• Research article
  • Open access
  • Published: 12 August 2020

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

Psychiatric comorbidity is very common, which may complicate identification and treatment [ 14 ]. In children with ADHD this includes conduct disorder (CD), oppositional defiant disorder (ODD), disruptive mood dysregulation disorder, autism spectrum disorder (ASD), developmental coordination disorder, tic disorders, anxiety and depressive disorders, reading disorders, and learning and language disorders [ 15 , 16 , 17 ]. Comorbid conditions are also extremely common in adults and include ASD, anxiety and depressive disorders, bipolar disorder, eating disorders, obsessive compulsive disorder, substance use disorders, personality disorders, and impulse control disorders [ 18 , 19 ].

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

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

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

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

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

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

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

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

1: Identification and assessment of ADHD in females

Presentation in females and what might trigger referral?

Considering sex differences when conducting ADHD assessments

2: Interventions and treatments for ADHD in females

Pharmacological

Non-pharmacological

3: Multi-agency liaison

Educational considerations

Other multi-agency considerations

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

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

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

Results and consensus outcome

Presentation of adhd in females.

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

ADHD symptoms

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

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

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

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

  • Comorbidity

Externalising problems are more prevalent in males with ADHD [ 24 ], manifesting as higher rates of comorbid oppositional defiant disorder (ODD) and conduct disorder (CD) [ 40 ], characterised by rule-breaking behaviour [ 50 , 51 ] and fights in school [ 36 ]. In adulthood, men with ADHD more commonly show antisocial behaviours characteristic of antisocial personality disorder [ 52 , 53 , 54 ]. Whilst these problems are more prevalent in males, they typically remain elevated in individuals with ADHD across both sexes in comparison with the general population. The lower rates of disruptive behavioural problems in females may contribute to lower rates of referral for ADHD assessment and support [ 48 , 55 ].

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

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

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

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

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

Associated features, functional problems and impairments

In both children and adults ADHD is commonly accompanied by emotional lability and emotion dysregulation problems (irritability, low frustration tolerance, mood changes) [ 72 , 73 , 74 ]. Difficulties of this nature may be more common or severe in girls and women [ 30 , 56 , 57 , 58 ] and emotion dysregulation problems are associated with a broad range of impairments in adulthood, including educational, occupational, social, familial, criminal, driving and financial problems [ 75 , 76 ]. In an Icelandic study of ADHD symptoms in university students, poor social functioning best predicted dissatisfaction with life in males, whereas among females the best predictor of life dissatisfaction was poor emotional control [ 77 ].

Cognitive problems are well established in ADHD [ 78 , 79 , 80 ], spanning difficulties with executive dysfunction (such as inhibition, planning, working memory and set shifting) and non-executive cognitive domains (e.g. word reading, reaction times, colour or letter naming, response consistency). However, ADHD may also be associated with general impairments in intellectual functioning, which tends to be more prominent in females [ 24 , 40 ]. Subtle social cognition deficits, including facial and vocal emotion recognition, have also been reported in both males and females with ADHD, with no clear sex-related differences [ 81 ].

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

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

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

Throughout adolescence and the transition into adulthood, there is an increase in risk taking behaviour which may be associated with symptoms of hyperactivity and/or impulsivity [ 48 ]. For example, young people with ADHD become sexually active earlier, have more sexual partners and are more frequently treated for sexually transmitted infections [ 99 ]. Rates of teenage, early or unplanned pregnancies are elevated in girls and women with ADHD [ 100 , 101 , 102 ]. Pregnant women with ADHD are more likely to smoke up to the third trimester, or be obese or underweight [ 102 ].

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

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

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

Triggers for referral

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

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

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

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

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

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

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

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

Rating Scales

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

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

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

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

The clinical interview

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

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

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

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

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

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

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

Objective assessments

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

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

Interventions and Treatments

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

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

Pharmacological management

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

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

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

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

Parents and carers may not be as aware of the benefits of medication in girls, especially those with inattentive presentations in the absence of challenging or disruptive behaviour. Psychoeducation regarding available treatments and what they are targeting, provided for parents and girls with ADHD themselves, may help to ensure engagement in treatment and improve adherence to treatment regimens. Where required, adherence may be improved by using long-acting stimulant medication in place of short-acting medications [ 155 , 156 , 157 ].

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

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

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

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

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

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

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

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

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

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

Non-pharmacological management

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

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

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

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

Primary age

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

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

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

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

Secondary age

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

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

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

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

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

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

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

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

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

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

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

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

The bulk of household, and parental and caring duties are often borne by women [ 190 , 191 , 192 ], reflecting social and cultural constraints and expectations. These may result in increased impairment and anxiety in relation to these roles and duties in women compared with men. The consensus group identified that the demands placed on mothers often differ from those of fathers and that low self-esteem may be related to perceived failure to reach societal expectations. Mothers may lack confidence or experience feelings of guilt over their perceived inadequacy as a parent. Dysfunctional beliefs of this nature may be reinforced if they have a difficult-to-manage child with ADHD and are offered ‘parent training’ interventions. The group acknowledged that the term ‘parent training’ is unhelpful and may be perceived as pejorative.

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

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

Multi-agency liaison

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

Educational considerations and adjustments

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

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

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

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

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

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

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

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

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

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

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

Occupational considerations and adjustments

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

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

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

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

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

Health and social care

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

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

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

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

Criminal justice system

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

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

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

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

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

ADHD Child Evaluation

Attention-Deficit/Hyperactivity Disorder

Autism Spectrum Disorder

Adult ADHD Self-report Rating Scale

Borderline Personality Disorder

Conners’ Adult Rating Scales

Cognitive Behavioural Therapy

Conners’ Comprehensive Behavior Rating Scales

Conduct Disorder

Conners’ Continuous Performance Test, third edition

Development and Wellbeing Assessment

Diagnostic Interview of Adult ADHD

Diagnostic Interview for ADHD in Adults with Intellectual Disability

Diagnostic and Statistical Manual of Mental Disorders

Education, Health and Care Plan

International Classification of Diseases

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

Learning Disability

Oppositional Defiant Disorder

Personalised Education Plan

The Vanderbilt ADHD Rating Scales

Quantified Behavior Test

Strengths and Difficulties Questionnaire

Swanson, Nolan, and Pelham-IV Questionnaire

Substance Use Disorder

United Kingdom of Great Britain and Northern Ireland

United Kingdom ADHD Partnership

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Acknowledgements

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

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

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St Thomas’ Hospital London, London, UK

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

Jane Sedgwick

Cambridge Cognition, Cambridge, UK

Caroline Skirrow

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

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

Kevin Tierney

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

Kobus van Rensburg

Compass, London, UK

Emma Woodhouse

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

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Correspondence to Susan Young .

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

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

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Young, S., Adamo, N., Ásgeirsdóttir, B.B. et al. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry 20 , 404 (2020). https://doi.org/10.1186/s12888-020-02707-9

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ADHD: Reviewing the Causes and Evaluating Solutions

Luis núñez-jaramillo.

1 División de Ciencias de la Salud, Universidad de Quintana Roo, Chetumal 77039, Quintana Roo, Mexico; xm.ude.oorqu@zenunl

Andrea Herrera-Solís

2 Laboratorio Efectos Terapéuticos de los Canabinoides, Subdirección de Investigación Biomédica, Hospital General Dr. Manuel Gea González, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan 14080, Ciudad de México, Mexico; moc.liamg@shaerdnaard

Wendy Verónica Herrera-Morales

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in which patients present inattention, hyperactivity, and impulsivity. The etiology of this condition is diverse, including environmental factors and the presence of variants of some genes. However, a great diversity exists among patients regarding the presence of these ADHD-associated factors. Moreover, there are variations in the reported neurophysiological correlates of ADHD. ADHD is often treated pharmacologically, producing an improvement in symptomatology, albeit there are patients who are refractory to the main pharmacological treatments or present side effects to these drugs, highlighting the importance of developing other therapeutic options. Different non-pharmacological treatments are in this review addressed, finding diverse results regarding efficacy. Altogether, ADHD is associated with different etiologies, all of them producing changes in brain development, leading to the characteristic symptomatology of this condition. Given the heterogeneous etiology of ADHD, discussion is presented about the convenience of personalizing ADHD treatment, whether pharmacological or non-pharmacological, to reach an optimum effect in the majority of patients. Approaches to personalizing both pharmacological therapy and neurofeedback are presented.

1. Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder (NDD) presenting with inattention, hyperactivity, and impulsivity. It can be classified in three subtypes, depending on the intensity of the symptoms: predominantly inattentive, predominantly hyperactive–impulsive, and combined [ 1 , 2 ]. ADHD has a global prevalence of 5.9% to 7.1% in children and 1.2% to 7.3% in adults [ 3 ].

While most studies address ADHD in children from 7 to 17 years old, it is important to outline that this condition is also present in adults. It has been proposed that the number of adults with ADHD has increased over the last 20 years. A part of this increase is due to the permanence of ADHD symptoms in the adult age in 76% of diagnosed patients. ADHD implies important challenges for academic, personal, and job performance [ 4 ].

As for any other condition affecting brain function, in order to find an adequate treatment for ADHD, it is important to first understand its physiological basis. As with other NDDs, the causes of ADHD are aberrant neural development, affecting neurogenesis, synaptogenesis, myelination, and neuronal and glial proliferation and migration. Even though symptoms begin to appear in childhood, neuronal development is affected from early embryogenesis [ 5 ].

The etiology of ADHD is diverse—gestational, perinatal, and genetic factors have been associated with ADHD incidence. However, each patient presents only a few of them.

2. Environmental Factors Associated with ADHD

The incidence of ADHD is associated with a number of environmental factors during different stages of central nervous system (CNS) development, such as gestational and perinatal periods. In this section, we will address some of the environmental factors that have been associated with ADHD.

2.1. Preconceptional, Gestational, and Perinatal Conditions

Premature birth is an important risk factor for ADHD, since it has been reported that it occurs 2.6 to 4 times more frequently in babies born with low weight or very low weight. Premature birth is associated with alterations in neurogenesis and cell death [ 6 ], and these are in turn associated with reduced cortical expansion, as reported in ADHD patients [ 7 ]. One possible reason for increased risk of developing ADHD in preterm children is inflammation; an increase in inflammation-related molecules is associated with increased risk of developing ADHD symptoms [ 8 ].

Perinatal hypoxia is an environmental factor that increases the risk of developing AHDH, probably due to its effects on dopaminergic transmission and neurotropic signaling [ 9 ].

The intake of nutrients during gestation is very important for proper brain development. An important element during neural development is the polyunsaturated fatty acid docosahexaenoic acid (DHA), promoting proliferation and neural differentiation of neural progenitor cells. Decreased levels of DHA during brain development have been associated with ADHD and other neurodevelopmental disorders [ 10 ], and decreased levels of serum DHA levels have been reported in adult ADHD patients [ 11 ]. Additionally, malnutrition or immune activation in the pregnant mother is a risk factor for ADHD and other neurodevelopmental disorders [ 12 ]. High sucrose consumption during pregnancy is possibly related with ADHD incidence. A study performed on rats reported that high sucrose intake in pregnant rats led to the appearance of ADHD-like symptoms in the offspring, who showed increased locomotor activity, decreased attention, and increased impulsivity. Furthermore, the offspring also presented increased dopamine transporter (DAT) and a decrease in dopamine receptors and mRNA expression in the striatum [ 13 ].

Interestingly, there is evidence in a rat model of the influence of preconceptional conditions on ADHD incidence. Offspring of Female rats administered with ethanol for 8 weeks before mating presented ADHD-like symptoms such as hyperlocomotive activity, impulsivity, and attention deficit. These rats also presented low levels of striatal DAT and increased presence of norepinephrine transporter (NET) in the frontal cortex [ 14 ]. A later work by this group revealed that paternal preconceptional alcohol exposure also produced ADHD-like symptoms in the offspring, presenting decreased expression of DAT mRNA and DAT protein in the cortex and striatum. Furthermore, authors report epigenetic changes in both the sperm of these alcohol-exposed male rats and in the frontal cortex and striatum of the offspring, presenting increased methylation in a CpG region of DAT gene promoter, which is in agreement with the reduced expression of DAT in the offspring [ 15 ].

Another environmental factor associated with ADHD is pesticide exposure during development. A study addressing the issue, both at experimental and epidemiological levels, reported that exposure to the pesticide deltamethrin during gestation and lactation in rats led to ADHD-like symptoms, such as working memory and attention deficits, hyperactivity, and impulsive-like behavior. It also produced increased presence of DAT and D1 receptor in the striatum, as well as increased dopamine release and increased presence of D1 dopamine receptor in the nucleus accumbens. Interestingly, the authors also performed an epidemiological study in humans, revealing that children (6 to 15 years old) with detectable levels of pyrethroid metabolites in urine had more than twice the probability of being diagnosed with ADHD [ 16 ].

2.2. Heavy Metal Exposure

One of the most reported environmental factors associated with ADHD is exposure to neurotoxic heavy metals. A study performed on school children revealed that children (6–7 years old) with ADHD presented higher levels of salivary mercury. However, when including all age groups studied (12–13 years and 15–16 years), no significant correlation was found between increased salivary mercury and ADHD, although a mild tendency was observed [ 17 ].

In the case of manganese, both too high and too low blood levels are associated with cognitive deficits. High concentration of manganese in blood is associated with deficits in thinking, reading, and calculations, as well as with lower learning quotient (indicative of learning disability) and more errors in the continuous performance test (measuring attention and response inhibition). Conversely, low blood level of manganese is associated with a poorer performance in the Stroop test, which is used to assess cognitive inhibition [ 18 ]. Similarly, a study addressing the relationship between manganese in drinking water and ADHD found a higher risk of developing this condition (inattentive but not combined subtype) as exposure to manganese in drinking water increased [ 19 ]. However, a study on manganese in children’s deciduous teeth failed to find an association between this metal and cognitive deficits [ 20 ].

The presence of lead in children’s deciduous teeth is positively associated with hyperactivity or impulsivity, as well as inattention and oppositional or defiant disorder [ 20 ]. A study on children from a lead-contaminated region reported that blood levels of cadmium, lead, and manganese correlated with conduct problems and antisocial behavior [ 21 ]. Another work found a higher concentration of blood lead in ADHD children, which was correlated with hyperactivity–impulsivity symptoms but not with inattention [ 22 , 23 ]. Both genetic [ 24 ] and epigenetic [ 25 ] factors have been reported to contribute to lead-related pathogenesis of ADHD. Moreover, a study carried out in Argentina found that children with high blood concentrations of lead are more likely to develop ADHD [ 26 ].

A review on the effects of prenatal and childhood metal exposure on cognition found suggestive evidence of a relation between cadmium exposure and impaired cognitive ability in children. They did not find evidence of a relationship between cadmium exposure and ADHD [ 27 ]. A more recent study addressing cadmium exposure during pregnancy revealed that a higher blood cadmium concentration during pregnancy is associated with higher scores in ADHD diagnostic tests in female children at 6 years of age, but not in the case of male children [ 28 ].

A recently published work reported that ADHD children present higher urine concentrations of chromium, manganese, cobalt, nickel, copper, molybdenum, tin, barium, and lead [ 29 ]. A recent study analyzing serum concentrations of different metals in ADHD children reported low levels of chromium, manganese, and zinc, as well as increased copper/zinc ratios in these children [ 30 ]. A meta-analysis on the relation between blood and hair zinc and ADHD found no statistical difference between ADHD and control children [ 31 ].

Thus, there are a number of environmental factors associated with ADHD incidence. While environmental factors are not found in all ADHD cases, the data reviewed herein highlight the importance of environment in different developmental stages—and even before conception—in regard to the risk of developing ADHD.

3. Sleep Disorders and ADHD

Sleep deprivation, either acute or chronic, produces decreased cognitive functioning (one of the main traits of ADHD). Interestingly, it also produces the externalizing symptoms observed in ADHD patients. For example, a very tired child might become hyperactive, while in a sleepy adult in a condition where it is not possible to sleep (for example, while driving), the externalizing behavior will help them to remain awake. Thus, both of the core ADHD symptoms can be produced by sleep deprivation. Conversely, hyperactivity in children or high internal activity in adults in the evening might lead to sleep disruption [ 32 ].

Among the sleep disorders found in ADHD patients are delayed sleep phase disorders, insomnia, sleep-disordered breathing, increased motor activity during the night, sleep anxiety, clenching teeth, periodic limb movement, restless legs, increased sleep onset latency and shorter sleep time, night awakenings, narcolepsy, and parasomnias [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. Among them, delayed sleep phase disorder is one of the most frequently found, being present in 73–78% of both ADHD children and adults. This condition consists of a delay between the sleep propensity cycle and the circadian cycle, leading to increased daytime sleepiness and decreased cognitive functioning [ 32 ].

Sleep disturbance have an impact on daytime vigilance, producing excessive sleepiness [ 32 , 37 , 39 ], and can exacerbate inattention, impulsivity, and hyperactivity as means to remain awake [ 32 , 37 ]. Additionally, stimulant medication might also cause sleep disturbances, although OROS methylphenidate produces less adverse effects on sleep [ 34 , 36 ]. LDX, a stimulant prodrug that undergoes hydrolysis in the bloodstream releasing d-amphetamine, and atomoxetine, a non-stimulant pharmacological treatment for ADHD, do not produce adverse effects on sleep [ 36 ].

Sleep disturbances in ADHD patients can produce significant impairments in attention, mood, and behavior [ 32 , 35 ]. Physiologically, there is evidence supporting an overlap between brain centers regulating sleep and those regulating attention and arousal, so it is possible that affectation of one of these systems also affects the other. Similarly, affectation of noradrenergic and dopaminergic pathways is found in both ADHD and sleep disturbances [ 40 ].

Conversely, during wake time, sleep disturbances produces symptoms resembling those observed in ADHD patients [ 35 , 41 , 42 ]. It is, thus, recommended to assess sleep disorders in patients with ADHD symptoms in order to avoid misdiagnosis [ 41 , 42 ].

The relationship between sleep disorders and ADHD is complex. While ADHD might produce sleep disorders, they could also be coincident conditions [ 36 ]. Moreover, sleep disorders have been proposed to be not only one of the intrinsic features of ADHD, but also might be one of its causes [ 32 , 36 ]. Another possible explanation for this interaction would be an underlying common neurological disease leading to both sleep disorders ad ADHD [ 36 ]. A recent review on the subject proposed that chronic sleep disorders are some of the main causes of ADHD symptoms [ 32 ]. The authors suggested that patients presenting ADHD symptoms should undergo quantification of sleep and sleep problems in order to rule them out as the sole cause of ADHD symptoms. Thus, ADHD treatment should address both the symptoms (with classic ADHD treatment) and the sleep problem [ 32 , 34 , 35 , 36 ], although the effect of this combined treatment still requires further research [ 32 ].

4. Genetic Factors Associated with ADHD

Different studies have revealed an important genetic influence in the etiology of ADHD [ 43 ]. It is a polygenic condition with an important number of genes involved, as confirmed by a genome-wide association study on ADHD reporting 12 significant loci associated with this condition [ 44 ]. Many of the genes reported to be associated with ADHD participate in processes such as neurotransmission, neuritogenesis, synaptogenesis, or receptor location in synapses [ 45 ]. In this review, we will focus on two genes, a neurotrophin (brain-derived neurotrophic factor –BDNF-) and a molecule involved in dopaminergic signaling (DAT).

Brain-derived neurotrophic factor (BDNF) is a neurotrophin with high expression in the brain that is highly concentrated in the hippocampus and cortex. It has an important role in neuronal development, being important for neuronal proliferation, migration, differentiation, and maturation, as well as for synaptogenesis [ 46 ].

BDNF has been implied in ADHD pathophysiology. It has been proposed that low levels of this neurotrophin may explain the reduction in brain volume observed in ADHD patients, and it has also been implied in dopaminergic system homeostasis. Some pharmacological treatments for ADHD promote the regulation of plasma BDNF levels [ 47 ].

4.1.1. Circulating BDNF

Since BDNF is able to cross the blood–brain barrier and plasma concentrations of BDNF are highly correlated with its levels on cerebrospinal fluid, a number of studies have searched for a difference in plasma concentrations of BDNF in ADHD patients when compared against controls. There are reports indicating a lower concentration of BDNF in plasma of ADHD patients, both in children [ 48 ] and adults [ 49 ]. In another study involving children, an increase in plasma BDNF was observed after 6 weeks of treatment with an effective dose of methylphenidate [ 50 ]. In accordance, a recent study revealed that methylphenidate treatment produces an increase in serum BDNF in boys with ADHD [ 51 ]. However, this has not always been replicated, since there are also articles reporting no difference in serum BDNF between children with ADHD and controls [ 52 , 53 , 54 ].

A recently published meta-analysis encompassing studies comparing BDNF levels in ADHD patients without any other comorbidity found no overall difference between ADHD patients and controls. However, when analyzing males and females separately, they found significantly higher levels of plasma BDNF in males with AHDH than in control males, while no difference was found between females with and without ADHD [ 55 ].

Thus, different and even contrary results have been obtained regarding BDNF concentrations in plasma or sera of ADHD patients. While this suggests that the link between BDNF and ADHD is not completely clear, other alternatives should be considered. For example, fluctuations in serum BDNF concentrations in morning and evening samples have been reported [ 56 ], meaning the lack of relation between peripheral BDNF concentration and ADHD might be due to the time of the day when the sample was obtained.

4.1.2. Genetics of BDNF

There are a number single nucleotide polymorphisms (SNP) of the BDNF gene that have been associated with ADHD. Among the most studied variations in the BDNF gene, there is a polymorphism called Val66Met (also known as rs6265), in which a change in codon 66 produces a substitution of the original amino acid (valine) by methionine. The anatomical effects of this variation are more apparent in the hippocampus and cortex [ 46 ]. While some studies have assessed the presence of this SNP in ADHD patients [ 57 , 58 , 59 ], other studies failed to find an association between this polymorphism and ADHD [ 46 , 60 , 61 , 62 , 63 ].

Another SNP of the BDNF gene whose association with ADHD is not conclusive is rs2030324, since some studies report an association between this polymorphism and ADHD [ 57 , 58 , 59 , 64 ], while other reports fail to find this association [ 46 , 60 , 61 , 62 , 63 ].

There are other SNPs of the BDNF gene that have been studied so far, with positive correlations being shown between ADHD and the presence of C270T (rs27656701) [ 58 , 61 ], rs11030101 [ 62 , 64 , 65 ], and rs10835210 [ 62 , 63 ]. There are also reports addressing SNPs of the BDNF gene for which no association with ADHD has been found, including rs12291186, rs7103411 [ 63 ], and rs7103873 [ 62 , 63 ].

Moreover, rare single nucleotide variants of BDNF gen have also been associated with a higher risk of developing ADHD [ 66 ]. However, this is an area that requires further research.

As observed with peripheral BDNF concentrations, genetic variants of the BDNF gene have been associated with ADHD in numerous cases, although in some cases there are contradictory results in different articles (see Table 1 ). Moreover, some of the genetic variants of the BDNF gene associated with ADHD have also been studied in association with other neurological conditions and treatments. For example, C270T is reported to be associated with intellectual disabilities [ 58 ]. Moreover, rs11030101 is associated with a better response to electroconvulsive shock therapy for treatment-resistant depression [ 67 ], with body weight gain in schizophrenic patients treated with atypical antipsychotics [ 68 ], as well as with the presence of major depressive disorder [ 69 ], schizophrenia, and bipolar disorder [ 70 ], although there is another publication in which no evidence of association between this SNP and bipolar disorder was found [ 71 ]. Additionally, rs10835210 has been associated with bipolar disorder, schizophrenia [ 70 ], and phobic disorders [ 72 ].

Polymorphisms of the BDNF gene studied in relation with ADHD incidence. * Polymorphisms for which contradictory results have been reported. rs, reference SNP ID number.

For rs6265 (Val66Met), there are many articles addressing the association of this SNP with different conditions, and in some of them it has been found. For example, some articles report an association of this SNP with major depressive disorder [ 69 , 73 ], while other studies fail to find this association [ 74 , 75 ]. An association has also been reported between rs6265 and amnestic mild cognitive impairment, as well as with the transition from this condition to Alzheimer’s disease [ 76 ]. However, in patients with early-stage breast cancer, this SNP is associated with a lower probability of presenting cognitive impairment after chemotherapy [ 77 ].

4.1.3. Other Neurotrophines

While BDNF has been widely studied in association with ADHD, it is not the only neurotrophin studied in relation with this condition, given the important role of neurotrophines in central nervous system development and synaptic plasticity. In this regard, there are studies addressing the participation of fibroblast growth factor (FGF), vascular endothelial growth factor, insulin-like growth factor (IGF2) [ 47 ], glial-derived neurotrophic factor (GDNF), nerve growth factor (NGF), and neurotrophin-3 (NTF-3) [ 47 , 53 ] in ADHD pathophysiology.

BDNF is a molecule highly involved in synaptic plasticity and has an undisputed role in central nervous system development. Therefore, it is not surprising to find a number of studies associating alterations in the presence of this neurotrophin in serum, or different SNPs of its gene, with ADHD. However, its role in ADHD development is not a constant for every sample of ADHD patients studied so far, and for many of the aspects of this molecule (serum levels, SNPs) there are reports indicating associations, with others finding no association at all. This does not mean that the alterations associated with this molecule are not important for ADHD, but rather highlight the variable etiology of this condition.

4.2. Dopaminergic System

The dopaminergic system emerges in early stages of CNS embryonic development, and an imbalance in this system might affect brain development. It is related with cell proliferation, neuronal differentiation and migration, synaptogenesis, and neurogenesis. Thus, it is not surprising that a role of this neurotransmitter system has been reported in different neurological diseases, including ADHD [ 78 ].

One of the most studied molecules of the dopaminergic system in relation to ADHD is DAT, a molecule responsible for dopamine reuptake, and the main target of two commonly used pharmacological treatments for ADHD, methylphenidate and amphetamines [ 78 ]. Genetic studies support the importance of this neurotransmission system for ADHD. Mice heterozygous for the DAT gene (+/− heterozygotes) are reported to present altered attentional function [ 79 , 80 ] and hyperactivity [ 80 ], while rat models with this heterozygous genotype do not present major affectations [ 81 , 82 ]. However, DAT knockout rats present hyperactivity [ 81 , 82 ], as well as a dysregulation in frontostriatal BDNF function [ 82 ]. Hyperactivity in these rats can be counteracted by amphetamine, haloperidol, and methylphenidate [ 82 ].

In humans, ADHD patients present lower DAT availability in the basal ganglia, caudate nucleus, and putamen [ 83 ]. The DAT gene presents a variable tandem repeat region (VNTR) at the untranslated 3′region, and there are different alleles for this VNTR, with the 9-repeat and 10-repeat alleles being the most frequently encountered. The reported effects of this VNTR on DAT expression vary in different articles, however the most recent results indicate that the 9-repeat allele is associated with a higher DAT expression than the 10-repeat allele. [ 84 ]. The possible association between this VNTR and ADHD has been addressed in various studies. For example, an analysis of both patients and the literature found an association of the 10-repeat/10-repeat genotype with ADHD only in adolescents [ 85 ], studies performed in children reported an association between the 10-repeat/10-repeat genotype and ADHD [ 86 , 87 ], while a recently published meta-analysis reported an association of the 10-repeat allele with ADHD in children and adolescents, specifically in European population [ 88 ]. However, there are also reports indicating no association at all between ADHD and the VNTR of DAT gene (9-repeat/10-repeat, 10-repeat/10-repeat, and 10-repeat/11-repeat genotypes) [ 89 ], no association between the 10-repeat/10-repeat allele with ADHD [ 90 ], and no association between ADHD and the 9-repeat or the 10-repeat alleles for this polymorphism [ 91 ]. The last three studies were performed in children.

Additionally, the relevance of this VNTR has been studied in relation to cognitive function in healthy subjects. Again, mixed results were found. A meta-analysis published in 2016 addressing studies performed in healthy subjects did not find any association between DAT VNTR and different cognitive functions, such as executive functions, inhibition, attention, and long-term declarative memory [ 92 ]. A study performed in children aged 3 to 5 years old addressing the presence of the 9-repeats and 10-repeats alleles revealed that the presence of the 10-repeat allele of the DAT gene is associated with diminished ability to voluntarily regulate reactivity in healthy children [ 93 ]. A recent study on both ADHD and healthy children reported an effect of the specific genotype in the performance of children on attentional switching when studying the whole research sample, in which children carrying the 9-repeat allele performed worse than those carrying the 10-reapet homozygous or the 10-repeat/11-repeat heterozygous allele [ 91 ]

The participation of the dopaminergic system in the pathophysiology of ADHD has been widely reported [ 78 ]. Herein, we study a particular variation of the DAT gene, a VNTR in the 3′ region of the gene, finding articles supporting a role of this polymorphism in ADHD, as well as works failing to find an association between this VNTR and ADHD. This does not imply a lack of importance of this variation, but rather highlights the variability in the genetic etiology of this condition. Moreover, while the dopaminergic system is highly involved in the pathophysiology of ADHD, given its role in CNS development, it is also strongly related with other neuropsychiatric conditions, such as autism [ 78 , 94 , 95 ] and schizophrenia [ 78 , 94 , 96 , 97 ].

5. Changes in Brain Structure and Function in ADHD Patients

As an NDD, ADHD involves alterations of mechanisms such as neurogenesis and synaptogenesis. There are a number of possible mechanisms through which these alterations take place, both environmental and genetic, some of which have been mentioned in the present review. In the end, all of these altered mechanisms produce an altered brain function affecting attention and impulse control, functions regulated by the central nervous system. Understanding the changes in brain function associated with ADHD might shed some light not only on the functional causes of this condition, but also on possible ways to deal with it.

5.1. Brain Imaging Studies

Children with ADHD present atypical connectivity in reward circuitry when compared with control children. Increased connectivity of the nucleus accumbens with the prefrontal cortex was observed to be associated with greater impulsivity [ 98 ].

Hypofunction and abnormal cortico-striatal pathways of the cortico-striato-thalamo-cortical (CSTC) circuit are associated with ADHD. Five different CSTC circuits have been reported: the sustained attention circuit, emotion circuit, selective attention circuit, hyperactivity circuit, and impulsivity–compulsivity circuit. Four of them (except emotion circuit) have been related with ADHD diagnostic criteria. However, pathogenesis of the emotion circuit is also related with ADHD [ 99 ]

A study on ADHD children reported significantly decreased white matter volume, as well as decreased volume in the cortex and caudate nucleus, although it did not reach statistical significance. Cortical thickness was reduced in ADHD patients bilaterally in the frontal cortex and in the right cingulate cortex, structures related with executive function and attention. Regarding default mode network, functional connectivity was reduced in ADHD children in the anterior and posterior cingulate cortexes, lateral prefrontal cortex, left precuneus, and thalamus. However, connectivity was increased in the bilateral posterior medial frontal cortex [ 100 ].

A study on male adolescents with ADHD and controls reported decreased gray matter volume in the left anterior cingulate cortex and bilateral decreases in the occipital cortex, hippocampus–amygdala complex, and cerebellum in ADHD adolescents [ 101 ]. Such decreases in cerebellar volume have been previously reported in both female and male ADHD patients [ 102 ].

An important issue with many of the imaging studies in ADHD patients has been small sample size. A large-scale study performed on children, adolescents, and adults with ADHD reported decreased surface area in children, mainly in the frontal, cingulate, and temporal regions. This effect was more pronounced in younger children (4–9 years old). Moreover, cortical thickness in ADHD children is also reduced in the fusiform gyrus and temporal lobe, an effect more prominent in children of 10 and 11 years old. No change in surface area or cortical thickness was observed in adolescent or adult ADHD patients [ 103 ].

There are important changes in brain morphology in ADHD patients. An elegant study performed in ADHD patients and controls from 6 to 28 years of age analyzed differences in neurodevelopmental trajectories. This study reported that ADHD patients present overall reduced cortical volume, mainly in frontal lobes, and primarily due to a decrease in surface area and gyrification. Interestingly, although both groups presented maturational changes due to age, they presented different trajectories for these changes, suggesting that ADHD is associated with developmentally persistent changes in the whole cortex, mostly due to decreased surface expansion (reduced surface area and less convolution) [ 7 ].

When comparing children with comorbid epilepsy and ADHD with control children, a widespread decrease in cortical thickness is observed, along with decreased volume in some subcortical structures and the brainstem. These alterations were observed early in the course of epilepsy, thus the authors suggested that neurodevelopmental changes occurred before epilepsy onset [ 104 ]. In children with comorbid autism spectrum disorder and ADHD, when compared with typically developing controls, presented significantly lower volumes in left postcentral gyrus. This was observed through magnetic resonance imaging in both children and preadolescents, but was absent in adolescents. The authors suggested that pathophysiology in these comorbid patients may be related to somatosensory deficits and delayed maturation in this area [ 105 ].

5.2. Quantitative Electroencephalography

All these changes lead to alterations in brain function. A frequently used technique for the study of brain activity is quantitative electroencephalography (qEEG), since it has a low cost, a high temporal resolution, and does not need special facilities to be performed. Furthermore, qEEG has also been used to determine the effects of pharmacological treatments on brain activity in order to assess effectiveness [ 106 , 107 ], to choose the correct pharmacological option for a patient [ 108 ], to study the effects of previous pharmacological treatments on the current one [ 109 , 110 ], as well as to determine a possible cognitive effect of the chosen pharmacological treatment [ 111 ].

During the last decades, several studies have performed qEEG analyses on ADHD patients. A review on the subject published in 2012 addressed the main associations between brain activity and ADHD, including increased frontocentral theta activity. Another frequently reported factor, although not always replicated, is an increased theta/beta ratio. For beta and alpha bands, most of the reports have indicated decreased activity, although there are also reports that have indicated increased activity in these frequency bands in ADHD patients [ 112 ]. One of the most used indicators for ADHD is the theta/beta ratio in the Cz region. It has been reported that ADHD children (inattentive and combined subtypes) present increased theta/beta ratios [ 1 ]. Another study found that children with ADHD presented more delta and theta activity [ 113 ]. However, some authors have mentioned that this measure is not necessarily useful for diagnosis, since among other issues, it presents variations according to age [ 114 ].

Another example of the influence of age on brain electrical activity associated with ADHD is a study comparing children with and without ADHD, as well as adults with and without ADHD. Interestingly, children with ADHD presented higher delta and theta activity than control children, while in adults no difference was found between ADHD group and controls in the frequency bands analyzed [ 115 ]. Among the few differences in qEEG activity found in adults with ADHD is a higher gamma activity (39.25–48 Hz), suggesting a functional alteration in dorsal attention network [ 116 ].

ADHD patients often present comorbidities [ 117 ], which might influence qEEG in a different way to the findings in ADHD only patients. For example, children with ADHD and problematic Internet use present differences in qEEG when compared to ADHD only patients. However, no differences were found between ADHD only patients and ADHD patients with depression [ 118 ]. Another study found that adolescents with ADHD and Internet gaming disorder presented lower relative delta power and greater relative beta power than adolescents with ADHD only [ 119 ].

It is noteworthy that although a number of studies have been published regarding neurophysiological correlates of ADHD through qEEG, there are still some differences in the results reported by different authors. Beyond possible methodological differences, there are a number of factors reported to influence qEEG activity in ADHD patients, which might be responsible—at least in part—for the differences reported so far, and which might be of importance when using qEEG information to choose or design a therapeutic approach. These factors include comorbidities [ 4 , 120 ] and the ages of the patients [ 114 , 116 , 121 ]. Other factors reported to affect qEEG activity in other populations and conditions are ethnicity [ 122 , 123 , 124 , 125 , 126 ], sociocultural environment during development [ 127 , 128 ], and the degree of advancement of a psychiatric condition, as reported for alcohol dependence [ 129 , 130 , 131 ].

6. Therapeutic Approaches

6.1. pharmacological treatment.

Both stimulant and non-stimulant pharmacological treatments have proven to be effective in diminishing ADHD symptoms in children and adolescents [ 132 , 133 ], although stimulant medication seems to have greater effectiveness [ 133 , 134 ]. Herein, we will address one frequently used stimulant (methylphenidate) and one frequently used non-stimulant (atomoxetine)

6.1.1. Methylphenidate

Methylphenidate is one of the most used drugs for ADHD treatment. It has been present in the market for 50 years and it reduces excessive hyperactivity, impulsivity, and inattention in children and adolescents with ADHD. In the United States, it is prescribed to 8% of children and adolescents under 15 years of age and to around 3% to 5% of the same population in Europe [ 135 ].

Methylphenidate blocks DAT and NET, reducing reuptake and producing an increase in available dopamine and norepinephrine in the synaptic cleft [ 135 , 136 , 137 ], leading to increased dopamine and norepinephrine transmission in the prefrontal cortex [ 132 ]. A meta-analysis on the effects of methylphenidate treatment on ADHD in adults found it effective in improving neurocognitive performance, accomplishing better results than placebo groups in terms of working memory, reaction time variability, vigilance, driving, and response inhibition [ 136 ].

6.1.2. Atomoxetine

Atomoxetine has been reported to be effective for ADHD treatment [ 138 ], being more effective in adults than in children [ 134 ].

Atomoxetine blocks norepinephrine reuptake, producing increased presence of norepinephrine and dopamine in prefrontal cortex [ 132 ]. Since atomoxetine does not produce an increase of dopamine or norepinephrine in the nucleus accumbens, it lacks abuse potential [ 132 , 139 ]. This drug is associated with improvements in quality of life in children adolescents and adults, although this parameter is not further increased with long-term use [ 139 ].

6.1.3. Adverse Effects

Both stimulant and non-stimulant pharmacological treatments for ADHD produce adverse effects in a percentage of treated patients. The main adverse effects found for these drugs (% of patients treated with stimulants/% of patients treated with non-stimulants) are decreased appetite (28.6%/14.2%), nausea (7.9%/10.3%), headache (14.5%/20.8%), insomnia (12.3%/8.6%), nasopharyngitis (6.0%/7.1%), dizziness (5.1%/10.0%), abdominal pain (7.8%/11.5%), irritability (9.3%/6.9%), and somnolence (4.4%/34.1%) [ 133 ].

A systematic review on the adverse effects of methylphenidate in children and adolescents revealed that about 1 in 100 patients present serious adverse events after methylphenidate treatment (including death, cardiac problems and psychiatric disorders), while more than half of the patients treated with methylphenidate suffer one or more adverse events. The authors concluded that it is important to identify subgroups of patients who might be harmed by methylphenidate treatment and highlight the importance of remaining alert to possible adverse events in patients with this treatment [ 135 ]. There might also be uncommon adverse effects. For example, there is a report of 3 cases of systemic sclerosis associated with methylphenidate treatment [ 140 ]. The authors of the last study suggested that patients with signs of autoimmune or vasospastic conditions should be briefed about this possible side effect before commencing methylphenidate treatment.

A systematic review on possible adverse effects of atomoxetine, including decreased growth rate, cardiovascular and hepatic effects, aggression, psychosis, seizures, and suicidal ideation, determined that evidence indicates it is safe to use in ADHD patients [ 141 ]. Furthermore, the presence of comorbidities does not interfere with treatment efficacy, nor does treatment exacerbate comorbid symptoms [ 142 , 143 ]. However, it is important to be alert to other possible adverse effects. A case report and review indicated that the appearance of tics is a common side effect of atomoxetine treatment [ 144 ].

Methylphenidate and atomoxetine are known to increase heart rate and blood pressure, raising concern regarding possible cardiovascular effects of these drugs in ADHD patients. A review on the cardiovascular effects of these drugs in healthy subjects found the drug to be safe to use. Most of these studies were performed in children and adolescents, although there have also been some studies performed on adults, with no serious risk being reported in these subjects either. However, patient blood pressure and heart rate should be monitored on a regular basis. Moreover, careful follow-up should be performed for patients presenting certain cardiovascular conditions [ 145 ].

Weight loss has also been reported after atomoxetine treatment, occurring during the first two years of treatment. However, evidence suggests this decrease begins to be compensated between 2 and 5 years after the beginning of treatment [ 141 ]. Similarly, methylphenidate has been associated with adverse effects such as anorexia, weight loss, and insomnia [ 146 ].

A comparative study on short-term effects of methylphenidate and atomoxetine on ADHD reported significantly higher weight loss in children treated with atomoxetine [ 147 ]. However, a more recent study reported that children present significantly more weight loss after methylphenidate than after atomoxetine treatment [ 148 ].

A meta-analysis on gastrointestinal adverse effects of methylphenidate reported increased risk of decreased appetite, weight loss, and abdominal pain in children and adolescents under this pharmacological treatment [ 149 ].

A comparison between the presence of adverse effects after methylphenidate and atomoxetine treatments in ADHD children indicated methylphenidate as a safer option, since children under atomoxetine treatment presented higher incidence rates of anorexia, nausea, somnolence, dizziness, and vomiting than children under methylphenidate treatment [ 147 ]. A more recent study reported similar results, since children treated with atomoxetine presented higher incidence rates of mild adverse effects, such as decreased appetite, weight loss, dyspepsia, abdominal pain, stomach ache, irritability, mood disorders, and dizziness. As for severe adverse effects, patients under atomoxetine treatment presented higher incidence rates of gastrointestinal, neuropsychiatric, and cardiovascular effects [ 150 ].

6.1.4. Long-Term Adverse Effects

Long-term adverse effects of methylphenidate are the subject of intense study, given that it is the first-line stimulant drug used for ADHD treatment in children, adolescents, and adults [ 11 , 151 ]. A review on the subject addressed different adverse effects studied in patients after long-term (over one year) administration of methylphenidate, including low mood or depression, anxiety, irritability or emotional reactivity, suicidal behavior or ideation, bipolar disorder, psychotic symptoms, substance use disorders, tics, seizures or EEG abnormalities, and sleep disorders. The authors concluded that existing information indicates that methylphenidate is safe to use, although caution should be taken when prescribing this drug to specific groups, such as preschool children, patients prone to psychosis or tics, and high-risk adolescents [ 152 ]. However, the need for more studies on the long-term effects of treatment with this drug is highlighted, since studies in humans are rather scarce and with a high degree of heterogeneity in terms of methodological approach [ 151 , 152 ].

6.1.5. Long-Term Therapeutic Effect

Given that ADHD is a chronic disorder and that many of the children presenting ADHD will still present symptoms in adulthood, it is particularly important to determine the long-term effectiveness of pharmacological treatments. However, very few studies address this issue, and no conclusion can yet be drawn regarding the long-term effects (years) of pharmacological treatment of ADHD on symptom reduction and quality of life. Thus, the long-term efficacy of drug treatment for ADHD remains under debate [ 153 , 154 , 155 , 156 ]

Current pharmacological treatments for ADHD have proven to be safe and effective. The efficacy of these treatments on ADHD symptoms is clear, and thus pharmacological therapy is often used to treat ADHD patients [ 136 , 138 , 141 , 152 ]. However, there are also some drawbacks to this therapeutic approach, including the time required to reach the effective dose for each patient [ 3 , 157 ]; the lack of response in some patients [ 121 , 158 , 159 , 160 ]; the unresolved issue of long-term effectiveness (of great importance given that in many cases the treatment must go on for years) [ 153 , 154 , 155 , 156 ]; the presence of adverse effects, which although not life threatening in most cases, are nevertheless upsetting [ 133 , 135 , 144 ]; and the existence of specific groups of patients with whom a greater caution must be taken [ 140 , 145 , 152 ]. Altogether, these drawbacks have led to the search of new therapeutic approaches. One of the strategies studied so far is the possibility of using other drugs to treat ADHD, including drugs interacting with serotoninergic (metadoxine, paroxetine, duloxetine, buspirone), glutamatergic (memantine), cholinergic (AZD3480, AZD1446, lobeline, galantamine, mecamylamine), histaminergic (mk-0249), and catecholaminergic neurotransmission systems (modafinil, droxidopa, desipramine, bupropion, nomifensine, reboxetine, venlafaxine, duloxetine, guanfacine, aripiprazol, dasotraline, selegiline), as well as lithium [ 161 ].

6.2. Non-Pharmacological Therapies

Pharmacological therapy is effective although presents some inconveniences, including the existence of adverse effects in some patients and lack of effect in others. Therefore, there are also different non-pharmacological approaches for ADHD treatment.

6.2.1. Behavioral Parent Training

The goal of parent training is to equip parents with techniques that will be useful in managing ADHD-related behavior presented by their children. A systematic review published on 2011 found no reliable effect of ADHD children’s behavior, although it may lead to increased confidence and decreased stress in parents [ 162 ]. Later studies found an effect of behavioral parent training on ADHD symptoms, which is not increased by previous working memory training, although this combination did produce positive effects on working memory storage and processing [ 163 ]. It is noteworthy that cognitive functioning of both parents and children influences the effectiveness of this therapeutic approach on ADHD symptoms. Better working memory in children and higher parental response caution presented an association with improvements in inattention. As for conduct problems, better parental self-regulation was associated with a better result in this area. However, none of the measured cognitive functions in children or parents were associated with improvements in hyperactivity [ 164 ]. Moreover, behavioral parent training improves coexistence at home, since a reduction in the frequency and severity of problematic situations is produced, along with a reduction of stress in parents [ 165 ].

6.2.2. Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) has also been used to treat ADHD. A review performed on the subject found CBT to be effective in reducing ADHD symptoms in adults, however only when improvement was evaluated by the patient and not when evaluated by the clinician [ 166 ], although a more recent meta-analysis on the subject reported a good effect of CBT on ADHD adults [ 167 ]. A Cochrane systematic review concluded that CBT has a positive effect on ADHD symptoms, either alone or in conjunction with other therapies, although considered the evidence to be low-quality in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group approach. [ 168 ]. A meta-analysis found that CBT is one of the most effective non-pharmacological options to treat ADHD, ranking just after physical exercise [ 169 ]. A later systematic review confirmed the effects of CBT on ADHD symptoms [ 170 ]. A recent study reported CBT to be effective in reducing ADHD symptoms in patients, either with or without conjunct medication [ 171 ].

6.2.3. Attention Training Techniques

Attention training techniques are often used to improve life quality and increase well-being. Given the effect of these techniques on brain activity, as well as on attention and self-regulation, their use to reduce ADHD symptoms and improve life quality in these patients is currently under study [ 172 ].

Mindfulness can be defined as paying attention to the present, an activity that implies sustained attention. A systematic review on the effects of mindfulness-based interventions on ADHD found that such approaches were popular among adults with ADHD, finding improvements in attention, although the effects of such approaches in children and adolescents are still unclear [ 173 ]. A recent meta-review reported a large effect size of mindfulness on ADHD [ 174 ]. A review on the effects of mindfulness-based cognitive therapy on ADHD adults reported good effects of this therapeutic approach, especially when used in conjunction with pharmacological therapy [ 175 ], while a systematic review analyzing the effects of meditation-based techniques (either on parents and children or on children only) on ADHD children could not draw a clear conclusion regarding beneficial effects [ 176 ].

Adult ADHD patients that underwent an 8-week mindfulness awareness practice period presented decreased ADHD, depression, and anxiety symptoms [ 177 ]. Similarly, a study performed with children revealed that an 8-week period of mindfulness-oriented meditation produced improvements in the performance of neuropsychological tests, as well as in ADHD symptoms. Although encouraging, the authors stated that the results are still preliminary, given the small number of children participating in the study [ 178 ]. There are also results indicating that this technique produces an improvement in ADHD symptoms in ADHD children with oppositional defiant disorder [ 179 ].

6.2.4. Neurofeedback

Neurofeedback (NFB) is a therapy in which patients learn to modify EEG patterns through operant conditioning. There are articles reporting the induction of plastic changes after NFB training [ 180 , 181 , 182 , 183 ], supporting a theory explaining the effects of NFB on different brain disorders through the induction of synaptic plasticity, leading to an homeostatic set point. Additionally, besides some unusual cases of headache, no collateral effects have been reported with this technique. One of the most interesting aspects of NFB is the induction of plastic changes from within the brain under normal physiological conditions, without the need for an external stimuli such as pharmacological treatments or transcranial stimulation to alter brain activity, thus the probability of adverse effects is minimal [ 181 ].

Specific NFB protocols have been developed over the decades. These protocols were designed based on articles reporting specific qEEG variations in neurological patients or qEEG patterns associated with cognitive function. Some of these standardized protocols have been studied in terms of their ability to treat ADHD [ 184 ].

Several articles have addressed the use of NFB in ADHD patients. The results have been mixed and numerous meta-analyses have been published on the subject. The conclusions of these meta-analyses have also been mixed. There are meta-analyses reporting good effects of NFB on ADHD [ 185 , 186 , 187 ], not finding reliable effects [ 188 ], not reaching a conclusion on the subject of efficacy [ 189 ], finding a minor effect of this therapeutic approach significantly below what is observed with pharmacological treatment [ 190 ], or finding a minor effect only in the presence of pharmacological treatment [ 191 ].

An overview of recent publications gave the same impression. Some reports found effects of NFB theta/beta or theta/alpha protocols on ADHD, measurable at follow-up 8 weeks or 12 months after treatment completion [ 192 , 193 ]. Other reports found no effect [ 194 , 195 , 196 ]. Moreover, there are reports revealing a minor effect of NFB, below the effect levels of other therapeutic approaches [ 197 , 198 , 199 ].

NFB is a therapeutic approach widely studied for ADHD treatment. The results so far have been mixed. However, given the absence of side effects and its ability to induce synaptic plasticity [ 181 ], it is an option worth keeping in mind.

6.2.5. Other Non-Pharmacological Approaches

The use of non-pharmacological supplementations, such as polyunsaturated fatty acids, peptides, amino acids, plat extracts, probiotics, micronutrients, and herbal supplementation, is currently being studied in order to determine their usefulness in treating ADHD. However, further research is still needed in this area [ 200 ].

A study performed in ADHD children under methylphenidate treatment for whom zinc supplementation was added reported no significant effect of zinc supplementation on the total score for a parent’s questionnaire for ADHD or in the hyperactivity and impulsivity subscales. However, zinc-supplemented children present improvements in inattention scores [ 201 ].

A meta-analysis on non-pharmacological interventions for ADHD patients found that physical exercise produced a good effect on ADHD cognitive symptoms, especially aerobic exercise targeting executive functions [ 169 ].

7. Treatment Personalization

In the first sections of this review, we addressed some of the factors associated with ADHD incidence, ranging from a variety of environmental factors to the presence of different genetic polymorphisms. However, these different etiologies are not always present, since patients might present one or another (see Section 2 and Section 3 ). Similarly, while there are some changes in brain activity associated with ADHD, they are not always the same (see Section 4 ). Accordingly, there is also variation in the response of patients to both pharmacological and non-pharmacological treatments (see Section 5 ).

Since the etiology of ADHD could be very different from patient to patient, the precise nature of the physiological changes underlying the clinical manifestations of ADHD in each case could be slightly different, affecting the effectiveness of the chosen treatment and possibly explaining the variation in the effect of the same treatment on different patients. This can be observed in the variations in qEEG activity observed in different studies [ 112 , 113 , 114 , 116 , 121 ]. However, the design of personalized treatments based on specific characteristics of each patient could lead to better clinical results. In this regard, strategies to adjust therapeutic approaches based on patients’ characteristics have been used for both pharmacological and non-pharmacological therapies.

Selecting the appropriate pharmacological treatment and the dose to be used takes some time, given the large inter-individual variability regarding treatment efficacy, leading to a delay in reaching a therapeutic effect, and in some cases producing an early termination of treatment due to frustration, either by the provider or the family [ 157 ]. Moreover, there is some variability regarding patient response to methylphenidate, including patients that do not achieve adequate symptom control or experience adverse effects with commonly used doses. Therefore, dose optimization has been proposed as a means to achieve an adequate effect for most of the patients, enhancing both the efficacy and safety of methylphenidate treatment [ 3 ]. This has led to the search for strategies to find adequate treatments for each patient, such as pharmacogenomics, in which a patient’s genotype for a particular gene is used to predict the effects of medication in that patient. However, in spite of the progress that has already been made, no pharmacogenomic test so far has been found to be helpful in treatment selection [ 157 ].

Treatment resistance has been reported for both atomoxetine [ 158 ] and methylphenidate [ 121 , 159 , 160 ]. For this reason, qEEG can be used as a source of information to determine at an earlier point whether methylphenidate [ 121 , 160 , 202 ] or atomoxetine [ 107 , 202 ] is effective or if an alternative treatment is needed for a patient.

Most of the reports on the use of NFB for ADHD use a standardized protocol, either equal for all participants or adapted to each patients after qEEG analysis. However, there is another more personalized approach known as qEEG-informed (or qEEG-guided) NFB. In this variant of NFB, rather than selecting a particular protocol (for example, theta/beta ratio) and applying it to all participants, subjects receive a NFB protocol selected for them after qEEG analysis. This type of NFB has been successfully used in schizophrenia [ 203 ], obsessive compulsive disorder [ 204 ], migraine [ 205 ], dementia [ 206 ], and with learning-disabled children [ 207 , 208 ].

There are so far only two studies applying qEEG-informed NFB in ADHD patients, so it is not yet possible to perform a meta-analysis on the effects of this type of NFB on ADHD. However, a positive effect of NFB has been reported in both published studies [ 209 , 210 ].

8. Discussion

ADHD is an NDD with a complex etiology. While it is clear that its main cause is alterations in neurodevelopmental processes such as synaptogenesis, myelination, and neurogenesis [ 5 ], the causes of these neurodevelopmental alterations are diverse. In some cases they might be associated with environmental factors such as premature birth [ 6 ], perinatal problems [ 9 ], nutrition during pregnancy [ 10 ], or exposure to heavy metals [ 17 , 18 , 19 , 26 , 27 , 29 ]. Additionally, there is strong evidence of genetic influence on ADHD [ 43 , 44 ], and an interaction between environmental and genetic factors cannot be discarded.

The purpose of this review is not to fully describe all factors associated with ADHD appearance, but rather to address some of the main etiologies described so far, in order to clarify the high diversity of factors associated with this NDD. When analyzing the different sections of this review, one thing becomes evident—that ADHD patients are diverse regarding the etiology of their condition and their responses to treatment. This heterogeneity outlines the high variability in patients’ particular conditions regarding ADHD symptom manifestation and treatment, since it is probable that the underlying neurophysiological alterations for each patient are at least slightly different. Thus, standardized treatment (either pharmacological or non-pharmacological) may not be equally efficient in all cases.

Moreover, there could be other factors that are usually disregarded in relation with ADHD incidence, but which might play an important role in this condition. Recently, the gut microbiome has been the subject of intense research as an ADHD-associated factor, and even though further research is needed in order to determine its precise influence on ADHD, there are already reports indicating a possible link between them [ 211 , 212 , 213 , 214 ].

In the end, all of these factors produce changes in brain structure and function [ 1 , 7 , 112 , 113 , 114 , 115 ], leading to the symptomatology observed in ADHD patients. Therapeutic approaches to treat this condition have the objective of compensating such alterations in order to reduce symptoms and improve quality of life. However, as we have observed in this review, not all patients present the same neurophysiological changes. Studies performed on qEEG activity have yielded different results regarding brain electrical activity in ADHD patients [ 4 , 112 , 114 , 120 ]. Additionally, both brain imaging and qEEG techniques have revealed that changes are not consistent throughout the lifespan, being different in children and adults [ 114 , 115 , 116 , 121 ]. Therefore, there is a need for treatment personalization for each ADHD patient in order to achieve greater effect with minimal adverse effects.

Pharmacological treatments, both stimulants and non-stimulants have proven to be effective and safe for ADHD patients [ 132 , 133 ], and thus are widely prescribed to treat this condition. However, the pharmacological approach to ADHD treatment has some drawbacks, mostly regarding difficulties in reaching effectiveness in all patients [ 3 , 121 , 157 , 158 , 159 , 160 ] and the presence of adverse effects [ 133 , 135 , 144 ].

The search for other therapeutic options has led to the assessment of the effects of other drugs on ADHD [ 161 ], as well as the design of non-pharmacological treatments, such as behavioral parent training, CBT, attention-improving techniques, and NFB.

The effects of behavioral parent training on ADHD symptoms in children are not consistent, with some articles finding effects [ 163 ] and others not finding any [ 162 ]. However, behavioral parent training does reduce stress in parents and promotes a better coexistence at home, which is favorable for children [ 162 , 165 ]. In the case of CBT, there is more evidence indicating a good effect in reducing ADHD symptoms [ 167 , 168 , 169 , 170 , 171 ]

Attention training techniques are still under intense study. There is some evidence regarding the effect of this technique on ADHD in adults [ 173 , 175 ], while in children and adolescents the results are not clear so far [ 173 , 176 ].

A number of studies on the effect of NFB on ADHD symptoms have yielded different results, either finding a positive effect [ 185 , 186 , 187 , 192 , 193 ], a mild effect [ 190 , 197 , 198 , 199 ], or no effect at all [ 188 , 194 , 195 , 196 ]. However, NFB has a number of advantages that encourage the search for an adequate protocol to treat ADHD patients. It is targeted directly to change brain activity associated with the condition under treatment, it has virtually no side effects, and the therapeutic effect is due to the induction of plastic changes in the central nervous system, thus it might establish a long-term changes [ 180 , 181 , 182 , 183 ].

9. Conclusions

In the present review, we have gone through some of the factors associated with ADHD, and it is clear that a great heterogeneity exists in the etiology of this condition. Therapeutic approaches, although functional in many cases, also show heterogeneity in their effects in certain groups of patients. The diverse range of effects of the therapeutic approaches used should not be a surprise, given the diversity of etiologies found in ADHD. Even though clinical manifestations of this condition might be similar (diagnosis is based on the presence certain symptoms), the same clinical manifestations could occur with different underlying physiological changes, considering the variations in qEEG activity in different groups of patients [ 112 , 113 , 114 , 116 , 121 ]. Thus, these neurophysiological changes presented by patients may not necessarily respond in equal form to a given therapeutic approach. Given the inter-personal variance in the etiology of ADHD, it is advisable to personalize the therapeutic approach. Regarding pharmacological therapies, dosage optimization [ 3 ], pharmacogenomics [ 157 ], and the use of qEEG to select the adequate drug for a given patient have been proposed [ 107 , 121 , 160 , 202 ].

Regarding non-pharmacological options, the use of qEEG-informed NFB has been proposed for personalized treatment in ADHD patients. The studies carried out to date have shown positive results [ 209 , 210 ], although the number of studies is still too small to draw a conclusion. However, given the advantages of NFB [ 181 ] and the positive effects of this approach reported for other conditions [ 203 , 204 , 205 , 206 , 207 , 208 ], it is worth performing further studies on the effectiveness of this type of NFB on ADHD.

Author Contributions

Conceptualization, L.N.-J. and W.V.H.-M. writing—reviewing and editing, L.N.-J., W.V.H.-M., and A.H.-S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Olfson M , Wall MM , Wang S , Laje G , Blanco C. Treatment of US Children With Attention-Deficit/Hyperactivity Disorder in the Adolescent Brain Cognitive Development Study. JAMA Netw Open. 2023;6(4):e2310999. doi:10.1001/jamanetworkopen.2023.10999

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Treatment of US Children With Attention-Deficit/Hyperactivity Disorder in the Adolescent Brain Cognitive Development Study

  • 1 Department of Psychiatry, College of Physicians and Surgeons, Columbia University and the New York State Psychiatric Institute, New York
  • 2 Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, Rockville, Maryland
  • 3 Maryland Institute for Neuroscience and Development Inc, Chevy Chase
  • 4 Washington Behavioral Medicine Associates, LLC, Chevy Chase, Maryland
  • 5 Department of Psychiatry, Texas Tech University Health Science Center, Lubbock

Question   What percentage of children with parent-reported attention-deficit/hyperactivity disorder (ADHD) receive treatment?

Findings   In this cross-sectional study of 11 723 children aged 9 and 10 years, 12.9% of children with parent-reported ADHD were currently receiving ADHD medications, including 15.7% of boys, 7.0% of girls, 14.8% of White children, 9.4% of Black children, 32.3% of children of parents without a high school education, and 11.5% of children whose parents had a bachelor’s degree. Approximately 26.2% of children with parent-reported ADHD had ever received outpatient mental health care.

Meaning   This study suggests that pervasive gaps exist in the treatment of children, especially girls, with parent-reported ADHD.

Importance   Characterizing the extent and pattern of unmet needs for treatment of children with attention-deficit/hyperactivity disorder (ADHD) could help target efforts to improve access to ADHD medications and outpatient mental health care.

Objective   To describe current ADHD medication use and lifetime outpatient mental health care among a large national sample of children with ADHD.

Design, Setting, and Participants   This study uses cross-sectional survey data from the first wave of the Adolescent Brain and Cognitive Development Study (n = 11 723), conducted from June 1, 2016, to October 15, 2018, among 1206 school children aged 9 and 10 years who met parent-reported Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for current ADHD. Statistical analysis was performed from March 23, 2022, to March 10, 2023.

Main Outcomes and Measures   Current ADHD medications including stimulants and nonstimulants, lifetime outpatient mental health care, or either treatment. Weighted results are reported.

Results   Among a sample of 11 723 children, 1206 had parent-reported ADHD (aged 9-10 years; 826 boys [68.2%]; 759 White, non-Hispanic children [62.2%]), 149 (12.9%) were currently receiving ADHD medications. Children receiving ADHD medications included a significantly higher percentage of boys (15.7% [121 of 826]) than girls (7.0% [28 of 108]), White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), children of parents without a high school education (32.2% [9 of 36]) than of parents with a bachelor’s degree or higher (11.5% [84 of 715]), and children with the combined subtype of ADHD (17.0% [83 of 505]) than with the inattentive subtype (9.5% [49 of 523]). Approximately 26.2% of children (301 of 1206) with parent-reported ADHD had ever received outpatient mental health care. Children receiving outpatient mental health care included a significantly higher percentage of children whose parents had a high school education (36.2% [29 of 90]) or some college (31.0% [109 of 364]) than a bachelor’s degree or higher (21.3% [153 of 715]), children with family incomes of less than $25 000 (36.5% [66 of 176]) or $25 000 to $49 999 (27.7% [47 of 174]) than $75 000 or more (20.1% [125 of 599]), and children with the combined subtype of ADHD (33.6% [166 of 505]) than with the predominantly inattentive subtype (20.0% [101 of 523]) or the hyperactive-impulsive subtype (22.4% [34 of 178]) of ADHD.

Conclusions and Relevance   This cross-sectional study of children with parent-reported ADHD suggests that most were not receiving ADHD medications and had never received outpatient mental health care. Gaps in treatment, which were not directly associated with socioeconomic disadvantage, underscore the challenges of improving communication and access to outpatient mental health care for children with ADHD.

In the US and other high-income countries, an increasing number of children receive a clinical diagnosis of and are treated for attention deficit/hyperactivity disorder (ADHD). 1 - 7 The percentage of US children whose parents report their child has received a diagnosis of ADHD increased from 5.5% in 1999 to 9.8% in 2018. 8 The Centers for Disease Control and Prevention (CDC) further report that 77% of US children who received a diagnosis of ADHD received treatment and that 69% received medications. 8 , 9

Reports of increasing rates of children treated with medications for ADHD have fueled public 10 - 12 and professional 13 perceptions that childhood ADHD is overdiagnosed and overtreated. However, a focus on the increasing numbers of children treated for ADHD does not give a sense of what fraction of children in the population with ADHD receive treatment. To estimate the unmet need for ADHD treatment, it is necessary to ascertain children from outside of clinical settings, evaluate them for ADHD, and assess their treatment use.

Beyond estimating the overall proportion of children with ADHD who receive treatment, it is important to understand which children with ADHD are more or less likely to receive treatment. Characterizing treatment patterns could guide efforts to improve mental health care access for underserved groups. Prior studies have reported that, among children with ADHD, girls are less likely than boys 2 , 14 - 17 to receive ADHD medications, as are children from ethnic and racial minority groups compared with non-Hispanic White (hereafter, White) children. 15 , 16 , 18 , 19 Although some research further suggests that children with ADHD who are from lower-income families compared with higher-income families are less likely to receive ADHD medications, 19 - 22 other studies have reported the reverse. 9 , 23 , 24 In a school-based sample, children with the combined subtype of ADHD were more likely than those with either the inattentive or hyperactive-impulsive subtype of ADHD to receive stimulants. 25 One study found that hyperactive symptoms were associated with ADHD medication use, 26 while another found that severity of inattention and hyperactivity-impulsivity symptoms had similar correlations with ADHD medication treatment. 27

We characterize treatment patterns among a cohort of US school children aged 9 and 10 years whose parents reported that their children met Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-5 ) ADHD criteria. We estimate the percentages of these children who were currently treated with ADHD medications, had ever received outpatient mental health care, or both. We hypothesized that most children with parent-reported ADHD would not be currently receiving ADHD medications or have never received outpatient mental health care and that treatment gaps would be greater for girls than boys and for children from families of lower socioeconomic status.

Analyses were performed with baseline data from the Adolescent Brain Cognitive Development (ABCD) Study of 11 723 children ages 9 and 10 recruited from primary schools and public school systems at 21 sites nationwide from June 1, 2016, to October 15, 2018. By recruiting from demographically, geographically, and socioeconomically diverse school systems, the ABCD Study sought a sample reflecting the US demographic composition. 28 A stratified probability sample of schools was selected from each site to approximate national representativeness with respect to sex, race and ethnicity, and socioeconomic status. Survey weights were developed to further balance the sample with respect to basic sociodemographic characteristics, including child age, sex, and race and ethnicity, as well as household family income, family type (married parents or single parent), household size, parent’s work status, and US Census region. 29 Parent and child recruitment within schools was voluntary and therefore self-selected, and response rates were not available to incorporate into the sampling weights. As a consequence, the sample is not representative of the selected school systems or the nation. 30 The institutional review board of the University of California, San Diego gave centralized approval for data collection, and each individual study site obtained approval from their local institutional review board. All parents and caregivers provided written informed consent, and the children provided verbal assent. This report followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline for reporting cross-sectional studies.

Inclusion criteria were age 9.00 to 10.99 years and attendance at the sampled school. In brief, exclusion criteria included not being fluent in English; neither parent being fluent in English or Spanish; a major medical or neurologic condition; gestational age less than 28 weeks or birth weight less than 1200 g; a contraindication to magnetic resonance image scanning; a history of traumatic brain injury; a diagnosis of moderate or severe autism spectrum disorder, intellectual disability, or schizophrenia; or a substance use disorder.

Sociodemographic characteristics including age, birth sex, parent-reported race and ethnicity, parental marital status, and highest parental educational level were derived from the PhenX toolkit. 31 Family income was assessed with General Social Survey items, 32 and the language predominantly spoken to the child by their parent or guardian was coded as English vs other.

Current mental health disorders were assessed with the parent version of the self-administered computerized Kiddie Schedule for Affective Disorders and Schizophrenia for DSM-5 (KSADS). 33 , 34 Following DSM-5 criteria, respondents were classified by current ADHD symptoms as combined, predominantly inattentive, or predominantly hyperactive or impulsive presentations. Prior research demonstrates 90% agreement between parent and clinician ADHD current diagnoses from the computerized KSADS (Cohen κ = 0.79). 34

Some analysis involved comparing treatment of children with ADHD with or without the following comorbid conditions: disruptive behavior disorders (oppositional defiant or conduct disorder); anxiety (panic, separation anxiety, social anxiety, and generalized anxiety disorder) or mood (major depressive, persistent depressive, unspecified depressive, and bipolar disorder) disorders; and obsessive-compulsive disorder.

In a secondary analysis (n = 4594), the ADHD definition was narrowed to require parent-reported ADHD and a T score of 65 or more on the Brief Problem Monitor teacher-version attention scale. 35 Children with psychotic disorders, bipolar disorder, and IQ less than 70 (measured by the Wechsler Intelligence Scale for Children, Fifth Edition) 36 were also excluded. Requirement of teacher ratings follows the DSM-5 criteria of symptoms in 2 or more settings. 37

Parents were asked what medications their children had taken in the past 2 weeks. Medications for ADHD included stimulants (amphetamine, dexmethylphenidate, dextroamphetamine, dextroamphetamine-amphetamine, lisdexamfetamine, methamphetamine, and methylphenidate) and nonstimulants (atomoxetine, clonidine, and guanfacine). Parents were also asked whether their child had ever received outpatient mental health care. Three nonmutually exclusive groups were considered: ADHD medications, any outpatient mental health care, or either (“any treatment”).

Statistical analysis was performed from March 23, 2022, to March 10, 2023. First, the background characteristics of children with or without parent-reported ADHD were evaluated. Second, among children with parent-reported ADHD, the percentages of children with any treatment were determined overall and stratified by sociodemographic and diagnostic characteristics. A series of unadjusted logistic regressions was performed with each treatment measure as dependent variables to generate odds ratios (ORs) with 95% CIs. Corresponding logistic regressions were adjusted for ADHD subtype and comorbid psychiatric disorders. Third, the percentages of children with ADHD currently receiving stimulant medications or other ADHD medications were determined stratified by background characteristics. Fourth, among children who met the more restricted ADHD criteria involving parent and teacher ratings, ADHD treatment rates were determined overall. For these analyses, nonresponse inverse probability weights were created using logistic regression of the Brief Problem Monitor teacher response (present or absent) as the dependent variable associated with child sociodemographic variables (eTable in Supplement 1 ). Statistical tests were 2-sided. Analyses were performed in SAS, version 9.4 (SAS Institute Inc) and incorporated propensity-based population weights.

Compared with children without parent-reported ADHD (n = 10 517), children with parent-reported ADHD (n = 1206) included a larger percentage of boys (68.2% [826 of 1206] vs 49.4% [5295 of 10 517]), White children (62.2% [759 of 1206] vs 55.3% [6234 of 10 517]), Black children (15.2% [206 of 1206] vs 13.6% [1614 of 10 517]), and children whose parents had never married (16.8% [175 of 1206] vs 14.2% [1261 of 10 517]) ( Table 1 ). Children with parent-reported ADHD were also more likely than those without parent-reported ADHD to have each of the psychiatric comorbid conditions.

Approximately 10.1% (n = 1206) of children had parent-reported ADHD. Among this group, 149 (12.9%) were currently receiving ADHD medications, 301 (26.2%) had ever received outpatient mental health care, and 400 (34.8%) had received either ( Table 2 ). Among children without parent-reported ADHD (n = 10 517), 1.9% (n = 180), or 57.0% of all children receiving ADHD medications, were currently receiving ADHD medications.

Children receiving ADHD medications included a significantly higher percentage of boys (15.7% [121 of 826]) than girls (7.0% [28 of 108]), White children (14.8% [104 of 759]) than Black children (9.4% [22 of 206]), children of parents without a high school education (9 of 36 [32.2%]) than of parents with a bachelor’s degree or higher (11.5% [84 of 715]) ( Table 1 ), and children with the combined subtype of ADHD (17.0% [83 of 505]) than with the inattentive subtype (9.5% [49 of 523]) ( Table 3 ). Approximately 26.2% of children (301 of 1206) with parent-reported ADHD had ever received outpatient mental health care. Children receiving outpatient mental health care included a significantly higher percentage of children whose parents had a high school education (36.2% [29 of 90]) or some college (31.0% [109 of 364]) than a bachelor’s degree or higher (21.3% [153 of 715]), children with family incomes of less than $25 000 (36.5% [66 of 176]) or $25 000 to $49 999 (27.7% [47 of 174]) than $75 000 or more (20.1% [125 of 599]) ( Table 1 ), and children with the combined subtype of ADHD (33.6% [166 of 505]) than with the predominantly inattentive subtype (20.0% [101 of 523]) or the hyperactive-impulsive subtype (22.4% [34 of 178]) ADHD ( Table 3 ).

Among those meeting the more stringent criteria of both parent-reported and teacher-reported ADHD (prevalence, 2.7% [n = 110]), 15 (12.3%) were currently receiving ADHD medications, 35 (33.7%) had ever received outpatient mental health care, and 44 (39.4%) had received either service.

In the parent-reported ADHD sample, the odds of any mental health care did not significantly vary by child sex or race and ethnicity or by parental marital status ( Table 2 ). However, children with parent-reported ADHD whose parents had less education and whose families had lower incomes were more likely than those whose parents had more education and whose families had higher incomes to have received any treatment. Children from families in which a language other than English was spoken in the home were less likely to have received outpatient treatment. Associations between child sociodemographic characteristics and receipt of any treatment were slightly reduced after controlling for the potential confounders associated with ADHD subtype and the psychiatric comorbid conditions ( Table 4 ). For example, the odds of any ADHD medication for boys compared with girls decreased from 2.46 (95% CI, 1.42-4.27) ( Table 2 ) to 2.25 (95% CI, 1.27-4.00) ( Table 4 ) after adjusting for ADHD subtype and comorbid conditions.

In unadjusted analyses, current ADHD medication use was significantly more common among boys than girls (OR, 2.46; 95% CI, 1.42-4.27) and among children whose parents did not have a high school education than children of parents with a bachelor’s degree (OR, 3.66; 95% CI, 1.72-7.77), but it was less common among Black than White children (OR, 0.60; 95% CI, 0.36-0.99) ( Table 2 ). Lower parental educational level (parents without a high school education: OR, 1.46; 95% CI, 0.72-2.93) and lower family income (<$25 000: OR, 2.29; 95% CI, 1.64-3.19) were associated with higher odds of receiving outpatient treatment. The associations with treatment were marginally attenuated after controlling for ADHD subtype and psychiatric comorbidities ( Table 4 ).

Children with parented-reported inattentive ADHD were significantly less likely than those with the combined subtype to have received all 3 treatment outcomes ( Table 3 ). Children with parent-reported hyperactive-impulsive ADHD were less likely than those with parent-reported combined ADHD to have received outpatient mental health care (OR, 0.57; 95% CI, 0.39-0.83). Compared with children without comorbid disruptive disorders, those with disruptive behavior disorders were more likely to have received outpatient mental health care (OR, 2.19; 95% CI, 1.51-3.18). Similar findings were noted for comorbid mood disorders, anxiety disorders, and obsessive-compulsive disorder. However, comorbid psychiatric disorders were not associated with increased odds of receiving ADHD medications.

Approximately 8.0% of children (n = 97) with parent-reported ADHD were receiving stimulants, and 5.1% (n = 53) were receiving atomoxetine, guanfacine, or clonidine ( Table 5 ). Stimulants were significantly more common among boys than girls (OR, 2.00; 95% CI, 1.14-3.50), although less common among Black than White children (OR, 0.44; 95% CI, 0.24-0.82). Nonstimulant ADHD medications were significantly more commonly prescribed to children whose parents had a high school diploma without attending college than to children whose parents had a bachelor’s degree or higher (OR, 2.79; 95% CI, 1.09-7.13). They were also more commonly prescribed to children with parent-reported combined ADHD than to children with parent-reported inattentive ADHD (OR, 2.74; 95% CI, 1.51-4.95), and to children with rather than without comorbid disruptive behavior disorders (OR, 2.80; 95% CI, 1.43-5.47).

In this cohort of children with parent-reported ADHD, 26.2% had ever received outpatient mental health care, 12.9% were currently receiving ADHD medications, and 34.8% had received either treatment. Contrary to our expectations, children whose parents had higher incomes and a higher educational level tended to be less likely than those whose parents had lower incomes and a lower educational level to have received outpatient mental health care. Medication treatment for children with parent-reported ADHD was also more common among children whose parents had a lower rather than higher educational level. Use of ADHD medications was more common among boys than girls, White children than Black children, and children with combined rather than inattentive ADHD.

Low treatment rates among children with parent-reported ADHD suggest a need to increase mental health service availability; enhance knowledge of ADHD symptoms among parents, teachers, and primary care clinicians; and develop accessible care pathways. 38 Because most US children receive an annual well-child visit, 39 opportunities exist to improve ADHD detection in primary care. However, because no screening tool has sufficient accuracy for stand-alone use, 40 primary care clinicians should consider multiple informants when evaluating children for ADHD. Local shortages of child mental health clinicians also hinder care access in many communities. 41

These ADHD treatment rates contrast with CDC reports that most children with ADHD receive treatment. 42 - 44 This discrepancy is likely associated with ascertainment bias. Unlike the current analysis, the CDC reports were based on parent-reported treatment of children who had received a clinical ADHD diagnosis. By contrast, the current treatment rates in our study more closely align with earlier epidemiologic studies. 45

In keeping with prior research, 2 , 14 - 17 boys were more likely than girls to receive ADHD medications. A common explanation for this sex-based difference is that, because boys tend to have more disruptive clinical presentations than girls, they have a higher likelihood of referral for evaluation. 46 However, we found that boys compared with girls had more than twice the odds of receiving ADHD medications after adjustment for ADHD subtype, comorbid disruptive behavior disorders, and other common psychiatric comorbid conditions. Other factors, such as diagnostic biases favoring boys vs girls, 47 greater prevalence of educational problems in boys compared with girls, 14 or higher levels of physical aggression in boys than in girls with ADHD 48 might be associated with greater ADHD medication use among boys than girls.

Children with parent-reported ADHD from families with the highest income level were less likely than those from families with the lowest income level to receive outpatient mental health care. It is unclear what inhibited highly resourced families from seeking treatment. Compared with families with lower income, those with higher income might more frequently rely on nontraditional strategies, such as tutoring, exercise, sports programs, and healthy eating, 49 or have greater apprehension concerning the stigma of receiving treatment or the long-term effects of stimulant therapy. 50

Black children compared with White children with parent-reported ADHD were significantly less likely to receive ADHD medications. This finding is broadly consistent with prior research. 51 Black children were specifically less likely than White children to receive stimulants, while this difference was less pronounced for nonstimulants. Because nonstimulant medications tend to yield smaller therapeutic effects than stimulants, 52 , 53 all parents should be provided with relevant clinical information to make informed ADHD medication choices. Prescriber implicit bias might be associated with disparities in stimulant prescribing. 54 Strong population-based racial and ethnic gradients exist in prescriptions for stimulants and other controlled substances, with the highest rates in majority-White areas. 55 As a result of structural racism, 56 Black parents’ perspectives might further influence ADHD management decisions through mistrust in clinicians and concerns over safety and efficacy of stimulants. 57 Physician efforts to recognize and manage their own implicit biases, 58 together with patient-centered clinical approaches that promote shared decision-making, including open explorations of Black parents’ knowledge, attitudes, and beliefs concerning ADHD and its management, might help reduce these treatment disparities.

Children whose parents had the lowest educational level were most likely to receive ADHD medications. Earlier research has reported an association between low parental educational level and ADHD medication prescription. 59 , 60 In a discrete choice study of parents of young children with medication-naive ADHD, medication-avoidant parents had a significantly higher educational level than more outcome-oriented parents who favored the use of ADHD medication. 61 As a group, parents with a lower educational level may be more focused on improving their child’s functioning than parents with a higher educational level who may be more concerned with medication-associated risks and might therefore be more motivated to implement parent-based interventions.

Children with parent-reported combined ADHD tended to be more likely than those with either inattentive or hyperactive-impulsive ADHD to receive ADHD medications. This pattern contrasts with a previous report that hyperactivity is specifically associated with ADHD medication treatment, 26 but it supports the hypothesis that children with more severe or complex presentations are more likely to receive ADHD medications. Common psychiatric comorbid conditions were not significantly associated with increased likelihood of ADHD medication use. This finding suggests that community ADHD medication prescribing practices are appropriately and specifically focused on ADHD symptoms. In evaluating the finding that 57.0% of all children who received ADHD medications did not have parent-reported ADHD, it is important to consider the possibility of symptom response.

Among children with parent-reported ADHD, nonstimulant ADHD medications were significantly more commonly prescribed to children with combined ADHD than inattentive ADHD and were more commonly prescribed to those with than without comorbid disruptive behavior disorders. Although there is some evidence to support the use of guanfacine and atomoxetine for disruptive behavior disorders, psychostimulants have more evidence for effectiveness, and there is little evidence of the effectiveness of clonidine. 62

This study has several limitations. First, although the ABCD Study involved multistage probability sampling of schools and survey weights were applied, the study did not involve nationally representative sampling, 30 and stimulant prescriptions have demonstrated substantial regional variation. 23 Second, treatment and medication assessments were based on parent reports without confirmatory administrative or prescription data, and no information was available concerning medication dose, duration, or prescriber. Because many children with ADHD stop and start stimulants, 63 measuring medication use in the past 2 weeks will miss children who recently stopped medications. Third, information was also not available concerning the clinical focus of the lifetime child mental health care, whether it occurred before or after the onset of ADHD, or whether it included evidence-based treatments, such as parent training in child behavioral management 62 for ADHD. Parents may also vary in how they define what constitutes outpatient mental health care. Fourth, the study was limited to a narrow age range, and treatment patterns vary by patient age. Fifth, eligibility criteria for the ABCD Study, which include English fluency, gestational age, birth weight, major medical conditions, and other factors, as well as imperfections in the survey weights, limit the generalizability of the study findings. Sixth, parent-reported ADHD may have excluded children who, due to active interventions, did not meet ADHD criteria.

In this cross-sectional study of children with parent-reported ADHD, 26.2% had ever received outpatient mental health care, and 15.7% of boys and 7.0% of girls were currently receiving ADHD medications. These findings contrast with the view that most children with ADHD receive treatment for their symptoms. 42 - 44 Contrary to our expectations, children with ADHD from families with a lower educational level and lower incomes tended to be more likely than those with a higher educational level and higher incomes to have received outpatient mental health treatment. These patterns suggest that attitudinal rather than socioeconomic factors often impede the flow of children with ADHD into treatment.

It would be naive to assume that all children with parent-reported ADHD need or would benefit from treatment. Parent reports from research diagnostic interviews do not substitute for a thorough clinical assessment involving a patient history, clinical child interview and observation, physical examination, teacher reports, and validated rating scales. Nevertheless, the findings provide a sense of the scale and distribution of children with parent-reported ADHD not receiving treatment. As such, they highlight the importance of developing strategies to increase clinical recognition of children with ADHD, especially girls, and increasing access to acceptable treatments.

Accepted for Publication: March 17, 2023.

Published: April 28, 2023. doi:10.1001/jamanetworkopen.2023.10999

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Olfson M et al. JAMA Network Open .

Corresponding Author: Mark Olfson, MD, MPH, New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 1051 Riverside Dr, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Olfson, Wall, Blanco.

Acquisition, analysis, or interpretation of data: Olfson, Wang, Laje, Blanco.

Drafting of the manuscript: Olfson, Wall.

Critical revision of the manuscript for important intellectual content: Olfson, Wang, Laje, Blanco.

Statistical analysis: Wall, Wang.

Administrative, technical, or material support: Olfson, Laje.

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily represent those of National Institutes of Health or the US Government.

Data Sharing Statement: See Supplement 2 .

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Book cover

The Palgrave Handbook of Male Psychology and Mental Health pp 291–307 Cite as

Attention Deficit Hyperactivity Disorder (ADHD): A Case Study and Exploration of Causes and Interventions

  • Bijal Chheda-Varma 5  
  • First Online: 02 March 2019

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The male to female ratio of ADHD is 4:1. This chapter on ADHD provides a wide perspective on understanding, diagnosis and treatment for ADHD. It relies on a neurodevelopmental perspective of ADHD. Signs and symptoms of ADHD are described through the DSM-V criteria. A case example (K, a patient of mine) is illustrated throughout the chapter to provide context and illustrations, and demonstrates the relative merits of “doing” (i.e. behavioural interventions) compared to cognitive insight, or medication alone. Finally, a discussion of the Cognitive Behavioral Modification Model (CBM) for the treatment of ADHD provides a snapshot of interventions used by clinicians providing psychological help.

  • Neuro-developmental disorders
  • Behaviour modification

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Chheda-Varma, B. (2019). Attention Deficit Hyperactivity Disorder (ADHD): A Case Study and Exploration of Causes and Interventions. In: Barry, J.A., Kingerlee, R., Seager, M., Sullivan, L. (eds) The Palgrave Handbook of Male Psychology and Mental Health. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-04384-1_15

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    The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [ 1] describes ADHD as a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity manifesting in children before the age of 12 years old more frequently and with greater severity than expected in children of equi...

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    Conclusion: The present case shows that in ADHD and comorbid obsessive–compulsive disorder, treatment with psychostimulants can improve the obsessive–compulsive symptoms in addition to the ADHD-specific symptoms.

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    In the US and other high-income countries, an increasing number of children receive a clinical diagnosis of and are treated for attention deficit/hyperactivity disorder (ADHD). 1-7 The percentage of US children whose parents report their child has received a diagnosis of ADHD increased from 5.5% in 1999 to 9.8% in 2018. 8 The Centers for ...

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    Despite increased awareness, Attention-deficit hyperactivity disorder (ADHD) is a chronic condition that affects 8% to 12% of school-aged children and contributes significantly to academic and social impairment. There is currently broad agreement on evidence-based best practices of ADHD identification and diagnosis, therapeutic approach, and ...