equitable mental health outcomes. The purpose of this article is to discuss the biopsychosocial-cultural model, its advantages and disadvantages, and its application in a case study of a Hispanic child with ADHD.

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Pham, A.V. Understanding ADHD from a Biopsychosocial-Cultural Framework: A Case Study. Contemp School Psychol 19 , 54–62 (2015). https://doi.org/10.1007/s40688-014-0038-2

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A CASE STUDY

Observations of a student with ADHD over a 3-week time span.

Student X is a 14 year-old male in a 9 th Grade English class. He is average height and build. He has no physical disabilities, but suffers from a mental disorder – ADHD. He often makes careless mistakes in schoolwork. He does not pay attention to detail. He has trouble staying focused while reading long texts. He also has difficulty staying still during a lecture. He fidgets and shakes his legs uncontrollably when seemingly annoyed or anxious. He has trouble turning in homework on time and meeting deadlines in general. He frequently does not respond when spoken to directly and appears to be distracted even though he is performing no obvious task. He lets his mind wander and appears to daydream often. When he does respond and participate, he is usually off topic. Overall, he appears uninterested and aloof. One might say that the behavior is defiant – a consciously overt reluctance to participate in school. However, this student has been diagnosed by a physician as being ADHD. He has an involuntary learning disability which requires support, therapy, social skills training and/or medication.

Ready to Make a Change?

Educating children with ADHD is no easy task. Know that you are not alone. Please enlist the help of our school to find the right plan and solution for your child.

Patient Case Study

Case history: mary, diagnosis: adhd and anxiety, “i don’t know what you did—but i have my child back.”.

When I first saw Mary in my office—an 18-year-old woman diagnosed with ADHD and anxiety—she was extremely anxious.

Perspiration flowed down her face, she was constantly shaking her legs, there was a tremor in her hands, and her voice cracked as she told me her story.

Mary was in her last year of high school, and an avid softball player. Six months earlier, she had been in a car accident, which required surgery that had stopped her from participating in sports—an accident, she added, that had made her nervousness a lot worse.

Now, she had many of the classic symptoms of post-traumatic stress disorder (PTSD): avoidance; a heightened startle response, intrusive thoughts that interfered with her focus at school; nightmares; and constant sense of isolation and disconnection.

Mary had seen a psychiatrist, who had prescribed Dexmethylphenidate XR, 20 mg per day, and Escitalopram, 15 mg per day.

She said the medications for ADHD had been very helpful, but she disliked the feeling of being so “zoned in”—so focused and attentive—that she felt isolated.

After listening to Mary’s story, I talked with her about the possibility that her elevated anxiety could be trigged by the Dexmethylphenidate XR—and we agreed to lower the dose. We kept her Escitalopram at 15 mg. I also suggested she take a magnesium supplement at bedtime, and she agreed to start taking magnesium glycinate, 420 mg, before she went to bed.

Bloodwork, revealed the following:

Vitamin B12, 237 pg/mL (low)
Folate, 7.2 ng/mL (low)
Vitamin D, 5000 IUs

I put together a treatment plan that included a referral to accelerated

Resolution Therapy—which combines CBT, EMDR, and exposure therapy—to help her resolve her recent trauma. I also treated her with subcutaneous methylcobalamin (and active and bioavailable form of B12), 1 mg, twice per week, for 8 weeks. I prescribed 1 mg of L-Methyl-Folate per day. And we optimized her vitamin D supplementation, at a lower dose of 1000 IU per day.

Mary came in for a follow up visit two months after we implemented her treatment plan. Follow up labs showed normal levels of B12, folate, and vitamin D. Mary told me that all of her PTSD symptoms had gone away—the disturbing thoughts, the nightmares, all of it. She said she’d been much less isolated—much more involved with her family and boyfriend. And her academic performance had improved.

Her father had accompanied Mary to her follow up appointment. Before they left, he said to me, “I don’t know what you did—but I have my child back.”

Want to learn nutritional and functional medicine interventions like these to help your patients? Enroll in our comprehensive Fellowship for mental health providers! Book a private phone call with Dr. James Greenblatt to learn more today.

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Childhood ADHD – Luke’s story

Posted on Thursday, 05 April 2018, in Child & Teen ADHD

In the final part of her ADHD series, Dr Sabina Dosani, Child and Adolescent Psychiatrist and Clinical Partner London, introduces Luke, a patient she was able to help with his ADHD.

ADHD is one of the most common diagnoses for children in the UK and it is thought that 1 in 10 children will display some signs. For some children, their ADHD is severe and can have a huge impact on their ability to engage in school and to build and sustain relationships. Left untreated, evidence shows that those with ADHD are more likely to get into car accidents, engage in criminal activity and may struggle to keep a job or maintain relationships.

Luke, aged six, gets into trouble a lot at school. His mother gets called by his teacher three or four times a week for incidents of fighting, kicking and running in corridors. He is unable to finish his work and becomes quickly distracted. At home, he seems unable to sit still for any length of time, has had several falls when climbing trees and needs endless prompts to tidy his toys.

At school, he annoys his classmates by his constant interruptions, however if he has one-to-one attention from a student teacher who happens to be in his class on a placement he is able to settle and finish the work set. His father was said to have been a ‘lively’ child, then a ‘bright underachiever’ who occasionally fell foul of the law.

The school thought a visit to the GP might be a good idea. At the GP surgery, Luke ran and jumped about making animal noises. He swung on the back legs of a chair and took the batteries out of an ophthalmoscope. He was referred to a me for an assessment.

After a careful assessment, which included collecting information from school, questionnaires and observations of Luke, a diagnosis of ADHD was made. Following a discussion of the treatment options, the family decided they did not want any medication.

The first-line treatment for school‑age children and young people with severe ADHD and severe impairment is drug treatment. If the family doesn’t want to try a pharmaceutical, a psychological intervention alone is offered but drug treatment has more benefits and is superior to other treatments for children with severe ADHD.

Luke's mother was asked to list the behaviours that most concern her. She was encouraged to accept others like making noises or climbing as part of Luke’s development as long as it is safe.

Now, when Luke fights, kicks others or takes risks like running into the road he is given “time-out” which isolates him for a short time and allows him and his parents or teacher to calm down. To reduce aggression and impulsivity, Luke is taught to respond verbally rather than physically and channel energy into activities such as sports or energetic percussion playing.

Over time, Luke’s parents have become skilled at picking their battles. Home is more harmonious. They fenced their garden, fitted a childproof gate and cut some branches off a tree preventing him climbing it. His parents are concerned about Luke’s use of bad language. They have been supported to allow verbal responses as a short-term interim. Whilst these might be unacceptable in other children they are preferable to physical aggression.

At school, Luke is less aggressive, has a statement of special educational need and now works well with a classroom assistant. He has been moved to the front of the class, where the teacher can keep a close eye on him, and given one task at a time. He is given special tasks, like taking the register to the school office, so he can leave class without being expected to sit still for long periods.

Through parental training, Luke’s parents have been able to help Luke work with his challenges to better manage them. As Luke grows and develops and as he faces new challenges in life, Luke may need to revisit the efficacy of ADHD medication. His parents now feel a lot more confident in being able to help Luke and he is a happier child and more settled.

Dr Sabina Dosani Consultant Child & Adolescent Psychiatrist

Dr Sabina Dosani is a highly experienced Consultant Psychiatrist currently working for the Anna Freud Centre looking after Children and Adolescents. She has a Bachelor of Medicine and Bachelor of Surgery as well as being a member of the Royal College of Psychiatrists . Dr Dosani also has a certificate in Systemic Practice (Family Therapy).

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UQ responds

Women with ADHD needed for Australian-first study

Women diagnosed in adulthood with Attention Deficit Hyperactivity Disorder (ADHD) are encouraged to join a University of Queensland study into the impact of the diagnosis.

Dr Kate Witteveen from UQ’s School of Nursing, Midwifery and Social Work said women and girls had been under-represented in previous ADHD research, most of which had been done overseas.

“The studies that did include girls noted they are less likely to get an early diagnosis of ADHD, as they have flown under the radar during their formative years,” Dr Witteveen said.

“The impact of ADHD symptoms typically increases during primary school years, which coincides with the development of self-perception and identity.

“When girls are not diagnosed with ADHD and form their own interpretation of their behaviour and tendencies, they may become highly self-critical.

“Undiagnosed women may struggle with negative feelings and not realise that their challenges are symptoms of ADHD – things like being able to accurately estimate the time tasks take to be completed.”

The UQ study will involve a 15-minute online questionnaire and a video-recorded interview which will take approximately one hour.

The information collected will be used to understand the experiences of women pre and post diagnosis.

“It was apparent that each of my clients could achieve great things and were highly capable of managing their challenges,” Dr Witteveen said.

“However, their lack of understanding of why they may have had difficulties with things such as getting started on boring tasks, typically resulted in negative self-perceptions.

“The negative impacts associated with undiagnosed ADHD can be considerable and include self-critical beliefs, burnout, exhaustion, misdiagnosis, and lack of access to appropriate treatment that could potentially alleviate symptoms.

“This study will address the notable gap in knowledge and understanding of women’s experiences.

“We hope to contribute to better recognition and earlier diagnosis of ADHD in girls and women and provide meaningful insights into the ways they may be better supported.”

Interested participants can register their interest in this study via this link .

Image above left: Dr Kate Witteveen

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The lived experiences of adults with attention-deficit/hyperactivity disorder: A rapid review of qualitative evidence

Callie m. ginapp.

1 Yale School of Medicine, Yale University, New Haven, CT, United States

Grace Macdonald-Gagnon

2 Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States

Gustavo A. Angarita

3 Connecticut Mental Health Center, New Haven, CT, United States

Krysten W. Bold

Marc n. potenza.

4 Connecticut Council on Problem Gambling, Wethersfield, CT, United States

5 Child Study Center, Yale School of Medicine, New Haven, CT, United States

6 Department of Neuroscience, Yale University, New Haven, CT, United States

7 Wu Tsai Institute, Yale University, New Haven, CT, United States

Associated Data

Attention-deficit/hyperactivity disorder (ADHD) is a common condition that frequently persists into adulthood, although research and diagnostic criteria are focused on how the condition presents in children. We aimed to review qualitative research on lived experiences of adults with ADHD to characterize potential ADHD symptomatology in adulthood and provide perspectives on how needs might be better met. We searched three databases for qualitative studies on ADHD. Studies ( n = 35) in English that included data on the lived experiences of adults with ADHD were included. These studies covered experiences of receiving a diagnosis as an adult, symptomatology of adult ADHD, skills used to adapt to these symptoms, relationships between ADHD and substance use, patients’ self-perceptions, and participants’ experiences interacting with society. Many of the ADHD symptoms reported in these studies had overlap with other psychiatric conditions and may contribute to misdiagnosis and delays in diagnosis. Understanding symptomatology of ADHD in adults may inform future diagnostic criteria and guide interventions to improve quality of life.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) has an estimated prevalence of 7% among adults globally ( 1 ). ADHD has historically been considered a disorder of childhood; however, 40–50% of children with ADHD may meet criteria into adulthood ( 2 ). Diagnostic criteria for ADHD include symptoms of inattention, hyperactivity, and impulsiveness present since childhood ( 3 ). These criteria are largely based on presentations in children, although diagnostic criteria have changed over time to better but not completely encompass considerations of experiences of adults ( 3 , 4 ).

Although adult ADHD is highly treatable with stimulant medication ( 5 ), adults with ADHD often have unmet needs. Substance use disorders (SUDs) are approximately 2.5-fold more prevalent among adults with versus without ADHD ( 6 , 7 ). Adults with ADHD are particularly likely to be incarcerated, with 26% of people in prison having ADHD ( 8 ). As diagnosis of ADHD has increased considerably in recent decades ( 9 ), there are likely many adults with ADHD who were not originally diagnosed as children. In more recent years, ADHD is still frequently underdiagnosed or misdiagnosed as other psychiatric conditions such as mood or personality disorders ( 10 ). Even when patients are diagnosed with ADHD as children, many patients lose access to resources when transitioning from child to adult health services ( 11 ) which may contribute to less than half of people with ADHD adhering to stimulant medication ( 12 ).

Non-pharmacological interventions such as cognitive behavioral therapy (CBT) have shown promise with helping adults manage their ADHD symptoms, although such symptoms are not completely ameliorated by therapy ( 13 – 15 ). A more thorough understanding of the symptoms adults with ADHD experience and the effects that these symptoms have on their lives may allow for more efficacious or targeted therapeutic interventions.

Qualitative research may provide insight into lived experiences, and findings from such studies may direct future research into potential symptoms and therapeutic interventions. The aim of this review is to describe the current qualitative literature on the lived experiences of adults with ADHD. This review may provide insight into the symptomatology of adult ADHD, identify areas where patient needs could be better met, and define gaps in understanding.

Search strategy

Using rapid review methodology ( 16 ), PubMed, PsychInfo, and Embase were searched on October 11th, 2021 with no date restrictions. The search terms included “ADHD” and related terms as well as “qualitative methods” present in the titles or abstracts. The full search ( Supplementary Appendix 1 ) was conducted with the help of a clinical librarian. The search yielded 417 articles which were uploaded to Endnote X9 where 111 duplicates were removed. The remaining 307 articles were uploaded to Covidence Systematic Review Management Software for screening, with one additional duplicate removed. The search also yielded a previous review on the lived experiences of adults with ADHD ( 17 ). The ten articles present in this review were also uploaded to Covidence where two duplicates were removed resulting in 314 unique articles.

Study selection

Studies reporting original peer-reviewed qualitative data on the lived experience of adults with ADHD, including mixed-methods studies, were eligible for inclusion. “Adult” was defined as being 18 years of age or older; studies that included adolescent and young adult participants were only included if results were reported separately by age. Studies that included some participants without ADHD were included if results were reported separately by diagnosis. Any studies with adult participants who were exclusively reflecting on their childhood experiences with ADHD were considered outside this study’s scope, as were studies on family members, medical providers, or other groups commenting on adults with ADHD. Articles could be from any country, but needed to have been published in English. Individual case studies were not included due to concerns with generalizability.

Twenty percent of titles and abstracts were screened by two reviewers for meeting the inclusion criteria. Studies were not initially excluded based on participants’ ages as many titles and abstracts did not specify age. One reviewer screened the remaining abstracts; a second reviewer screened all excluded abstracts. For full-text screening, ten articles were screened by both reviewers to ensure consistency. One reviewer screened the remaining articles; a second reviewer screened all excluded articles.

Quality appraisal

Quality appraisal was completed by one reviewer using the Joanna Briggs Institute critical appraisal checklist for qualitative research ( 18 ). Half of included studies did not state philosophical perspectives, two-thirds did not locate researchers culturally or theoretically, nearly one-third did not include specific information about ethics approval, and only two studies commented on reflexivity ( Supplementary Appendix 2 ). Given the varied quality appraisal results and the small body of literature, all studies were included regardless of methodological rigor.

Data extraction

Data extracted included general study characteristics and methodology, participant characteristics (sample size, demographics, and country of residence), study aims, and text excerpts of qualitative results. Study characteristics were entered into a Google Sheets document. PDFs of all studies were uploaded into NVivo 12, and results sections were coded using grounded theory ( 19 ). One reviewer extracted and coded data; a second reviewed extracted data for thematic consistency.

Study characteristics

One-hundred-and-seventy-three articles were deemed relevant in title and abstract screening. Of these, 35 were included after the full-text review ( Figure 1 ). Articles were published between 2005 and 2021, and methodology mostly consisted of individual interviews (91%), with other studies utilizing focus groups (14%). Eight studies focused on young adults (18–35 years), and three were specific to older adults (>50 years). Two had exclusively male participants, and three had exclusively female participants. Nineteen were conducted in Europe, nine in North America, and three in Asia. No studies included participants from Africa, South America, or Oceania. In six studies, participants had current or prior SUDs, six studies focused on college students, four included participants diagnosed in adulthood, and two included highly educated/successful participants ( Table 1 ).

An external file that holds a picture, illustration, etc.
Object name is fpsyt-13-949321-g001.jpg

PRISMA flow diagram showing the search strategy for identifying qualitative studies on the lived experience of adult attention-deficit/hyperactivity disorder (ADHD).

Article characteristics of included studies.

1 Ages not reported consistently across studies.

2 Substance use disorder.

An overview of the identified themes is described in Figure 2 , and Table 2 provides a summary of main findings. Several of the themes overlap with each other, and such areas are identified in the main text.

An external file that holds a picture, illustration, etc.
Object name is fpsyt-13-949321-g002.jpg

Schematic diagram of the domains of features linked to the lived experiences of adults with ADHD.

Summary of results.

Adult diagnosis

Assessment and diagnosis of adult ADHD were reported as laborious and included prior misdiagnoses ( 20 – 22 ), lack of psychiatric resources ( 23 ), and physicians’ stigma regarding adult ADHD ( 24 ). Participants were often diagnosed only after their children were diagnosed ( 23 , 24 ). However, after receiving a diagnosis, relief was commonly reported initially. Adults noted that receiving a diagnosis helped explain previously seemingly inexplicable symptoms and feelings of being different, and allowed for participants to blame themselves less for perceived shortcomings ( 24 – 31 ).

Identity changes were another reported finding after diagnosis, both positive and negative. Some participants reported experiencing existential questioning of their identities ( 25 , 26 ); others reported feeling increased levels of self-awareness ( 26 , 28 ). Some participants reported having initial doubts about the validity of their diagnoses ( 26 , 28 ). Some reported experiencing emotional turmoil and concerns about the future ( 25 , 26 , 29 ). A commonly reported late step involved acceptance, both of themselves and their diagnoses, sometimes coupled with increased interest in researching ADHD ( 24 , 25 , 28 , 29 , 32 ). A ubiquitous finding was participant regret that they had not been diagnosed earlier, largely because of the many years they had gone without understanding their condition or receiving treatment ( 22 , 24 , 26 – 30 ). In one study, participants who had been diagnosed as children had better emotional control and self-esteem ( 33 ). No studies reported participant regret about their ADHD diagnosis.

Symptomatology of attention-deficit/hyperactivity disorder

Inattention, impulsivity, and hyperactivity.

Consistent with current diagnostic conceptualizations, difficulties with attention and concentration were described. These difficulties hindered completion of daily life tasks at home, school, and work ( 24 , 27 , 28 , 32 , 34 – 37 ). Some participants reported not experiencing a pervasive deficit of attention, but rather only struggling when the topic was not of personal interest and could sustain attention on interesting tasks for long periods of time ( 33 , 38 – 42 ). Attention could be influenced by the environment; for example, attention worsened in distracting environments or improved in intense, stimulating environments ( 40 , 41 ).

Impulsivity was widely reported and reflected in risk-taking including reckless driving, unprotected sex, and extreme sports ( 20 , 24 , 28 , 33 , 36 , 43 ). Impulsive spending was noted ( 20 , 36 – 38 , 44 ). Impulsive speech (“blurting out”) was common and often led to strained interpersonal relationships ( 24 , 32 , 33 , 36 , 37 , 40 ).

Fewer studies described participants’ struggles with hyperactivity, such as with staying still or not being constantly busy ( 24 , 34 , 36 ). Hyperactivity was reported as an internal symptom by some participants, noted as inner feelings of restlessness ( 22 , 36 , 37 , 39 ), or described as resulting in excessive talking ( 36 ). This more subtle hyperactivity was mostly reported by women or older adults.

Chaos, lack of structure, and emotions

Living in chaos was often reported, whether involving internal feelings of being unsettled ( 28 ), or external aspects such as turbulent schedules or disorganized living spaces ( 22 , 24 , 27 , 36 ). Participants often struggled with maintaining structure in daily routines, resulting in irregular sleeping and eating, difficulty completing household tasks, and strained social lives ( 36 – 38 , 43 , 44 ). Increased autonomy in adulthood was often perceived as difficult to manage compared to more highly structured childhoods.

Although lacking from current diagnostic criteria, emotional dysregulation was often noted. Participants reported experiencing extreme emotional reactions to interpersonal conflicts such as terminations of romantic relationships or receiving negative feedback at work ( 24 , 34 , 38 , 40 ). Negative feelings of anxiety and agitation were common ( 22 , 24 , 29 , 31 , 33 , 34 , 36 , 38 , 44 ), as was difficulty with controlling, recognizing, naming, and managing emotions ( 30 , 40 , 41 , 44 ). One study noted that emotional lability has positive aspects since participants’ emotional highs were higher ( 45 ).

Positive aspects of attention-deficit/hyperactivity disorder

Not all aspects of ADHD were perceived as negative. Impulsivity was reported by some as fun and spontaneous ( 26 , 37 , 45 ), struggles with attention were reported as promoting creativity and motivating focus on details ( 21 , 33 , 40 , 41 , 45 ), and hyperactivity was described as providing energy to pursue one’s passions ( 40 , 45 ). Learning to live with ADHD-related impairments was reported as promoting resilience and humanity ( 45 ), and increased tendencies to keep calm in chaotic settings ( 40 ). Ability to maintain focus for extended periods on topics of personal interest was sometimes seen as helpful, although unpredictable ( 33 ).

Adapting to symptoms

Coping skills.

Participants reported compensatory organizational strategies that increased structure in their daily lives. Creating regimented sleeping, eating, working, and relaxing schedules ( 30 , 35 , 42 , 44 , 46 ), and keeping to-do lists or using reminder apps ( 24 , 32 , 37 , 40 , 42 , 46 ) were frequently-reported strategies. Some participants reported thriving without formal structure while working from home since they were able to maintain daily routines and were free from distractions ( 34 ).

Participants reported being able to adjust their environment to best suit their needs, whether that be decreasing distracting stimulation ( 32 , 46 ) or cultivating a highly stressful and stimulating environment ( 39 ). Creating space for physical activity was reported as a helpful outlet for hyperactivity ( 24 , 33 , 39 , 43 , 46 ). Having awareness of their diagnosis allowed newly-diagnosed participants to attribute their symptoms to their disorder, thereby decreasing self-blame ( 24 , 26 , 32 ). In one study, participants engage in self-talk to modify their behavior ( 32 ). Participants reported implementing social skills to prevent interrupting others and adjusting their social circles to accommodate their symptoms ( 24 , 35 , 46 ).

Substance use was also described as a coping strategy, although there were also drawbacks associated with using substances. Such findings are discussed under “substance use.”

Stimulant medications were commonly used to help manage ADHD symptoms; participants reported that stimulants facilitated task prioritization, goal achievement, and productivity often to “life-changing” extents ( 22 , 24 – 27 , 29 , 32 , 35 , 40 , 46 – 48 ). Stimulants were sometimes reported as assisting with social and emotional functioning by promoting calmness ( 22 , 24 , 30 , 40 ). Some participants took their medications on an as-needed basis, choosing to take them only when they had much work ( 20 , 27 , 32 , 33 , 47 ). In one study, participants reported feeling pressured to sell their medication, and in another, participants reported increasing their dosages to stay up all night in order to better complete school work ( 27 , 47 ).

Participant ambivalence or hesitation to take stimulants was reported due to therapeutic and adverse effects. Reported adverse effects included “not feeling like oneself,” resulting in difficulties with socializing and creativity ( 22 , 27 , 35 , 40 , 47 ), somatic effects such as appetite suppression and insomnia ( 22 , 27 , 35 , 40 , 47 ), unpleasant emotions including irritability and numbness ( 35 , 40 , 47 ), and rebound symptoms and withdrawal side effects when the medications wore off ( 29 , 47 ).

Outside support

Studies noted participants adapting to living with their symptoms by receiving formal accommodations at work and school. Reported workplace accommodations included reduction of auditory distractions and bosses who would provide organizational advice or extra reminders about due dates ( 24 , 25 , 40 ). Reported accommodations in college consisted of separate testing environments and extra time on examinations. However, inaccessibility of disability offices, limited willingness of professors to comply with accommodations, and lack of participant engagement with accommodations due to not wanting to seem different resulted in many participants not utilizing such resources ( 27 , 32 ).

Individual therapy was reported as helpful for managing symptoms and acquiring self-knowledge, especially therapeutic interventions designed for ADHD and CBT ( 22 , 23 , 27 , 41 ). However, some participants reported minimal benefits from seeing therapists who did not specialize in ADHD, and CBT was reported to need improvement to be specially tailored to adults with ADHD such as being more engaging or being reframed as ADHD coaching ( 22 , 27 , 33 ). Community care workers added structure to some participants’ lives and aided with motivation in one study ( 42 ).

In some studies, participants expressed desires to be involved with support groups for adults with ADHD in order to learn new coping skills and find community, but not knowing where to access such services ( 28 , 40 ). Those who had participated in ADHD support or focus groups reported feeling validated and less isolated, as well leaving with improved strategies for symptom management ( 24 , 31 , 41 , 49 ). Support was also reported in personal relationships. Having a supportive partner often helped participants tremendously with organization and life tasks, especially for men married to women ( 24 , 43 ). A close friend or family member encouraging accountability and creating a sense of togetherness was viewed as advantageous ( 32 , 42 ).

Substance use and addiction

Reasons for substance use.

The SUDs were commonly reported among adults with ADHD and often seen as a form of self-medication. In every study that discussed self-medication, participants reported using substances to feel calm and relaxed; substances included nicotine/tobacco, alcohol, marijuana, cocaine, and methamphetamine ( 20 , 24 , 32 , 46 , 50 – 52 ). Nicotine/tobacco, marijuana, ecstasy (MDMA), and methamphetamine were used to help improve focus, particularly before diagnosis and subsequent to stimulant treatment ( 20 , 24 , 32 , 51 , 52 ). Participants also reported using substances to help feel “normal” as they facilitated social interactions and helped complete activities of daily life ( 20 , 50 , 52 ). One study described college males’ experiences with video game addictions which resulted in neglecting schoolwork ( 32 ).

The tendencies of people with ADHD to make impulsive decisions were suggested as linking ADHD and substance use ( 20 , 52 ). Substance use worsened ADHD symptoms, most notably impulsivity ( 44 , 52 ). One study attributed high rates of substance use to participants with ADHD being less fearful and more rebellious than individuals without ADHD ( 50 ).

Although discontinuing substance use was regarded as a difficult process with frequent relapses, participants considered their quality of life to improve after quitting ( 30 , 44 , 53 ). Nicotine withdrawal was reported to worsen ADHD symptoms, and participants desired smoking-cessation programs specifically tailored for those with ADHD ( 53 ). Even after discontinuation of substance use, participants reported difficulties accessing stimulant medication due to their substance-use histories ( 52 ).

Stimulants and use of other substances

Findings relating stimulant use and use of other substances were mixed. Prescription stimulant usage was reported as a protective factor against use of other substances. Participants who had previously been self-medicating reported that when they had been on stimulants, they did not need other substances to help them feel calm and focused ( 46 , 47 , 50 , 52 ). Stimulants were reported to decrease cigarette cravings ( 50 ). In one study, a participant commented that her stimulant prescription generated a hatred of taking pills, which she reported subsequently prevented her from using drugs ( 54 ).

Some participants reported stimulant prescriptions as increasing risk of substance use. Some reported that stimulants directly increased nicotine cravings ( 50 ). Indirect connections were reported, such as feelings of social exclusion due to being labeled as medicated or due to participants feeling used to taking drugs since childhood ( 54 ). Other participants reported no connection between stimulant medication and use of other substances ( 50 , 54 ).

Perceptions of self and diagnosis

Self-esteem.

Participants often reported experiencing low self-esteem which they attributed to feeling unable to keep up with work or school, being told they were not good enough by others, and frequently failing at life goals ( 24 , 27 – 29 , 33 , 36 , 37 , 41 , 43 ). Low self-image was typically worse in childhood and improved over time, especially after receiving a diagnosis ( 28 , 36 , 43 ). In one study, some participants did not see themselves as having any flaws despite repeatedly being told otherwise, possibly due to being distracted from the emotional impact of these remarks ( 29 ).

Views of attention-deficit/hyperactivity disorder

Some participants viewed ADHD as a personality trait or difference as opposed to a disorder or disability ( 31 , 32 , 39 , 41 , 45 ). Some participants reported finding the ADHD diagnosis limiting and not wanting the disorder to define who they were ( 27 , 28 ). When asked if they would want their ADHD “cured” in one study, participants’ responses ranged from “definitively yes” to “definitely no.” Many reported feeling ambivalent as they described both positive and negative aspects of ADHD ( 20 ).

Interactions with society

Relationships with others.

Difficulties building and maintaining relationships with others were regularly reported. Participants reported that impulsivity hindered their social interactions due to their tendencies to make inappropriate remarks, engage in reckless behaviors, and agree to engagements without thinking through consequences, resulting in being associated with people to whom they did not want to be linked ( 20 , 22 , 32 , 33 , 36 , 43 ). Reported organizational struggles contributed to participants frequently being late and having cluttered living spaces ( 24 , 38 ). Participants reported misunderstanding social norms and hierarchies and being hesitant about starting conversations ( 28 , 30 , 40 , 43 ). They reported feeling overwhelmed by others’ emotions and unsure how to respond to them ( 44 ). Some participants reported choosing to hide their ADHD diagnoses, and the resultant barrier made socializing feel exhausting ( 24 ). Participants reported that these factors made sustaining long-term relationships especially difficult ( 22 , 31 , 38 , 43 ).

Feeling different from others was widely reported, most notably in childhood ( 20 , 24 , 27 , 29 , 31 , 32 ). This experience was described as feeling misunderstood, like a misfit, abnormal, and/or like there was something wrong with them ( 20 , 24 , 27 , 29 , 33 , 43 , 45 , 50 ). Participants reported consciously pretending to be normal as an attempt to fit in ( 28 , 41 ). Some participants reported seeing themselves as more brave or rebellious than their peers, which sometimes resulted in positive self-images ( 24 , 36 , 50 ). A strong desire to advocate for “the underdog” in interpersonal relationships was described by some women ( 31 ). In one study, most participants did not describe feeling different from others, but reported having felt misunderstood as children ( 36 ).

Participants with ADHD who also had children diagnosed with ADHD reported that their approaches to their children’s diagnoses were shaped by their own ADHD experiences. Parents reported uniform support of diagnostic testing, although the best time for testing was not agreed-upon ( 26 , 48 ). Opinions on starting their children on stimulants varied, ranging from enthusiastic support to viewing medication as a last resort, even among participants who had responded positively to stimulants themselves ( 48 ). Most participants reported supporting shared decision-making with the child.

Outside perceptions of attention-deficit/hyperactivity disorder

Participants reported their social networks often expressed preconceived notions about the diagnosis, such as ADHD being “fake” or restricted to children ( 27 – 29 , 37 , 41 ). Stigma about ADHD was reported as having prevented many from disclosing their diagnosis both personally and professionally ( 24 , 26 , 28 , 29 , 32 ). Increased awareness and education about ADHD were desired by participants to help them function better in society ( 28 , 41 ).

Societal expectations

Some studies discussed participants’ difficulties with meeting societal expectations. Participants reported struggling to keep up with daily tasks such as maintaining their living spaces, paying bills and remembering to eat ( 28 , 33 , 35 , 41 ). These difficulties were reported to result in exasperation, low self-esteem, and exhaustion ( 29 , 33 ).

Education and occupation

Academic underachievement was widely reported; most studies focused on postsecondary education. Some participants reported having to try harder than their peers for the same results ( 28 , 35 ), while others reported that they fell behind due to not putting in much effort ( 24 , 27 ). Reports of low motivation to complete assignments until the last minute, as it then became easier to focus, led to missed deadlines ( 32 , 35 , 38 ). Participants reported difficulties paying attention in class ( 24 , 27 , 32 , 35 ), struggling with reading comprehension ( 27 , 32 ), and needing extra tutoring ( 24 , 28 ). Participants reported these difficulties prevented them from “reaching their potential” as they were unable to complete advanced courses or degrees necessary for their careers of choice ( 20 , 22 , 31 , 37 , 39 ). A third of participants in one study noted that they did not struggle academically ( 31 ). Reported coping mechanisms for mitigating academic impairment included medications ( 35 , 47 ), active engagement with materials facilitated by small class sizes or study groups ( 23 , 35 ), and studying from home with fewer distractions ( 34 ). Formal academic accommodations are discussed under the outside support subheading of adapting to symptoms.

Occupational struggles were commonly reported, with many studies detailing participant underemployment or unemployment and high job-turnover rates ( 22 , 31 , 33 , 37 , 41 , 43 ). Difficulties with punctuality and keeping up with tasks and deadlines were reported to generate tensions in the workplace ( 20 , 22 , 24 , 33 , 35 , 39 ), and participants reported frequently being bored and unable to stay focused on their responsibilities, with noisy workplaces promoting distractibility ( 20 , 24 , 33 , 35 , 39 , 40 ). Some studies noted difficulties understanding and navigating social hierarchies in the workplace ( 20 , 40 ). In one study, participants reported feeling unable to maintain work-life balance, overworking until they felt burnt out ( 36 ). Working in fields of intrinsic interest, multitasking, and self-employment were reported strategies used to achieve occupational success ( 24 , 31 , 40 ). Having an understanding employer who could assist with task delegation and understand their needs was described as promoting positive workplace dynamics ( 25 , 33 , 40 ). Clearly defied roles and working with others helped some participants remain engaged in work ( 42 ). College students often reported part-time jobs as rewarding, with responsibilities helping them manage their academic pursuits ( 35 ).

Accessing services

Adults described difficulties accessing healthcare for ADHD. Most reported having to fight to receive a diagnosis and medication due to perceptions of stigma from physicians about adult ADHD ( 22 ). After diagnosis, participants often felt they did not receive adequate counseling or follow-up, especially when seeing general practitioners ( 22 , 26 ). Many participants reported not seeing physicians regularly for medication management due to bureaucratic difficulties ( 21 ); college students reported often having their former pediatricians refill prescriptions without regular appointments ( 47 ). Many participants in one study had little knowledge of ADHD services available to them despite regular appointments ( 32 ).

This review characterizes the current literature on the lived experiences of adults with ADHD. This includes experiences of having been diagnosed as an adult, symptomatology of adult ADHD, skills used to adapt to ADHD symptoms, relationships between ADHD and substance use, individual perceptions of self and of having received ADHD diagnoses, and social experiences interacting in society.

Similar themes were noted in a previous review on lived experiences of adults with ADHD consisting of ten studies, three of which were included here ( 17 ). Such themes included participants feeling different from others, perceiving themselves as creative, and implementing coping skills. There were also other similar findings from a review of eleven studies on the experiences of adolescents with ADHD ( 55 ). Overlapping themes included participants feeling that ADHD symptomatology has some benefits, experiencing difficulties with societal expectations, emotions and interpersonal conflicts, struggling with identity and stigma, and having varying experiences with stimulants. The overlaps in findings from these two reviews suggest there are shared experiences between adolescents and adults with ADHD. Unique from previous reviews on lived experiences of people with ADHD are the present qualitative findings of experiences of having received diagnoses in adulthood, reflections on ADHD and substance use, occupational struggles, attention dysregulation, and emotional symptoms of ADHD.

The relationship between ADHD effects and poor occupational performance has been previously described. People with ADHD often struggle with unemployment and underemployment and functional impairment at work ( 56 – 58 ). The findings of this review suggest that adults with ADHD may benefit from workplace accommodations and from decreased stigma around adult ADHD.

Findings suggest that people with ADHD often experience attention dysregulation as opposed to attention deficits, per se . This notion builds on previous clinical observations ( 59 ) and quantitative literature ( 60 , 61 ) documenting that adults with ADHD may hyperfocus on tasks of interest. These findings suggest that inattention does not fully capture the attentional symptoms of the condition and suggest a possible need for updated diagnostic criteria.

Emotional dysregulation was described by many studies in this review, and there were no studies in which participants denied struggling with emotions. These findings provide support for a conceptual model of ADHD that presents emotional dysregulation as a core feature of ADHD, as opposed to models stating that emotional dysregulation is a subtype of ADHD or simply that the domains are correlated ( 62 ). Debates exist regarding whether or not specific clinical aspects of disorders constitute core or diagnostic features ( 63 ). The DSM-5 and ICD-11 have viewed differently the criteria for specific disorders, including with respect to engagement for emotional regulation or stress-reduction purposes [e.g., behavioral addictions like gambling and gaming disorders, and other behaviors relating to compulsive sexual engagement ( 3 , 64 , 65 )]. Because emotional dysregulation is often overlooked as being associated with ADHD, patients experiencing such symptoms may be mistaken for having other conditions such as mood or personality disorders. Appreciating the emotional symptoms of ADHD may help psychiatrists, psychologists, and social workers more accurately diagnose ADHD in adults and decrease misdiagnosis.

The recurrent themes of difficulty naming and recognizing emotions found here suggest that ADHD may be associated with alexithymia. One study found that 22% of adults with ADHD were highly alexithymic but their mean scores on the rating scale for alexithymia were not significantly different from controls ( 66 ). Parenting style, attachment features, and ADHD symptoms have been found to predict emotional processing and alexithymia measures among adults with ADHD ( 67 ). More research is needed into the relationship between ADHD symptoms and alexithymia.

There was considerable heterogeneity in wishes regarding cures for ADHD (suggesting both perceived benefits and detriments) and stimulant use being association with SUDs. From a clinical perspective, both points will be important to understand better. With regard to the latter, ADHD and SUDs frequently co-occur; one meta-analysis found that 23% of people with SUDs met criteria for ADHD ( 68 ). Furthermore, youth with ADHD are seven-fold more likely than those without to experience/develop SUDs; however, early treatment with stimulants appeared to decrease this risk ( 69 ). Understanding better motivations for substance use in adults with ADHD as may be gleaned through considering lived experiences may help decrease ADHD/SUD co-occurrence and improve quality of life.

This review highlights gaps in the qualitative literature on adult ADHD. Nearly all included studies took place in Europe, North America or Asia; there is a dearth of qualitative research on ADHD in the Global South. Although most studies did not report race, those that did often had a majority of White participants. Racial/ethnic disparities in ADHD diagnosis may contribute to the relatively low diversity of study participants ( 9 ), and such disparities are further reason to expand research focused on non-White individuals with ADHD. Most studies focused on young or middle-aged adults and most participants were male; more research is needed on how ADHD may impact older adults and other gender identities. Although long considered to disproportionately affect male children at approximately 3:1 ( 70 ), ADHD in adults has been reported to have gender ratios of 1.5:1 ( 71 ). Among the adult psychiatric population, some studies have found no gender difference in prevalence or up to a 2.5:1 female predominance ( 72 ). This finding suggests that women often may not receive diagnoses until adulthood and there may be strong links with other psychopathologies in women. The lived experience of women with ADHD should be further examined; this insight may help to understand why women often go undiagnosed and experience other psychiatric concerns.

Future qualitative studies should explore how ADHD symptoms change over the lifespan as this was not addressed in any of the included studies. There were very few findings relating to how adults with ADHD conceptualize the condition and how their diagnosis interacts with their identities. Some studies reported on difficulties adults with ADHD have with accessing services; further exploration is needed into how the medical community can better meet the needs of this population. Findings from this review may be used to inform future ADHD screening tools. The Adult ADHD Self-Report Scale (ASRS) is a widely used screening tool that covers symptoms of inattention, impulsivity, and hyperactivity ( 73 ). This review suggests that symptoms may be more expansive than what is included in the ASRS and that questions on attentional dysregulation and hyperfocusing, emotional dysregulation, internal chaos, low self-esteem, and strained interpersonal relationships could be tested for validity for inclusion. The Conners’ Adult ADHD Rating Scales (CAARS) includes questions on emotional lability and low self-esteem in addition to symptoms covered by the ASRS ( 74 ), although the scale has been found to have high false-positive and false-negative rates ( 75 ). Further studies are needed to develop screening tools that capture the lived experience of adults with ADHD while maintaining appropriate sensitivity and specificity. This review may also inform tailoring CBT and other therapeutic interventions for ADHD. For example, CBT may help develop skills for volitional hyperfocusing on productive tasks instead of feeling pulled away from daily activities.

This study has limitations. Being a rapid review, it was not an exhaustive search of the available literature and may have missed some relevant studies that would have been identified by a systematic search. The search strategy consisted of ADHD and qualitative research methods; studies that did not include “qualitative” in their titles or abstracts may not have been identified. This may explain why the previous review on the lived experiences of adults with ADHD ( 17 ) included studies not identified by this search. Although a formal quality appraisal was completed, all studies were included regardless of the quality assessment as to not further narrow the review. For example, studies were not excluded based on how they verified ADHD diagnosis as many studies did not specify if or how this was completed. Although restricting studies based on quality metrics may have made the present findings more robust, the amount of data that would have been excluded would have been considerable and may have resulted in omitting important findings. These variable quality metrics not only limit the findings of the present review, but also speak to limitations in the methodological rigor of qualitative research on adult ADHD.

Attention-deficit/hyperactivity disorder is a relatively common diagnosis among adults. Exploration of the lived experiences of adults with ADHD may illuminate the breadth of symptomatology of the condition and should be considered in the diagnostic criteria for adults. Understanding symptomatology of adults with ADHD and identifying areas of unmet need may help guide intervention development to improve the quality of life of adults with ADHD.

Author contributions

CG and MP contributed to the conception of the review. CG and GM-G performed the abstract and full text screening. CG performed the data synthesis and wrote the first draft of the manuscript. GM-G, GA, KB, and MP contributed to the revising and editing the manuscript. All authors read and approved the submitted version.

Acknowledgments

We would like to express gratitude to clinical librarian Courtney Brombosz for her assistance in developing the search strategy.

This work was supported by the Yale School of Medicine Office of Student Research One-Year Fellowship and the K12 DA000167 grant.

Conflict of interest

MP has consulted for and advised Opiant Pharmaceuticals, Idorsia Pharmaceuticals, BariaTek, AXA, Game Day Data, and the Addiction Policy Forum; has been involved in a patent application with Yale University and Novartis; has received research support from the Mohegan Sun Casino and Connecticut Council on Problem Gambling; has participated in surveys, mailings or telephone consultations related to drug addiction, impulse control disorders or other health topics; and has consulted for law offices and gambling entities on issues related to impulse control or addictive disorders. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2022.949321/full#supplementary-material

ADHD Medications and Long-Term Cardiovascular Risk

“The heart of the matter.” Researchers investigated the risk of cardiovascular disease associated with long-term ADHD medication use.

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CASE VIGNETTE

“Kelly” is an 11-year-old Caucasian female with recently diagnosed attention-deficit/hyperactivity disorder (ADHD). She presented with primarily inattentive symptoms and minimal issues with hyperactivity and impulsivity. She also has a history of seasonal allergies and mild asthma. She had a positive response to treatment with methylphenidate, which she continues to take. At an outpatient visit, her mother asks about potential risks of long-term treatment with ADHD medication. As her psychiatrist, how would you respond?

There is ongoing concern regarding the cardiovascular safety of medications for ADHD. 1 Meta-analyses of randomized controlled trials (RCTs) have found increased pulse and blood pressure associated with both stimulant and non-stimulant ADHD medications. 1-3 Given the shorter-term nature of RCTs, whether these changes lead to clinically significant long-term risk of cardiovascular disease (CVD) remains unknown.

Previous longitudinal observational studies have yielded mixed findings, 4,5 and a meta-analysis of observational studies did not find an association. 6 However, most of these studies had a follow-up of <2 years. Given that ADHD symptoms may persist into adulthood 7 and the trend for long-term use of ADHD medications, 8 long-term risks of these medications represent an important area of study.

The Current Study

Zhang and colleagues 9 assessed the association between cumulative ADHD medication use (up to 14 years) and CVD risk using nationwide health registers in Sweden. Diagnoses were obtained from the National Inpatient Register. Medication information was retrieved from the Swedish Prescribed Drug Register. Socioeconomic factors were obtained from the Longitudinal Integrated Database for health Insurance and Labour Market studies. Death information was retrieved from the Swedish Cause of Death Register.

The investigators conducted a nested case-control study on all individuals in Sweden aged 6 to 64 years who received an incident diagnosis of ADHD (ICD-10) or ADHD medication dispensation (after at least 18 months without any such medication dispensation) between 2007 and 2020. Exclusion criteria were ADHD medication prescriptions for indications other than ADHD, individuals who emigrated or died, or individuals with a history of CVD before study baseline.

Cohort members were followed until the date of CVD diagnosis, death, migration, or the end of 2020 (whichever came first). Incident diagnosis of CVD included ischemic heart disease, cerebrovascular disease, hypertension, heart failure, arrhythmia, thromboembolic disease, arterial disease, and other heart disease. For each case, up to 5 controls without CVD were randomly selected and matched based on age, sex, and calendar time. Controls were alive, living in Sweden, and free of CVD at the time when their matched case received a diagnosis of CVD.

The primary exposure was cumulative duration of ADHD medication use, based on free text in prescription records. The last 3 months before the index date of CVD were excluded to reduce reverse causation. The authors conducted conditional logistic regression analyses to estimate odds ratios (ORs) for the association between cumulative ADHD medication duration and incident CVD. Analyses were adjusted for age, sex, calendar time, country of birth, education, and somatic and psychiatric comorbidity.

Duration of ADHD medication use was assessed using both continuous and categorical measures. The risk of CVD was also estimated for each 1-year increase in use of ADHD medication across different dosage groups categorized by the average defined daily dose (DDD). Subgroup analyses examined the association between ADHD medication use and specific CVDs, as well as the most commonly prescribed medications (methylphenidate, lisdexamfetamine, and atomoxetine).

The study cohort consisted of 278,027 individuals with ADHD. The incidence rate of CVD was 7.3 per 1000 person-years. The analyses included 10,388 cases and 51,672 matched controls (median age 35 years; 59% male). The median follow-up was 4.1 years. The most common types of CVD in cases were hypertension (41%) and arrhythmias (13%). Cases had high rates of somatic and psychiatric comorbidities and less education compared with controls.

Longer cumulative duration of ADHD medication use was associated with increased CVD risk compared with non-use in a dose-response fashion (>5 years: aOR=1.23, 95% CI 1.12-1.36). Throughout follow-up, each 1-year increase in the use of ADHD medication was associated with a 4% increased risk of CVD (aOR=1.04, 95% CI 1.03-1.05).

A similar pattern of findings was observed when considering 1) males and females, and 2) children/adolescents and adults, separately. Dosage analysis found that CVD risk associated with each 1 year of ADHD medication use increased with higher-average DDDs and was statistically significant for individuals with a mean dose of at least 1.5 DDD.

Regarding specific CVDs, long-term use of ADHD medication was associated with increased risk of hypertension (>5 years: aOR=1.80, 95% CI 1.55-2.08) and arterial disease (>5 years: aOR=1.49, 95% CI 0.96-2.32). Regarding specific medications, methylphenidate (>5 years: aOR=1.19, 95% CI 1.08-1.31), and lisdexamfetamine (>3 years: aOR=1.17, 95% CI 10.98-1.40) were associated with increased CVD risk. Atomoxetine use was significant only for the first year of use (aOR=1.07, 95% CI 1.01-1.13).

Study Conclusions

The investigators concluded that long-term ADHD medication use was associated with increased risk of incident CVD, and this risk increased in a dose-response manner. Findings were consistent regardless of age or sex. The primary drivers of this association were increased risk of hypertension and arterial disease.

Study strengths include the longer duration of follow-up than previous studies and consideration of specific causes of CVD. Another study strength was the use of prospective data collection, so results were not affected by recall bias.

Study limitations include potential lack of ascertainment of cases of CVD that did not require medical care, which would tend to underestimate associations. Exposure misclassification may have occurred if patients did not take medications as prescribed. Finally, the observational nature of the study design did not permit causal inferences.

The Bottom Line

Findings suggest that long-term use of ADHD medication is associated with an increase in CVD risk, especially hypertension and arterial disease, and with a higher risk for stimulant medications. Clinicians should vigilantly monitor patients, especially those taking higher doses, for signs and symptoms of CVD.

Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for Psychiatric Times®. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

1. Storebø OJ, Ramstad E, Krogh HB, et al. Methylphenidate for children and adolescents with attention deficit hyperactivity disorder (ADHD) . Cochrane Database Syst Rev . 2015;2015(11):CD009885.

2. Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis . Lancet Psychiatry . 2018;5(9):727-738.

3. Mick E, McManus DD, Goldberg RJ. Meta-analysis of increased heart rate and blood pressure associated with CNS stimulant treatment of ADHD in adults . Eur Neuropsychopharmacol . 2013;23(6):534-541.

4. Cooper WO, Habel LA, Sox CM, et al. ADHD drugs and serious cardiovascular events in children and young adults . N Engl J Med . 2011;365(20):1896-1904.

5. Habel LA, Cooper WO, Sox CM, et al. ADHD medications and risk of serious cardiovascular events in young and middle-aged adults . JAMA . 2011;306(24):2673-2683.

6. Zhang L, Yao H, Li L, et al. Risk of cardiovascular diseases associated with medications used in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis . JAMA Netw Open . 2022;5(11):e2243597.

7. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies . Psychol Med . 2006;36(2):159-165.

8. Bruno C, Havard A, Gillies MB, et al. Patterns of attention deficit hyperactivity disorder medicine use in the era of new non-stimulant medicines: a population-based study among Australian children and adults (2013-2020) . Aust N Z J Psychiatry . 2023;57(5):675-685.

9. Zhang L, Li L, Andell P, et al. Attention-deficit/hyperactivity disorder medications and long-term risk of cardiovascular diseases . JAMA Psychiatry . 2024;81(2):178-187.

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Wonder why your brain operates differently with ADHD? Study shows 'altered' brain wiring

Children with ADHD have notably different brain functioning when they're resting than children who don't have the neurological disorder, according to a national study released this week.

Scans of thousands of children with and without attention-deficit hyperactivity disorder highlighted a key difference: The National Institutes of Health study in the American Journal of Psychiatry found young people with ADHD had more wiring, or nerve cell networks, in their brains, making it harder for their brains to send clear signals about a task like following instructions or sitting still.

The findings build on evidence that can make it easier for experts to explain how a child's brain circuiting correlates to the ADHD symptoms that teachers or parents may see. In essence, the researchers found that children with ADHD have hyperconnected wiring that may make it harder for their brains to transmit a given signal.

“These are the brain regions that we know to be important in controlling impulsive behaviors and controlling attention,” Luke Norman, a staff scientist at the National Institute of Mental Health and author of the study, told USA TODAY. “These networks appear to be inefficient in ADHD.”

Drug pricing: ADHD drug prices rise as Adderall shortage leaves patients scrimping to fill prescriptions

Earlier studies of brain function for people with ADHD have involved smaller groups, typically less than 100 participants. None have amassed definitive evidence to identify the parts of the brain affected by ADHD, a neurodevelopmental disorder characterized by a person having difficulty paying attention and staying still.

The NIH study used thousands of brain scans of children with ADHD traits from six datasets. Outside experts said this larger sample size helps understand how brains work in people with ADHD, even though the results were relatively small because people were resting during the MRI scans and not active.

The study doesn't explore how to diagnose ADHD. That is typically done through evaluations that include input from doctors, teachers and parents. Instead, the findings help identify specific signals in the brain that are in play for people with the disorder, said Lauren Friedman, an assistant professor of psychology at Arizona State University , who was not affiliated with the study.

About 6 million U.S. children ages 3 to 17 have been diagnosed with ADHD, meaning young people facing these challenges make up just under 10% of children, according to the Centers for Disease Control and Prevention . Research suggests genetics play a role in a child developing ADHD, as well as other factors, including premature birth, low birth weight, lead poisoning, brain injuries and use of alcohol or tobacco during pregnancy.

The study also looked at scans of more than 8,000 children who were, on average, younger than 11. Nearly 1,700 of the children were diagnosed ADHD and more than 6,700 others didn't have the disorder. All of the children were lying in an MRI machine, with their eyes open, as an image was taken of their brain.

Among children with ADHD, researchers found the frontal cortex of their brains, the area that controls attention and manages unwanted behaviors, had increased wiring linked to structures centered deeper in the brain, that deal with information processing. This part of the brain is where learning happens. It's also where a person creates movement and experiences emotion. The children with ADHD had more connections between these two parts of their brains, but that didn't mean signals arrived more easily. Instead, the hyperconnected wiring led to what the study called "altered connectivity."

Norman, the NIH researcher, said the images build on earlier research. For example, when children with ADHD play games that require attention and controlling impulses, their brain scans showed they had difficulty making neural connections to perform the tasks. The study seems to affirm the same results, even when a person is resting.

The findings capture only a small portion of brain activity for people with ADHD. More research is needed looking at children with ADHD doing different activities, and at children with the disorder as they get older, Norman said. The study does not reflect children across the U.S. population, researchers noted. More than 15% of children with ADHD in the study came from households with incomes over $200,000, and about two-thirds of those with ADHD diagnoses were boys.

Sarah Karalunas, an associate professor of psychology at Purdue University , said the study helps establish a pattern of brain differences for children with ADHD who may be working harder than their peers to control their emotions and attention.

For his next study, Norman plans to look at how children practice skills that use these brain connections. The goal, he said, is to bring work toward finding treatments to change how brains function.

ADHD medications linked to weakening of heart muscle

A DHD stimulant medications like Ritalin or Adderall appear linked to a heightened risk for cardiomyopathy (a weakening of the heart muscle), and the risk grows with time, new research shows.

However, researchers were quick to note that cardiomyopathies are rare in the young, and even with ADHD medication use the absolute risk to any one patient remains very small.

Overall, folks ages 20 to 40 who were on a medication for attention-deficit/hyperactivity disorder ( ADHD ) were 17% more likely to have cardiomyopathy at one year and 57% more likely to have cardiomyopathy at eight years, compared to their peers who weren't taking the drugs. The study wasn't designed to prove cause-and-effect.

"The longer you leave patients on these medications, the more likely they are to develop cardiomyopathy, but the risk of that is very low," said study lead author Pauline Gerard. She's a second-year medical student at the University of Colorado School of Medicine.

"I don't think this is a reason to stop prescribing these medications," she said. "There's very little increased risk of these medications over the long term; it's a real risk, but it's small."

The findings are slated to be presented April 7 at the American College of Cardiology annual meeting in Atlanta.

The new study was based on data from 80 hospitals from across the United States, looking at people ages 20 to 40. Gerard's team compared rates of cardiomyopathy among patients with ADHD who took stimulant meds and people who were matched by age, sex and health conditions but who did not take the drugs.

The study showed that, over a period of 10 years, the relative risk for cardiomyopathy rose among people taking stimulant meds for about eight years, then tapered off during the last two years.

However, in absolute numbers, the incidence of cardiomyopathy was still quite low: At the 10-year mark, just under 1% of patients taking ADHD medications was found to have a weakened heart, Gerard's team reported.

Put another way, "you can have almost 2,000 patients on these medications for a year and you might only cause one of them to have a cardiomyopathy that they otherwise would not have had, but if you leave them on it for 10 years, 1 in 500 will have that happen," Gerard said in a meeting news release.

All of this means that doctors and patients should be aware of the risk, but no change in prescribing practices is needed, the researchers said. Testing for heart issues before prescribing ADHD medications is also probably not warranted, they said.

Because these findings were presented at a medical meeting, they should be considered preliminary until published in a peer-reviewed journal.

More information

Find out more about cardiomyopathy at the U.S. National Heart, Lung and Blood Institute.

Overall, people ages 20 to 40 who were on a medication for attention-deficit/hyperactivity disorder (ADHD) were 17% more likely to have cardiomyopathy at one year and 57% more likely to have cardiomyopathy at eight years, compared to their peers who weren't taking the drugs.

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ADHD Stimulants May Increase Risk of Heart Damage in Young Adults

While likelihood of cardiomyopathy grows over time, the overall risk remains low.

Mar 27, 2024

Contact: Nicole Napoli, [email protected], 202-669-1465

WASHINGTON (Mar 27, 2024) -

Young adults who were prescribed stimulant medications for attention-deficit/hyperactivity disorder (ADHD) were significantly more likely to develop cardiomyopathy (weakened heart muscle) compared with those who were not prescribed stimulants, in a study presented at the American College of Cardiology’s Annual Scientific Session.

The study found that people prescribed stimulants such as Adderall and Ritalin were 17% more likely to have cardiomyopathy at one year and 57% more likely to have cardiomyopathy at eight years compared with those who were not taking these medications. Cardiomyopathy involves structural changes in the heart muscle that weaken its pumping ability. It can cause a person to tire easily and limit their ability to perform daily tasks, and it often worsens over time.

However, researchers said that the overall risk of cardiomyopathy remained relatively low even when stimulants were used long-term. They said the findings do not necessarily point to a need for clinicians to change their approach to screening patients or prescribing stimulants.

“The longer you leave patients on these medications, the more likely they are to develop cardiomyopathy, but the risk of that is very low,” said Pauline Gerard, a second-year medical student at the University of Colorado School of Medicine in Aurora, Colorado, and the study’s lead author. “I don’t think this is a reason to stop prescribing these medications. There’s very little increased risk of these medications over the long term; it’s a real risk, but it’s small.”

ADHD is one of the most common neurodevelopmental disorders in children, affecting about 1 out of 10 American children aged 3 to 17, and can continue into adulthood. It is typically treated with behavioral therapy initially, which may be combined with stimulant or non-stimulant medications to help control behaviors that interfere with daily life and relationships. Stimulant medications can elevate blood pressure by causing the heart to beat faster and with greater force.

Most previous studies assessing the safety of stimulant medications have focused on the first year or two of use and found no evidence of harm to the heart. Since many patients are prescribed these medications in early childhood and continue taking them into adulthood, this new study was designed to assess their potential to cause harm over a longer period of time, Gerard said.

Using the TriNetX research database that includes information from about 80 hospitals across the U.S., researchers analyzed data from people diagnosed with ADHD between 20-40 years of age. Individuals with the presence or absence of a prescription for stimulant medications along with rates of cardiomyopathy that could potentially be linked to stimulant use were included. Those with heart damage caused by other known factors, such as cancer treatments, were excluded.

For the analysis, the researchers paired each person who had been prescribed stimulants with an individual who had not been prescribed stimulants but was as similar as possible in all other respects, such as age, sex and other health conditions. Overall, 12,759 pairs were created and were followed for at least 10 years. Of these pairs, people prescribed stimulants were found to be significantly more likely to develop cardiomyopathy throughout the 10-year follow-up period, with the gap growing larger each year except the last two, when it narrowed slightly.

Despite the significant gap, the overall prevalence of cardiomyopathy was still quite low in both groups. After being prescribed stimulants for 10 years, 0.72% (less than three-quarters of one percent) of patients developed cardiomyopathy, compared with 0.53% (a little over half of one percent) among those who were not prescribed stimulants.

To put the numbers into context, Gerard said, “You can have almost 2,000 patients on these medications for a year and you might only cause one of them to have a cardiomyopathy that they otherwise would not have had, but if you leave them on it for 10 years, 1 in 500 will have that happen.”

At these levels, researchers said the study does not suggest that aggressive testing for cardiovascular risk is warranted before prescribing stimulants, given that the potential benefits of testing must be balanced against the risks and costs. They suggest that further studies could help to identify subgroups of patients at greater risk who may benefit from future screening approaches.

Gerard said that it could also be helpful to study potential differences among different types of ADHD medications and different types of cardiomyopathies.

Gerard will present the study, “ADHD Stimulant Use Associated with Increased Risk of Cardiomyopathy in Young Adults,” on Sunday, April 7, at 2:15 p.m. ET / 18:15 UTC in Hall B4-5.

ACC.24 will take place April 6-8, 2024, in Atlanta, bringing together cardiologists and cardiovascular specialists from around the world to share the newest discoveries in treatment and prevention. Follow @ACCinTouch , @ACCMediaCenter and #ACC24 for the latest news from the meeting.

The American College of Cardiology (ACC) is the global leader in transforming cardiovascular care and improving heart health for all. As the preeminent source of professional medical education for the entire cardiovascular care team since 1949, ACC credentials cardiovascular professionals in over 140 countries who meet stringent qualifications and leads in the formation of health policy, standards and guidelines. Through its world-renowned family of JACC Journals, NCDR registries, ACC Accreditation Services, global network of Member Sections, CardioSmart patient resources and more, the College is committed to ensuring a world where science, knowledge and innovation optimize patient care and outcomes. Learn more at ACC.org .

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A Case Study in Attention-Deficit/Hyperactivity Disorder: An Innovative Neurofeedback-Based Approach
1.1. Evaluation of ADHD. The current diagnostic criteria for ADHD can be found in the DSM-5 [] and in the International Statistical Classification of Diseases and Related Health Problems, eleventh revision, from the World Health Organization [].Various evaluation instruments are used to identify ADHD, from general assessments via broad scales such as the Wechsler scale, to more specific tests ...
PDF Case Study 1
Case Study 1 - Jack Jack is a 7 year old male Grade 1 student who lives in Toronto with his parents. He is the only child to two parents, both of whom have completed post-graduate education. There is an extended family history of Attention Deficit/Hyperactivity Disorder (ADHD), mental health concerns as well as academic excellence.
PDF CASE STUDY 10-year-old boy diagnosed with ADHD
up the case study, names those activities in brief without the full details and explicit information each client-family receives in why and how to implement the program. Go to www.handle.org for more information. The HANDLE® Institute 7 Mt. Lassen Drive, Suite B110 San Rafael, CA 94903 415-479-1800
Attention deficit/hyperactivity disorder in adults: A case study
In adult ADHD, the symptoms may be comorbid or mimic other conditions making diagnosis and treatment difficult. Adults with ADHD require an in-depth assessment for proper diagnosis and treatment. The presentation and treatment of adults with ADHD can be complex and often requires interdisciplinary care.
Attention Deficit Hyperactivity Disorder (ADHD): A Case Study and
Twin, family and adoption studies conducted highlight important generic links to ADHD. Individuals are 60-90% more likely to develop ADHD if there is a familymember who has ADHD (Gizer et al. 2009).Neurotransmitters and genetic coding for specific genes are linked with ADHD traits.
Attention deficit/hyperactivity disorder in adults: A case study
ADHD can result in profound impairments in cognitive and social functioning. For example, impaired short-term memory was higher in college students with ADHD (Dudukovic, Gottshall, Cavanaugh, & Moody, 2014); adults with ADHD are more likely to procrastinate in ... Attention deficit/hyperactivity disorder in adults: A case study ...
Case Report: Treatment of a Comorbid Attention Deficit Hyperactivity
Most of these studies were performed in child and adolescent populations, and as far as we know, only one was conducted in an adult population . Some of the case reports described obsessive-compulsive symptoms as a side effect of MPH treatment in patients with ADHD (12-14, 29-32).
Attention-deficit Hyperactivity Disorder (ADHD): Two Case Studies
Despite increased awareness, Attention-deficit hyperactivity disorder (ADHD) is a chronic condition that affects 8% to 12% of school-aged children and contributes significantly to academic and social impairment. There is currently broad agreement on evidence-based best practices of ADHD identification and diagnosis, therapeutic approach, and ...
Treatments for ADHD in Children and Adolescents: A Systematic Review
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 ...
Attention-deficit Hyperactivity Disorder (ADHD): Two Case Studies
Despite increased awareness, Attention-deficit hyperactivity disorder (ADHD) is a chronic condition that affects 8% to 12% of school-aged children and contributes significantly to academic and social impairment. There is currently broad agreement on evidence-based best practices of ADHD identification and diagnosis, therapeutic approach, and ...
Patient Case #1: 19-Year-Old Male With ADHD
OK, let's move on to the case presentation. This first patient is a 19-year-old male, who presented to his psychiatrist after being referred by his primary care provider, PCP for ADHD consultation, during the interview, he noted he was a sophomore in college and is taking 17 credits. This semester chief complaint includes a lack of ability to ...
ADHD: Reviewing the Causes and Evaluating Solutions
1. Introduction. Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder (NDD) presenting with inattention, hyperactivity, and impulsivity. It can be classified in three subtypes, depending on the intensity of the symptoms: predominantly inattentive, predominantly hyperactive-impulsive, and combined [ 1, 2 ].
ADHD Diagnosis and Treatment in Children and Adolescents
Future studies of ADHD should more systematically address the modifier effects of these patient characteristics. More research is needed on the performance of diagnostic tools, the consequences of being misdiagnosed as either having or not having ADHD, the real-world effectiveness and long-term outcomes of medication and other therapies, and ...
Altered brain connections in youth with ADHD
However, the differences found by the researchers were small and likely capture only part of the processes involved in ADHD. "The findings from this study help further our understanding of the brain processes contributing to ADHD symptoms. Such understanding is a first step in thinking of new ways to help those who find the symptoms cause ...
Females with ADHD: An expert consensus statement taking a lifespan
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 .
An ADHD diagnosis in adulthood comes with challenges and benefits
In a 2020 study, researchers compared 444 adults with diagnosed ADHD with 1,055 adults who exhibited symptoms but had no formal diagnosis. After matching for age and gender, those with a diagnosis reported a higher quality of life, which included metrics for work productivity, self-esteem, and functional performance ( Pawaskar, M., et al ...
Understanding ADHD from a Biopsychosocial-Cultural Framework: A Case Study
The purpose of this article is to discuss the biopsychosocial-cultural model, its advantages and disadvantages, and its application in a case study of a Hispanic child with ADHD. The biopsychosocial-cultural framework is a systemic and multifaceted approach to assessment and intervention that takes into account biological, psycholog
CASE STUDY Jen (attention-deficit/hyperactivity disorder)
Case Study Details. Jen is a 29 year-old woman who presents to your clinic in distress. In the interview she fidgets and has a hard time sitting still. She opens up by telling you she is about to be fired from her job. In addition, she tearfully tells you that she is in a major fight with her husband of 1 year because he is ready to have ...
A CASE STUDY
A CASE STUDY. Observations of a student with ADHD over a 3-week time span. ... He has no physical disabilities, but suffers from a mental disorder - ADHD. He often makes careless mistakes in schoolwork. He does not pay attention to detail. He has trouble staying focused while reading long texts. He also has difficulty staying still during a ...
Case Study: ADHD & Anxiety
Diagnosis: ADHD and Anxiety. "I don't know what you did—but I have my child back.". When I first saw Mary in my office—an 18-year-old woman diagnosed with ADHD and anxiety—she was extremely anxious. Perspiration flowed down her face, she was constantly shaking her legs, there was a tremor in her hands, and her voice cracked as she ...
PDF Attention deficit hyperactivity disorder : a case study
This thesis presented a case study of a nine year old boy with Attention Deficit Hyperactivity Disorder (hereafter ADHD). ADHD is the current diagnostic label for children presenting with problems in attention, impulse control, and overactivity. These primary characteristics, and the related problems of ADHD
Childhood ADHD
In the final part of her ADHD series, Dr Sabina Dosani, Child and Adolescent Psychiatrist and Clinical Partner London, introduces Luke, a patient she was able to help with his ADHD. ... Case Study. Luke, aged six, gets into trouble a lot at school. His mother gets called by his teacher three or four times a week for incidents of fighting ...
Women with ADHD needed for Australian-first study
"The negative impacts associated with undiagnosed ADHD can be considerable and include self-critical beliefs, burnout, exhaustion, misdiagnosis, and lack of access to appropriate treatment that could potentially alleviate symptoms. "This study will address the notable gap in knowledge and understanding of women's experiences.
Attention deficit/hyperactivity disorder in adults: A case study
Clinical case presentation. LB is a 31-year-old divorced woman who presented with complaints of racing thoughts, irritability, worrying, nervousness, labile sleep due to racing thoughts, and inability to remain focused on tasks. ... Impaired early information processing in adult ADHD: A high-density ERP study. BMC Psychiatry, 20 (1) (2020), 10. ...
ADHD medication proves most effective in treating symptoms, new study finds
The study found limited evidence on whether different types of ADHD or coexisting psychiatric conditions influence treatment outcomes. Long-term follow-up data, especially beyond 12 months, were ...
The lived experiences of adults with attention-deficit/hyperactivity
Studies reporting original peer-reviewed qualitative data on the lived experience of adults with ADHD, including mixed-methods studies, were eligible for inclusion. "Adult" was defined as being 18 years of age or older; studies that included adolescent and young adult participants were only included if results were reported separately by age.
ADHD Medications and Long-Term Cardiovascular Risk
The investigators conducted a nested case-control study on all individuals in Sweden aged 6 to 64 years who received an incident diagnosis of ADHD (ICD-10) or ADHD medication dispensation (after at least 18 months without any such medication dispensation) between 2007 and 2020.
ADHD: Study shows differences in kids' brains who have the disorder
The study also looked at scans of more than 8,000 children who were, on average, younger than 11. Nearly 1,700 of the children were diagnosed ADHD and more than 6,700 others didn't have the disorder.
ADHD medications linked to weakening of heart muscle
ADHD stimulant medications like Ritalin or Adderall appear linked to a heightened risk for cardiomyopathy (a weakening of the heart muscle), and the risk grows with time, new research shows.
ADHD Stimulants May Increase Risk of Heart Damage in Young Adults
Gerard said that it could also be helpful to study potential differences among different types of ADHD medications and different types of cardiomyopathies. Gerard will present the study, "ADHD Stimulant Use Associated with Increased Risk of Cardiomyopathy in Young Adults," on Sunday, April 7, at 2:15 p.m. ET / 18:15 UTC in Hall B4-5.

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Altered brain connections in youth with ADHD

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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

Conclusions

Results and consensus outcome

ADHD symptoms

Associated features, functional problems and impairments

Triggers for referral

Rating Scales

The clinical interview

Objective assessments

Interventions and Treatments

Pharmacological management

Non-pharmacological management

Primary age

Secondary age

Multi-agency liaison

Educational considerations and adjustments

Occupational considerations and adjustments

Health and social care

Criminal justice system

Availability of data and materials

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Understanding ADHD from a Biopsychosocial-Cultural Framework: A Case Study

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