The management of ADHD typically involves counseling or medications, either alone or in combination. While there are various options of treatment to improve ADHD symptoms, medication therapies substantially improve long-term outcomes, and while eliminating some elevated risks such as obesity,^[9] they do come with some risks of adverse events.^[230] Medications used include stimulants, atomoxetine, alpha-2 adrenergic receptor agonists, and sometimes antidepressants.^[85]^[196] In those who have trouble focusing on long-term rewards, a large amount of positive reinforcement improves task performance.^[200] Medications are the most effective treatment,^[9]^[231] and any side effects are typically mild and easy to resolve^[9] although any improvements will be reverted if medication is ceased.^[232] ADHD stimulants also improve persistence and task performance in children with ADHD.^[185]^[200] To quote one systematic review, "recent evidence from observational and registry studies indicates that pharmacological treatment of ADHD is associated with increased achievement and decreased absenteeism at school, a reduced risk of trauma-related emergency hospital visits, reduced risks of suicide and attempted suicide, and decreased rates of substance abuse and criminality".^[233] Data also suggest that combining medication with cognitive behavioral therapy (CBT) can have positive effects: although CBT is substantially less effective, it can help address problems that reside after medication has been optimised.^[9] The nature and range of desirable endpoints of ADHD treatment vary among diagnostic standards for ADHD.^[234] In most studies, the efficacy of treatment is determined by reductions in symptoms.^[235] However, some studies have included subjective ratings from teachers and parents as part of their assessment of treatment efficacies.^[236]

Behavioural therapies

There is good evidence for the use of behavioural therapies in ADHD. They are the recommended first-line treatment in those who have mild symptoms or who are preschool-aged.^[237]^[238] Psychological therapies used include: psychoeducational input, behavior therapy, cognitive behavioral therapy,^[239] interpersonal psychotherapy, family therapy, school-based interventions, social skills training, behavioural peer intervention, organization training,^[240] and parent management training.^[184] Neurofeedback has greater treatment effects than non-active controls for up to 6 months and possibly a year following treatment, and may have treatment effects comparable to active controls (controls proven to have a clinical effect) over that time period.^[241] Despite efficacy in research, there is insufficient regulation of neurofeedback practice, leading to ineffective applications and false claims regarding innovations.^[242] Parent training may improve a number of behavioural problems including oppositional and non-compliant behaviours.^[243]

There is little high-quality research on the effectiveness of family therapy for ADHD—but the existing evidence shows that it is similar to community care, and better than placebo.^[244] ADHD-specific support groups can provide information and may help families cope with ADHD.^[245]

Social skills training, behavioural modification, and medication may have some limited beneficial effects in peer relationships. Stable, high-quality friendships with non-deviant peers protect against later psychological problems.^[246]

Digital interventions

Several clinical trials have investigated the efficacy of digital therapeutics, particularly Akili Interactive Labs's video game-based digital therapeutic AKL-T01, marketed as EndeavourRx. The pediatric STARS-ADHD randomized, double-blind, parallel-group, controlled trial demonstrated that AKL-T01 significantly improved performance on the Test of Variables of Attention, an objective measure of attention and inhibitory control, compared to a control group after four weeks of at-home use.^[247] A subsequent pediatric open-label study, STARS-Adjunct, published in Nature Portfolio's npj Digital Medicine evaluated AKL-T01 as an adjunctive treatment for children with ADHD who were either on stimulant medication or not on stimulant pharmacotherapy. Results showed improvements in ADHD-related impairment (measured by the Impairment Rating Scale) and ADHD symptoms after 4 weeks of treatment, with effects persisting during a 4-week pause and further improving with an additional treatment period.^[248] Notably, the magnitude of the measured improvement was similar for children both on and off stimulants.^[248] In 2020, AKL-T01 received marketing authorization for pediatric ADHD from the FDA, becoming "the first game-based therapeutic granted marketing authorization by the FDA for any type of condition."^[249]

In addition to pediatric populations, a 2023 study in the Journal of the American Academy of Child & Adolescent Psychiatry investigated the efficacy and safety of AKL-T01 in adults with ADHD. After six weeks of at-home treatment with AKL-T01, participants showed significant improvements in objective measures of attention (TOVA - Attention Comparison Score), reported ADHD symptoms (ADHD-RS-IV inattention subscale and total score), and reported quality of life (AAQoL).^[250] The magnitude of improvement in attention was nearly seven times greater than that reported in pediatric trials.^[250] The treatment was well-tolerated, with high compliance and no serious adverse events.^[250]

Medication

The medications for ADHD appear to alleviate symptoms via their effects on the pre-frontal executive, striatal and related regions and networks in the brain; usually by increasing neurotransmission of norepinephrine and dopamine.^[251]^[252]^[253]

Stimulants

Methylphenidate and amphetamine or its derivatives are often first-line treatments for ADHD.^[254]^[255] About 70 per cent respond to the first stimulant tried and as few as 10 per cent respond to neither amphetamines nor methylphenidate.^[231] Stimulants may also reduce the risk of unintentional injuries in children with ADHD.^[256] Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD.^[257]^[258]^[259] A 2018 review found the greatest short-term benefit with methylphenidate in children, and amphetamines in adults.^[236] Studies and meta-analyses show that amphetamine is slightly-to-modestly more effective than methylphenidate at reducing symptoms,^[260]^[261] and they are more effective pharmacotherapy for ADHD than α2-agonists^[262] but methylphenidate has comparable efficacy to non-stimulants such as atomoxetine. In a Cochrane clinical synopsis, Dr Storebø and colleagues summarised their meta-review^[263] on methylphenidate for ADHD in children and adolescents. The meta-analysis raised substantial doubts about the drug's efficacy relative to a placebo. This led to a strong critical reaction from the European ADHD Guidelines Group and individuals in the scientific community, who identified a number of flaws in the review.^[264]^[265]^[266]^[267]^[268]^[269] Since at least September 2021, there is a unanimous and global scientific consensus that methylphenidate is safe and highly effective for treating ADHD.^[9]^[270] The same journal released a subsequent systematic review (2022) of extended-release methylphenidate for adults, concluding similar doubts about the certainty of evidence.^[271] Other recent systematic reviews and meta-analyses, however, find certainty in the safety and high efficacy of methylphenidate for reducing ADHD symptoms,^[236]^[272]^[273] for alleviating the underlying executive functioning deficits,^[274] and for substantially reducing the adverse consequences of untreated ADHD with continuous treatment.^[9] Clinical guidelines internationally are also consistent in approving the safety and efficacy of methylphenidate and recommending it as a first-line treatment for the disorder.^[9]

Safety and efficacy data have been reviewed extensively by medical regulators (e.g., the US Food and Drug Administration and the European Medicines Agency), the developers of evidence-based international guidelines (e.g., the UK National Institute for Health and Care Excellence and the American Academy of Pediatrics), and government agencies who have endorsed these guidelines (e.g., the Australian National Health and Medical Research Council). These professional groups unanimously conclude, based on the scientific evidence, that methylphenidate is safe and effective and should be considered as a first-line treatment for ADHD.^[9] The likelihood of developing insomnia for ADHD patients taking stimulants has been measured at between 11 and 45 per cent for different medications,^[275] and may be a main reason for discontinuation. Other side effects, such as tics, decreased appetite and weight loss, or emotional lability, may also lead to discontinuation.^[231] Stimulant psychosis and mania are rare at therapeutic doses, appearing to occur in approximately 0.1% of individuals, within the first several weeks after starting amphetamine therapy.^[276]^[277]^[278] The safety of these medications in pregnancy is unclear.^[279] Symptom improvement is not sustained if medication is ceased.^[280]^[232]^[281]

The long-term effects of ADHD medication have yet to be fully determined,^[282]^[283] although stimulants are generally beneficial and safe for up to two years for children and adolescents.^[284] A 2022 meta-analysis found no statistically significant association between ADHD medications and the risk of cardiovascular disease (CVD) across age groups, although the study suggests further investigation is warranted for patients with preexisting CVD as well as long-term medication use.^[285] Regular monitoring has been recommended in those on long-term treatment.^[286] There are indications suggesting that stimulant therapy for children and adolescents should be stopped periodically to assess continuing need for medication, decrease possible growth delay, and reduce tolerance.^[287]^[288] Although potentially addictive at high doses,^[289]^[290] stimulants used to treat ADHD have low potential for abuse.^[254] Treatment with stimulants is either protective against substance abuse or has no effect.^[63]^: 12^[282]^[289]

The majority of studies on nicotine and other nicotinic agonists as treatments for ADHD have shown favorable results; however, no nicotinic drug has been approved for ADHD treatment.^[291] Caffeine was formerly used as a second-line treatment for ADHD but research indicates it has no significant effects in reducing ADHD symptoms. Caffeine appears to help with alertness, arousal and reaction time but not the type of inattention implicated in ADHD (sustained attention/persistence).^[292] Pseudoephedrine and ephedrine do not affect ADHD symptoms.^[254]

Modafinil has shown some efficacy in reducing the severity of ADHD in children and adolescents.^[293] It may be prescribed off-label to treat ADHD.

Non-stimulants

Two non-stimulant medications, atomoxetine and viloxazine, are approved by the FDA and in other countries for the treatment of ADHD.

Atomoxetine, due to its lack of addiction liability, may be preferred in those who are at risk of recreational or compulsive stimulant use, although evidence is lacking to support its use over stimulants for this reason.^[63]^: 13 Atomoxetine alleviates ADHD symptoms through norepinephrine reuptake and by indirectly increasing dopamine in the pre-frontal cortex,^[253] sharing 70-80% of the brain regions with stimulants in their produced effects.^[252] Atomoxetine has been shown to significantly improve academic performance.^[294]^[295] Meta-analyses and systematic reviews have found that atomoxetine has comparable efficacy, equal tolerability and response rate (75%) to methylphenidate in children and adolescents. In adults, efficacy and discontinuation rates are equivalent.^[296]^[297]^[298]^[299]

Analyses of clinical trial data suggests that viloxazine is about as effective as atomoxetine and methylphenidate but with fewer side effects.^[300]

Amantadine was shown to induce similar improvements in children treated with methylphenidate, with less frequent side effects.^[301] A 2021 retrospective study showed that amantadine may serve as an effective adjunct to stimulants for ADHD–related symptoms and appears to be a safer alternative to second- or third-generation antipsychotics.^[302]

Bupropion is also used off-label by some clinicians due to research findings. It is effective, but modestly less than atomoxetine and methylphenidate.^[303]

There is little evidence on the effects of medication on social behaviours.^[304] Antipsychotics may also be used to treat aggression in ADHD.^[305]

Alpha-2a agonists

Two alpha-2a agonists, extended-release formulations of guanfacine and clonidine, are approved by the FDA and in other countries for the treatment of ADHD (effective in children and adolescents but effectiveness has still not been shown for adults).^[306]^[307] They appear to be modestly less effective than the stimulants (amphetamine and methylphenidate) and non-stimulants (atomoxetine and viloxazine) at reducing symptoms,^[308]^[309] but can be useful alternatives or used in conjunction with a stimulant. These medications act by adjusting the alpha-2a ports on the outside of noradrenergic nerve cells in the pre-frontal executive networks, so the information (electrical signal) is less confounded by noise.^[310]

Guidelines

Guidelines on when to use medications vary by country. The United Kingdom's National Institute for Health and Care Excellence recommends use for children only in severe cases, though for adults medication is a first-line treatment.^[311] Conversely, most United States guidelines recommend medications in most age groups.^[312] Medications are especially not recommended for preschool children.^[311]^[184] Underdosing of stimulants can occur, and can result in a lack of response or later loss of effectiveness.^[313] This is particularly common in adolescents and adults as approved dosing is based on school-aged children, causing some practitioners to use weight-based or benefit-based off-label dosing instead.^[314]^[315]^[316]

Exercise

Exercise does not reduce the symptoms of ADHD.^[9] The conclusion by the International Consensus Statement is based on two meta-analyses: one of 10 studies with 300 children and the other of 15 studies and 668 participants, which showed that exercise yields no statistically significant reductions on ADHD symptoms. A 2024 systematic review and meta analysis commissioned by the Patient-Centered Outcomes Research Institute (PCORI) identified seven studies on the effectiveness of physical exercise for treating ADHD symptoms.^[205] The type and amount of exercise varied widely across studies from martial arts interventions to treadmill training, to table tennis or aerobic exercise. Effects reported were not replicated, causing the authors to conclude that there is insufficient evidence that exercise intervention is an effective form of treatment for ADHD symptoms.^[205]

Diet

Dietary modifications are not recommended as of 2019^[update] by the American Academy of Pediatrics, the National Institute for Health and Care Excellence, or the Agency for Healthcare Research and Quality due to insufficient evidence.^[317]^[311] A 2013 meta-analysis found less than a third of children with ADHD see some improvement in symptoms with free fatty acid supplementation or decreased consumption of artificial food colouring.^[167] These benefits may be limited to children with food sensitivities or those who are simultaneously being treated with ADHD medications.^[167] This review also found that evidence does not support removing other foods from the diet to treat ADHD.^[167] A 2014 review found that an elimination diet results in a small overall benefit in a minority of children, such as those with allergies.^[182] A 2016 review stated that the use of a gluten-free diet as standard ADHD treatment is not advised.^[318] A 2017 review showed that a few-foods elimination diet may help children too young to be medicated or not responding to medication, while free fatty acid supplementation or decreased eating of artificial food colouring as standard ADHD treatment is not advised.^[319] Chronic deficiencies of iron, magnesium and iodine may have a negative impact on ADHD symptoms.^[320] There is a small amount of evidence that lower tissue zinc levels may be associated with ADHD.^[321] In the absence of a demonstrated zinc deficiency (which is rare outside of developing countries), zinc supplementation is not recommended as treatment for ADHD.^[322] However, zinc supplementation may reduce the minimum effective dose of amphetamine when it is used with amphetamine for the treatment of ADHD.^[323]