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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Outcomes: Patient health and psychosocial outcomes

Setting: Any

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

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

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

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

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

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

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

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

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

Literature flow diagram.

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

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

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

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

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

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

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

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

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

Combination treatment. CLON, clonidine, GXR guanfacine.

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

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

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

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

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

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

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

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

Nonmedication intervention effects on ADHD symptom severity.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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• Published: 13 May 2024

ADHD grows up

Nature Mental Health volume  2 ,  pages 461–462 ( 2024 ) Cite this article

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ADHD is the most common neurodevelopmental disorder in children, yet despite a large increase in awareness and in the number of diagnoses, much less is known about how this disorder affects adults. More research is needed to understand how ADHD may present differently as a function of age or how the experience of ADHD may change in people as they age.

It has been nearly 20 years since the Time Magazine cover exclaimed “Disorganized? Distracted? Discombobulated? Doctors Say You May Have Attention Deficit Disorder — It’s not just kids who suffer from it.” Wresting the attention deficit label away from ‘youngsters’, news outlets introduced the general public to the notion that this disorder could also be experienced in adulthood. The intervening decades have seen the name of the disorder changed from ‘attention deficit disorder (ADD)’ to the present moniker ‘attention-deficit/hyperactivity disorder (ADHD)’ and refinement of the definition, which has been expanded to include three main types: inattentive, hyperactive/impulsive, and combined presentation. There has been notable progress in clinical characterization, as well as in identifying some of the neurobiological pathways that are probably involved, yet there is much about ADHD that is not well understood, particularly about the disorder in adulthood.

One likely explanation for the gaps in knowledge about ADHD in adults is that it has long been classified as a neurodevelopmental disorder that emerges during childhood. It is certainly the case that the experience of symptoms of ADHD in childhood can profoundly interfere with social and academic activities and development. Estimates of ADHD prevalence can vary substantially by age group, gender and socioeconomic factors, which suggests that adverse social determinants, such as poverty, can increase risk and lead to poorer outcomes. Recent nationally representative data from the United States indicate that 11.3% of children and adolescents 5–17 years of age had received a diagnosis of ADHD (C. Reuben & N. Elgaddal. National Center for Health Statistics https://doi.org/10.15620/cdc/148043 ; 2024). By contrast to high-income countries such as the United States, however, global data indicate that closer to 5% of children and adolescents are affected by ADHD.

Determining the prevalence for ADHD in adulthood is even more challenging. Population-based estimates place the prevalence between 2% and 7%. Yet there are indications that in the United States, for example, the prevalence may be higher and climbing. The demand for diagnosis and treatment of ADHD in adults has surged, possibly because of an exceptional increase in public awareness. Interaction with digital and social media provides multifaceted exposure to direct-to-consumer marketing for medications, the proliferation of telehealth organizations offering diagnosis and treatment services, apps that incorporate artificial intelligence technology as attentional and productivity aids, and highly viewed video content featuring lived experience ADHD influencers.

Although the longer-term consequences of the greater visibility of ADHD are unknown, it has prompted more scrutiny about how and in whom ADHD is diagnosed. For both children and adults with ADHD, in addition to psychotherapy or behavioral therapy, the current standard of care includes medication, typically stimulants. For the past 2 years, the United States has seen widespread shortages of stimulants, including Adderall (amphetamine and dextroamphetamine) and Ritalin (methylphenidate), in part because of pandemic-related supply-chain issues, in addition to limitations imposed by the Drug Enforcement Agency, which regulates the production of controlled substances. Measured by the number of stimulant medications filled as a proxy for ADHD diagnoses, prescriptions for groups such as girls and women between 15 and 44 years of age increased by more than 10% between 2020 and 2021 alone (M. L. Danielson et al. MMWR Morb. Mortal. Wkly. Rep . 72 , 327–332; 2023).

Despite the large and rapid increases in ADHD diagnoses in adults, accompanied by calls to re-evaluate stimulant prescription policies, there are no clinical recommendations for diagnosing adults thus far. A diagnosis of ADHD in an adult by the most recent DSM criteria is contingent on the presence of ADHD symptoms during childhood. Indeed, DSM-5-TR indicates that “ADHD begins in childhood.” But it does not necessarily end there — about two thirds of children with ADHD have symptoms that persist into adulthood. Other recent work challenges the assumption that the disorder can begin only in childhood or adolescence. Longitudinal data suggest that there may be at least three sets of cases of ADHD that can be distinguished by when symptomatology emerges: ADHD with onset in childhood, ADHD with onset in childhood that persists into adulthood, and ADHD with no childhood history. Although these distinctions are under debate because of factors such as retrospectively self-reported symptoms or the potential of sub-threshold symptomatology that is exacerbated by the experience of stressors in adulthood, the question remains of whether childhood ADHD is a distinct entity from ADHD that may be diagnosed in adulthood. Other critiques of the diagnostic criteria of ADHD in adults suggest that they fail to encompass some of the potential differences in presentation, such as more substantial subjective impairment and emotional dysregulation. The results of efforts to produce clinical guidance and diagnostic tools designed for primary care practitioners and mental health specialists, led by the American Professional Society for ADHD and Related Disorders Association, are likely to be released sometime in 2024.

Other limitations apply to the existing research investigating the neurobiological bases of ADHD. For example, relatively fewer studies have been conducted that have identified structural and functional differences in brain imaging associated with ADHD than for other psychiatric disorders, such as depression. Many of these studies of ADHD have been conducted exclusively with children or adolescents. Because of the cascade of developmental changes that occur in the brain during maturation, compounded by the high degree of heterogeneity in ADHD symptom presentation, it is an open question whether neurofunctional and neuroanatomical differences that may be associated with childhood ADHD are representative of ADHD in adulthood. Much more work also needs to be done to identify consistent brain signatures and biomarkers associated with ADHD, irrespective of the age of onset.

In this issue of Nature Mental Health , work from Parlatini and colleagues seeks to provide some answers and some intriguing new insights into the neurobiology of ADHD in adults and how these differences may underlie response to medication treatment. Using a longitudinal design, the study assessed cortical anatomy with structural magnetic resonance imaging in adults with ADHD compared with that of matched neurotypical control participants. The authors then examined whether regional brain differences were associated with the response to methylphenidate, finding that the brains of people with ADHD who did not respond to treatment were characterized by reduced volume and thickness mainly in temporo-parietal areas that are implicated in attentional control. These findings indicate potential brain-based targets for future exploration.

Although not everyone with ADHD responds positively to medication, there is substantial evidence indicating that pharmacological and psychosocial treatments can be effective in managing symptoms in both children and adults. ‘Management’ is the operative word, as ADHD is not a curable condition but is a chronic condition that may require continued treatment over time. There is, however, little research about how best to provide support for youth with ADHD as they navigate the transition to adulthood. In a Review in this issue, Bui and coauthors present both the challenges of helping young people with ADHD cultivate self-management as they become adults, and possible supportive scaffolding that parents and caregivers can provide to achieve this. The piece highlights the incorporation of strategies such as motivational interviewing and environmental restructuring, but also emphasizes the need to tailor these approaches in socioeconomically and culturally meaningful ways.

As a means of better curating the work that has been published in Nature Mental Health and to track the progress made in unpacking some of the crucial questions about ADHD, we are pleased to announce the launch of a new Collection of papers, including primary research and commentary. We hope it will serve as a living repository for ADHD-focused content, and for researchers, clinicians and people with ADHD, and although limited now, we hope that understanding and management of the disorder will continue to grow.

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ADHD grows up. Nat. Mental Health 2 , 461–462 (2024). https://doi.org/10.1038/s44220-024-00262-w

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Adhd: reviewing the causes and evaluating solutions.

1. Introduction

2. environmental factors associated with adhd, 2.1. preconceptional, gestational, and perinatal conditions, 2.2. heavy metal exposure, 3. sleep disorders and adhd, 4. genetic factors associated with adhd, 4.1.1. circulating bdnf, 4.1.2. genetics of bdnf, 4.1.3. other neurotrophines, 4.2. dopaminergic system, 5. changes in brain structure and function in adhd patients, 5.1. brain imaging studies, 5.2. quantitative electroencephalography, 6. therapeutic approaches, 6.1. pharmacological treatment, 6.1.1. methylphenidate, 6.1.2. atomoxetine, 6.1.3. adverse effects, 6.1.4. long-term adverse effects, 6.1.5. long-term therapeutic effect, 6.2. non-pharmacological therapies, 6.2.1. behavioral parent training, 6.2.2. cognitive behavioral therapy, 6.2.3. attention training techniques, 6.2.4. neurofeedback, 6.2.5. other non-pharmacological approaches, 7. treatment personalization, 8. discussion, 9. conclusions, author contributions, conflicts of interest.

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Núñez-Jaramillo, L.; Herrera-Solís, A.; Herrera-Morales, W.V. ADHD: Reviewing the Causes and Evaluating Solutions. J. Pers. Med. 2021 , 11 , 166. https://doi.org/10.3390/jpm11030166

Núñez-Jaramillo L, Herrera-Solís A, Herrera-Morales WV. ADHD: Reviewing the Causes and Evaluating Solutions. Journal of Personalized Medicine . 2021; 11(3):166. https://doi.org/10.3390/jpm11030166

Núñez-Jaramillo, Luis, Andrea Herrera-Solís, and Wendy Verónica Herrera-Morales. 2021. "ADHD: Reviewing the Causes and Evaluating Solutions" Journal of Personalized Medicine 11, no. 3: 166. https://doi.org/10.3390/jpm11030166

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162 ADHD Essay Topics & Examples

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

🔝 Top 10 ADHD Research Topics

🏆 best adhd essay examples, 💡 most interesting adhd topics to write about, 🎓 exciting adhd essay topics, 🔥 hot adhd topics to write about, 👍 adhd research paper topics, ❓ research questions about adhd.

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

• ADHD and its subtypes
• The most common symptoms of ADHD
• The causes of ADHD: genetics, environment, or both?
• ADHD and the changes in brain structures
• ADHD and motivation
• Treating ADHD: the new trends
• Behavioral therapy as ADHD treatment
• Natural remedies for ADHD
• ADD vs. ADHD: is there a difference?
• Living with ADHD: the main challenges
• Learning Disabilities: Differentiating ADHD and EBD As for the most appropriate setting, it is possible to seat the child near the teacher. It is possible to provide instructions with the help of visual aids.
• Bright Not Broken: Gifted Kids, ADHD, and Autism It is possible to state that the book provides rather a high-quality review of the issues about the identification, education, and upbringing of the 2e children.
• Everything You Need to Know About ADHD The frontal hemisphere of the brain is concerned with coordination and a delay in development in this part of the brain can lead to such kind of disorder.
• Attention Deficit Hyperactivity Disorder (ADD / ADHD) Some critics maintain that the condition is a work of fiction by the psychiatric and pharmacists who have taken advantage of distraught families’ attempts to comprehend the behaviour of their children to dramatise the condition.
• Psychology: Attention Deficit and Hyperactivity Disorder It is important to pay attention to the development of proper self-esteem in children as it can negatively affect their development and performance in the future.
• ADHD and Its Effects on the Development of a Child In particular, this research study’s focus is the investigation of the impact of household chaos on the development and behavior of children with ADHD.
• The History of ADHD Treatment: Drug Addiction Disorders Therefore, the gathered data would be classified by year, treatment type, and gender to better comprehend the statistical distribution of the prevalence of drug addiction.
• Attention Deficit Hyperactivity Disorder and Recommended Therapy The condition affects the motivational functioning and abnormal cognitive and behavioural components of the brain. Dysfunction of the prefrontal cortex contributed to a lack of alertness and shortened attention in the brain’s short-term memory.
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Understanding and Supporting Attention Deficit Hyperactivity Disorder (ADHD) in the Primary School Classroom: Perspectives of Children with ADHD and their Teachers

• Original Paper
• Open access
• Published: 01 July 2022
• Volume 53 , pages 3406–3421, ( 2023 )

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• Emily McDougal   ORCID: orcid.org/0000-0001-7684-7417 1 , 3 ,
• Claire Tai 1 ,
• Tracy M. Stewart   ORCID: orcid.org/0000-0002-8807-1174 2 ,
• Josephine N. Booth   ORCID: orcid.org/0000-0002-2867-9719 2 &
• Sinéad M. Rhodes   ORCID: orcid.org/0000-0002-8662-1742 1  

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Children with Attention Deficit Hyperactivity Disorder (ADHD) are more at risk for academic underachievement compared to their typically developing peers. Understanding their greatest strengths and challenges at school, and how these can be supported, is vital in order to develop focused classroom interventions. Ten primary school pupils with ADHD (aged 6–11 years) and their teachers (N = 6) took part in semi-structured interviews that focused on (1) ADHD knowledge, (2) the child’s strengths and challenges at school, and (3) strategies in place to support challenges. Thematic analysis was used to analyse the interview transcripts and three key themes were identified; classroom-general versus individual-specific strategies, heterogeneity of strategies, and the role of peers. Implications relating to educational practice and future research are discussed.

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Characterised by persistent inattention, hyperactivity and impulsivity (APA, 2013), ADHD is a neurodevelopmental disorder thought to affect around 5% of children (Russell et al., 2014 ) although prevalence estimates vary (Sayal et al., 2018 ). Although these core symptoms are central to the ADHD diagnosis, those with ADHD also tend to differ from typically developing children with regards to cognition and social functioning (Coghill et al., 2014 ; Rhodes et al., 2012 ), which can negatively impact a range of life outcomes such as educational attainment and employment (Classi et al., 2012 ; Kuriyan et al., 2013 ). Indeed, academic outcomes for children with ADHD are often poor, particularly when compared with their typically developing peers (Arnold et al., 2020 ) but also compared to children with other neurodevelopmental disorders, such as autism (Mayes et al., 2020 ). Furthermore, children with ADHD can be viewed negatively by their peers. For example, Law et al. ( 2007 ) asked 11–12-year-olds to read vignettes describing the behaviour of a child with ADHD symptoms, and then use an adjective checklist to endorse those adjectives that they felt best described the target child. The four most frequently ascribed adjectives were all negative (i.e. ‘careless’, ‘lonely’, ‘crazy’, and ‘stupid’). These negative perceptions can have a significant impact on the wellbeing of individuals with ADHD, including self-stigmatisation (Mueller et al., 2012 ). There is evidence that teachers with increased knowledge of ADHD report more positive attitudes towards children with ADHD compared to those with poor knowledge (Ohan et al., 2008 ) and thus research that identifies the characteristics of gaps in knowledge is likely to be important in addressing stigma.

Previous research of teachers' ADHD knowledge is mixed, with the findings of some studies indicating that teachers have good knowledge of ADHD (Mohr-Jensen et al., 2019 ; Ohan et al., 2008 ) and others suggesting that their knowledge is limited (Latouche & Gascoigne, 2019 ; Perold et al., 2010 ). Ohan et al. ( 2008 ) surveyed 140 primary school teachers in Australia who reported having experience of teaching at least one child with ADHD. Teachers completed the ADHD Knowledge Scale which consisted of 20 statements requiring a response of either true or false (e.g. “A girl/boy can be appropriately labelled as ADHD and not necessarily be over-active ”). They found that, on average, teachers answered 76.34% of items correctly, although depth of knowledge varied across the sample. Almost a third of the sample (29%) had low knowledge of ADHD (scoring less than 69%), with just under half of teachers (47%) scoring in the average range (scores of 70–80%). Only a quarter (23%) had “high knowledge” (scores above 80%) suggesting that knowledge varied considerably. Furthermore, Perold et al. ( 2010 ) asked 552 teachers in South Africa to complete the Knowledge of Attention Deficit Disorders Scale (KADDS) and found that on average, teachers answered only 42.6% questions about ADHD correctly. Responses of “don’t know” (35.4%) and incorrect responses (22%) were also recorded, indicating gaps in knowledge as well as a high proportion of misconceptions. Similar ADHD knowledge scores were reported in Latouche and Gascoigne’s ( 2019 ) study, who found that teachers enrolled into their ADHD training workshop in Australia had baseline KADDS scores of below 50% accuracy (increased to above 80% accuracy after training).

The differences in ADHD knowledge reported between Ohan et al. ( 2008 ) and the more recent studies could be due to the measures used. Importantly, when completing the KADDS, respondents can select a “don’t know” option (which receives a score of 0), whereas the ADHD Knowledge Scale requires participants to choose either true or false for each statement. The KADDS is longer, with a total of 39 items, compared to the 20-item ADHD Knowledge Scale, offering a more in-depth knowledge assessment. The heterogeneity of measures used within the described body of research is also highlighted within Mohr-Jensen et al. ( 2019 ) systematic review; the most frequently used measure (the KADDS) was only used by 4 out of the 33 reviewed studies, showing little consensus on the best way to measure ADHD knowledge. Despite these differences in measurement, the findings from most studies indicate that teacher ADHD knowledge is lacking.

Qualitative methods can provide rich data, facilitating a deeper understanding of phenomena that quantitative methods alone cannot reveal. Despite this, there are very few examples in the literature of qualitative methods being used to understand teacher knowledge of ADHD. In one example, Lawrence et al. ( 2017 ) interviewed fourteen teachers in the United States about their experiences of working with pupils with ADHD, beginning with their knowledge of ADHD. They found that teachers tended to focus on the external symptoms of ADHD, expressing knowledge of both inattentive and hyperactive symptoms. Although this provided key initial insights into the nature of teachers’ ADHD knowledge, only a small section of the interview schedule (one out of eight questions/topics) directly focused on ADHD knowledge. Furthermore, none of the questions asked directly about strengths, with answers focusing on difficulties. It is therefore difficult to determine from this study whether teachers are aware of strengths and difficulties outside of the triad of symptoms. A deeper investigation is necessary to fully understand what teachers know, and to identify areas for targeted psychoeducation.

Importantly, improved ADHD knowledge may impact positively on the implementation of appropriate support for children with ADHD in school. For example, Ohan et al. ( 2008 ) found that teachers with high or average ADHD knowledge were more likely to perceive a benefit of educational support services than those with low knowledge, and teachers with high ADHD knowledge were also more likely to endorse a need for, and seek out, those services compared to those with low knowledge. Furthermore, improving knowledge through psychoeducation may be important for improving fidelity to interventions in ADHD (Dahl et al., 2020 ; Nussey et al., 2013 ). Indeed, clinical guidelines recommend inclusion of psychoeducation in the treatment plan for children with ADHD and their families (NICE, 2018 ). Furthermore, Jones and Chronis-Tuscano ( 2008 ) found that educational ADHD training increased special education teachers’ use of behaviour management strategies in the classroom. Together, these findings suggest that understanding of ADHD may improve teachers’ selection and utilisation of appropriate strategies.

Child and teacher insight into strategy use in the classroom on a practical, day-to-day level may provide an opportunity to better understand how different strategies might benefit children, as well as the potential barriers or facilitators to implementing these in the classroom. Previous research with teachers has shown that aspects of the physical classroom can facilitate the implementation of effective strategies for autistic children, for example to support planning with the use of visual timetables (McDougal et al., 2020 ). Despite this, little research has considered the strategies that children with ADHD and their teachers are using in the classroom to support their difficulties and improve learning outcomes. Moore et al. ( 2017 ) conducted focus groups with UK-based educators (N = 39) at both primary and secondary education levels, to explore their experiences of responding to ADHD in the classroom, as well as the barriers and facilitators to supporting children. They found that educators mostly reflected on general inclusive strategies in the classroom that rarely targeted ADHD symptoms or difficulties specifically, despite the large number of strategies designed to support ADHD that are reported elsewhere in the literature (DuPaul et al., 2012 ; Richardson et al., 2015 ). Further to this, when interviewing teachers about their experiences of teaching pupils with ADHD, Lawrence et al. ( 2017 ) specifically asked about interventions or strategies used in the classroom with children with ADHD. The reported strategies were almost exclusively behaviourally based, for example, allowing children to fidget or move around the classroom, utilising rewards, using redirection techniques, or reducing distraction. This lack of focus on cognitive strategies is surprising, given the breadth of literature focusing on the cognitive difficulties in ADHD (e.g. Coghill, et al., 2014 ; Gathercole et al., 2018 ; Rhodes et al., 2012 ). Furthermore, to our knowledge research examining strategy use from the perspective of children with ADHD themselves, or strengths associated with ADHD, is yet to be conducted.

Knowledge and understanding of ADHD in children with ADHD has attracted less investigation than that of teachers. In a Canadian sample of 8- to 12-year-olds with ADHD (N = 29), Climie and Henley ( 2018 ) found that ADHD knowledge was highly varied between children; scores on the Children ADHD Knowledge and Opinions Scale ranged from 5 to 92% correct (M = 66.53%, SD = 18.96). The authors highlighted some possible knowledge gaps, such as hyperactivity not being a symptom for all people with ADHD, or the potential impact upon social relationships, however the authors did not measure participant’s ADHD symptoms, which could influence how children perceive ADHD. Indeed, Wiener et al ( 2012 ) has shown that children with ADHD may underestimate their symptoms. If this is the case, it would also be beneficial to investigate their understanding of their own strengths and difficulties, as well as of ADHD more broadly. Furthermore, if children do have a poor understanding of ADHD, they may benefit from psychoeducational interventions. Indeed, in their systematic review Dahl et al. ( 2020 ) found two studies in which the impact of psychoeducation upon children’s ADHD knowledge was examined, both of which reported an increase in knowledge as a consequence of the intervention. Understanding the strengths and difficulties of the child, from the perspective of the child and their teacher, will also allow the design of interventions that are individualised, an important feature for school-based programmes (Richardson et al., 2015 ). Given the above, understanding whether children have knowledge of their ADHD and are aware of strategies to support them would be invaluable.

Teacher and child knowledge of ADHD and strategies to support these children is important for positive developmental outcomes, however there is limited research evidence beyond quantitative data. Insights from children and teachers themselves is particularly lacking and the insights which are available do not always extend to understanding strengths which is an important consideration, particularly with regards to implications for pupil self-esteem and motivation. The current study therefore provides a vital examination of the perspectives of both strengths and weaknesses from a heterogeneous group of children with ADHD and their teachers. Our sample reflects the diversity encountered in typical mainstream classrooms in the UK and the matched pupil-teacher perspectives enriches current understandings in the literature. Specifically, we aimed to explore (1) child and teacher knowledge of ADHD, and (2) strategy use within the primary school classroom to support children with ADHD. This novel approach, from the dual perspective of children and teachers, will enable us to identify potential knowledge gaps, areas of strength, and insights on the use of strategies to support their difficulties.

Participants

Ten primary school children (3 female) aged 7 to 11 years (M = 8.7, SD = 1.34) referred to Child and Adolescent Mental Health Services (CAMHS) within the NHS for an ADHD diagnosis were recruited to the study. All participant characteristics are presented in Table 1 . All children were part of the Edinburgh Attainment and Cognition Cohort and had consented to be contacted for future research. Children who were under assessment for ADHD or who had received an ADHD diagnosis were eligible to take part. Contact was established with the parent of 13 potential participants. Two had undergone the ADHD assessment process with an outcome of no ADHD diagnosis and were therefore not eligible to take part, and one could not take part within the timeframe of the study. The study was approved by an NHS Research Ethics Committee and parents provided informed consent prior to their child taking part. Co-occurrences data for all participants was collected as part of a previous study and are reported here for added context. All of the children scored above the cut-off (T-score > 70) for ADHD on the Conners 3 rd Edition Parent diagnostic questionnaire (Conners, 2008 ). The maximum possible score for this measure is 90. At the point of interview, seven children had received a diagnosis of ADHD, two children were still under assessment, and one child had been referred for an ASD diagnosis (Table 1 ). The ADHD subtype of each participant was not recorded, however all children scored above the cut-off for both inattention (M = 87.3, SD = 5.03) and hyperactivity (M = 78.6, SD = 5.8) which is indicative of ADHD combined type. Use of stimulant medication was not recorded at the time of interview.

Following the child interview and receipt of parental consent, each child’s school was contacted to request their teacher’s participation in the study. Three teachers could not take part within the timeframe of the study, and one refused to take part. Six teachers (all female) were successfully contacted and gave informed consent to participate.

Due to the increased likelihood of co-occurring diagnoses in the target population, we also report Autism Spectrum Disorder (ASD) symptoms and Developmental Co-ordination Disorder (DCD) symptoms using the Autism Quotient 10-item questionnaire (AQ-10; Allison et al., 2012 ) and Movement ABC-2 Checklist (M-ABC2; Henderson et al., 2007 ) respectively, both completed by the child’s parent.

Scores of 6 and above on the AQ-10 indicates referral for diagnostic assessment for autism is advisable. All but one of the participants scored below the cut-off on this measure (M = 3.6, SD = 1.84).

The M-ABC2 checklist categorises children as scoring green, amber or red based on their scores. A green rating (up to the 85th percentile) indicates no movement difficulty, amber ratings (between 85 and 95th percentile) indicate risk of movement difficulty, and red ratings (95th percentile and above) indicate high likelihood of movement difficulty. Seven of the participants received a red rating, one an amber rating, and two green ratings.

Socioeconomic status (SES) is also known to impact educational outcomes, therefore the SES of each child was calculated using the Scottish Index of Multiple Deprivation (SIMD), which is an area-based measure of relative deprivation. The child’s home postcode was entered into the tool which provided a score of deprivation on a scale of 1 to 5. A score of 1 is given to the 20% most deprived data zones in Scotland, and a score of 5 indicates the area was within the 20% least deprived areas.

Semi-Structured Interview

The first author, who is a psychologist, conducted interviews with each participant individually, and then a separate interview with their teacher. This was guided by a semi-structured interview schedule (see Appendix A, Appendix B) developed in line with our research questions, existing literature, and using authors (T.S. and J.B.) expertise in educational practice. The questions were adapted to be relevant for the participant group. For example, children were asked “If a friend asked you to tell them what ADHD is, what would you tell them?” and teachers were asked, “What is your understanding of ADHD or can you describe a typical child with ADHD?”. The schedule comprised two key sections for both teachers and children. The first section focused on probing the participant’s understanding and knowledge of ADHD broadly. The second section focused on the participating child’s academic and cognitive strengths and weaknesses, and the strategies used to support them. Interviews with children took place in the child’s home and lasted between 19 and 51 min (M = 26.3, SD = 10.9). Interviews with teachers took place at their school and were between 28 and 50 min long (M = 36.5, SD = 7.61). Variation in interview length was mostly due to availability of the participant and/or age of the child (i.e. interviews with younger children tended to be shorter). All interviews were recorded on an encrypted voice recorder and transcribed by the first author prior to data analysis. Pseudonyms were randomly generated for each child to protect anonymity.

Reflexive thematic analysis was used to analyse the data (Braun & Clarke, 2019 ). This flexible approach allows the data to drive the analysis, putting the participant at the centre of the research and placing high value on the experiences and perspectives of individual participants (Braun & Clarke, 2006 ). The six phases of reflexive thematic analysis as outlined by Braun and Clarke were followed: (1) familiarisation, (2) generating codes, (3) constructing themes, (4) revising themes, (5) defining themes, (6) producing the report. Due to the exploratory nature of this study, bottom-up inductive coding was used. Two of the authors (E.M. and C.T.) worked collaboratively to construct and subsequently define the themes using the process described above. More specifically, one author (E.M.) generated codes, with support from another author (C.T.). Collated codes and data were then abstracted into potential themes, which were reviewed and refined using relevant literature, as well as within the wider context of the data. This process continued until all themes were agreed upon.

In the first part of the analysis, focus was placed on summarising the participants’ understanding of ADHD, as well as what they thought their biggest strengths and challenges were at school. Following this, an in-depth analysis of the strategies used in the classroom was conducted, taking into account the perspective of both teachers and children, aiming to generate themes from the data.

Knowledge of ADHD

Children and teachers were asked about their knowledge of ADHD. When asked if they had ever heard of ADHD, the majority of children said yes. Some of the children could not explain to the interviewer what ADHD was or responded in a way that suggested a lack of understanding ( “it helps you with skills” – Niall, 7 years; “ Well it’s when you can’t handle yourself and you’re always crazy and you can just like do things very fast”— Nathan, 8 years). Very few of the children were able to elaborate accurately on their understanding of ADHD, which exclusively focused on inattention. For example, Paige (8 years) said “ its’ kinda like this thing that makes it hard to concentrate ” and Finn (10 years) said “ they get distracted more just in different ways that other people would ”. This suggests that children with ADHD may lack or have a limited awareness or understanding of their diagnosis.

When asked about their knowledge of ADHD, teachers tended to focus on the core symptoms of ADHD. All teachers directly mentioned difficulties with attention, focus or concentration, and most directly or indirectly referred to hyperactivity (e.g. moving around, being in “ overdrive ”). Most teachers also referred to social difficulties as a feature of ADHD, including not following social rules, reacting inappropriately to other children and appearing to lack empathy, which they suggested could be linked to impulsivity. For example, “ reacting in social situations where perhaps other children might not react in a similar way” (Paige’s teacher) and “ They can react really really quickly to things and sometimes aggressively” (Eric’s teacher). Although no teachers directly mentioned cognitive difficulties, some referred to behaviours indicative of cognitive difficulties, for example, “ they can’t store a lot of information at one time” (Eric’s teacher) and, “ it’s not just the concentration it’s the amount they can take in at a time as well” (Nathan’s teacher), which may reflect processing or memory differences. Heterogeneity was mentioned, in that ADHD can mean different things for different children (e.g., “ I think ADHD differs from child to child and I think that’s really important” —Nathan’s teacher). Finally, academic difficulties as a feature of ADHD were also mentioned (e.g., “ a child… who finds some aspects of school life, some aspects of the curriculum challenging ”—Jay’s teacher).

After being asked to give a general description of ADHD, each child was asked about their own strengths at school and teachers were also asked to reflect on this topic for the child taking part.

When asked what they like most about school, children often mentioned art or P.E. as their preferred subjects. A small number of children said they enjoyed maths or reading, but this was not common and the majority described these subjects as a challenge or something they disliked. There was also clear link between the aspects of school children enjoyed, and what they perceived to be a strength for them. For example, when asked what he liked about school, Eric (10 years) said, “ Math, I’m pretty good at that”, or when later asked what they were good at, most children responded with the same answers they gave when asked what they liked about school. It is interesting to note that subjects such as art or P.E. generally have a different format to more traditionally academic subjects such as maths or literacy. Indeed, Felicity (11 years) said, “ I quite like art and drama because there’s not much reading…and not really too much writing in any of those” . Children also tended to mention the non-academic aspects of school, such as seeing their friends, or lunch and break times.

Teachers’ descriptions of the children’s strengths were much more variable compared to strengths mentioned by children. Like the children, teachers tended to consider P.E and artistic activities to be a strength for the child with ADHD. Multiple teachers referred to the child having a good imagination and creative skills. For example, “ she’s a very imaginative little girl, she has a great ability to tell stories and certainly with support write imaginative stories” (Paige’s teacher) . Teachers referred to other qualities or characteristics of the child as strengths, although these varied across teachers. These included openness, both socially but also in the context of willingness to learn or being open to new challenges, being a hard worker, or an enjoyable person to be around (e.g., “ he is the loveliest little boy, I’ve got a lot of time for [Nathan]. He makes me smile every day, you know, he just comes out with stuff he’s hilarious”— Nathan’s teacher). The most noticeable theme that emerged from this data was that when some teachers began describing one of the child’s strengths, it was suffixed with a negative. For example, Henry’s teacher said, “ He’s got a very good imagination, his writing- well not so much the writing of the stories, he finds writing quite a challenge, but his verbalising of ideas he’s very imaginative”. This may reflect that while these children have their own strengths, these can be limited by difficulties. Indeed, Paige’s teacher said, “ I think she’s a very able little girl without a doubt, but there is a definite barrier to her learning in terms of her organisation, in terms of her focus” , which reinforces this notion.

Children were asked directly about what they disliked about school, and what they found difficult. Children tended to focus more on specific subjects, with maths and aspects of literacy being the most frequently mentioned of these. Children referred to difficulties with or a dislike for reading, writing and/or spelling activities, for example, Rory (9 years) said “ Well I suppose spelling because … sometimes we have to do some boring tasks like we have to write it out three times then come up with the sentence for each one which takes forever and it’s hard for me to think of the sentences if I’m not ready” . Linking this with known cognitive difficulties in ADHD, it is interesting to note that both memory and planning are implicated in this quote from Rory about finding spelling challenging. In terms of writing, children referred to both the physical act of writing (e.g., “ probably writing cause sometimes I forget my finger spaces ”—Paige, 8 years; “ [writing the alphabet is] too hard… like the letters joined together … [and] I make mistakes” —Jay, 7 years) as well as the planning associated with writing a longer piece of work (e.g. “ when I run out of ideas for it, it’s really hard to think of some more so I don’t usually get that much writing done ”—Rory (9 years) .

Aside from academic subjects, several children referred to difficulties with focus or attention (e.g. “ when I find it hard to do something I normally kind of just zone out ”—Felicity, 11 years, “ probably concentrating sometimes ”—Rory, 9 years), but boredom was also a common and potentially related theme (e.g. “ Reading is a bit hard though … it just sometimes gets a bit boring” —Finn, 10 years, “ I absolutely hate maths … ‘cause it’s boring ”—Paige, 8 years). It could be that children with ADHD find it more difficult to concentrate during activities they find boring. Indeed, when Jay (7 years) was asked how it made him feel when he found something boring, he said “ it made me not do my work ”. Some children also alluded to the social difficulties faced at school, which included bullying and difficulties making friends (e.g. “ just making all kind of friends [is difficult] ‘cause the only friend that I’ve got is [name redacted] ”—Nathan, 8 years; “ sometimes finding a friend to play with at break time [is difficult] ” – Paige, 8 years; “ there’s a lot of people in my school that they bully me” —Eric, 10 years).

When asked what they thought were the child’s biggest challenges at school, teachers' responses were relatively variable, although some common themes were identified. As was the case for children, teachers reflected on difficulties with attention, which also included being able to sit at the table for long periods of time (e.g. “ I would say he struggles the most with sitting at his table and focusing on one piece of work ”—Henry’s teacher). Teachers did also mention difficulties with subjects such as maths and literacy, although this varied from child to child, and often they discussed these in the context of their ADHD symptom-related difficulties. For example, Eric’s teacher said, “ we’ve struggled to get a long piece of writing out of him because he just can’t really sit for very long ”. This quote also alludes to difficulties with evaluating the child’s academic abilities, due to their ADHD-related difficulties, which was supported by other teachers (e.g. “ He doesn’t particularly enjoy writing and he’s slow, very slow. And I don’t know if that’s down to attention or if that’s something he actually does find difficult to do ” —Henry’s teacher). Furthermore, some teachers reflected on the child’s confidence as opposed to a direct academic difficulty. For example, Luna’s teacher said, “ I think it’s she lacks the confidence in maths and reading like the most ” and later, elaborated with “ she’ll be like “I can’t do it” but she actually can. Sometimes she’s … even just anxious at doing a task where she thinks … she might not get it. But she does, she’s just not got that confidence”.

Teachers also commonly mentioned social difficulties, and referred to these difficulties as a barrier to collaborative learning activities (e.g. “ he doesn’t always work well with other people and other people can get frustrated” —Henry’s teacher; “ [during] collaborative group work [Paige] perhaps goes off task and does things she shouldn’t necessarily be doing and that can cause friction within the group” —Paige’s teacher). Teachers also mentioned emotion regulation, mostly in relation to the child’s social difficulties. For example, Eric’s teacher said “ I think as well he does still struggle with his emotions like getting angry very very quickly, and being very defensive when actually he’s taken the situation the wrong way” , which suggests that the child’s difficulty with regulating emotions may impact on their social relationships.

Strategy Use in the Classroom

Strategies to support learning fell into one of four categories: concrete or visual resources, information processing, seating and movement, and support from or influence of others. Examples of codes included in each of these strategy categories are presented in Table 2 .

Concrete or visual resources were the most commonly mentioned type of strategy by teachers and children, referring to the importance of having physical representations to support learning. Teachers spoke about the benefit of using visual aids (e.g. “ I think [Henry] is quite visual so making sure that there is visual prompts and clues and things like that to help him ”—Henry’s teacher), and teachers and children alluded to these resources supporting difficulties with holding information in mind. For example, when talking about the times table squares he uses, Rory said “ sometimes I forget which one I’m on…and it’s easier for me to have my finger next to it than just doing it in my head because sometimes I would need to start doing it all over again ”.

Seating and movement were also commonly mentioned, which seemed to be specific to children with ADHD in that it was linked to inattention and hyperactivity symptoms. For example, teachers referred to supporting attention or avoiding distraction by the positioning of a child’s location in the classroom (e.g. “ he’s so easily distracted, so he has an individual desk in the room and he’s away from everyone else because he wasn’t coping at a table [and] he’s been so much more settled since we got him an individual desk” —Eric’s teacher). Some teachers also mentioned the importance of allowing children to move around the room where feasible, as well as giving them errands to perform as a movement break (e.g. “ if I need something from the printer, [Nathan] is gonna go for it for me…because that’s down the stairs and then back up the stairs so if I think he’s getting a bit chatty or he’s not focused I’ll ask him to go and just give him that break as well” —Nathan’s teacher). Children also spoke about these strategies but didn’t necessarily describe why or how these strategies help them.

Information processing and cognitive strategies included methods that supported children to process learning content or instructions. For example, teachers frequently mentioned breaking down tasks or instructions into more manageable chunks (e.g. “ with my instructions to [Eric] I break them down … I’ll be like “we’re doing this and then we’re doing this” whereas the whole class wouldn’t need that ”—Eric’s teacher). Teachers and children also mentioned using memory strategies such as songs, rhymes or prompts. For example, Jay’s teacher said, “ if I was one of the other children I could see why it would be very distracting but he’s like he’s singing to himself little times table songs that we’ve been learning in class” , and Paige (8 years) referred to using mnemonics to help with words she struggles to spell, “ I keep forgetting [the word] because. But luckily we got the story big elephants can always understand little elephants [which helps because] the first letter of every word spells because” .

Both groups of participants mentioned support from and influence of others, and referred to working with peers, the teacher–child relationship, and one-to-one teaching. Peer support was a common theme across the data and is discussed in more detail in the thematic analysis findings, where teachers and children referred to the importance of the role of peers during learning activities. Understanding the child well and adapting to them was also seen as important, for example, Luna’s teacher said, “ with everything curricular [I] try and have an art element for her, just so I know it’ll engage her [because] if it’s like a boring old written worksheet she’s not gonna do it unless you’re sitting beside her and you’re basically telling her the answers” . As indicated in this quote, teachers also referred to the effectiveness of one-to-one or small group work with the child (e.g. “ when somebody sits beside her and explains it, and goes “come on [Paige] you know how to do this, let’s just work through a couple of examples”… her focus is generally better ” – Paige’s teacher), however this resource is not always available (e.g. “ I’d love for someone to be one-to-one with [Luna] but it’s just not available, she doesn’t meet that criteria apparently ” – Luna’s teacher). Children also referred to seeking direct support from their teacher (e.g. “if I can’t get an idea of what I’m doing then I ask the teacher for help” – Paige, 8 years), but were more likely to mention seeking support from their peers than the teacher.

Thematic Analysis

In addition to summarising the types of strategies that teachers and children reported using in the classroom, the data were also analysed using thematic analysis to generate themes. These are now presented. The theme names, definitions, and example quotes for each theme are presented in Table 3 .

Theme 1: Classroom-General Versus Individual-Specific Strategies

During the interviews, teachers spoke about strategies that they use as part of their teaching practice for the whole class but that are particularly helpful for the child/children with ADHD. These tended to be concrete or visual resources that are available in the classroom for anyone, for example, a visual timetable or routine checklist (e.g. “ there’s also a morning routine and listing down what’s to be done and where it’s to go … it’s very general for the class but again it’s located near her” —Paige’s teacher).

Teachers also mentioned using strategies that have been implemented specifically for that child, and these strategies tended to focus on supporting attention. For example, Nathan’s teacher spoke about the importance of using his name to attract his attention, “ maybe explaining to the class but then making sure that I’m saying “[Nathan], you’re doing this”, you know using his name quite a lot so that he knows it’s his task not just the everybody task ”, and this was a strategy that multiple teachers referred to using with the individual child and not necessarily for other children. Other strategies to support attention with a specific child also tended to be seating and movement related, such as having an individual desk or allowing them to fidget. For example, Luna’s teacher said, “ she’s a fidgeter so she’ll have stuff to fidget with … [and] even if she’s wandering around the classroom or she’s sitting on a table, I don’t let other kids do that, but as long as she’s listening, it’s fine [with me]” .

Similar to teachers, children spoke about strategies or resources that were in place for them specifically as well as about general things in the classroom that they find helpful. That said, it was less common for children to talk about why particular strategies were in place for them and how they helped them directly.

In addition to recognising strategies that teachers had put in place for them, children also referred to using their own strategies in the classroom. The most frequently mentioned strategy was fidgeting, and although some of the younger children spoke about having resources available in the classroom for fidgeting, some of the older children referred to using their own toy or an object that was readily available to them but not intended for fidgeting. For example, Finn (10 years) and Rory (9 years) both spoke about using items from their pencil case to fiddle with, and explained that this would help them to focus. (“ Sometimes I fidget with something I normally just have like a pencil holder under the table moving about … [and] it just keeps my mind clear and not from something else ”—Rory; “ Sometimes I fiddle with my fingers and that sometimes helps, but if not I get one of my coloured pencils and have a little gnaw on it because that actually takes my mind off some things and it’s easier for me to concentrate when I have something to do ”—Finn). Henry (9 years) spoke about being secretive with his fidgeting as it was not permitted in class, “ if you just bring [a fidget toy] in without permission [the teacher will] just take it off of you, so it has to be something that’s not too big. I bring in a little Lego ray which is just small enough that she won’t notice ”. Although some teachers did mention having fidget toys available, not all teachers seemed to recognise the importance of this for the child, and some children viewed fidgeting as a behaviour they should hide from the teacher.

Another strategy mentioned uniquely by children was seeing their peers as a resource for ideas or information. This is discussed in more detail in Theme 3—The role of peers , but reinforces the notion that children also develop their own strategies, independently from their teacher, rather than relying only on what is made available to them.

Theme 2: Heterogeneity of Strategies

Teachers spoke about the need for a variety of strategies in the classroom, for two reasons: (1) that different strategies work for different children (e.g. “ some [strategies] will work for the majority of the children and some just don’t seem to work for any of them ”—Jay’s teacher), and (2) what works for a child on one occasion may not work consistently for the same child (e.g. “ I think it’s a bit of a journey with him, and some things have worked and then stopped working, so I think we’re constantly adapting and changing what we’re doing ”—Eric’s teacher). One example of both of these challenges of strategy use came from Luna’s teacher, who spoke about using a reward chart with Luna and another child with ADHD, “ [Luna] and another boy in my class [with ADHD] both had [a reward chart]… but I think whereas the boy loved his and still loves his, she was getting a bit “oh I’m too cool for this” or that sort of age… so I stopped doing that for her and she’s not missing that at all” . These quotes demonstrate that strategies can work differently for different children, highlighting the need for a variety of strategies for teachers to access and trial with children.

Some children also referred to the variability of whether a strategy was helpful or not; for example, Henry (9 years) said that he finds it helpful to fidget with a toy but that sometimes it can distract him and prevent him from listening to the teacher. He said, “ Well, [the fidget toy] helps but it also gets me into trouble when the teacher spots me building it when I’m listening…but then sometimes I might not listen in maths and [use the fidget toy] which might make it worse”. This highlights that both children and teachers might benefit from support in understanding the contexts in which to use particular strategies, as well as why they are helpful from a psychological perspective.

For teachers, building a relationship with and understanding the child was also highly important in identifying strategies that would work. Luna’s teacher reflected upon the difference in Luna’s behaviour at the start of the academic year, compared to the second academic term, “ at the start of the year, we would just clash the whole time. I didn’t know her, she didn’t know me … and then when we got that bond she was absolutely fine so her behaviour has got way better ”. Eric’s teacher also reflected on how her relationship with Eric had changed, particularly after he received his diagnosis of ADHD, “ I think my approach to him has completely changed. I don’t raise my voice, I speak very calmly, I give him time to calm down before I even broach things with him. I think our relationship’s just got so much better ‘cause I kind of understand … where he’s coming from ”. She also said, “ it just takes a long time to get to know the child and get to know what works for them and trialling different things out ”, which demonstrates that building a relationship with and understanding the child can help to identify the successful strategies that work with different children.

Theme 3: The Role of Peers

Teachers and children spoke about the role of the child’s peers in their learning. Teachers talked about the benefit of partnering the child with good role models (e.g. “ I will put him with a couple of good role models and a couple of children who are patient and who will actually maybe get on with the task, and if [Jay] is not on task or not on board with what they’re doing at least he’s hearing and seeing good behaviour ”—Jay’s teacher), whereas children spoke more about their peers as a source of information, idea generation, or guidance on what to do next. For example, when asked what he does to help him with his writing, Henry (9 years) said, “ [I] listen to what my partner’s saying… my half of the table discuss what they’re going to do so I can literally hear everything they’re doing and steal some of their ideas ”. Henry wasn’t the only child to use their peers as a source of information, for example, Niall (7 years) said, “ I prefer working with the children because some things I might not know and the children might help me give ideas ”, and with a more specific example, Rory (9 years) said, “ somebody chose a very good character for their bit of writing, and I was like “I think I might choose that character”, and somebody else said “my setting was going to be the sea”, and I chose that and put that in a tiny bit of my story ”.

Some children also spoke about getting help from their peers in other ways, particularly when completing a difficult task. Paige (8 years) said, “ if the question isn’t clear I try and figure it out, and if I can’t figure it out then… don’t tell my teacher this but I sometimes get help from my classmates ”, which suggests some guilt associated with asking for help from her peers. This could be related to confidence and self-esteem, which teachers mentioned as a difficulty for some children with ADHD. In some instances, children felt it necessary to directly copy their peers’ work; for example, Nathan (8 years) spoke about needing a physical resource (i.e. “ fuzzies ”) to complete maths problems, but that when none were available he would “ just end up copying other people ”. This could also be related to a lack of confidence, as he may feel as though he may not be able to complete the task on his own. Indeed, Nathan’s teacher mentioned that when he is given the option to choose a task from different difficulty levels, Nathan would typically choose something easier, and that it was important to encourage him to choose something more difficult to build his confidence, “ I quite often say to him “come on I think you can challenge yourself” and [will] use that language”.

Peers clearly play an important role for the children with ADHD, and this is recognised both by the children themselves, and by their teachers. Teachers also mentioned that children with ADHD respond well to one-to-one learning with staff, indicating that it is important for these children to have opportunities to learn in different contexts: whole classroom learning, small group work and one-to-one.

In this study, a number of important topics surrounding ADHD in the primary school setting were explored, including ADHD knowledge, strengths and challenges, and strategy use in the classroom, each of which will now be discussed in turn before drawing together the findings and outlining the implications.

ADHD Knowledge

Knowledge of ADHD varied between children and their teachers. Whilst most of the children claimed to have heard of ADHD, very few could accurately describe the core symptoms. Previous research into this area is limited, however this finding supports Climie and Henley’s ( 2018 ) finding that children’s knowledge of ADHD can be limited. By comparison, all of the interviewed teachers had good knowledge about the core ADHD phenotype (i.e. in relation to diagnostic criteria) and some elaborated further by mentioning social difficulties or description of behaviours that could reflect cognitive difficulties. This supports and builds further upon existing research into teachers’ ADHD knowledge, demonstrating that although teachers understanding may be grounded in a focus upon inattention and hyperactivity, this is not necessarily representative of the range of their knowledge. By interviewing participants about their ADHD knowledge, as opposed to asking them to complete a questionnaire as previous studies have done (Climie & Henley, 2018 ; Latouche & Gascoigne, 2019 ; Ohan et al., 2008 ; Perold et al., 2010 ), the present study has demonstrated the specific areas of knowledge that should be targeted when designing psychoeducation interventions for children and teachers, such as broader aspects of cognitive difficulties in executive functions and memory. Improving knowledge of ADHD in this way could lead to increased positive attitudes and reduction of stigma towards individuals with ADHD (Mueller et al., 2012 ; Ohan et al., 2008 ), and in turn improving adherence to more specified interventions (Bai et al., 2015 ).

Strengths and Challenges

A range of strengths and challenges were discussed, some of which were mentioned by both children and teachers, whilst others were unique to a particular group. The main consensus in the current study was that art and P.E. tended to be the lessons in which children with ADHD thrive the most. Teachers elaborated on this notion, speaking about creative skills, such as a good imagination, and that these skills were sometimes applied in other subjects such as creative writing in literacy. Little to no research has so far focused on the strengths of children with ADHD, therefore these findings identify important areas for future investigation. For example, it is possible that these strengths could be harnessed in educational practice or intervention.

Although a strength for some, literacy was commonly mentioned as a challenge by both groups, specifically in relation to planning, spelling or the physical act of writing. Previous research has repeatedly demonstrated that literacy outcomes are poorer for children with ADHD compared to their typically developing peers (DuPaul et al., 2016; Mayes et al., 2020 ), however in these studies literacy tended to be measured using a composite achievement score, where the nuance of these difficulties can be lost. Furthermore, in line with a recent systematic review and meta-analysis (McDougal et al., 2022 ) the present study’s findings suggest that cognitive difficulties may contribute to poor literacy performance in ADHD. This issue was not unique to literacy, however, as teachers also spoke about academic challenges in the context of ADHD symptoms being a barrier to learning, such as finding it difficult to remain seated long enough to complete a piece of work. Children also raised this issue of engagement, who referred to the most challenging subjects being ‘boring’ for them. This link between attention difficulties and boredom in ADHD has been well documented (Golubchik et al., 2020 ). The findings here demonstrate the need for further research into the underlying cognitive difficulties leading to academic underachievement.

Both children and teachers also mentioned social and emotional difficulties. Research has shown that many different factors may contribute to social difficulties in ADHD (for a review see Gardner & Gerdes, 2015 ), making it a complex issue to disentangle. That said, in the current study teachers tended to attribute the children’s relationship difficulties to behaviour, such as reacting impulsively in social situations, or going off task during group work, both of which could be linked to ADHD symptoms. Despite these difficulties, peers were also considered a positive support. This finding adds to the complexity of understanding social difficulties for children with ADHD, demonstrating the necessity and value of further research into this key area.

The three key themes of classroom-general versus individual-specific strategies , heterogeneity of strategies and the role of peers were identified from the interview transcripts with children and their teachers. Within the first theme, classroom-general versus individual-specific strategies, it was clear that teachers utilise strategies that are specific to the child with ADHD, as well as strategies that are general to the classroom but that are also beneficial to the child with ADHD. Previously, Moore et al. ( 2017 ) found that teachers mostly reflected on using general inclusive strategies, rather than those targeted for ADHD specifically, however the methods differ from the current study in two key ways. Firstly, Moore et al.’s sample included secondary and primary school teachers, for whom the learning environment is very different. Secondly, focus groups were used as opposed to interviews where the voices of some participants can be lost. The merit of the current study is that children were also interviewed using the same questions as teachers; we found that children also referred to these differing types of strategies, and reported finding them useful, suggesting that the reports of teachers were accurate. Interestingly, children also mentioned their own strategies that teachers did not discuss and may not have been aware of. This finding highlights the importance of communication between the child and the teacher, particularly when the child is using a strategy considered to be forbidden or discouraged, for example copying a peer’s work or fidgeting with a toy. This communication would provide an understanding of what the child might find helpful, but more importantly identify areas of difficulty that may need more attention. Further to this, most strategies specific to the child mentioned by teachers aimed to support attention, and few strategies targeted other difficulties, particularly other aspects of cognition such as memory or executive function, which supports previous findings (Lawrence et al., 2017 ). The use of a wide range of individualised strategies would be beneficial to support children with ADHD.

Similarly, the second theme, heterogeneity of strategies , highlighted that some strategies work with some children and not others, and some strategies may not work for the same child consistently. Given the benefit of a wide range of strategy use, for both children with ADHD and their teachers, the development of an accessible tool-kit of strategies would be useful. Importantly, and as recognised in this second theme, knowing the individual child is key to identifying appropriate strategies, highlighting the essential role of the child’s teacher in supporting ADHD. Teachers mostly spoke about this in relation to the child’s interests and building rapport, however this could also be applied to the child’s cognitive profile. A tool-kit of available strategies and knowledge of which difficulties they support, as well as how to identify these difficulties, would facilitate teachers to continue their invaluable support for children and young people with ADHD. This links to the importance of psychoeducation; as previously discussed, the teachers in our study had a good knowledge of the core ADHD phenotype, but few spoke about the cognitive strengths and difficulties of ADHD. Children and their teachers could benefit from psychoeducation, that is, understanding ADHD in more depth (i.e., broader cognitive and behavioural profiles beyond diagnostic criteria), what ADHD and any co-occurrences might mean for the individual child, and why certain strategies are helpful. Improving knowledge using psychoeducation is known to improve fidelity to interventions (Dahl et al., 2020 ; Nussey et al., 2013 ), suggesting that this would facilitate children and their teachers to identify effective strategies and maintain these in the long-term.

The third theme, the role of peers , called attention to the importance of classmates for children with ADHD, and this was recognised by both children and their teachers. As peers play a role in the learning experience for children with ADHD, it is important to ensure that children have opportunities to learn in small group contexts with their peers. This finding is supported by Vygotsky’s ( 1978 ) Zone of Proximal Development; it is well established in the literature that children can benefit from completing learning activities with a partner, especially a more able peer (Vygotsky, 1978 ).

Relevance of Co-Occurrences

Co-occurring conditions are common in ADHD (Jensen & Steinhausen, 2015 ), and there are many instances within the data presented here that may reflect these co-occurrences, in particular, the overlap with DCD and ASD. For ADHD and DCD, the overlap is considered to be approximately 50% (Goulardins et al., 2015 ), whilst ADHD and autism also frequently co-occur with rates ranging from 40 to 70% (Antshel & Russo, 2019 ). It was not an aim of the current study to directly examine co-occurrences, however it is important to recognise their relevance when interpreting the findings. Indeed, in the current sample, scores for seven children (70%) indicated a high likelihood of movement difficulty. One child scored above the cut-off for autism diagnosis referral on the AQ-10, indicating heightened autism symptoms. Further to this, some of the discussions with children and teachers seemed to be related to DCD or autism, for example, the way that they can react in social situations, or difficulties with the physical act of handwriting. This finding feeds into the ongoing narrative surrounding heterogeneity within ADHD and individualisation of strategies to support learning. Recognising the potential role of co-occurrences should therefore be a vital part of any psychoeducation programme for children with ADHD and their teachers.

Limitations

Whilst a strong sample size was achieved for the current study allowing for rich data to be generated, it is important to acknowledge the issue of representativeness. The heterogeneity of ADHD is recognised throughout the current study, however the current study represents only a small cohort of children and young people with ADHD and their teachers which should be considered when interpreting the findings, particularly in relation to generalisation. Future research should investigate the issues raised using quantitative methods. Also on this point of heterogeneity, although we report some co-occurring symptoms for participants, the number of co-occurrences considered here were limited to autism and DCD. Learning disabilities and other disorders may play a role, however due to the qualitative nature of this study it was not feasible to collect data on every potential co-occurrence. Future quantitative work should aim to understand the complex interplay of diagnosed and undiagnosed co-occurrences.

Furthermore, only some of the teachers of participating children took part in the study; we were not able to recruit all 10. It may be, for example, that the six teachers who did take part were motivated to do so based on their existing knowledge or commitment to understanding ADHD, and the fact that not all child-teacher dyads are represented in the current study should be recognised. Another possibility is the impact of time pressures upon participation for teachers, particularly given the increasing number of children with complex needs within classes. Outcomes leading from the current study could support teachers in this respect.

It is also important to recognise the potential role of stimulant medication. Although it was not an aim of the current study to investigate knowledge or the role of stimulant medication in the classroom setting, it would have been beneficial to record whether the interviewed children were taking medication for their ADHD at school, particularly given the evidence to suggest that stimulant medication can improve cognitive and behavioural symptoms of ADHD (Rhodes et al., 2004 ). Examining strategy use in isolation (i.e. with children who are drug naïve or pausing medication) will be a vital aim of future intervention work.

Implications/Future Research

Taking the findings of the whole study together, one clear implication is that children and their teachers could benefit from psychoeducation, that is, understanding ADHD in more depth (i.e., broader cognitive and behavioural profiles beyond diagnostic criteria), what ADHD might mean for the individual child, and why certain strategies are helpful. Improving knowledge using psychoeducation is known to improve fidelity to interventions (Dahl et al., 2020 ; Nussey et al., 2013 ), suggesting that this would facilitate children and their teachers to identify effective strategies and maintain these in the long-term.

To improve knowledge and understanding of both strengths and difficulties in ADHD, future research should aim to develop interventions grounded in psychoeducation, in order to support children and their teachers to better understand why and in what contexts certain strategies are helpful in relation to ADHD. Furthermore, future research should focus on the development of a tool-kit of strategies to account for the heterogeneity in ADHD populations; we know from the current study’s findings that it is not appropriate to offer a one-size-fits-all approach to supporting children with ADHD given that not all strategies work all of the time, nor do they always work consistently. In terms of implications for educational practice, it is clear that understanding the individual child in the context of their ADHD and any co-occurrences is important for any teacher working with them. This will facilitate teachers to identify and apply appropriate strategies to support learning which may well result in different strategies depending on the scenario, and different strategies for different children. Furthermore, by understanding that ADHD is just one aspect of the child, strategies can be used flexibly rather than assigning strategies based on a child’s diagnosis.

This study has provided invaluable novel insight into understanding and supporting children with ADHD in the classroom. Importantly, these insights have come directly from children with ADHD and their teachers, demonstrating the importance of conducting qualitative research with these groups. The findings provide clear scope for future research, as well as guidelines for successful intervention design and educational practice, at the heart of which we must acknowledge and embrace the heterogeneity and associated strengths and challenges within ADHD.

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The funding was provided by Waterloo Foundation Grant Nos. (707-3732, 707-4340, 707-4614).

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Emily McDougal, Claire Tai & Sinéad M. Rhodes

Moray House School of Education and Sport, University of Edinburgh, Edinburgh, United Kingdom

Tracy M. Stewart & Josephine N. Booth

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E.M. Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Writing - original draft, C.T. Formal Analysis, Writing - review & editing, T.M.S., J.N.B. and S.M.R. Conceptualization, Methodology, Writing - review & editing.

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Interview Schedule—Teacher

Demographic/experience.

How many years have you been teaching?

Are you currently teaching pupils with ADHD and around how many?

If yes, do you feel competent/comfortable/equipped teaching pupils with ADHD?

If no, how competent/comfortable/equipped would you feel to teach pupils with ADHD?

Would you say your experience of teaching pupils with ADHD is small/moderate/significant?

Psychoeducation

What is your understanding of ADHD/Can you describe a typical child with ADHD?

Probe behaviour knowledge

Probe cognition knowledge

Probe impacts of behaviour/cognition difficulties

Probe knowledge that children with ADHD differ from each other

Probe knowledge that children with ADHD have co-occurring difficulties as the norm

(If they do have some knowledge) Where did you learn about ADHD?

e.g. specific training, professional experience, personal experience, personal interest/research

Cognitive skills and strategies

Can you tell me about the pupil’s strengths?

Can you tell me about the pupil’s biggest challenges/what they need most support with?

When you are supporting the pupil with their learning, are there any specific things you do to help them? (i.e. strategies)

Probe internal

Probe external

Probe whether they think those not mentioned might be useful/feasible/challenges

Probe if different for different subjects/times of the day

In your experience, which of these you have mentioned are the most useful for the pupil?

Probe for examples of how they apply it to their learning

Probe whether these strategies are pupil specific or broadly relevant

Probe if specific to particular subjects/times of the day

In your experience, which of these you have mentioned are the least useful for the pupil?

What would you like to be able to support the pupil with that you don’t already do?

Probe why they can’t access this currently e.g. lack of training, resources, knowledge, time

Is there anything you would like to understand better about ADHD?

Probe behaviour

Probe cognition

Interview Schedule—Child

Script: We’re going to have a chat about a few different things today, mostly about your time at school. This will include things like how you get on, how you think, things you’re good at and things you find more difficult. I’ve got some questions here to ask you but try to imagine that I’m just a friend that you’re talking to about these things. There are no right or wrong answers, I’m just interested in what you’ve got to say. Do you have any questions?

Script: First we’re going to talk about ADHD (Attention Deficit Hyperactivity Disorder).

Have you ever heard of/has anyone ever told you what ADHD is?

(If yes) If a friend asked you to tell them what ADHD is, what would you tell them?

Is there anything you would like to know more about ADHD?

Cognition/strategy use

Script: Now we’re going to talk about something a bit different. Everyone has things they are good at, and things they find more difficult. For example, I’m quite good at listening to what people have to say, but I’m not so good at remembering people’s names. I’d like you to think about when you’re in school, and things you’re good at and things you are not so good at. It doesn’t just have to be lessons, it can be anything.

Do you like school?

Probe why/why not?

Probe favourite lessons

What sort of things do you find you do well at in school?

Is there anything you think that you find more difficult in school?

Probe: If I asked your teacher/parent what you find difficult, what would they say?

Probe: Is there anything at school you need extra help with?

Probe: Is there anything you do to help yourself with that?

Script: Some people do things to try to help themselves do things well. For example, when someone tells me a number to remember, I repeat it in my head over and over again.

Can you try to describe to me what you do to help you do these things?

Solving a maths problem

Planning your writing

Doing spellings

Trying to remember something

Concentrating/ignoring distractions

Listening to the teacher

Remaining seated in class when doing work

Working with other children in the class

Probe: Do you use anything in lessons to help you with your work?

Probe: What kind of things do you think could help you with your work?

Probe: Is there anything you do at home, such as when you’re doing your homework, to help you finish what you are doing to do it well?

Probe: Does someone help you with your homework at home? If yes, what do they do that helps? If no, what do you think someone could do to help?

Script: In this last part we’re going to talk about your time at school.

How many teachers are in your class?

Is there anyone who helps you with your work?

Do you work mostly on your own or in groups?

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McDougal, E., Tai, C., Stewart, T.M. et al. Understanding and Supporting Attention Deficit Hyperactivity Disorder (ADHD) in the Primary School Classroom: Perspectives of Children with ADHD and their Teachers. J Autism Dev Disord 53 , 3406–3421 (2023). https://doi.org/10.1007/s10803-022-05639-3

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DOI : https://doi.org/10.1007/s10803-022-05639-3

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TOP TEN RESEARCH PRIORITIES FOR ATTENTION DEFICIT/HYPERACTIVITY DISORDER TREATMENT

Affiliations.

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

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

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

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

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

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

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ADHD Research Roundup: New Studies, Findings & Insights

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

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

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

General ADHD Research

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

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

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

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

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

ADHD and Children

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

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

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

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

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

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

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

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

ADHD and Adolescents

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

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

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

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

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

ADHD and Adults

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

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

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

ADHD, Race, and Culture

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

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

Treating ADHD

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

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

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

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

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

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

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

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

ADHD and Comorbid Conditions

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

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

ADHD Research: Next Steps

• Read: New Insights Into Rejection Sensitive Dysphoria
• Download: The All-Time Best Books on ADHD
• Learn: What Is ADHD? Definition, Myths & Truths

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The impact of attention deficit hyperactivity disorder (ADHD) in adulthood: a qualitative study

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73 ADHD Research Topics & Essay Examples

📝 adhd research papers examples, 🏆 best adhd essay titles, 🎓 simple research topics about adhd, ❓ adhd research questions.

• Attention-Deficit Hyperactivity Disorder: Treatment and Financing The paper describes Attention-Deficit Hyperactivity Disorder, controversy about the existence of ADHD, and presents additional evidence on the existence of ADHD.
• Attention Deficit Hyperactivity Disorder in Teenager The patient is a 15-year-old Hispanic male diagnosed with Attention Deficit Hyperactivity Disorder. He reports increased hyperactivity, problems with concentration, and anxiety.
• Children and ADHD: Control Within the Constraints of Diagnosis
• ADHD: Latest Research and Recommended Treatment
• Current and Retrospective Childhood Ratings of Emotional Fluctuations in Adults With ADHD
• Children With ADHD Continue to Pose a Considerable Challenge to Their Families and the Society
• Facts About ADHD and Ritalin as Its Most Common Treatment
• ADD & ADHD, Mental Retardation, Learning Disabilities
• Efficacy of Mind-Body Therapy in Children With ADHD When it comes to the methods of treating ADHD in children, mind-body therapies have proved to provide a multitude of potential benefits.
• ADD/ADHD and Use of Stimulant Drugs To Treat Children
• ADHD Scores and Dyslexia Scores Impact on Academic Performance
• ADHD, Ritalin, Families, and Pharmaceutical Companies
• Behavioral and Pharmacological Treatment of Children With ADHD
• Exploiting the Brain’s Network Structure in Identifying ADHD Subjects
• ADHD: Managed Through Medications and Behavioral Therapy
• ADHD Alternative Treatments for Children
• Children With ADHD and How Teachers Perceive Them
• ADHD Children and How Behavior Therapy Is Necessary With the Use of Medication
• ADHD Medications Versus Side Effects
• ADHD and ADD and School Compulsory Medication
• ADHD Diagnosis, Diagnostic Tools, and Its Cultural and Ethical Implications
• The Lateral Prefrontal Cortex and Selection and Inhibition in ADHD
• Genetic Insights Into ADHD Biology
• The Causes, Treatment and Ethical Issues Related to the Attention-deficit Hyperactivity Disorder in Children
• ADHD: History and Background of Disease
• ADD/ADHD: Differences Between Boys and Girls
• Child Mental Health and Human Capital Accumulation: The Case of ADHD Revisited
• Children With ADHD and Ritalin Effects Research Proposal
• ADHD and the Role of the Psychiatric Nurse
• The Symptoms and Treatment of ADHD in Children and Teenagers
• ADHD and What Causes the Childhood Behavioral Condition
• Children With ADHD Have Difficulties Paying Attention and Are More Impulsive
• ADHD: Inattention, Distractibility, Impulsivity, Hyperactivity
• Difference Between ADHD, Conduct Disorder, Oppositional Defiance Disorder, and Antisocial Disorder
• Entrepreneurship and Psychological Disorders: How ADHD Can Be Productively Harnessed
• The Advantage and Disadvantage of Using Psychostimulants in the Treatment of ADHD
• The Young Children and Children With ADHD, and Thinking Skills
• ADHD Children and Using Family and Group Therapies
• Growing Into Successful Adults With ADHD
• Classroom Seating Arrangements for ADHD Students
• The Relation Between Sleep, Memory Enhancement, Causes of Emotional Deficiency Among ADHD Patients
• ADHD and Its Impact on Longevity
• ADHD Medication Side Effects on Children
• What Are the Effects of ADHD in the Classroom?
• What Is the Relationship Between ADHD and Depression in Adolescents?
• How Does ADHD Affect School Performance?
• Should Children With ADHD Be On Ritilan or Similar Drugs?
• What’s the Connection Between Technology and Teen Mental Health, Especially ADHD?
• What Should Future Research Help Resolve the Debate About the Efficacy of Eeg Neurofeedback in Children With ADHD?
• Are Children Being Diagnosed With ADHD Too Hastily?
• How Does ADHD Affect a Person?
• What Effect Does Being Identified ADHD Have On a Child?
• Children With Low Working Memory and Children With ADHD: Same or Different?
• How Does ADHD and Autism Affect Education?
• How Does ADHD Affect Learning?
• Why Should Parents Use Alternative Treatments for ADHD?
• Is It Possible To Treat ADHD Without Pharmaceutical Risks?
• How Do People With ADHD See Themselves in the Community?
• How Can You Tell if an Adult Has ADHD?
• Television Overexposure and ADHD: Is There a Connection?
• Should Children Diagnose With ADHD Be Given Medication To Address Their Symptoms?
• ADHD Treatment: Should Antihypertensive Medications Be Used?
• Why Do Teachers Need To Understand ADHD?
• Why Are More and More People Getting the Misdiagnosis of ADHD?
• How Does ADHD Affect Cognitive Development?
• What Is the Natural Cure for ADHD?
• How School Systems Deal With ADHD?
• How Society Views Children With ADHD?
• What Is the Relationship Between ADHD and Electronic Stimulation?
• How ADHD Medication Affects the Brain?
• What Is the Correlation Between Age and ADHD?
• What Are the Teaching Strategies for Children With ADHD?

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ADHD Diagnostic Trends: Increased Recognition or Overdiagnosis?

The prevalence of Attention Deficit Hyperactivity Disorder (ADHD) has seen a consistent rise in recent years. These numbers spark a debate over the reason for the observed trends, with some concerned about over diagnosis and over prescription of stimulant medications, and others raising the issue of diagnostic disparities, particularly in underrepresented populations. In this paper we look at both sides, starting with the history of ADHD and its diagnostic criteria changes, from early concepts of alterations in attention and hyperactivity in the 19th and 20th century, to its introduction in the Diagnostical and Statistical Manual of Mental Disorders (DSM), and its evolution into how it is defined today. The general broadening of ADHD diagnostically over time plays a role in the increased prevalence over the years, but it is not the only reason. Increased awareness of physicians and the public is also believed to play a big role, particularly in underrepresented minorities and women. However, there continues to be disparities in detection of ADHD in these groups. There are significant consequences to a patient’s social, interpersonal, and professional life when ADHD is left unrecognized and untreated. Thoughtful evaluation, accurate diagnosis, and adequate treatment can make a big difference.

Case History

Agatha has been struggling with school work since starting college in the fall. She always had difficulty paying attention in certain subjects, but did fairly well in high school. Lately she has been feeling more anxious because her study habits that worked throughout high school no longer seem to be effective. She feels completely inundated by the sheer volume and difficulty of her current assignments. She finds herself constantly procrastinating, regularly feeling guilty about her inability to adhere to deadlines. Problem sets are riddled with careless errors and papers contain numerous typos and grammatical errors. Sometimes, especially after doing poorly on an exam, guilt and anxiety about school become so high that she simply shuts down and avoids doing any work for the rest of the day. She has seen a lot of ADHD content on TikTok recently, and wonders if she may have ADHD herself. Her college friend has offered her Adderall, and while she hasn’t taken it without a prescription, she wonders if she may benefit from it.

Introduction

The past couple of decades have seen a continuous increase in attention deficit hyperactivity disorder (ADHD) diagnoses. National population surveys reflect an increase in the prevalence from 6.1% to 10.2% in the 20-year period from 1997 to 2016 and experts continue to debate and disagree on the causes for this trend. 1 On the one hand, while there are children whose diagnoses are irrefutable and undeniably require treatment, some experts worry about the risk of overdiagnosis and subsequent over prescription of stimulants and other psychotropics. Like with most psychotropic medications, treatment consideration needs to be carefully weighed with regards to potential adverse outcomes. For stimulants there is also concern for diversion and misuse of the medication for performance enhancement rather than for treatment. On the other hand, diagnostic disparities and underdiagnosis exist in various communities, including women and underrepresented minorities, as seen with Agatha. In this article, we aim to better understand the debate about the growing number of those affected by reviewing how ADHD morphed into the diagnosis we know today, and the variability and disparities observed.

Attention Deficit Hyperactivity Disorder: The Basics

Attention Deficit Hyperactivity Disorder is a neurodevelopmental disorder that globally affects 5% – 7.2% of youth and 2.5% – 6.7% of adults. 2 – 4 Recent estimates indicate that prevalence is even higher in children in the United States (U.S.), around 8.7% or 5.3 million. 5 Although it has long been conceptualized as a disorder of childhood, up to 90% of children with ADHD continue to experience symptoms into adulthood. 6 Obtaining a diagnosis in adulthood is also possible, as in one study, 75% of adults with ADHD were not previously diagnosed in childhood. 7 While in childhood the male to female ratio is 4:1, the ratio is closer to 1:1 in adults. 8

Attention Deficit Hyperactivity Disorder is thought to be caused by a combination of factors: genetic, neurobiologic, and environmental. Twin studies show that ADHD is highly hereditable (60–70%), and scientists have identified a number of genes believed to underlie vulnerability to the disorder. 9 This includes genes that regulate the expression of Brain Derived Neurotrophic Factor, which plays a role in learning and memory, as well as those involved in modulation of the brain’s dopaminergic system. 9 Environmental risk factors like perinatal complications and toxic exposures are also believed to play a role. 9 – 10

ADHD is a clinical diagnosis, which is accomplished through questionnaires, clinical interview, and in some cases, neuropsychiatric testing. While neuroimaging studies suggest a potential correlation between ADHD and white matter volume abnormalities in cortico-striatal pathways and the prefrontal cortex in study samples, biomarkers are not currently sensitive enough to assist with diagnosis.

The treatment for ADHD is often a combination of medication, skill building, and psychotherapy. In the 1930s, Charles Bradley, MD, noticed a drastic improvement in children’s behavior and school performance after administration of amphetamine sulfate—a drug he was hoping would help treat headaches. That serendipitous discovery led to the development of other stimulants, a class of medications that is still considered the gold standard and first line ADHD treatment. Pharmacologic therapy is reported to be effective in up to 70% of cases, yet the benefits are not without risk. 11 The most common side effects are decreased appetite, anxiety, nausea, headaches, and in children in particular, concern about tolerance, weight loss, and insomnia. Data on long-term stimulant use also remains limited. A recent literature review found long-term use to be generally safe, but authors did advise providers to use caution when prescribing stimulants to pre-school age children, adolescents at high risk of abuse, and children with tics and psychosis. 12

There are also many non-pharmacological modalities of treatment for ADHD, including behavioral parent training and mindfulness-based attention training. 13 – 14 Psychotherapy, especially cognitive behavioral techniques, has also been shown to be quite effective. 11 Finally, a newer non-pharmacological approach, neurofeedback, has some benefits, though clinical application remains logistically challenging. More research is required into its efficacy. 15

ADHD: Changes in Diagnostic Criteria Over Time

To understand its diagnostic trends, it is important to consider the origins of ADHD and its diagnostic criteria. In the Eighteenth century, Sir Alexander Crichton wrote one of the earliest documented clinical descriptions of a disorder in attention in his 1798 book On Attention and its Diseases. He described “morbid alterations” of attention that “render [individuals] incapable of attending with constancy to any one object of education.” 16 Although not globally recognized and treated at the time, his observations bear striking similarities to modern descriptions of the inattention domains of ADHD.

In the early 1900s, British physician Sir George Frederic Still described a number of children with a “defect of moral control.” 17 Although more similar to the modern concepts of conduct disorder (CD) or oppositional disorder (ODD), his description identified a number of features typically seen in ADHD like impulsivity and impaired frustration tolerance. Later, in the 1930s, physicians Kramer and Pollnow wrote about children with “hyperkinetic disease of infancy”, a syndrome that more closely resembled modern ADHD descriptions including both hyperactivity, emotional excitability and impulsivity, and inattention. 17

ADHD made its first appearance in the Diagnostic and Statistical Manual of Mental Disorders (or DSM) in 1968, as “Hyperkinetic Reaction of Childhood.” As the name implies, the emphasis was on overactivity and distractibility. In the years that followed, and with subsequent editions of the DSM, there was a clear shift in focus towards attention deficit as the defining feature of the disorder. The publication of the DSM-III in 1980 gave rise to the diagnosis of “attention deficit disorder,” or ADD, a term that remains part of popular vernacular to this day. The DSM-III also introduced a cutoff for the number of symptoms to earn the diagnosis, as well as age at onset, symptom duration, and exclusion of confounding psychiatric disorders and substance use.

The label ADHD that we know and use today first appeared in 1987 with the DSM-III-R, and combined both inattention and hyperactivity domains into one diagnosis. Then, the DSM-IV iteration divided the diagnosis into three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined type. The release of the DSM-V in 2013 saw the definition of ADHD broaden significantly. The changes are summarized in Table 1 . One such change allowed for autism spectrum disorder (ASD) and ADHD to coexist, which was not the case in previous iterations. Given the high comorbidity between ADHD and ASD, it is clear that this change, along with others ( Table 1 ), contributed to the rise in ADHD prevalence, as it added a large group of children who were previously excluded. 18

Changes in diagnostic determination for ADHD between the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV and V editions

Clearly, the evolution of the diagnostic criteria accounts for some of the rise in ADHD. In fact, Polanczyk and his collaborators have done a lot of work on ADHD epidemiology—and they have consistently demonstrated that the observed variability in prevalence rates across various studies was attributed largely to differences in measurement of outcomes, namely the criteria used to diagnose ADHD and the inclusion or exclusion of functional impairment. 19 – 20

The changing criteria only makes clinical diagnosis more difficult. In the absence of biomarkers, diagnosis is made by signs and symptoms. Some helpful questions for screening by clinicians are suggested in Table 2 . However, this leaves a lot up to the clinician, and may lead to under and over diagnosis. Due to the overlapping nature of psychiatric symptoms, ADHD is often missed, and patients end up with inaccurate psychiatric diagnoses and medication regimen. This latter point is important as we now know ADHD has high rates of psychiatric comorbidities, such as behavioral aberrances (52%), anxiety (33%), depression (17%), and autism (14%). While this may lead to overdiagnosis, more likely than not, ADHD can be misdiagnosed as a result, and subsequently inadequately treated. 21 Screening tools have been developed and validated for detection of ADHD in adults such as WHO’s Adult ADHD Self Report Scales or ASRS and many clinicians will ask for reports from schools and loved ones as well. 22 Referring to neuropsychiatric testing is also an option, though it is expensive and not required to make the diagnosis.

Example of questions clinicians can ask when assessing for ADHD. Adapted from “Integrative Treatment for Adult ADHD: A Practical, Easy-to-use Guide for Clinicians” by Ari Tuckman (New Harbinger Publications, 2007). Broader questions can often elicit more information and will allow clinicians to explore more in depth than a memorizable check-list.

ADHD: Increased Awareness, Increased Prevalence

Outside of simply diagnostic changes, studies have provided other explanations for the rise in ADHD, including increased awareness and familiarity of physicians and the public with the diagnosis, geographic location and cultural differences, as well as other public health related factors such as improved access to care. 23 ADHD has even earned its own Awareness Month as of October of 2004. A quick search on Google Trend shows a steady increase in ADHD-related searches throughout the years, with popularity in March 2022 at the highest it has ever been ( Figure 1 ).

Google search trends for the term “ADHD”, from 2004 to present

ADHD has also become prominent in popular culture. Characters with problems in attention and hyperactivity can be found all over early literary works - physician Heinrich Hoffman wrote short stories in the mid-1800s featuring characters like “Fidgety Philip” and “Johnny Look-in-the-Air,” the names of which alone indicate hyperactivity and inattention as core features of the characters. 24 Today, a number of movies and television characters have ADHD as part of their plotline and defining features - from Barney Stinson on “How I Met Your Mother,” to Phil Dunphy on “Modern Family,” and even Bart Simpson. Social media has also propelled ADHD into popular awareness, as it has taken over platforms like TikTok and Twitter. As of May 2022, the hashtag #adhd has 11.4 billion views on TikTok. Many people credit these platforms with helping them realize they had the diagnosis and subsequently seeking treatment for it. However, as is always the case with the internet and social media, misinformation about ADHD is fairly prevalent. A recent study has found that more than half of ADHD content on TikTok was misleading, most of them posted by non-health care providers. 25 That same study however did show that content posted by health care providers was overwhelmingly more accurate and useful to consumers. 25

ADHD and Undertreatment

While there is concern from rising ADHD diagnoses, a U.S. national survey reported in 2006 that only 11% of adults with ADHD were being treated for it. This is critical as deficits in organization and time management can lead to major educational, professional, or financial problems, with higher drop-out rates, higher unemployment rates, and lower income attainment in adults with ADHD. 26 Deficits can also have major interpersonal implications, with higher rates of divorce documented in adults with ADHD, for example. 27 People with untreated ADHD are also at elevated risk of substance use, car accidents, unintentional injuries, depression, anxiety, and suicide. 28 In other words, underdiagnosis has significant implications, far beyond inability to focus.

Some have raised concerns over non-medical use of stimulants. Non-medical use is most studied in student populations, where medications can function as either a cognitive enhancer, or are used recreationally. However, while some studies reported non-prescribed use of stimulants in about 7% of college students, most of the misuse was in the setting of attentional difficulties impairing the student’s ability to succeed in class. 29 This is a possible indication that said student has undiagnosed ADHD, and not a desire to use the medication to get ahead. More importantly, a recent review has found that pharmacological treatment of ADHD was associated with a decreased risk of substance use, not the opposite. 30

Disparities in ADHD Diagnosis in Minoritized Populations

Any discussion of ADHD diagnostic trends would be incomplete without a review of disparities among minoritized population. Increasing awareness of these disparities might be contributing to the increase in rates of diagnosis. Over the past 20 years, available literature showcases the presence of pervasive disparities in ADHD diagnosis related to both race and gender. For instance, between 2004–2006, Black students were more likely than their White counterparts to have ADHD symptoms (12% vs. 7% respectively), but were less likely to have received a diagnosis (9% vs. 14% respectively). 31 During the following decade, rates of diagnosis among Black individuals grew at a rate 3 times higher than among White individuals. 32 Similar trends have been seen among girls, who demonstrated a 3 times higher increase in diagnosis rates than boys over the past two decades. 32 – 33 In fact, with regard to gender, experts have attributed changes in DSM-IV diagnostic criteria to recent diagnostic trends. Following changes that placed increased focus on inattention, rather than hyperactivity, there was a correspondingly significant increase in ADHD diagnosis among females. 34 Specifically, between 1991 and 2008, diagnosis rates increased by a factor of 5.6 in girls compared to only 3.7 in boys. 35 In other words, knowing girls and underrepresented groups are more likely to have missed diagnoses, and even present with different symptoms, patients and clinicians might be asking more questions as a result. The rise might be due to the fact that these groups are just simply finally diagnosed, rather than over-diagnosed.

Even still, the data suggests we still are missing groups and underdiagnosing ADHD for many. To date, recent findings indicate that ADHD continues to be less frequently diagnosed in youth who are Black Indigenous and Persons of Color (BIPOC) and female, compared to those who are White and male, even after controlling for potential confounders such as socioeconomic status and adverse childhood experiences. 36 – 37 Girls continue to be diagnosed at older ages than boys and tend to endorse higher levels of perceived stress. 38 Reasons for these disparities stem from a multitude of systems level factors, however racial and gender bias is likely to play a major role. For example, diagnosis of any mental illness, especially ADHD, depends on individual interpretations of behavior and the way that a clinician integrates multiple informant reports from parents, caregivers, and teachers. Studies have found that clinicians tend to be more responsive to White parents who solicit an ADHD diagnosis and treatment for their child compared to BIPOC parents. 39 Further, BIPOC youth with ADHD are disproportionately more likely to be misdiagnosed with ODD or CD. 40–41

ADHD manifests differently across gender, as there may be stronger social pressures for girls to sit quietly compared to boys. In fact, studies show that boys have historically been more likely to exhibit hyperactivity and disruptive behaviors, prompting earlier detection of the disorder, compared to those with inattentive symptoms, a group that most often includes girls. 42 Interestingly, other studies have indicated there to be no true difference in level of hyperactivity across gender, rather a bias among teachers leading to under-recognition of hyperactive symptoms among girls. 43 While some are concerned about the overdiagnosis of ADHD, there are still many groups who are underdiagnosed and unaccounted for in the data. Ultimately, focusing on the idea of “overdiagnosis” among providers may be harmful, particularly for these populations, as this may present additional barriers to them receiving appropriate care.

ADHD is not a new phenomenon, however its prevalence has increased significantly in the recent years. Given changing diagnostic criteria and increasing awareness of the disorder in marginalized populations, especially individuals of color and females, this finding is not surprising. The general public has become increasingly more aware of ADHD through the media and social media. People are more likely to bring up their concerns to a physician, which in turn might prompt more numbers of people to be diagnosed. While some may argue that the increase is concerning and due to intentional feigning of symptoms in order to gain access to stimulant medication or test accommodations, the evidence suggests these groups have a negligible impact on diagnostic trends. In fact, as medical providers, focus on the idea of “overdiagnosis” may instead be harmful, create additional barriers to care, and add to the stigma towards their requests for help. It is important, instead, to approach patients holistically, and with an understanding of both the risks of treatment and undertreatment in mind. For those who have been struggling with unrecognized ADHD, there are significant impacts to mental health, social life, and work life. Thoughtful diagnosis and subsequent treatment can make all the difference.

Elie Abdelnour, MD, (above) and Jessica A. Gold, MD, MS , are in the Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri. Madeline O. Jansen, MD, MPH, is with the Department of Psychiatry, Child and Adolescent Division, University of California-Los Angeles, Los Angeles, California.

None reported.