introduction adhd research paper

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• Published: 22 February 2024

Attention-deficit/hyperactivity disorder

• Stephen V. Faraone   ORCID: orcid.org/0000-0002-9217-3982 1 ,
• Mark A. Bellgrove   ORCID: orcid.org/0000-0003-0186-8349 2 ,
• Isabell Brikell 3 , 4 , 5 ,
• Samuele Cortese 6 , 7 , 8 , 9 , 10 ,
• Catharina A. Hartman 11 ,
• Chris Hollis   ORCID: orcid.org/0000-0003-1083-6744 12 ,
• Jeffrey H. Newcorn 13 ,
• Alexandra Philipsen   ORCID: orcid.org/0000-0001-6876-518X 14 ,
• Guilherme V. Polanczyk   ORCID: orcid.org/0000-0003-2311-3289 15 ,
• Katya Rubia 16 , 17 ,
• Margaret H. Sibley   ORCID: orcid.org/0000-0001-7167-2240 18 &
• Jan K. Buitelaar   ORCID: orcid.org/0000-0001-8288-7757 19 , 20  

Nature Reviews Disease Primers volume  10 , Article number:  11 ( 2024 ) Cite this article

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• Cognitive neuroscience
• Medical genetics

An Author Correction to this article was published on 15 April 2024

This article has been updated

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

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Change history, 15 april 2024.

A Correction to this paper has been published: https://doi.org/10.1038/s41572-024-00518-w

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Acknowledgements

S.V.F. is supported by the European Union’s Horizon 2020 research and innovation programme (grant agreement 965381), NIMH (grants U01AR076092-01A1, 1R21MH1264940, R01MH116037 and 1R01NS128535-01), Oregon Health and Science University, Otsuka Pharmaceuticals, Noven Pharmaceuticals Incorporated, and Supernus Pharmaceutical Company. M.A.B. is supported by a Senior Research Fellowship (level B) from the Australian National Health and Medical Research Council (NHMRC; 1154378). His research programme is supported by the NHMRC (2010899) and Medical Research Future Fund of Australia (MRF2006438, EPCD000002). I.B. is supported by the European Union’s Horizon 2020 research and innovation programme (grant agreement 965381). S.C., NIHR Research Professor (NIHR303122), is funded by the NIHR for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care. S.C. is also supported by NIHR grants NIHR203684, NIHR203035, NIHR130077, NIHR128472 and RP-PG-0618-20003 and by grant 101095568-HORIZONHLTH-2022-DISEASE-07-03 from the European Research Executive Agency. C.A.H. is supported by the European Union’s Horizon 2020 research and innovation programme (grant agreement 965381), and ZonMW (grants 636340003 and 636340002). C.H. is supported by the NIHR (grants MIC-2016-003 and NIHR203310), and by the UKRI Medical Research Council (grant MR/T046864/1). J.H.N. is supported by grants from the National Institute of Child Health and Human Development (R01; HD093612) and the National Institute on Drug Abuse (R21; DA054281). A.P. is currently supported by funding from the National Institute for Health and Care Research (grant NIHR203035), the European Union’s Horizon 2020 research and innovation programme (grant agreement 945151), German Research Foundation (grant PH 177/7-1), Ministry of Culture and Science of the State of North Rhine-Westphalia (grant IBehave), Ministry of Research and Education (grants 01NVF20004 and 01IS22085D (Eureka Cluster on software innovation)). G.V.P. is supported by São Paulo Research Foundation (FAPESP) (grant 2016/22455-8), and National Council for Scientific and Technological Development (CNPq; grant 310582/2017-2). K.R. is supported by the National Institute of Health Research (grants NIHR130077 and NIHR203684) and the UK Department of Health and Social Care via the NIHR Biomedical Research Centre (BRC) for Mental Health at South London and the Maudsley National Health Service (NHS) Foundation Trust and the IoPPN, King’s College London. M.H.S. is supported by the Institute of Education Sciences (grant R305A210462) and the National Institute of Mental Health (grants R34 MH125037 and R34 MH122225). J.K.B. is supported by the European Union’s Horizon 2020 research and innovation programme (grant agreements 115300 and 777394 (EU-AIMS and AIMS-2-TRIALS), 847818 (CANDY), and 847879 (PRIME)).

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Stephen V. Faraone

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Mark A. Bellgrove

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Isabell Brikell

Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

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Introduction (S.V.F. and J.K.B.); Epidemiology (C.A.H. and G.V.P.); Mechanisms/pathophysiology (I.B., K.R., M.A.B. and S.V.F.); Diagnosis and screening (M.H.S. and S.C.); Management (J.H.N., S.C., A.P., M.H.S., J.K.B., M.A.B., K.R. and C.H.); Quality of life (G.V.P. and A.P.); Outlook (J.K.B. and S.V.F.). Aside from the first and last authors, authorship is alphabetical. All authors extensively commented on each other’s sections.

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Correspondence to Stephen V. Faraone .

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S.V.F. in the past year received income, potential income, travel expenses, continuing education support and/or research support from Aardvark, Aardwolf, AIMH, Tris, Otsuka, Ironshore, Kanjo, Johnson & Johnson/Kenvue, KemPharm/Corium, Akili, Supernus, Atentiv, Noven, Sky Therapeutics, Axsome and Genomind; with his institution, he has US patent US20130217707 A1 for the use of sodium–hydrogen exchange inhibitors in the treatment of ADHD; he also receives royalties from books published by Guilford Press ( Straight Talk about Your Child’s Mental Health ), Oxford University Press ( Schizophrenia: The Facts ) and Elsevier ( ADHD: Non-Pharmacologic Interventions ); and he is Program Director of www.ADHDEvidence.org and www.ADHDinAdults.com . S.C. declares honoraria and reimbursement for travel and accommodation expenses for lectures from the following non-profit associations: Association for Child and Adolescent Central Health (ACAMH), Canadian ADHD Resource Alliance (CADDRA), British Association for Psychopharmacology (BAP), and Healthcare Convention for educational activity on ADHD. C.H. was a member of the UK National Institute for Health and Care Excellence (NICE) ADHD Guideline Committee (CG87); has received honoraria for lectures from BAP; and is a member of the European ADHD Guideline Group (EAGG) (eunethydis.eu/eunethydis-initiatives/european-adhd-guideline-group/). J.H.N. in the past year is/has been an adviser and/or consultant for Corium, Hippo T&C, Ironshore, Lumos, Medice, MindTension, OnDosis, Otsuka, Signant Health and Supernus; he has received research support from the National Institute on Drug Abuse (NIDA), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and Otsuka; he also has received honoraria from for disease state presentations from Otsuka, and served as a consultant for the US National Football League. A.P. declares that she served on advisory boards, gave lectures, performed phase III studies and received travel grants within the last 5 years from MEDICE Arzneimittel, Pütter GmbH and Co KG, Takeda, Boehringer and Janssen-Cilag, and receives royalties from books published by Elsevier, Hogrefe, MWV, Kohlhammer, Karger, Oxford University Press, Thieme, Springer and Schattauer; she is a member of the German ADHD Guideline Group, and is an author of the Updated European Consensus Statement. G.V.P. has served as a speaker and/or consultant to Abbott, Ache, Medice, Novo Nordisk, Pfizer and Takeda, and receives authorship royalties from Manole Editors. K.R. has received a grant from Takeda Pharmaceuticals for another project and consulting fees from Supernus and Lundbeck. M.H.S. has consulted with Supernus Pharmaceuticals and Tieffenbacher Pharmaceuticals in the past 12 months, and receives book royalties from Guilford Press. J.K.B. has been in the past 3 years a consultant to/member of advisory board of and/or speaker for Takeda, Roche, Medice, Angelini, Boehringer-Ingelheim and Servier; he is not an employee of any of these companies, and is not a stock shareholder of any of these companies; he has no other financial or material support, including expert testimony, patents and royalties. M.A.B. declares travel expenses and speaking fees attached to conference presentations and professional groups. I.B. and C.A.H. declare no competing interests.

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Faraone, S.V., Bellgrove, M.A., Brikell, I. et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers 10 , 11 (2024). https://doi.org/10.1038/s41572-024-00495-0

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European Child & Adolescent Psychiatry (2024)

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Peer-reviewed

Research Article

The impact of psychological theory on the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adults: A scoping review

Contributed equally to this work with: Rebecca E. Champ

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft

* E-mail: [email protected]

Affiliation Department of Nursing and Midwifery, School of Human and Health Sciences, University of Huddersfield, Huddersfield, United Kingdom

Roles Supervision

¶ ‡ These authors also contributed equally to this work.

Affiliation School of Health and Life Sciences, Teeside University, Middlesbrough, United Kingdom

• Rebecca E. Champ, 
• Marios Adamou, 
• Barry Tolchard

• Published: December 21, 2021
• https://doi.org/10.1371/journal.pone.0261247
• Peer Review
• Reader Comments

Psychological theory and interpretation of research are key elements influencing clinical treatment development and design in Attention Deficit Hyperactivity Disorder (ADHD). Research-based treatment recommendations primarily support Cognitive Behavioural Therapy (CBT), an extension of the cognitive behavioural theory, which promotes a deficit-focused characterisation of ADHD and prioritises symptom reduction and cognitive control of self-regulation as treatment outcomes. A wide variety of approaches have developed to improve ADHD outcomes in adults, and this review aimed to map the theoretical foundations of treatment design to understand their impact. A scoping review and analysis were performed on 221 documents to compare the theoretical influences in research, treatment approach, and theoretical citations. Results showed that despite variation in the application, current treatments characterise ADHD from a single paradigm of cognitive behavioural theory. A single theoretical perspective is limiting research for effective treatments for ADHD to address ongoing issues such as accommodating context variability and heterogeneity. Research into alternative theoretical characterisations of ADHD is recommended to provide treatment design opportunities to better understand and address symptoms.

Citation: Champ RE, Adamou M, Tolchard B (2021) The impact of psychological theory on the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adults: A scoping review. PLoS ONE 16(12): e0261247. https://doi.org/10.1371/journal.pone.0261247

Editor: Gerard Hutchinson, University of the West Indies at Saint Augustine, TRINIDAD AND TOBAGO

Received: May 21, 2021; Accepted: November 25, 2021; Published: December 21, 2021

Copyright: © 2021 Champ et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The combination of psychological theory and interpretation of research have been highlighted as critical influencers guiding decision-making for clinical treatment design and development for Attention Deficit Hyperactivity Disorder (ADHD) [ 1 , 2 ]. ADHD is a neurodevelopmental disorder of self-regulation with symptoms negatively affecting daily functioning at work and at home, with long-term impacts in academic, occupational, social and emotional areas of functioning [ 3 – 8 ]. Effective, long-term treatment outcomes benefit both the individual with ADHD and society as a whole as undiagnosed and untreated adults with ADHD may become an economic burden due to increased health care costs and decreased productivity at work [ 9 , 10 ].

Russell Barkley [ 11 ] postulated the first unifying theory of ADHD, which places a core deficit of behavioural inhibition at the source of ADHD behaviours. Several theoretical models attribute additional and alternative cognitive sources for the development of ADHD symptoms [ 12 – 14 ]. While a variety of different interventions are available and the benefit of other forms of support is acknowledged (e.g. psychotherapy or coaching), only Cognitive Behavioural Therapy (CBT), Mindfulness, Dialectical Behavioural Therapy (DBT) and potentially Neurofeedback have the most empirical support [ 15 ]. Results of non-pharmacological intervention studies suggest these interventions have a positive effect on core behavioural symptoms of ADHD (inattention, hyperactivity/impulsivity), particularly when compared to inactive control conditions [ 15 , 16 ]. However, recent systematic reviews of non-pharmacological treatment highlight that different classes of intervention design take similar approaches; that heterogeneity in sample size, study design, quality and symptom outcome measurement makes meta-analysis difficult, and there is a high risk of bias [ 15 – 17 ]. Additionally, the National Institute for Health and Care Excellence (NICE) [ 18 ] only recommends interventions that match a similar protocol to medications: Randomised Controlled Trials (RCTs), primarily based in CBT [ 15 ], despite a growing wider evidence base.

It is hypothesised that much of current research for the characterisation of ADHD is based on a cognitive behavioural theoretical paradigm that does not account comprehensively for the broad spectrum of ADHD presentation [ 1 , 19 – 24 ]. This paradigm is deficit-focused with primary treatment outcomes of symptom reduction and control of maladaptive behaviours. Recent research in psychology suggests that this may not be the best approach to improving mental health, and it may be necessary to develop positive psychological factors and emotions that cultivate health and wellbeing [ 25 , 26 ]. This scoping review aims to map the evidence and understand the influence of current psychological theories on design and treatment recommendations in adult ADHD by answering the following questions:

• Are characterisations of ADHD dominated by a cognitive behavioural paradigm?
• Does that paradigm influence treatment design and outcomes?
• Are there any alternative characterisations of ADHD that present a different perspective to the cognitive behavioural paradigm?

A broad approach was considered most effective to identify gaps in the literature, as data regarding supportive psychological theories would likely be identified in publications beyond specific study designs. To our knowledge, this is the first scoping review providing an overview of the theoretical characterisations of ADHD and their impact on available treatments.

Search strategy

The scoping review was carried out over three months: February, March and April 2020. The scoping review protocol was published on the Open Science Framework ( https://osf.io/ ). Search design and criteria were formulated based on guidance and recommendations by Arksey & O’Malley [ 27 ], Colquhoun et al. [ 28 ], O’Brien et al. [ 29 ] and the Joanna Briggs Institute [ 30 ]. A starting timeframe from the publication of Barkley’s [ 11 ] theory was selected as the foundation for current theoretical characterisations of ADHD. Papers were reviewed from multiple countries, including the United States, the United Kingdom, The Netherlands, Canada, Argentina, Brazil, Colombia, Iceland, Ireland, Portugal, Spain, Belgium, Germany, Switzerland, Finland, Sweden, Israel, Iran, China, Hong Kong, India and Australia, and multiple languages including English, Dutch, German, French, and Spanish.

Research evidence was identified by conducting searches across web-based databases with pre-determined search terms. Table 1 outlines the search terms and syntax used in primary and secondary searches.

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• TIFF original image

https://doi.org/10.1371/journal.pone.0261247.t001

Additional searches were in generic search engines Google and Google Scholar, and checks of references from guidance documents and systematic reviews for additional material. Once identified, these references were collected through additional database searches or a direct search in the specific journal or publication.

Inclusion criteria

Titles and abstracts of materials were reviewed for eligibility. Materials were considered appropriate if they met the following criteria:

• Studies involving research on a pilot, efficacy, or applicability of a treatment intervention for adults with ADHD (19–65+, male and female)
• Systematic reviews of treatment literature or specific approaches to treatment for adults with ADHD
• Thesis, conference papers, or reports reviewing, presenting, or recommending treatment approaches for adults with ADHD
• Documents, articles, books, or consensus statements presenting guidance or recommendations for treatment for adults with ADHD

Exclusion criteria

In addition to meeting the inclusion criteria, materials were excluded if they met one of the following exclusion criteria:

• Treatment approaches designed for a specific subset of participants (couples, military, substance abuse)
• Treatment approaches designed to treat specific comorbidities (Autism, Bi-polar, Learning Disabilities, Tourette’s, Oppositional Defiant Disorder, Personality Disorder, Traumatic Brain Injury)
• Treatment approaches designed for the inclusion of younger age groups (children, adolescents) or their parents
• Materials summarising and updating recent developments in the field of treatment for adult ADHD (general practice journals, nursing practice journals, medical student journals)
• Characterisations of adult ADHD that were not empirically researched

A large body of literature has been published over the years which present different characterisations of adult ADHD and subsequent recommendations for treatment. Predominantly based in the US, these biopsychosocial models range from origin theories of genetic strengths [ 31 ], diversity [ 32 ] and developmental impairment of the prefrontal cortex due to issues with attachment and trauma [ 33 ], to identifying multiple presentations of ADHD diagnosed individually with SPECT imaging [ 34 ]. While these models do present alternative characterisations of ADHD, they are not empirically researched and therefore will be excluded from this review.

The following PRISMA flowchart ( Fig 1 ) presents the search process details, including the number of articles located, those eliminated and those included in the final analysis.

https://doi.org/10.1371/journal.pone.0261247.g001

Results and analysis

The 221 articles were subdivided into the following categories according to their primary content: Cognitive Behavioural Therapy (122), Coaching (36), Psychotherapy (16), and Other (47). All articles were assessed for quality against the relevant Critical Appraisals Skills Programme (CASP) checklists. Results summary of the ADHD characterisation cited for each intervention category is displayed in a mosaic plot ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0261247.g002

An overview of interventions published by year is displayed in a column chart ( Fig 3 ).

https://doi.org/10.1371/journal.pone.0261247.g003

Due to the number and variety of materials, a narrative analysis was performed to review the publications’ composition. Systematic reviews were also analysed separately to see if any review of the characterisation of ADHD had been completed previously.

Systematic reviews

Over the years, several systematic reviews of treatments for adult ADHD have been published. Searches were undertaken through Joanna Briggs Institute Evidence Synthesis, The Cochrane Database of Systematic Reviews, and the Campbell Library show some of these reviews are specific to the efficacy of a particular intervention approach, such as psychodynamic therapy [ 35 ], homoeopathy [ 36 ], Cognitive Behavioural Therapy (CBT) [ 37 – 41 ], Mindfulness [ 42 , 43 ], and Meditation [ 44 , 45 ]. Others have been focused on efficacy [ 2 , 15 , 16 , 46 – 48 ], long term outcomes [ 10 , 49 ], or guidance [ 50 ]. Only one systematic review investigated the characterisation of adult ADHD but failed to find evidence of neurocognitive disfunction as a predictor of persistence [ 51 ]. Interestingly, one systematic review investigated how adults with ADHD experience and manage their symptoms [ 52 ]. Therefore, it seems that no recent attempt has reviewed the psychological theories for the characterisation of adult ADHD.

Data extraction

Articles were reviewed, and data extracted into categorised excel spreadsheets for comparison. Each document was examined for the following criteria:

• Research Purpose/Outcome
• Treatment Approach
• ADHD Characterisation
• ADHD Theory

Intervention analysis

Research studies and guidance documents present treatment approaches in various environments, contexts and skill levels of delivery. The following interventions present a wide range of delivery in clinical and non-clinical environments; therapeutic, academic, and social contexts; and professionals including psychiatrists, clinical psychologists, nurses, occupational therapists, psychotherapists, as well as counsellors, coaches, and mentors.

Cognitive Behavioural Therapy (CBT).

Due to the involvement of cognitive behavioural theory in establishing the characterisation of ADHD, the bulk of research in the field has used this intervention model. While recommended as the primary treatment modality, treatment goals and methodologies have changed over time. Due to this shift in focus, some early research references non-empirical anecdotal work. This analysis will use the delineation of “waves” as seen in the current theoretical literature to demonstrate these changes [ 53 ] ( S1 Appendix ).

First wave : Behaviourism . Before 1990, ADHD was still considered a disorder of childhood. Although considerable research exists regarding “first wave” treatments in children, the few approaches developed for adults apply pure behavioural theory and techniques. A case study of three subjects focused on improving attentional behaviour in psychiatric patients [ 54 ], and the design utilises operant theory and models used for brain injury [ 55 ]. Guidance documents for teachers, parents and counsellors [ 56 ] and psychotherapists [ 57 ] highlight the importance of behavioural skill development. The conceptualisation of ADHD in these treatment models is a disorder of attention [ 54 ] and a neurobiological disorder of self-regulation, executive function deficits and disinhibition [ 56 , 57 ]. Burgess et al. [ 54 ] exemplify the transition of the conceptualisation of attentional deficits in ADHD from mental illness to mental disorder.

The therapist’s role in these models is to assist the client in learning and practising practical behavioural strategies for task attention, organisation, listening and scheduling, and planning and organising daily activities. Treatment designs are varied, with only one specifying weekly sessions from 6–10 weeks [ 54 ]. Characterisation of ADHD aetiology highlight issues with inability to maintain vigilance (attention deficit) and distractibility [ 54 ], self-regulation, impaired inhibition, developmental delay, and deficits in executive function, referencing Barkley [ 56 , 57 ].

Rational Emotive Behaviour Therapy (REBT) . A single case study for ADHD specifically used REBT [ 58 ]. REBT approaches ADHD as a combination of neurobiological deficits [ 59 ] and developed secondary psychological personality disorders. Failure to develop cognitive structures leads to a lack of connection between thoughts, emotions and feelings, leading to deeply held distorted convictions and beliefs. The therapist’s role in this model is to assist the individual to dispute evaluative cognitions (“musts”) to develop a more rational philosophical orientation to the world. The approach incorporates independent “experiments” by clients outside of therapy, problem-solving methodology, and gentle introduction of rational self-statements for clients who lack the cognitive sophistication to engage in disputing of irrational beliefs [58, p. 95]. Treatment design has a developmental and longitudinal focus, in this case eight years. Characterisation of ADHD is described as DSM-IV core symptoms of attentional difficulties, impulsivity and hyperactivity [ 60 ] and references both Douglas’s [ 61 ] cognitive processing deficit model and Barkley’s [ 59 ] model of response inhibition and executive function deficits contributing to deficient self-regulation, impaired cross-temporal organisation of behaviour, and diminished social effectiveness and adaptation.

Second wave : Cognitive and cognitive behavioural therapy model . Cognitive and Cognitive Behavioural approaches are the primary and recommended treatment for working with ADHD and therefore make up the bulk of studies reviewed for this analysis. Considered “second wave” cognitive behavioural therapies, they consist of systematic reviews [ 2 , 37 , 38 , 41 ], randomised controlled trials (RCT) [ 62 – 80 ], group interventions [ 81 – 87 ], individual interventions [ 88 – 90 ], quantitative analysis [ 91 ], qualitative analysis [ 92 ], a cohort study [ 93 ], case-control studies [ 69 , 94 – 98 ], single case studies [ 99 – 102 ], multiple case studies [ 103 – 106 ], and psychotherapeutic treatment guidance [ 8 , 106 – 138 ]. Many of these studies deliver CBT as a standalone intervention, however multimodal treatment is recommended, and several treatment models include individual coaching or mentoring support alongside or in between CBT sessions [ 57 , 72 , 77 , 86 , 103 , 112 , 127 , 131 , 137 , 139 ]. One intervention also includes hypnosis and CBT [ 140 ].

Second wave interventions for ADHD recognise the neurobiological deficits as specific to the disorder and not brain injury. While they stress there is no “cure” for ADHD and the literature is clear that ADHD does not arise from distorted cognitions, cognitive treatment models focus primarily on improving, strengthening, or retraining cognitive abilities to increase awareness of behaviour and behavioural control. Early research identified cognitive distortions and maladaptive strategies and beliefs as interfering with skills acquisition and therefore needed support [ 104 , 136 ]. Further research shifted this view slightly to perceive the development of a negative self-concept as the core issue for maladaptive schema or “secondary symptoms” of stress, anxiety, depression, and chronic perceived failure attributed to a history of unachieved potential and negative feedback resulting from a lack of recognition of the disorder. [ 122 , 141 , 142 ]. Aims of treatment reduce deficit-based symptoms, develop environmental restructuring and accommodations, improve self-esteem and negative self-concept through disorder psychoeducation, and increase confidence in capabilities through supported skills practice and repetition. Approaches vary widely, including cognitive rehabilitation, cognitive and metacognitive remediation, and cognitive restructuring. However, most treatment approaches in this area are defined as Cognitive Behavioural Therapy (CBT) ( S1 Appendix ).

The therapists’ role in these models is more a “partner”, “expert teacher-motivator” [ 122 ] and collaborator than the traditional medical expert role [ 117 , 121 , 129 ]. Originally defined by Hallowell & Ratey [ 143 ] as “coaching”, therapists are encouraged to be active and directive in providing structure and redirection to goals or session topics [ 83 , 87 , 101 , 108 , 129 , 135 , 137 , 144 ]. Failure to initiate behavioural changes or maintain new habits and strategies, or “procrastivity”, is attributed to motivational problems due to the nature of the disorder [ 8 , 108 , 121 , 145 ]. CBT for ADHD identifies the ADHD client’s difficulty with delayed gratification and generation of positive emotions as the reason for lack of engagement or “Coping Drift”, where individuals stop implementing the skills taught in treatment [ 121 , 145 ]. Professionals are cautioned that repetition is key, and strategies must be reinforced, or relapse is likely. Therefore relapse prevention is included in practice as well as model design [ 8 , 70 , 71 , 74 , 83 , 86 , 93 , 94 , 108 , 121 , 126 , 136 , 145 , 146 ]. Recommendations for resistance or avoidance of aversive emotional states is to provide therapist support to develop tolerance [ 107 , 122 , 135 ], reframe past experiences [ 112 , 128 , 147 ], and build resilience when encountering setbacks [ 8 , 111 , 118 , 137 , 138 , 146 ]. Treatment designs are limited in length, either by the number of sessions (3 to 16) or by relevance (academic year) except for single case studies [ 99 – 102 , 104 ]. Intervention delivery methods vary from individual or group therapy and didactic teaching with therapeutic support to a computerised program and self-help manuals ( S1 Appendix ).

Characterisation of ADHD and aetiology highlight issues with attentional and behavioural control (hyperactivity, impulsivity, disorganisation) initially, but broadens to give a higher priority to executive dysfunction deficits, motivation and sustained attention, issues with emotional control and self-regulation. Guidance documents definitions of ADHD are often cited: of the 84 papers in this Second Wave analysis, 29 reference DSM-IV [ 60 ], seven reference DSM-IV-TR [ 148 ], and eight reference DSM-V [ 149 ]. Several studies reference alternative characterisations of ADHD, such as similarity to brain injury [ 117 ] and Brown’s Executive Function model [ 83 , 94 ]. However, Barkley is cited in 70 documents.

Third Wave : Mindfulness and acceptance . Third Wave cognitive behavioural interventions take a different treatment approach to traditional CBT. While they are similar in the practical application of behavioural techniques, they differ in their theoretical approach and the focus on cognitive change. Third-wave approaches explore context: the relationship between a person’s thoughts and emotions rather than content alone. This relationship includes a more holistic perspective of health beyond the reduction of disorders [ 53 ]. Therefore, this analysis will review them separately. These approaches include Metacognitive Therapy (MCT), Dialectical Behavioural Therapy (DBT), and Mindfulness Cognitive Behavioural Therapy (MCBT).

Metacognitive Therapy (MC) . Four documents used a metacognitive approach (MC), divided into group metacognitive therapy [ 5 , 76 , 150 ] and metacognitive remedial psychotherapeutic guidance [ 151 ]. Metacognitive interventions conceptualise ADHD as neurobiological dysfunction in the corticostriatal pathways, displayed as deficits in executive functions [ 151 ]. MC highlights the importance of awareness of cognitions or thinking about thinking to strengthen executive functions to enhance functioning and improve self-control. Borrowing from the psychoanalytic frame [ 152 ], treatment of this hybrid model aims to develop an “observing ego” or self-awareness, increasing the ability to be conscious of maladaptive thoughts and behaviours and confront them via self-analysis. The therapist’s role is to focus on cognitive and behavioural aspects of treatment and only address motivational or unconscious elements if they remain unexplained by neurobehavioural origins. Individual treatment plans are designed on a case-by-case basis to capture the individual’s unique problems and strengths. Analysis of authentic and emotionally charged experiences facilitates self-awareness using metaphoric problem identification, followed by strategy design and modification [ 151 ]. In group therapy, the therapist acts as an educator and facilitator, assisting with goal identification, the leading theme focused or problem assessment discussion, and offering support and encouragement [ 76 ]. Characterisation of ADHD focuses primarily on executive function deficits, followed by inattention and memory. This focus is reflected practically in treatment design as hyperactivity/impulsivity is considered less prevalent in adults [ 76 ]. Barkley is a primary citation in all four documents.

Dialectical Behavioural Therapy (DBT) . Ten studies identified an adapted model of Dialectical Behavioural Therapy (DBT) for ADHD. These consist of randomised controlled trials [ 21 , 153 – 155 ], a pragmatic open study [ 156 ], and group interventions [ 157 – 161 ]. This treatment model recognises ADHD neurobiological deficits but is grounded in a phenomenological conceptualisation, perceiving the nature of ADHD as a personality disorder. This conceptualisation is supported by similarities in symptoms and the positive response to the treatment of ADHD with comorbid Borderline Personality Disorder (BPD) [ 158 ]. Linehan [ 162 ] characterises BPD as a disorder of self-regulation from biological irregularities combined with dysfunctional environments, including their interaction and transaction. Experiences of invalidating environments impair childhood ability to learn to label experiences and emotions, modulate emotional arousal, tolerate distress, or form realistic goals and expectations, resulting in a child who invalidates their own experiences, generating a lack of self-trust. The adapted model is presented in group format of 13 weeks of 2-hour sessions. The design prioritises ADHD symptom-oriented modules, highlights non-empirically researched resources of ADHD [ 163 ], and includes DBT “mindfulness” training explicitly. The therapist’s role in the DBT adapted model for ADHD supports treatment aims of learning to “control ADHD—instead of being controlled by ADHD” through psychoeducation and provision of session structure and flexibility for individuals. A key therapist practice adopted from DBT is the dialectical balance between validating symptoms, aiming for a stabilising effect and encouragement of motivation, and skills training for behavioural change [ 158 ]. These models characterise ADHD as a deficit of attention and emotional control with hyperactive and impulsive behaviour, but later papers highlight issues with executive function and self-regulation [ 157 ]. Four studies cite Wender [ 164 ] as diagnostic criteria [ 153 , 158 – 160 ], two studies cite DSM-IV [ 154 , 155 ], and four studies cite Barkley specifically [ 21 , 156 , 157 , 161 ].

Mindfulness . Twenty-two documents included mindfulness in treatment options for ADHD. These included systematic reviews [ 42 , 165 – 167 ], randomised controlled trials [ 168 – 174 ], a pragmatic open study [ 156 ], group interventions [ 98 , 175 , 176 ], a case-control study [ 177 ], a multiple case study [ 178 ], and psychotherapeutic guidance [ 8 , 179 – 182 ]. Only two studies presented mindfulness treatment alone [ 98 , 156 ]. In Edel et al. [ 156 ], mindfulness was used as a comparator to DBT.

Mindfulness-based approaches conceptualise ADHD as a neurobiological disorder of self-regulation with deficits in executive function. Issues with sustained and selective attention are addressed by mindfulness meditation, which is presented as a self-regulatory practice recognised as mental training to strengthen and improve regulation of attention, emotions and brain function [ 167 , 175 , 177 , 181 ]. The therapist’s role is primarily to introduce and support developing the new skill set of “mindful awareness” or cognitive defusion to facilitate the ability to decrease emotional responses while continuing to act [ 8 ]. Interestingly, Zylowska’s [ 175 , 176 ] Mindfulness-Based Cognitive Therapy treatment model includes within its psychoeducation a characterisation of ADHD as a “neurobiological difference” with both evolutionary non-adaptive and potentially adaptive aspects [ 183 – 185 ]. However, within the treatment approach, the ADHD characterisation remains based on cognitive behavioural theory.

Treatment is in a group format, and length varies from 8 to 12 weeks of 2 to 3-hour sessions. The characterisation is reasonably consistent across this group, focusing primarily on poor sustained attention, inhibition and emotional dysregulation attributed to executive dysfunction, with one study highlighting impairments in performance monitoring [ 173 ]. Two papers cite DSM IV [ 42 , 168 ], two cite DSM V [ 167 , 170 ], and sixteen cite Barkley specifically [ 8 , 98 , 156 , 165 , 166 , 169 , 171 – 173 , 175 , 176 – 180 , 182 ].

Thirty-six documents presented coaching as a beneficial intervention for ADHD. These include a systematic review [ 186 ], a randomised controlled trial [ 187 ], individual interventions [ 188 – 199 ], qualitative studies [ 200 – 204 ], quantitative studies [ 205 – 207 ], and psychotherapeutic guidance [ 118 , 143 , 208 – 218 ]. It is important to note that nineteen studies were conducted at university for students, and therefore have academic goal achievement as a focus [ 187 – 195 , 197 – 199 , 201 , 204 , 206 , 208 , 212 ].

The term “coaching therapy” was coined by Hallowell and Ratey [ 143 ] to highlight the need for a therapist to take a more “active, encouraging role” with ADHD patients. The role of the “therapist-coach” was to provide a structuring force, maintaining focus and reminding patients of goals and objectives through directive interaction, as opposed to open-ended psychoanalysis. ADHD Coaching has since developed into an independent modality, which can be delivered alone or as part of a multi-modal approach. The ADHD Coaches Organisation (ACO) defines ADHD Coaching as a blending of three elements: Life Coaching, Skills Coaching, and Education [ 218 ]. Life coaching separates ADHD Coaching from therapy by highlighting the therapist-client relationship’s collaborative nature, where the coach supports client self-awareness and achievement of self-identified goals, providing structure and accountability as needed. The client is viewed as a creative and resourceful expert with individual strengths which are leveraged in skills coaching to design systems and strategies to strengthen clients’ ability to manage daily life. Education is provided through relevant ADHD research and tools, as requested by the client or as needed.

Conceptualisations of ADHD within coaching models focus almost exclusively on working with neurobiological deficits in executive function, with the primary treatment aim to set and achieve goals and develop skill sets to support practical day to day management. Some models even define themselves specifically as “Executive Function Coaching” [ 191 , 195 , 198 , 204 , 206 , 208 ]. However, some models highlight ADHD Coaching as based on or similar to CBT [ 186 , 196 , 199 , 208 ]. The role of the coach is to support clients to improve self-regulation, defined as the ability to persist in goal-directed behaviour through time [ 204 , 209 ], by modelling cognitive strategies, practising non-judgement, offering pragmatic support and guidance, and holding clients accountable by reflection in session or monitoring progress via between session check-ins. Negative emotions are addressed as barriers to goal achievement and confidence, but models are specific that ADHD coaching is practical [ 186 ], dealing with “what, when and how–never why” [ 213 ].

Six documents mention self-determination models as part of a wider ADHD Coaching treatment model [ 190 , 191 , 194 , 195 , 204 , 206 ]. These are functional theory models designed to assist students, particularly those with learning disabilities, to develop internal or dispositional characteristics of self-determined behaviour and goal acquisition [ 219 – 221 ]. Field & Hoffman’s model [ 221 ] defines self-determination as the ability to define and achieve goals grounded in knowing and valuing oneself, which can be supported or thwarted by internal variables and environmental factors. The model specifically focuses on internal controllable variables to assist individuals to adapt to environments with unpredictable support. The core theory is that to be self-determined, one must develop internal awareness and the skills and strength to act on this internal foundation. The model has five major components:

• “Know Yourself”: Increase awareness of one’s preferences, strengths, weaknesses and needs by “dreaming” or overcoming barriers in socialised expectations for individuals with disabilities that limit options and perceptions of self-efficacy, building on a foundation for self-determined decision making.
• “Value Yourself”: Develop affective variables of self-esteem, including identifying strengths in areas commonly perceived as weakness, supporting the self-acceptance of disability and motivation for self-advocacy, increasing the ability to be self-determined.
• Plan: Learn planning skills and visual rehearsal of creative and effective actions for short-range steps leading to long term goals.
• Act: Awareness of how to assertively communicate goals, desires and intentions to others and access relevant resources. Understanding persistence, negotiation, and conflict resolution around risk-taking and barriers that may result from taking action.
• Experience Outcomes and Learn: Learn skills in evaluation of progress based on experience of change and comparison to expected outcomes. Recognition and celebration of successes crystallises the self-determination process.

Wehmeyer et al.’s model [ 219 , 222 ] is a teaching model to help students become causal agents. Based on cognitive behavioural theory [ 223 , 224 ], social cognitive theory [ 225 ] and research in self-management and self-control [ 226 ], this model defines self-determination as the abilities necessary to act as one’s primary causal agent and make choices and decisions about the quality of life free from external influence and interference [ 227 ]. Developed from a model designed to teach students decision making, independent performance, self-evaluation, and adjustment skills, the updated model includes defining those who are self-determined to persistently regulate problem-solving to meet self-directed personal goals using student-directed learning strategies [ 219 ]. This ability is developed through a learned problem-solving sequence of thoughts and actions to reduce the discrepancy between what students want or need and what they have or know. The sequence requires the students to 1) identify the problem; 2) identify potential solutions; 3) identify barriers to solving the problem; and 4) identify consequences to each solution, thereby enabling the student to regulate problem-solving by setting goals to meet needs, constructing plans to meet goals, and adjusting actions to complete plans [ 219 ]. A comprehensive combined curriculum of these frameworks was later developed [ 220 ]. While they provide support for client autonomy and causal agency within the design of these ADHD Coaching models, these models prioritise goal setting and identification as regulators for human behaviour and recommend student-directed learning strategies based on operant psychology, applied behavioural analysis and positive reinforcement techniques. Thus, treatment approaches for ADHD remain based on cognitive behavioural theory.

Treatment approaches in ADHD Coaching models are primarily cognitive behavioural, including reframing negative self-talk [ 228 ], continuous reinforcement [ 189 , 209 ], implementing rewards and consequences [ 188 , 189 , 192 , 196 , 212 ], and between-session assignments [ 192 , 196 , 209 , 217 ]. These models focus on the characterisation of ADHD as deficits in executive function relating to goal-directed behaviour, disorganisation and planning, motivation, and ultimately self-regulation. Citations for characterisation in ADHD Coaching models include one referencing DSM IV [ 211 ], three reference DSM-IV-TR [ 191 , 202 , 214 ], one reference to Brown’s Executive Function Model [ 195 ], and twenty-eight reference Barkley specifically [ 118 , 128 , 143 , 186 , 188 , 189 , 191 – 194 , 196 – 201 , 203 – 207 , 209 , 212 , 214 – 218 ].

Other interventions.

Fourty-seven documents describe non-pharmacological interventions not based on psychotherapy. These include Neurofeedback, Transcranial Stimulation, Hypnotherapy, Light Therapy, Computer-Based, Mentoring, Self-Monitoring, Binaural Beat Auditory Stimulation, and Movement-related interventions.

Neurofeedback . Twelve documents explored Neurofeedback as an intervention for ADHD. These include randomised controlled trials [ 229 – 231 ], individual interventions [ 232 , 233 ], case-control studies [ 234 , 235 ], a single case study [ 236 ], and treatment guidance [ 118 , 237 – 239 ]. Neurofeedback (NF) treatment models focus heavily on neurocognitive deficits as being the origin of ADHD behaviours. The research uses Electroencephalography (EEG) measures to study the correspondences between intracranial electrical currents and responding voltages on the scalp. These measures indicate aspects of brain electrical function and processing, such as the electrical activity of various brain regions and their response to stimuli during cognitive tasks. EEG activity is quantified by computation of amplitude and power values for specific frequency bands of activity, source localization, and brain electrical activity mapping. Frequency refers to the number of oscillations, or waveforms, within a given time period. Analysis of waveforms, or a mixture of frequency bands, is a relational and complex process of examining frequency bands associated with both regions of the brain and cognitive or behavioural characteristics.

Characterisations of ADHD are presented as disturbances in cortical arousal, executive function, and self-regulation. Theta/beta and theta/alpha waveform ratios (TBR) are considered a measure of differences in excess, slow-wave activity and epileptiform spike and wave activity [ 240 ], interpreted as abnormal brain processes indicating cortical under arousal, insufficient inhibitory control, and maturational delay in ADHD [ 241 ]; however recent studies have challenged TBR as a marker for ADHD diagnosis [ 235 ]. Sensory-motor rhythm (SMR) or low beta waveform ratios are thought to indicate cortical hypo-arousal, interpreted as deficiencies in the early stages of information processing [ 230 ]. Decreased contingent negative variation (CNV), a steady, slow, negative-going waveform associated with cognitive energy in anticipation of task performance, is considered indicative of dysfunctional regulation of energetical resources in ADHD [ 234 ].

Based on research in children, two treatment approaches reflect changes in the conceptualisation of ADHD and, therefore, treatment aims. Traditionally, the focus of treatment has been based on a “conditioning and repair model” [ 242 ]. Treatment aims to address dysfunctions and see behavioural improvement and remediation of symptoms following NF application [ 243 ]. Skill acquisition and learning are implicit, automatic, and unconscious. Changes in activity indicate positive results: the ability to decrease slow-wave activity (theta) and/or increase fast wave EEG activity (beta) should correlate with symptom improvement; or modulation of slow cortical potentials (SCP), changes of cortical electrical activity, indicate improved cortical regulatory processes [ 244 ]. The role of the therapist is to act as a model for affect regulation [ 236 ] as well as use behavioural principles such as operant conditioning (i.e., positive reinforcement) in the training process resulting in normalisation and stable change in resting EEG, or “EEG trait” [ 245 ], and behaviour [ 231 , 233 , 234 ].

More recently, the NF treatment focus has developed into a “skills acquisition model” [ 242 ]. Rather than simply improving neuropsychological deficits, it is thought that NF may be used as a tool for enhancing or optimising specific cognitive or attentional states [ 246 , 247 ]. This model recognises the bio-psycho-social model of neurodevelopmental disorders, characterising ADHD as impairments in attention, executive functions and self-regulation [ 229 , 230 ]. In this model, self-regulation, or neuro-regulation, is defined as explicit learning of controlled cognitive processes of cortical regulation evidenced by normalised shifts in EEG amplitudes [ 242 , 248 , 249 ]. Performance optimisation is evidenced by improved skill in changing the “EEG state” via self-initiated effort during task performance [ 243 , 250 ]. The therapist’s role is to use cognitive behavioural therapy elements such as positive feedback and coaching and operant procedures as active support within treatment sessions to enhance self-efficacy and self-confidence to support neuro-regulation [ 244 , 251 ]. Citations for characterisation of ADHD in NF models include two citations for DSM-IV-TR [ 231 , 238 ], two for DSM -V [ 232 , 233 ], one for Sonuga-Barke’s Delay Aversion Model [ 237 ], three for Sergeant’s Cognitive-Energic Model [ 230 , 234 , 237 ], and four citations for Barkley [ 118 , 229 , 237 , 239 ].

Transcranial stimulation . Four documents present Transcranial Stimulation as a treatment approach for ADHD. These include a systematic review [ 252 ], two randomised controlled trials of Transcranial Direct Stimulation (tDCS) [ 253 , 254 ], and a randomised controlled trial of Transcranial Magnetic Stimulation (rTMS) [ 255 ]. Both forms of transcranial stimulation conceptualise ADHD as a neurobiological disorder with deficits in executive functions, including attention, working memory, impulsivity, and inhibitory control. The treatment aims to increase cortical excitability in the area of stimulation, leading to improved neuropsychological and cognitive functions.

Treatment approaches are non-invasive but differ in their application. Transcranial Magnetic Stimulation uses a coil placed on the subjects head to deliver brief, intense pulses of current (up to 50 Hz) to generate a sizeable electromagnetic induction field initiating neurotransmitter release in the cortex and subcortical white matter of the brain [ 255 , 256 ]. Transcranial Direct Current Stimulation uses conductive sponge electrodes applied to the scalp in specific locations to deliver a weak electrical current (1–2 mA or milliamps) for up to 20 minutes. It is hypothesised that the electrical current changes the polarisation of the neurons, affecting their average level of discharge [ 253 , 254 , 256 ]. Multiple treatments are administered daily for 3–4 weeks. Protocols suggest two applications of stimulation: “online”, or while a patient is completing a task, or “offline” where the treatment is applied before or without specific targeted tasks. Citations for characterisation of ADHD in these models include DSM-IV [ 252 ], DSM-IV-TR [ 254 ], DSM V [ 255 ] and Barkley [ 253 ].

Hypnotherapy . Two RCTs examined hypnotherapy as a treatment approach for ADHD [ 74 , 257 ]. These studies conceptualise ADHD as a developmental neurobiological disability with deficits in attention, issues with hyperactivity/impulsivity and problems in executive function, including processing speed, regulating alertness, modulating emotions, and utilizing memory. Treatment aims to improve symptoms, mood, quality of life and cognitive performance. Treatment design is based on symptoms outlined in the DSM-IV and Brown’s Executive Dysfunction Model [ 258 ]. The therapist’s role was to follow a semi-structured manual to review the previous session, present the theme for the current session, perform induction and guided hypnotherapy with a post-hypnotic suggestion, and lead discussion. Treatment length was ten weekly sessions of 40 to 60 minutes. Citations for characterisation of ADHD were the DSM-IV [ 257 ] and Brown’s Executive Dysfunction Model [ 74 ].

Light therapy . Five documents present light therapy as a treatment approach for ADHD: a systematic review [ 259 ], an individual intervention [ 260 ], a quantitative study [ 261 ], a literature review [ 262 ], and treatment guidance [ 263 ]. These documents conceptualise ADHD as a neuropsychiatric disorder with primary symptoms of impulsivity, inattention, and hyperactivity impacted by mood regulation difficulties, maintaining arousal and sleep disturbances that contribute to pathophysiology. This conceptualisation is supported by links between ADHD, seasonal affective disorder (SAD) and circadian rhythms and highlighted by similarities in symptoms between sleep deprivation and ADHD [ 261 , 263 ]. Research indicates abnormalities in circadian related physiological measures such as heart rate increase relevant to autonomic function, dysregulation in melatonin rhythm leading to delays in melatonin onset, which may affect the modulation of the sleep/wake cycle [ 263 , 264 ], as well as some evidence of low cortisol impacting wakening times [ 259 ]. Also, a later diurnal preference, or evening chronotype, is highly prevalent in the ADHD population. Its association with shorter night sleep periods is believed to generate sleep debt, delay the sleep phase, and exacerbate symptoms or potentially play a causal role in ADHD symptoms [ 262 , 263 ].

Light Therapy (LT) treatment aims to assist with phase-shifting abnormal circadian rhythms through light exposure to achieve sleep onset to improve alignment with work, academic, or social norms. Treatment outcomes are improved sleep and improved ability to maintain effort, arousal and attention [ 260 , 262 ]. The treatment has been trialled as a three-week self-administered daily dose of 10,000 lux at a distance of 24 inches using a full-spectrum fluorescent lightbox [ 260 ]. Citations for the characterisation of ADHD in these documents include DSM-IV [ 260 ], DSM-V [ 259 ], Douglas [ 262 ], Brown’s Executive Dysfunction Theory [ 261 ], and Barkley [ 261 ].

Computer-based interventions . Eight documents presented computer-based interventions as a treatment approach for ADHD. These include randomised controlled trials [ 265 – 268 ], individual interventions [ 269 , 270 ], and case-control studies [ 271 , 272 ]. These approaches characterise ADHD as a neurobiological disorder with executive function deficits, including difficulties in sustained attention, response inhibition, goal persistence, and working memory. Computer-based interventions take two approaches: supportive or training. Supportive interventions aim to target specific symptoms and facilitate functioning via supportive software. Individuals are given access to tools used independently following training for a set timeframe. In Hecker et al. [ 271 ], a software tool designed to reduce internal and external distractions aimed to reduce effort and improve engagement, resulting in increased time reading and comprehension. In Irvine [ 269 ], a smartphone app for time management aimed to reduce the discrepancy between the perception of time and actual time spent by providing immediate real-time feedback on the current status and time use, leading to adjustments of future tasks according to behavioural therapeutic principles.

Training interventions aim to strengthen cognitive skills and/or remediate deficiencies via cognitive behavioural learning strategies of repetition and positive reinforcement. Working Memory Training [ 265 , 266 , 268 ] aimed to enhance auditory-verbal and visual-space working memory through intensive training with increasing task difficulty leading to improved cognitive and academic performance and attentional self-regulation. Cognitive ability training [ 272 ] aimed to improve cognitive skills of decision making, attention, organisation and time management through simulated activities in a gaming environment, providing immediate real-time rewards. Cognitive training for executive function [ 267 , 270 ] aimed to remediate cognitive processes deficiencies by repeated and graded exposure to neutral and universal stimuli and feedback. Training is self-administered, hierarchical and adjusted to individual performance with outcomes for improvements in daily executive functioning, occupational performance, and quality of life. Treatment length varied in frequency and intensity, from 20-minute sessions 3–5 times a week for 12 weeks to 45-minute sessions five days a week for five weeks and included weekly check-ins or supportive coaching. Citations for characterisation of ADHD in these approaches include DSM-IV [ 265 , 266 , 268 , 270 ], DSM V [ 271 ], Brown’s Executive Dysfunction Model [ 267 , 270 ], Nigg’s Integrative Theory [ 267 ], and Barkley [ 266 , 267 , 269 , 270 ].

Mentoring . One study presented mentoring as an individual intervention for ADHD [ 273 ]. Based in a university environment, ADHD is characterised as deficits in basic cognitive skills, such as attention, concentration, and memory and higher-level cognitive skills or “executive functioning”, such as planning, organization, judgment, problem-solving, and cognitive flexibility. These can negatively affect the university experience, as more independent self-management and a complex skill set are required for success, particularly time management and organization, academic skills, and social skills.

The mentoring program pairs second-year master’s level occupational therapy (MSOT) students (mentors) with undergraduate college students (mentees) for one-to-one support twice weekly for 2-hour sessions in the fall and spring semesters. This mentoring is a credit-bearing course that addresses skill development in time management and organization, academic skills, and social skills for college success. Mentees are graded on attendance, professional behaviours, compliance on a weekly to-do list, a presentation on academic resources, and a 4-part written paper on an academic skill. Mentors are participating as part of a professional Occupational Therapy training programme with an overall goal to facilitate student success in college, and if factors overwhelmingly interfere with this goal, to identify an alternate, suitable plan. As part of the training, mentors meet in discussion groups to brainstorm ways to overcome the mentoring process’s challenges. The citation for the characterisation of ADHD in this intervention is primarily the DSM V [ 273 ].

Self-monitoring . One study presented individual self-monitoring as an intervention for ADHD [ 274 ]. Based in a university environment, ADHD is characterised as a neurobehavioral disorder with symptoms of inattention, hyperactivity, and impulsivity, which increases the risk of academic failure or underachievement.

A checklist tool is co-designed and supported with integrity checks and email reminders every 2–4 days, with face-to-face check-in sessions every two weeks. The self-monitoring intervention aims to teach participants to observe and record behaviours to change the behaviour in the future. Outcomes are to obtain higher grades, endorse fewer ADHD symptoms, engage in more positive study skills, further attain goals, and improve medication adherence. Citations for characterisation of ADHD is DSM IV [ 274 ].

Binaural beat auditory stimulation . Two documents present binaural beat auditory stimulation as a treatment for ADHD. These include an individual intervention [ 275 ] and a literature review [ 276 ]. These approaches characterise ADHD as a disorder with core deficits in behavioural inhibition and sustained attention, highlighting a decrease in beta wave states interfering with maintenance of attention as a contributing factor.

Binaural beat auditory stimulation generates tones of two frequencies presented separately in each ear which are synthesised by the medulla into a single low-frequency tone. The pulse frequency from this binaural beat is the difference between the two tones and generates electrical activity that EEG can record. Treatment aims to match the difference between the tones to a particular brain-wave state, such as the beta range, which will correspondingly be maintained by overall brain activity and affect cognition levels [ 277 ]. Treatment involves exposure to auditory stimulus via headphones during an active task. Citations for characterisation of ADHD only directly reference Barkley [ 275 ].

Movement-related interventions . Twelve documents present movement-related interventions as a treatment for ADHD, including a systematic review [ 278 ], a pilot study [ 279 ], case-control studies [ 280 – 285 ], and treatment guidance [ 286 – 289 ]. In these approaches, ADHD is a disorder with core issues in special working memory, attention control, response inhibition, motor control, delay aversion, emotional self-regulation, and executive dysfunction. Movement-related interventions approach treatment in two ways: passive and active.

One document presented a passive intervention. Whole Body Vibration (WBV) devices deliver sinusoidal or oscillating wave vibrations at low frequencies to enhance mechanical muscular performance [ 290 ], improve balance and proprioception [ 291 ], and increase vigilance [ 292 ], potentially by inducing muscle contractions and increasing tension through the stretch reflex. Treatment is passive, delivered while sitting still, and aims to improve attention, inhibitory control, and cognitive performance in ADHD [ 280 ].

Active movement-related interventions aim to improve neurobiological factors such as increased cerebral blood flow, enhance neuroplasticity [ 288 , 289 ], assist the development of cortical and subcortical brain regions through activity [ 287 ], reduce the impact of comorbid anxiety, depression, stress and negative affect [ 279 , 288 ], and improve cognitive function and performance [ 282 – 286 ]. There is a specific focus on hypodopominergic functioning in ADHD and the upregulation of a brain-derived neurotrophic factor (BDNF) protein in several studies. [ 281 , 283 , 286 , 288 , 289 ]. Research shows that BDNF is linked to differentiation and survival of dopaminergic neurons, and decreased levels of BDNF have been suggested as being involved in ADHD pathology [ 293 ]. As well as improved cognition, one of the benefits of acute exercise is elevated levels of BDNF, which these models argue makes exercise an important intervention for ADHD. Treatment varies both in approach and length, from vigorous physical activity for 30 minutes, such as cycling, to fine motor movement stimulation using an anti-stress ball during a task. Citations for the characterisation of ADHD in these approaches include DSM IV [ 287 ], DSM V [ 285 ], Nigg [ 281 , 286 ], Sergeant [ 282 ], Sonuga-Barke [ 282 , 286 ], and Barkley [ 278 – 280 , 283 , 284 , 286 , 288 , 289 ].

Alternative models.

Psychoanalysis and Psychodynamic . There are very few studies in Psychoanalysis and Psychodynamic approaches for adult ADHD. A group intervention [ 294 ], single [ 295 , 296 ] or double case studies [ 297 – 299 ] were reviewed, as well as an evaluation study [ 300 ]. Much of the literature consists of literature reviews [ 35 , 301 – 304 ] and guidance pieces [ 152 , 305 , 306 ], which demonstrate considerable debate in the characterisation and aetiology of ADHD. Early papers reflect issues in clinical approaches by highlighting the importance of considering ADHD diagnosis as defined by DSM-IV in light of epidemiological evidence [ 301 , 307 ]. Both Psychoanalysis and Psychodynamic approaches present alternative models to Barkley, with distinct variation in characterisation.

Historically, Psychoanalysis does not recognise neurobiological deficits. Behaviours associated with ADHD are conceptualized as disturbances in the ego, identified as the organising force responsible for synthesis and integration of internal and external stimuli, internalisation of object relations and structure and development of the superego, and integral to facilitating the capacity for self-observation and self-reflection. Early presentations of these disturbances in childhood lead to attachment issues and interfere with sibling relationship development [ 301 ]. Behaviours are perceived as defence mechanisms, identified as an internal struggle for control [ 296 , 300 ]. Psychodynamic perspectives differ in that behaviours are conceptualized as a reaction to neurobiological deficits [ 152 , 302 , 306 ], facilitating engagement with Barkley’s model. Executive functioning deficits are presented as synonymous with self-regulation deficits, interfering with the development of personality structure and an internal representation of self about others. Self-regulation deficits disrupt the ability to empathise, which distorts the capacity to mentalise and develop a coherent sense of self [ 304 ].

The therapist’s role in these models is to act as the organising force for the client, assisting them to develop ego capacities via therapeutic relationship and transference. This enables the client to experience empathy, recognise mental states, and identify self in relation to others [ 35 , 301 , 304 ]. With the exception of the group intervention [ 294 ], treatment designs are intensive, up to four times a week [ 301 , 304 ] and long term, between 2 and 12 years [ 295 , 296 , 298 , 301 , 304 ]. Despite the alternative model to characterise ADHD, four studies reference international guidance [ 297 , 301 , 302 , 307 ], seven studies mention executive function or cognitive control [ 35 , 152 , 295 , 297 , 299 , 304 , 306 ], and seven reference Barkley specifically [ 35 , 294 , 295 , 297 – 299 , 304 ].

A review of 221 documents confirmed that treatment approaches for ADHD are based on a dominant cognitive behavioural paradigm for conceptualising ADHD, which attributes symptoms solely to neurobiological and developmental deficits leading to challenges with cognitive function, behavioural control, and management of self-regulation. This is reflected in descriptions of treatment aims, approaches and outcomes ( S1 Appendix ).

While this scoping review aimed for as broad a scope as possible, it is important to acknowledge the limitations of this study. First, while translation services were used as much as possible, the material identified in the results were primarily published in English. Further, the majority of the documents presented were published in the US, Canada and European countries. This may be due to documents being presented or published by journals not listed by the major search engines, and therefore not identified in the search strategies. Alternatively, there may not be a large existent body of published research in other countries, as the official diagnosis criteria for adults with ADHD was only recognised in 2013 [ 149 ]. Secondly, this scoping review was an enormous undertaking, and results are only up to date as of April 2020. However, searches did not reveal any other recent reviews of the theoretical charactarisation of ADHD, therefore it is believed this is the most current comprehensive scoping review on the topic.

This review reflects current research understanding that ADHD is complex and multidimensional in its presentation and impact. Clearly, it shows a broad, cross-disciplinary interest in developing treatment approaches to support individuals with ADHD to reduce symptoms, improve functioning and achieve a better quality of life. Critically, it highlights that a single theoretical perspective limits research into effective treatments for ADHD. Existing aetiological theories of ADHD have been challenged for their refutability [ 308 ], and other issues such as accounting for context variability, or inability to fully link or account for the full aspects of the symptomology [ 19 – 21 ], and heterogeneity [ 1 , 22 – 24 ] including specific links between domains and outcome [ 22 ] and cognition and motivation to select actions for a given context [ 309 ]. Recent recommendations for resolving challenges with heterogeneity in ADHD emphasise the importance of theoretical guidance in decision-making and recognise the critical role of beliefs, assumptions, and goals in preventing misapplication of conclusions to clinical circumstances or populations [ 1 ]. It is proposed that treatments based on approaches from a singular perspective on processes of self-regulation and a deficit-based origin of impairments in ADHD may be limited in scope and capacity to identify and support positive psychological factors for well-being and growth. Hence, the findings in this scoping review identify a gap in research and practice for alternative theoretical perspectives of ADHD.

This review concludes that further research into additional theoretical models of self-regulation would provide opportunities to develop alternative treatment approaches and benefit research and understanding of the symptomology of ADHD.

Supporting information

S1 appendix. analysis of treatment approaches..

https://doi.org/10.1371/journal.pone.0261247.s001

S1 File. PRISMA scoping review checklist.

https://doi.org/10.1371/journal.pone.0261247.s002

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• Volume 21, Issue 4
• Twenty years of research on attention-deficit/hyperactivity disorder (ADHD): looking back, looking forward
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• Samuele Cortese 1 , 2 , 3 , 4 , 5 ,
• David Coghill 6 , 7 , 8
• 1 Academic Unit of Psychology, Center for Innovation in Mental Health , University of Southampton , Southampton , UK
• 2 Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine , University of Southampton , Southampton , UK
• 3 Solent NHS Trust , Southampton , UK
• 4 New York University Child Study Center , New York City , New York , USA
• 5 Division of Psychiatry and Applied Psychology, School of Medicine , University of Nottingham , Nottingham , UK
• 6 Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences , University of Melbourne , Melbourne , Victoria , Australia
• 7 Murdoch Children’s Research Institute , Melbourne , Victoria , Australia
• 8 Royal Children’s Hospital , Melbourne , Victoria , Australia
• Correspondence to Dr Samuele Cortese, Academic Unit of Psychology and Clinical and Experimental Sciences (CNS and Psychiatry), University of Southampton, Southampton SO17 1BJ, UK; samuele.cortese{at}gmail.com

In this clinical review we summarise what in our view have been some the most important advances in the past two decades, in terms of diagnostic definition, epidemiology, genetics and environmental causes, neuroimaging/cognition and treatment of attention-deficit/hyperactivity disorder (ADHD), including: (1) the most recent changes to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases; (2) meta-analytic evidence showing that, after accounting for diagnostic methods, the rates of ADHD are fairly consistent across Western countries; (3) the recent finding of the first genome-wide significant risk loci for ADHD; (4) the paradigm shift in the pathophysiological conceptualisation of ADHD from alterations in individual brain regions to a complex dysfunction in brain networks; (5) evidence supporting the short-term efficacy of ADHD pharmacological treatments, with a different profile of efficacy and tolerability in children/adolescents versus adults; (6) a series of meta-analyses showing that, while non-pharmacological treatment may not be effective to target ADHD core symptoms, some of them effectively address ADHD-related impairments (such as oppositional behaviours for parent training and working memory deficits for cognitive training). We also discuss key priorities for future research in each of these areas of investigation. Overall, while many research questions have been answered, many others need to be addressed. Strengthening multidisciplinary collaborations, relying on large data sets in the spirit of Open Science and supporting research in less advantaged countries will be key to face the challenges ahead.

https://doi.org/10.1136/ebmental-2018-300050

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Introduction

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children, with an estimated worldwide prevalence around 5%. 1 Although it has for a long time been considered a childhood disorder, it is now established that impairing ADHD symptoms persist in adulthood in a sizeable portion of cases (around 65%), 2 although there is variability in the estimate due to methodological heterogeneity across studies. 3

As for other mental health conditions there has, over the past two decades, been an increasing body of research on ADHD. Reasons for this increase include: increased recognition of the impact of ADHD on functioning; advances in research methodology and technology; and interest from pharmaceutical companies.

Here, we provide an overview of what we deem have been some the most important advances, in the past two decades, in ADHD research. We also discuss key areas for future research.

Given the large body of literature and space constraints, this review is selective rather than systematic and comprehensive. We relied mostly on meta-analyses, retrieved with a search in PubMed using the following syntax/terms (update: 8 August 2018): (ADHD OR Attention Deficit OR Hyperkinetic Disorder) AND (meta-analy* OR metaanaly).

Presentation

Diagnostic definition.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 4 published in 2013, introduced several significant changes in relation to the DSM Fourth Edition Text Revision (DSM-IV-TR) 5 criteria. First, the threshold in the number of symptoms (criterion A) necessary for the diagnosis in older adolescents and adults was reduced from 6 to 5. This change is in keeping with the notion that, despite a reduction in the number of symptoms over development, adults with ADHD in childhood can still present with impairment. 2 The required age of onset was increased from ‘prior to 7’ to ‘prior to 12’. The purpose of these changes was well intended and designed to facilitate the diagnostic process in adults, who often have trouble pinpointing the exact age of onset, especially if early in the development. Unfortunately, neither change was based on empirical evidence, and methods used for diagnostic ascertainment in adults are still under debate. 3 Another pivotal change in DSM-5 is the removal of the veto around the dual diagnosis of ADHD and autism spectrum disorders (ASD) that was present in previous editions of the DSM. Unlike the age of onset and symptom number changes this change is supported by a significant body of research (see ref  6 ). Finally, the (sub)types of ADHD defined in the DSM-IV-(TR) were replaced by the notion of different presentations. This acknowledges the instability in the phenotypic manifestation of inattention or hyperactive/impulsive symptoms over time, 7 in contrast to the more static notion of a subtype.

With regard to the International Classification of Diseases (ICD), it appears that the veto to diagnose ASD in the presence of ADHD will be retained in the upcoming ICD 11th Revision ( https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f821852937 ).

Overall, while these changes to a degree reflect recent empirical evidence and/or practical needs in the diagnostic process, there are still issues that need to be addressed. First, current criteria still focus on the number of symptoms rather than on a more precise definition of functional impairment. This should be a priority for the field and efforts, such as the development of the International Classification of Functioning, Disability and Health: Child and Youth version, are already ongoing. 8 Second, while currently each of the symptoms listed in the DSM criterion A carries the same weight, it has been argued that inattention should be more heavily weighted than hyperactivity/impulsivity. 9 Supporting evidence, which comes from clinical samples, needs to be replicated in population-based studies. Third, from a practical standpoint, it is unclear on how to best integrate different information sources (eg, parents, teachers, etc). Addressing this challenge is pivotal. Fourth, although proposed as a separate type of ADHD or even a separate diagnostic entity, the extent to which the construct of sluggish cognitive tempo (impairment of attention in hypoactive-appearing individuals) overlaps with ADHD inattentive presentation remains still unclear. 10 11 Finally, one of the most controversial topics in the entire field of ADHD research is currently around the possibility that ADHD can emerge de novo in adulthood, in contrast to its conceptualisation as a neurodevelopmental disorder. Despite an increasing number of important studies, the controversy is far from being solved 12 and we expect it will be a major focus of research in the field in coming years.

We also expect that proposed radical, although controversial, changes in the nosographic approach to mental health conditions, such as the Research Domain Criteria will significantly influence future research on ADHD. 13

Epidemiology

One of the most controversial questions in relation to the epidemiology of ADHD has been around possible differences in the prevalence of the disorder in different countries. In particular, the differential rates of clinical diagnosis in North America and Europe are cited by detractors of ADHD, as supporting the notion that ADHD is not a ‘real’ disorder but rather a social construct. 14 However, a meta-analysis published in 2007 1 found that diagnostic criteria, source of information, requirement of impairment for diagnosis and geographic origin of the studies significantly impacted on the estimated pooled rate of ADHD (5.29%). A significant difference in prevalence emerged only between North America and both Africa and the Middle East, although evidence from non-Western countries was limited. However, as there were only a limited number of studies available for Africa and Middle East, these findings should be considered with caution. By contrast, no significant differences emerged between Europe and North America, suggesting that when using the same diagnostic approach the rates of the disorder are fairly consistent in Western countries, with variability in the prevalence accounted for primarily by methods used to diagnose ADHD. Another more recent meta-analysis 15 found no evidence to support an increase in the epidemiological prevalence of ADHD over the past three decades when standardised diagnostic procedures are followed. This implies that the trend for increased rates of diagnosis 16 are not accounted for by actual increases in prevalence. Rather, the mismatch between administrative and epidemiological rates of the disorder, which varies between the USA and Europe, is likely accounted for by cultural and social factors. 16

As the bulk of the available epidemiological studies focus on school-age children from North America and Europe, further population-based studies from other continents as well as in preschoolers and adults should be encouraged. Additionally, longitudinal epidemiological studies aimed at better understanding the developmental trajectories and predictors of remission/persistence of ADHD in adulthood will be instrumental, alongside other clinical, neuropsychological, genetic and neuroimaging studies, to inform prevention programmes. Development of a standardised definition of caseness and remission will be pivotal for this body of research to be fruitful.

Genetics and environmental causes of ADHD

Studies of twins and adopted children indicate a high heritability for ADHD (60%–90%). 17 Efforts to find the genes underpinning this heritability have been more challenging than initially anticipated. As for other mental health conditions, it became clear that ADHD aetiology is accounted for by a complex interaction of many genes each with a relatively small effect and by gene × environment interactions. 18

The first approach to finding the genes involved in ADHD was the ‘candidate gene’ approach. This approach focuses on identifying the variants in genes coding for proteins hypothesised, a priori, to be involved in the pathophysiology of ADHD. These studies identified only about 10 genes as having significant support, 19 which together accounted for only a small fraction of the total ADHD heritability. The next major approach, ‘genome-wide association studies’ (GWAS), which allows the analysis of a large number of common (ie, present at greater than 5% frequency in the population) single-nucleotide polymorphisms across the entire genome, was initially unsuccessful in ADHD, as the available sample was too small to show a meaningful effect. However, in a major breakthrough, the first 12 independent loci have been recently identified through GWAS. 20 Associations were enriched in loss-of-function intolerant genes and brain-expressed regulatory marks, paving the way for a number of novel lines of investigation on the neurobiology of ADHD.

A further recently developed approach focuses on rare (ie, a frequency in the general population below 1%) ‘copy number variants’ (CNV). These are defined as replications or deletions of the DNA with a length of at least 1 kb. CNVs over-represented in ADHD have been detected, but their contribution can so far only explain 0.2% of ADHD heritability. 21

As for environmental aetiological factors, there have been, over the past years, considerable data suggesting that prenatal and postnatal factors, such as maternal smoking and alcohol use, low birth weight, premature birth and exposure to environmental toxins, such as organophosphate pesticides, polychlorinated biphenyls and zinc, are associated with increased risk for ADHD. 17 22 However, except for preterm birth, genetics studies have implicated unmeasured familial confounding factors, which are not in line with a causal role of environmental factors. 23

Severe maternal deprivation has also been related to the development of ADHD-like symptoms. 24

The study of the causes of ADHD still has many unanswered questions. We need a better understanding of how genes interact with each other, and of the interplay between environmental factors and genes. Genetics has the potential to offer many other exciting future avenues of research in ADHD. We will only mention briefly here: (1) the use of induced pluripotent stem cell derived from peripheral tissue of patients with ADHD and used to generate brain cells with the aim to model brain circuits and responses to medications or other stressors; (2) the use of zebrafish and fruit fly models to augment currently available animal models of ADHD.

Neuroimaging and neurocognition

Initial pathophysiological models of ADHD published 20 years ago 25 were based on dysfunctions in a limited number of brain areas, namely the frontal cortex and the basal ganglia. Over the past two decades, and similar to other mental health conditions, a major paradigm shift from alterations in individual brain regions to dysfunction in brain networks has begun to reshape our understanding of the pathophysiology of ADHD. Structurally, meta-analyses and mega-analyses of the structural MRI studies conducted over the past two decades pointed to consistently replicated alterations in the basal ganglia, 26 and in a number of other subcortical areas. 27 Functionally, a comprehensive meta-analysis 28 found that the majority of the ADHD-related hypoactivated areas were related to the ventral attention and the frontoparietal networks. By contrast, the majority of ADHD-related hyperactivated areas fell within the default mode network and other hyperactivated areas were within the visual network. This is in line with the hypothesis that the attentional lapses that characterise ADHD result from an inappropriate intrusion of the default network in the activity of task-positive networks frontoparietal, ventral or dorsal attention networks, 28 according to the default network hypothesis of ADHD , 29 which has been arguably one of the most inspiring proposals in the neuroscience of ADHD over the past two decades.

While we have gained insight into the brain networks that are dysfunctional in ADHD and in the delay in cortical maturation, 30 we look forward to the next generation of neuroimaging studies which we hope will start to translate these findings into the clinical practice. The introduction of machine learning approaches, such as support vector machine, has been welcomed in the field of clinical neuroscience as a way to translate neuroscientific findings at the individual patient level, thus overcoming the main limitation of current studies that can only provide results valid at the group, rather than individual, level. 31 An increasing number of studies have used machine learning based on MRI data to validate the diagnosis of ADHD with varying degrees of success. 32 33

Neurocognitive studies have made a considerable contribution to our understanding of ADHD. In recent years, the field has moved away from linear single-cause models of ADHD towards multipathway models that emphasise the heterogeneity inherent to ADHD and provide a link between individual differences at the brain level and clinical presentation. 34 35

We believe that an interesting line of research for the future will be to combine genetics, clinical, neurocognitive and neuroimaging data to define, via machine learning approaches, response to treatment, tolerability profiles and functional trajectory of the disorder over time. This will be a crucial step towards personalised and precision approaches to treatment.

Over the past two decades, there has been a marked increase in the number of randomised controlled trials (RCT) aimed at testing the short-term efficacy and tolerability of pharmacological treatments for ADHD (both stimulant and non-stimulant medications). Most have been sponsored by Big Pharma and were designed to support the licence of the medication. In parallel, due to concerns around possible side effects of medications and lack of clarity around their long-term effects, several lines of research on non-pharmacological interventions have been developed. Recent important methodologically sound meta-analyses allow us to summarise and critically discuss this large body of evidence.

For the pharmacological interventions, a comprehensive network meta-analysis 36 of 133 double-blind RCTs demonstrated high to moderate effect sizes (in terms of efficacy) for the different medications versus placebo. Standardised mean differences (SMD) ranged from −1.02 (95% CI −1.19 to −0.85) for amphetamines to −0.56 (95% CI −0.66 to −0.45) for atomoxetine (methylphenidate: −0.78, 95% CI −0.93 to −0.62). In children/adolescents, methylphenidate was the only drug with better acceptability than placebo; in adults this was the case only for amphetamines (with no difference between placebo and other active drugs). Taking into account both efficacy and safety, evidence from this meta-analysis supported methylphenidate as preferred first-choice medication for the short-term treatment of ADHD in children/adolescents and amphetamines for adults.

As for non-pharmacological options, a comprehensive synthesis on non-pharmacological treatments for children and adolescents with ADHD has been provided in a series of meta-analyses by the European ADHD Guidelines Group (EAGG). In 2013, they published a first systematic review/meta-analysis 37 addressing the efficacy of behavioural interventions, diet interventions (restricted elimination diets, artificial food colour exclusions and free fatty acid supplementation), cognitive training and neurofeedback on ADHD core symptoms (ie, inattention, hyperactivity and impulsivity). The systematic review included only RCTs and considered two contrasting outcomes: those rated by individuals not blinded to the treatment condition (active vs control) and those rated by individuals who were probably blinded to treatment (eg, teachers in trials assessing a behavioural intervention implemented with parents). The results were strikingly different depending on the type rater. When considering not blinded ratings, all interventions resulted significantly more efficacious than the control condition in terms of reduction of ADHD core symptoms. However, when considering the more rigorous probably blinded ratings, only free fatty acid supplementation and artificial food colour exclusion remained significantly more efficacious than the control conditions, with small effect sizes (SMD=0.16 and 0.42, respectively), indicating that the clinical impact of these treatments on ADHD core symptoms is, at the group level, modest.

Subsequent EAGG meta-analyses focused on ADHD core symptoms and on ADHD-related problems. A meta-analysis 38 specifically focusing on behavioural interventions showed that, even when considering probably blinded ratings, the behavioural interventions were efficacious at improving important aspects related to ADHD, namely parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31). Another updated meta-analysis 39 on cognitive training, which was found efficacious in improving verbal and visual working memory, which are impaired in a sizeable portion of children with ADHD and have been demonstrated to dissociate from ADHD symptoms. 40 These meta-analyses also suggest that training which targets several neuropsychological aspects may be more efficacious at improving ADHD symptoms, than training targeting only one aspect of cognitive functioning. The most recent meta-analysis 41 by the EAGG on neurofeedback did not provide support for the efficacy of neurofeedback on any of the neuropsychological and academic outcomes. Overall, this body of research does not provide solid evidence to routinely recommend non-pharmacological interventions as highly effective treatments for ADHD core symptoms, although some of them (eg, behavioural interventions or cognitive training) may be effective for important associated impairments (oppositional behaviours and working memory deficits, respectively). The role of fatty acid supplementation and artificial food colours exclusion as possible treatment strategies should be considered cautiously given the small effect size, with CIs close to non-significance.

Probably, the most crucial area of future treatment research in ADHD will be to gain insight into the long-term positive and negative effects of treatments, using randomised trials with withdrawn designs, as well as additional population-based studies with self-controlled methodologies and longitudinal follow-up studies. These should clarify the conclusions from the various follow-up waves of the Multimodal Treatment of ADHD (MTA) study, showing that neither the type and intensity of treatment received during the initial 15-month randomised phase of the study (treatment as usual medication (MED), behavioural therapy (BEH), medication plus behavioural therapy (COMB)) nor exposure to medication over the subsequent observational periods predicted the functional outcome at follow-up which has now extended to 16 years. Of note, in the MTA, the treatments received in the three experimental arms (MED, BEH, COMB) during initial 15-month randomised phase were carefully crafted in an attempt to achieve optimal outcomes. After this initial phase all participants were free to choose the type of treatment they received from their regular provider. As it is likely that these treatments were not as carefully optimised and monitored as the three experimental groups during the randomised  phase, these  longer term findings of the MTA are not easily interpretable and might be, to some extent, misleading.

Conclusions

Many questions have been successfully answered in the field of ADHD. Many others remain to be addressed. Additional multidisciplinary collaborations, use of large data sets in the spirit of Open Science and support of research activities in less advantaged countries are key to address the challenge.

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Contributors SC drafted the paper. DC revised the first draft.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests SC declares reimbursement for travel and accommodation expenses from the Association for Child and Adolescent Central Health (ACAMH) in relation to lectures delivered for ACAMH, and from Healthcare Convention for educational activity on ADHD. DC declares grants and personal fees from Shire and Servier; personal fees from Eli Lilly, Novartis and Oxford University Press; and grants from Vifor.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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Twenty years of research on attention-deficit/hyperactivity disorder (ADHD): looking back, looking forward

Affiliations.

• 1 Academic Unit of Psychology, Center for Innovation in Mental Health, University of Southampton, Southampton, UK.
• 2 Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK.
• 3 Solent NHS Trust, Southampton, UK.
• 4 New York University Child Study Center, New York City, New York, USA.
• 5 Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK.
• 6 Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.
• 7 Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
• 8 Royal Children's Hospital, Melbourne, Victoria, Australia.
• PMID: 30301823
• PMCID: PMC10270437
• DOI: 10.1136/ebmental-2018-300050

In this clinical review we summarise what in our view have been some the most important advances in the past two decades, in terms of diagnostic definition, epidemiology, genetics and environmental causes, neuroimaging/cognition and treatment of attention-deficit/hyperactivity disorder (ADHD), including: (1) the most recent changes to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases; (2) meta-analytic evidence showing that, after accounting for diagnostic methods, the rates of ADHD are fairly consistent across Western countries; (3) the recent finding of the first genome-wide significant risk loci for ADHD; (4) the paradigm shift in the pathophysiological conceptualisation of ADHD from alterations in individual brain regions to a complex dysfunction in brain networks; (5) evidence supporting the short-term efficacy of ADHD pharmacological treatments, with a different profile of efficacy and tolerability in children/adolescents versus adults; (6) a series of meta-analyses showing that, while non-pharmacological treatment may not be effective to target ADHD core symptoms, some of them effectively address ADHD-related impairments (such as oppositional behaviours for parent training and working memory deficits for cognitive training). We also discuss key priorities for future research in each of these areas of investigation. Overall, while many research questions have been answered, many others need to be addressed. Strengthening multidisciplinary collaborations, relying on large data sets in the spirit of Open Science and supporting research in less advantaged countries will be key to face the challenges ahead.

© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.

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Conflict of interest statement

Competing interests: SC declares reimbursement for travel and accommodation expenses from the Association for Child and Adolescent Central Health (ACAMH) in relation to lectures delivered for ACAMH, and from Healthcare Convention for educational activity on ADHD. DC declares grants and personal fees from Shire and Servier; personal fees from Eli Lilly, Novartis and Oxford University Press; and grants from Vifor.

• Attention-deficit/hyperactive disorder: missing the bull's eye. Leon C, Sharma R, Kaur S. Leon C, et al. Evid Based Ment Health. 2019 Feb;22(1):e1. doi: 10.1136/ebmental-2018-300079. Epub 2019 Jan 21. Evid Based Ment Health. 2019. PMID: 30665988 Free PMC article. No abstract available.

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Understanding and Supporting Attention Deficit Hyperactivity Disorder (ADHD) in the Primary School Classroom: Perspectives of Children with ADHD and their Teachers

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

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

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

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

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

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

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

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

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

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

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

Participants

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

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

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

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

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

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

Semi-Structured Interview

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

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

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

Knowledge of ADHD

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

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

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

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

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

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

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

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

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

Strategy Use in the Classroom

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

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

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

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

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

Thematic Analysis

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

Theme 1: Classroom-General Versus Individual-Specific Strategies

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

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

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

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

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

Theme 2: Heterogeneity of Strategies

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

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

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

Theme 3: The Role of Peers

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

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

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

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

ADHD Knowledge

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

Strengths and Challenges

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

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

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

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

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

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

Relevance of Co-Occurrences

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

Limitations

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

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

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

Implications/Future Research

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

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

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

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

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Emily McDougal, Claire Tai & Sinéad M. Rhodes

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Interview Schedule—Teacher

Demographic/experience.

How many years have you been teaching?

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

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

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

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

Psychoeducation

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

Probe behaviour knowledge

Probe cognition knowledge

Probe impacts of behaviour/cognition difficulties

Probe knowledge that children with ADHD differ from each other

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

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

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

Cognitive skills and strategies

Can you tell me about the pupil’s strengths?

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

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

Probe internal

Probe external

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

Probe if different for different subjects/times of the day

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

Probe for examples of how they apply it to their learning

Probe whether these strategies are pupil specific or broadly relevant

Probe if specific to particular subjects/times of the day

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

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

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

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

Probe behaviour

Probe cognition

Interview Schedule—Child

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

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

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

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

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

Cognition/strategy use

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

Do you like school?

Probe why/why not?

Probe favourite lessons

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

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

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

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

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

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

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

Solving a maths problem

Planning your writing

Doing spellings

Trying to remember something

Concentrating/ignoring distractions

Listening to the teacher

Remaining seated in class when doing work

Working with other children in the class

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

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

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

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

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

How many teachers are in your class?

Is there anyone who helps you with your work?

Do you work mostly on your own or in groups?

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

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College students with adhd: a selective review of qualitative studies.

1. Introduction

1.1. qualitative research methods, 1.2. the present study, 2. materials and methods, 2.1. search strategy, 2.2. study selection, 2.3. variable identification, 3.1. quantitative results, 3.2. qualitative results, 3.2.1. the college experience of students with adhd, 3.2.2. interventions, 3.2.3. cognitive and academic functioning, 3.2.4. self-functioning, 4. discussion, 5. conclusions, author contributions, conflicts of interest, appendix a. summaries of included studies, appendix a.1. the college experience of students with adhd, appendix a.1.1. college transitions, appendix a.1.2. adhd as an identity, appendix a.1.3. race, appendix a.1.4. community college, appendix a.2. interventions, appendix a.2.1. coaching, appendix a.2.2. strategies, appendix a.2.3. medication, appendix a.3. cognitive and academic functioning, appendix a.4. self-functioning.

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Cohen, S.L.; Shavel, K.; Lovett, B.J. College Students with ADHD: A Selective Review of Qualitative Studies. Disabilities 2024 , 4 , 658-677. https://doi.org/10.3390/disabilities4030041

Cohen SL, Shavel K, Lovett BJ. College Students with ADHD: A Selective Review of Qualitative Studies. Disabilities . 2024; 4(3):658-677. https://doi.org/10.3390/disabilities4030041

Cohen, Shira L., Katie Shavel, and Benjamin J. Lovett. 2024. "College Students with ADHD: A Selective Review of Qualitative Studies" Disabilities 4, no. 3: 658-677. https://doi.org/10.3390/disabilities4030041

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South East Bay Pediatric Medical Group | Fremont, CA

Request an Appointment: (510) 792-4373

2191 mowry ave. #600c, fremont ca 94538, mon-fri: 8:45 am – 5pm, sat/sun/holiday: call at 8 am for appointment, an introduction to attention deficit hyperactivity disorder (adhd).

Almost all children have times when their behavior veers out of control. They may speed about in constant motion, make noise nonstop, refuse to wait their turn, and crash into everything around them. At other times they may drift as if in a daydream, failing to pay attention or finish what they start.

However, for some children, these kinds of behaviors are more than an occasional problem. Children with attention-deficit/hyperactivity disorder (ADHD) have behavior problems that are so frequent and/or severe that they interfere with their ability to live normal lives. These children often have trouble getting along with siblings and other children at school, at home, and in other settings. Those who have trouble paying attention usually have trouble learning. Some have an impulsive nature and this may put them in actual physical danger. Because children with ADHD have difficulty controlling their behavior, they may be labeled as “bad kids” or “space cadets.” Left untreated, more severe forms of ADHD can lead to serious, lifelong problems such as poor grades in school, run-ins with the law, failed relationships, substance abuse and the inability to keep a job.

What is ADHD?

ADHD is a condition of the brain that makes it difficult for children to control their behavior. It is one of the most common chronic conditions of childhood. It affects 4% to 12% of school-aged children. About 3 times more boys than girls are diagnosed with ADHD.

What are the symptoms of ADHD?

ADHD includes 3 behavior symptoms: inattention, hyperactivity, and impulsivity. A child with inattention symptoms may have the following behaviors:

• Has a hard time paying attention, daydreams
• Does not seem to listen
• Is easily distracted from work or play
• Does not seem to care about details, makes careless mistakes
• Does not follow through on instructions or finish tasks
• Is disorganized
• Loses a lot of important things
• Forgets things
• Does not want to do things that require ongoing mental effort

A child with hyperactivity symptoms may have the following behaviors:

• Is in constant motion, as if “driven by a motor”
• Cannot stay seated
• Squirms and fidgets
• Talks too much
• Runs, jumps, and climbs when this is not permitted
• Cannot play quietly (video games do not count)

A child with impulsivity symptoms may have the following behaviors:

• Acts and speaks without thinking
• May run into the street without looking for traffic first
• Has trouble taking turns
• Cannot wait for things
• Calls out answers before the question is complete
• Interrupts others

What is the difference between ADD vs. ADHD?

ADD stands for Attention Deficit Disorder. This is an old term that is now officially called Attention Deficit Hyperactivity Disorder, Inattentive Type. More on this will discussed below.

Are there different types of ADHD?

Children with ADHD may have one or more of the 3 main symptoms categories listed above. The symptoms usually are classified as the following types of ADHD:

• Inattentive type (formerly known as attention-deficit disorder [ADD])—Children with this form of ADHD are not overly active. Because they do not disrupt the classroom or other activities, their symptoms may not be noticed. Among girls with ADHD, this form is most common.
• Hyperactive/Impulsive type—Children with this type of ADHD show both hyperactive and impulsive behavior, but can pay attention.
• Combined Inattentive/Hyperactive/Impulsive type—Children with this type of ADHD show all 3 symptoms. This is the most common type of ADHD.

How can I tell if my child has ADHD?

Remember, it is normal for all children to show some of these symptoms from time to time. Your child may be reacting to stress at school or home. She may be bored or going through a difficult stage of life. It does not mean he or she has ADHD. Sometimes a teacher is the first to notice inattention, hyperactivity, and/or impulsivity and bring these symptoms to the parents’ attention. Sometimes questions from your pediatrician can raise the issue. Parents also may have concerns such as behavior problems at school, poor grades, difficulty finishing homework and so on. If your child is 6 years of age or older and has shown symptoms of ADHD on a regular basis for more than 6 months, discuss this with your pediatrician.

What causes ADHD?

ADHD is one of the most studied conditions of childhood but the cause of ADHD is still not clear at this time. The most popular current theory of ADHD is that ADHD represents a disorder of “executive function.” This implies dysfunction in the prefrontal lobes so that the child lacks the ability for behavioral inhibition or self-regulation of such executive functions as nonverbal working memory, speech internalization, affect, emotion, motivation, and arousal. It is believed that children with ADHD lack the right balance of neurotransmitters, which are specific chemicals in their brains, that help them to focus and inhibit impulses.

Research to date has shown the following:

• ADHD is a biological disorder, not just “bad behavior.” In a child with ADHD, the brain’s ability to properly use important chemical messengers (neurotransmitters) is impaired.
• A lower level of activity in the parts of the brain that control attention and activity level may be associated with ADHD.
• ADHD appears to run in families. Sometimes a parent is diagnosed with ADHD at the same time as the child.
• Environmental toxins can play a role in the development of ADHD, but that is extremely rare.
• Very severe head injuries may cause ADHD in rare cases.

There is no significant evidence that ADHD is caused by the following:

• Eating too much sugar
• Food additives
• Immunizations

Your pediatrician will determine whether your child has ADHD using standard guidelines developed by the American Academy of Pediatrics. Unfortunately, there is no single test that can tell whether your child has ADHD. The diagnosis process requires several steps and involves gathering a lot of information from multiple sources. You, your child, your child’s school, and other caregivers should be involved in assessing your child’s behavior.

Generally, if your child has ADHD:

• Some symptoms will occur in more than one setting, such as home, school, and social events
• The symptoms significantly impair your child’s ability to function in some of the activities of daily life, such as schoolwork and relationships with family and friends
• They will start before your child reaches 7 years of age
• They will continue for more than six months
• They will make it difficult for your child to function at school, at home, and/or in social settings

In addition to looking at your child’s behavior, your pediatrician will do a physical examination. A full medical history will be needed to put your child’s behavior in context and screen for other conditions that may affect your child’s behavior.

One of the challenges in diagnosing ADHD is that many disorders can look a lot like ADHD – including depression, anxiety, visual and hearing difficulties, seizures, learning disorders and even improper sleep quality. These conditions can show the same type of symptoms as ADHD. For example if your child has sleep apnea, a condition that involves disordered breathing during sleep, he may show signs of inattention and inability to focus that can sometimes be similar to a child with ADHD. Another example is a child that may have a learning disability. He/she may not pay attention in class due to inability to process that information and therefore be labeled with “inattention”. The same child may also be frustrated because he can’t process the material being taught in the classroom and therefore disturbs the classroom and acts as if he/she is “hyperactive.” In the case of this child with a learning disability, all the effort needs to be focused on the actual underlying problem, which again is the learning disability, and not on immediately trying to treat ADHD. Similarly, in our child with sleep apnea, parents need to address the sleeping problem first and not rush to place their child on medication for ADHD. As you will read below, it is possible to have ADHD with other conditions, so children who do have sleep apnea or learning disabilities MAY ALSO have ADHD and may eventually require treatment for both conditions.

The diagnosis of ADHD takes time, and the evaluation process usually takes at least 2-3 visits before the diagnosis can be made. Occasionally the process can take longer if referrals to psychologists or psychiatrists are warranted. Blood tests may or may not be indicated, and this will be discussed during your visit.

Coexisting conditions

• Oppositional defiant disorder or conduct disorder —Up to 35% of children with ADHD also have oppositional defiant disorder or conduct disorder. Children with oppositional defiant disorder tend to lose their temper easily and annoy people on purpose and are defiant and hostile toward authority figures. Children with conduct disorder break rules, destroy property, and violate the rights of other people. Children with coexisting conduct disorder are at much higher risk for getting into trouble with the law than children who have only ADHD. Studies show that this type of coexisting condition is more common among children with the primarily hyperactive/impulsive and combination types of ADHD. Your pediatrician may recommend counseling for your child if she has this condition.
• Mood disorders/depression —About 18% of children with ADHD also have mood disorders such as depression. There is frequently a family history of these types of disorders. Coexisting mood disorders may put children at higher risk for suicide, especially during the teenage years. These disorders are more common among children with inattentive and combined types of ADHD. Children with mood disorders or depression often require a different type of medication than those normally used to treat ADHD.
• Anxiety disorders —These affect about 25% of children with ADHD. Children with anxiety disorders have extreme feelings of fear, worry, or panic that make it difficult to function. These disorders can produce physical symptoms such as racing pulse, sweating, diarrhea, and nausea. Counseling and/or medication may be needed to treat these coexisting conditions.
• Learning disabilities —Learning disabilities are conditions that make it difficult for a child to master specific skills such as reading or math. ADHD is not a learning disability. However, ADHD can make it hard for a child to do well in school. Diagnosing learning disabilities requires evaluations such as IQ and academic achievement tests.
• Target outcomes for behavior
• Follow-up activities
• Education about ADHD
• Team work among doctors, parents, teachers, caregivers, other healthcare professionals, and the child

Behavior therapy

• Parent training
• Individual and family counseling

Treatment for ADHD uses the same principles that are used to treat other chronic conditions like asthma or diabetes. Long-term planning is needed because these conditions continue or recur for a long time. Families must manage them on an ongoing basis. In the case of ADHD, schools and other caregivers must also be involved in managing the condition. Educating the people involved with your child about ADHD is a key part of treating your child. As a parent, you will need to learn about ADHD. Read about the condition and talk to people who understand it. This will help you manage the ways ADHD affects your child and your family on a day-to-day basis. It will also help your child learn to help himself.

For most children, stimulant medications are a safe and effective way to relieve ADHD symptoms. As glasses help people focus their eyes to see, these medications help children with ADHD focus their thoughts better and ignore distractions. This makes them more able to pay attention and control their behavior. Stimulants may be used alone or combined with behavior therapy. Studies show that about 80% of children with ADHD who are treated with stimulants improve a great deal.

Different types of stimulants are available, in both short-acting (immediate-release) and long-acting forms. Short- acting forms usually are taken every 4 hours when the medication is needed. Long-acting medications usually are taken once in the morning. Children who use long-acting forms of stimulants can avoid taking medication at school or after school.

It may take some time to find the best medication, dosage, and schedule for your child. Your child may need to try different types of stimulants. Some children respond to one type of stimulant but not another. The amount of medication (dosage) that your child needs also may need to be adjusted. Realize that the dosage of the medicine is not based solely on your child weight. Our goal is for your child to be on the dose that is helping her to maximize her potential with the least amount of side effects.

The medication schedule also may be adjusted depending on the target outcome. For example, if the goal is to get relief from symptoms at school, your child may take the medication only on school days and none during weekends, summer time, and vacations if desired. Your child will have close follow up initially and once the optimal medication and dosage is found she will be seen every 2-3 months to monitor progress and possible side effects.

What side effects can stimulants cause?

Side effects occur sometimes. These tend to happen early in treatment and are usually mild and short-lived. The most common side effects include the following:

Decreased appetite/weight loss.

• Sleep problems
• Stomachaches

Some less common side effects include the following:

• Jitteriness
• Social withdrawal
• Rebound effect (increased activity or a bad mood as the medication wears off)
• Transient tics

Very rare side effects include the following:

• Increase in blood pressure or heart rate
• Growth delay

Most side effects can be relieved using one of the following strategies:

• Changing the medication dosage
• Adjusting the schedule of medication
• Using a different stimulant

There are many forms of behavior therapy, but all have a common goal— to change the child’s physical and social environments to help the child improve his behavior. Under this approach, parents, teachers, and other caregivers learn better ways to work with and relate to the child with ADHD. You will learn how to set and enforce rules, help your child understand what he needs to do, use discipline effectively, and encourage good behavior. Your child will learn better ways to control his behavior as a result.

Behavior therapy has 3 basic principles:

• Set specific goals. Set clear goals for your child such as staying focused on homework for a certain time or sharing toys with friends.
• Provide rewards and consequences. Give your child a specified reward (positive reinforcement) when she shows the desired behavior. Give your child a consequence (unwanted result or punishment) when she fails to meet a goal.
• Keep using the rewards and consequences. Using the rewards and consequences consistently for a long time will shape your child’s behavior in a positive way.

Behavior therapy recognizes the limits that having ADHD puts on a child. It focuses on how the important people and places in the child’s life can adapt to encourage good behavior and discourage unwanted behavior. It is different from play therapy or other therapies that focus mainly on the child and his emotions. Specific behavior therapy techniques that can be effective with children with ADHD include:

• Positive reinforcement: Parents provide rewards or privileges in response to desired behavior. For example, your child completes an assignment and he is permitted to play on the computer.
• Time-out: one removes access to desired activity because of unwanted behavior. For example, your child hits a sibling and, as a result, must sit for 5 minutes in the corner of the room.
• Response cost: Parents withdraw rewards or privileges because of unwanted behavior. For example, your child loses free-time privileges for not completing homework.
• Token economy: Combining reward and consequence. The child earns rewards and privileges when performing desired behaviors. He loses the rewards and privileges as a result of unwanted behavior. For example, you child can earn stars for completing assignments and loses stars for getting out of seat. Then, he cashes in the sum of her stars at the end of the week for a prize.

Tips for helping your child control his behavior

• Keep your child on a daily schedule . Try to keep the time that your child wakes up, eats, bathes, leaves for school, and goes to sleep the same each day.
• Cut down on distractions . Loud music, computer games, and television can be over-stimulating to your child. Make it a rule to keep the TV or music off during mealtime and while your child is doing homework. Whenever possible, avoid taking your child to places that may be too stimulating, like busy shopping malls.
• Organize your house . If your child has specific and logical places to keep his schoolwork, toys, and clothes, he is less likely to lose them. Save a spot near the front door for his school backpack so he can grab it on the way out the door.
• Reward positive behavior . Offer kind words, hugs, or small prizes for reaching goals in a timely manner or good behavior. Praise and reward your child’s efforts to pay attention.
• Set small, reachable goals . Aim for slow progress rather than instant results. Be sure that your child understands that he can take small steps toward learning to control himself.
• Help your child stay “on task.” Use charts and checklists to track progress with homework or chores. Keep instructions brief. Offer frequent, friendly reminders.
• Limit choices . Help your child learn to make good decisions by giving your child only 2 or 3 options at a time.
• Find activities at which your child can succeed. All children need to experience success to feel good about themselves and boost their self-confidence.
• Use calm discipline. Use consequences such as time-out, removing the child from the situation, or distraction. Sometimes it is best to simply ignore the behavior. Physical punishment, such as spanking or slapping, is not helpful. Discuss your child’s behavior with him when both of you are calm.

How can I help my child control her behavior?

Taking care of yourself also will help your child. Being the parent of a child with ADHD can be tiring and trying. It can test the limits of even the best parents. Parent training and support groups made up of other families who are dealing with ADHD can be a great source of help. Learn stress-management techniques to help you respond calmly to your child. Seek counseling if you feel overwhelmed or hopeless.

Ask us to help you find parent training, counseling, and support groups in your community. Under the resources section we will leave the link of a few handouts published by the NICHQ (National Initiative for Children’s Healthcare Quality) including:

• How to Establish a School-Home Daily Report Card

Unproven treatments

You may have heard media reports or seen advertisements for “miracle cures” for ADHD. Carefully research any such claims. Consider whether the source of the information is valid. At this time, there is no scientifically proven cure for this condition. The following methods have not been proven to work in scientific studies:

• Optometric vision training (asserts that faulty eye movement and sensitivities cause the behavior problems)
• Megavitamins and mineral supplements
• Anti–motion-sickness medication (to treat the inner ear)
• Treatment for candida yeast infection
• EEG biofeedback (training to increase brain-wave activity)
• Applied kinesiology (realigning bones in the skull)

Always tell your pediatrician about any alternative therapies, supplements, or medications that your child is using. These may interact with prescribed medications and harm your child.

Frequently asked questions

Will my child outgrow adhd.

ADHD continues into adulthood in most cases. However, by developing their strengths, structuring their environments, and using medication when needed, adults with ADHD can lead very productive lives. In some careers, having a high-energy behavior pattern can be an asset.

Are stimulant medications “gateway drugs” leading to illegal drug or alcohol abuse?

People with ADHD are naturally impulsive and tend to take risks. But those with ADHD who are taking stimulants are actually at lower risk of using other drugs. Children and teenagers who have ADHD and also have coexisting conditions may be at high risk for drug and alcohol abuse, regardless of the medication used.

Are children getting high on stimulant medications?

There is no evidence that children are getting high on stimulant drugs used to treat ADHD. These drugs also do not sedate or tranquilize children and have no addictive properties. Stimulants are classified as Schedule II drugs by the US Drug Enforcement Administration. There are recent reports of abuse of this class of medication, especially by college students who trying to obtain an edge during exam times to stay up and study more. 
If your child is on medication, it is always best to supervise the use of the medication closely.

Why do so many children have ADHD?

The number of children who are being treated for ADHD has risen. It is not clear whether more children have ADHD or more children are being diagnosed with ADHD. ADHD is now one of the most common and most studied conditions of childhood. Because of more awareness and better ways of diagnosing and treating this disorder, more children are being helped.

• AAP (American Academy of Pediatrics)
• About Our Kids (from NYU Child Study Center)
• Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)

Adapted directly from

• American Academy of Pediatrics
• The Zukerman Parker Handbook of Development and Behavioral Pediatrics for Primary care

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• v.3(2); 2015 Sep 30

Overview of Attention Deficit Hyperactivity Disorder in Young Children

1 Department of Early Childhood and Elementary Education, College of Education and Human Services, Murray State University, Murray, KY, USA

Chia Jung Yeh

2 Human Development and Family Science, College of Health and Human Performance, East Carolina University, Greenville, NC, USA

Nidhi Verma

3 Department of Psychology, Kurukshetra University, Kurukshetra, India

Ajay Kumar Das

4 Department of Adolescent, Career and Special Education, Murray State University, Murray, KY, USA

Contributions: AS, NV contributed equally as first authors.

Attention deficit hyperactivity disorder (ADHD) is a complex disorder, which can be seen as a disorder of life time, developing in preschool years and manifesting symptoms (full and/or partial) throughout the adulthood; therefore, it is not surprising that there are no simple solutions. The aim of this paper is to provide a short and concise review which can be used to inform affected children and adults; family members of affected children and adults, and other medical, paramedical, non-medical, and educational professionals about the disorder. This paper has also tried to look into the process of how ADHD develops; what are the associated problems; and how many other children and adults are affected by such problems all over the world basically to understand ADHD more precisely in order to develop a better medical and or non-medical multimodal intervention plan. If preschool teachers and clinicians are aware of what the research tells us about ADHD, the varying theories of its cause, and which areas need further research, the knowledge will assist them in supporting the families of children with ADHD. By including information in this review about the connection between biological behavior, it is hoped that preschool teachers and clinicians at all levels will feel more confident about explaining to parents of ADHD children, and older ADHD children themselves about the probable causes of ADHD.

Overview of attention deficit hyperactivity disorder in young children

Literally thousands of studies have been conducted on attention deficit hyperactivity disorder (ADHD) and it’s various predecessors in diagnostic nomenclatures prior to DSM-V (The Diagnostic and Statistical Manual of Mental Disorders-V). Despite this long research history, ADHD is not necessarily well understood among the lay public, given the many controversies and public misconceptions concerning the disorder. 1 , 2 Longitudinal evidence suggests that childhood ADHD persists into young adulthood in 60-70% of the cases when defined relative to same-age peers and in 58% of the cases when DSM-V criteria and parental reports are used. 3-6 These early studies of childhood hyperactivity excluded many children that would currently meet the DSM criteria for ADHD, particularly the inactive sub-type. 7 The scientific status of ADHD is one of the most controversial issues in child health. 8-10 This paper examines the overview of ADHD in children in relation to its genetics, taxonomy, neurobiology, comorbidity, diet, treatment, and concludes with a discussion.

Précis of attention deficit hyperactivity disorder

ADHD is recognized as a common childhood psychiatric disorder and has a strong genetic, neuro-biologic, and neurochemical basis. 11 , 12 It is characterized by symptoms of inattention and/or impulsivity and hyperactivity which can significantly impact many aspects of behavior as well as performance, both at school and at home. 13 ADHD is characterized by pervasive and impairing symptoms of inattention, hyperactivity, and impulsivity according to DSM-V. 14-16 The World Health Organization (WHO) uses a different name hyperkinetic disorder (HD)-but lists similar operational criteria for the disorder. 17 Regardless of name used, ADHD is one of the most thoroughly researched disorders in medicine. 18 The DSM diagnostic criteria for ADHD were based on reviews of existing research and a field trial in which alternative diagnostic criteria were evaluated. 19

Classification of what constitutes ADHD has changed dramatically over the last 32 years, with each successive revision of the Diagnostic and Statistical Manual, the diagnostic criteria used to describe the disorder. Current classification for combined type ADHD requires a minimum of six out of nine symptoms of inattention of hyperactivity/impulsivity. 16 , 17 , 20 In addition there must be some impairment from symptoms in two or more settings ( e.g . home and school) and clear evidence of significant impairment in social, school or work functioning. The DSM also allows the classification of two sub-type disorders: i) predominantly inattentive where the child only meets criteria for inattention; and ii) predominantly hyperactive-impulsive where only the hyperactive-impulsive criteria are met.

Prevalence of attention deficit hyperactivity disorder

The relatively prevalence of the disorder is high, affecting approximately 4% of all children, although estimates vary widely from 3% to 11% or more. 21 , 22 The disorder usually begins in early childhood and is characterized by excessive activity, even when developmental level and limited behavioral control are taken into consideration. 23 , 24 reviewed the findings of six large epidemiological studies that identified cases of ADHD within these samples. The prevalences found in these studies ranged from a low of 2% to a high of 6.3%, with most falling within the range of 4.2% to 6.3%. Other studies have found similar prevalence rates in elementary school-age children (4-5.5%; in Breton et al ., 25 7.9% in Briggs-Gowan et al. , 26 5-6% in DuPaul, 27 and 2.5-4% in Pelham et al . 28 Lower rates result from using complete DSM criteria and parent reports (2-6% in Breton et al ., 25 and higher ones if just a cutoff on teacher ratings is used (up to 23% in DuPaul, 27 15.8% in Nolan et al ., 29 14.3% in Trites et al . 30 Sex and age differences in prevalence are routinely found in research. For instance, prevalence rates may be 4% in girls and 8% in boys in the preschool age group, 29 yet fall to 2-4% in girls and 6-9% in boys during the 6- to 12-year-old age period based on parent reports. 25 The prevalence decreases again to 0.9-2% in girls and 1-5.6% in boys by adolescence. 25 , 31-33 Overall ADHD affects 2% to 9% in school age children.

Etiological elucidation of attention deficit hyperactivity disorder

Underlying etiological explanations of ADHD can be simply divided into biological and environmental. In simple terms biological explanations include genetics, brain structure and their influence on neuropsychology, while predominant environmental explanations include problems during and after birth, exposure to environmental toxins, parenting and diet.

Heredity of attention deficit hyperactivity disorder

Heredity of ADHD has been an important issue. 34 For years, researchers have noted the higher prevalence of psychopathology in the parents and other relatives of children with ADHD. Between 10% and 35% of the immediate family members of children with ADHD are also likely to have the disorder, with the risk to siblings being approximately 32%. 35-37

Even more striking is the finding that if a parent has ADHD, the risk to the offspring is 57%. 12 Thus, ADHD clusters significantly among the biological relatives of children with the disorder, strongly implying a hereditary basis to this condition. 38 Subsequently, these elevated rates of disorders have been noted in African American samples with ADHD, 39 as well as in girls with ADHD compared to boys. 40

Genetic factor

The heredity basis for psychiatric disorders was already recognized at the turn of the nineteenth century by Enail Kraepelin. 41 There is now little doubt that ADHD is a condition in which genetic factors (genetic differences between children) make a substantial contribution to the risk of the disorder. 42 Genetic factors are accounted for 80% of the etiology of ADHD, while more recent studies have begun to examine which particular genes might be implicated in ADHD, 43 , 44 reported an association between ADHD and a null allele of the C4B complement locus in the MHC -gene region of chromosome 6, a locus also associated with reading disability. 45 Interest in a potential genetic mechanism underlying ADHD increased with reports of an association with a single dopamine transporter gene, 46 and with reports of variations within the D4 receptor gene. 47 Genetic studies have focused mainly on candidate genes involved in dopaminergic transmission. Several reasons exist for this particular focus, dopaminergic drugs (methylphenidate) are clinically efficacious in addressing the core problems associated with ADHD. A gene related to dopamine, the DRD4 (repeater gene), has been the most reliably found in samples of children with ADHD. 48 It is the seven-repeat form of this gene that has been found to be overrepresented in children with ADHD. 47 Such a finding is quite interesting, because this gene has previously been associated with the personality trait of high novelty-seeking behavior; because this variant of the gene affects pharmacological responsiveness; and because the gene’s impact on postsynaptic sensitivity is primarily found in frontal and prefrontal cortical regions believed to be associated with executive functions and attention. 49 The finding of an overrepresentation of the seven-repeat DRD4 gene has now been replicated in a number of other studies, not only of children with ADHD, but also of adolescents and adults with the disorder. 42 , 48

Monitoring the correspondence between the intended and actually executed action, a fundamental mechanism of behavioral regulation, is reflected by error-related negativity (ERN), an ERP component generated by the anterior cingulate cortex. Based on this process assumption, a study by LaHoste et al . 50 examined genetic influences on the ERN and other components related to action monitoring (correct negativity, CRN, and error positivity, P e ). A flanker task was administered to adolescent twins (age 12) including 99 monozygotic (MZ) and 175 dizygotic (DZ) pairs. Genetic analysis showed substantial heritability of all three ERP components (40-60%) and significant genetic correlations between them. This study provides the first evidence for heritable individual differences in the neural substrates of action monitoring and suggests that ERN, CRN, and P e can potentially serve as endophenotypes for genetic studies of personality traits and psychopathology associated with abnormal regulation of behavior. 50

Cognitive genetics

The sequencing of the human genome and the identification of a vast array of DNA polymorphisms has afforded cognitive scientists with the opportunity to interrogate the genetic basis of cognition with renewed vigor. Advances in the understanding of the neural substrates of sustained and spatial attention arising from the cognitive neurosciences can help guide putative linkages in cognitive genetics. 51 In line with catecholamine models of sustained attention, associations have been reported between sustained attention and allelic variation in the dopamine beta hydroxylase gene ( DBH ), the dopamine D2 and D4 receptor genes ( DRD2, DRD4 ) and the dopamine transporter gene ( DAT1 ). 51 Much evidence implicates the cholinergic system in spatial attention. Accordingly, individual differences in spatial attention have been associated with variation in an alpha-4 cholinergic receptor gene (CHRNA4). APOE-4 allele dosage has been shown to influence the speed of attentional reorienting in independent samples of nonaffected individuals. Preliminary evidence in both healthy children and children with ADHD suggests association with variants of the DAT1 gene and the control of spatial attention across the hemifields. 51

Fronto-striatal circuitry in attention deficit hyperactivity disorder

Imaging studies using positron emission tomography (PET), and magnetic resonance imaging (MRI) techniques have implicated the fronto-striatal circuitry in ADHD, an area rich in dopaminergic activity. However certain meta-analytic studies have questioned the robust association between dopaminergic genes and ADHD. 52 Other candidate genes have also been investigated including serotonin transporter genes. 53 Genetic investigations aim to examine whether different genes contribute to specific aspects of ADHD. For example, a meta-analysis by Bellgrove and Mattingley has shown that the dopamine transporter gene DAT1 is more closely associated with the ADHD combined sub-type than with the inattentive +sub-type. 54 Future molecular genetic studies aim to examine gene-environment interactions, the extent to which environmental factors moderate genetic risks for ADHD. As well as gene-gene interactions, the extent to which having a cocktail of different genetic influences might elevate risk for ADHD.

Brain structure

A wealth of literature has examined the anatomical structure of the brain in children with ADHD. Using brain scanning technology such as MRI these studies suggest that the brain circuits linking the prefrontal cortex, striatum and cerebellum are not functioning normally in children with ADHD. 55 Further evidence has examined the relationship between brain structure and behavioral measures of inhibition and attention. These results suggest that compromised brain morphology of selected regions is related to behavioral measures of inhibition and attention. 56 Another study suggests that abnormalities in circuits important for motor response selection contribute to deficits in response inhibition in children with ADHD. 57 This lends support to the growing awareness of ADHD-associated anomalies in medial frontal regions which are important for the control of voluntary actions. Studies using PET to assess cerebral glucose metabolism have found diminished metabolism in adults with ADHD, particularly in the frontal region. 58 , 59 Using a radioactive tracer that indicates dopamine activity, 60 found abnormal dopamine activity in the right midbrain region of children with ADHD, and discovered that severity of symptoms was correlated with the degree of this abnormality. Another study pointed that children with ADHD were found to have a smaller corpus callosum, particularly in the area of the genu and splenium and that region just anterior to the splenium. 61 Interestingly, the study by Zametkin et al. 62 also found smaller cerebellar volume in those with ADHD. This would be consistent with views that the cerebellum plays a major role in executive functioning and the motor presetting aspects of sensory perception that derive from planning and other executive actions. 63 MRI showed no differences between groups in the regions of the corpus callosum in either of the other studies. 62 , 64 Further investigations of anatomical structure may allow the development of pharmacological interventions for ADHD, 65 which are better targeted to specific sites of action in the brain.

Neurobiology of attention deficit hyperactivity disorder

Neurobiology of ADHD has been another valued topic of investigation. 66 Researchers describe at least 11 different neuroanatomical theories of ADHD. 67 These theories can be categorized into two domains. The bottom-up theories propose disturbances in subcortical regions, such as the thalamus, and hypothalamus and reticular activating systems are responsible for ADHD symptomology. The top-down theories attribute the dysfunction to frontal and prefrontal and sagittal cortices. Smaller frontal lobe or right prefrontal cortex was found for the ADHD groups in all studies that examined this measure. Five of six studies found a smaller anterior or posterior corpus callosum. Four of six found loss of the normal caudate asymmetry, and these four also found a smaller left or right globus pallidus. 68 Neuroimaging studies of children with ADHD have investigated and found evidence of abnormalities in the frontal cortex, basal ganglia, corpus callosum, and cerebellum. 69-72 The cerebellum is functionally linked with the pre-frontal cortex, and three anatomical measures, namely the right globus pallidus volume, caudate asymmetry, and left cerebellum volume, correlate highly with ADHD in children. 68 Preliminary evidence has not found differences in the thalamus in children with ADHD. 62 , 73

Role of the basal ganglia

The role of the basal ganglia in ADHD has been given serious importance in neuropsychological research. The basal ganglia are a collection of large subcortical structures that can be divided into two sets of core structures: i) the striatum consisting of the caudate, putamen, and ventral striatum and ii) the pallidum or globus pallidus consisting of the external segment, internal segment, and ventral pallidum. The striatum receives input from the entire cerebral cortex, thalamus, substantia nigra, and amygdala and sends projections to the pallidum and substantia nigra. The pallidum sends input to the thalamic nuclei and additional subcortical nuclei, where information will be sent back to the frontal or pre-frontal cortex. 74 The organization of the striatum is important in the execution of motor planning, sequencing, and coordination, as well as feedback and learning after motor execution, 75 suggest that the striatum serves as a crossroads , combining sensory-motor information with emotional processing from the amygdala and dopamine mediated reinforcement. The primary neurotransmitter involved in modulation of the basal ganglia is dopamine, and disruption of this system has been found in ADHD. Initial studies found higher levels of the dopamine metabolite, and homovanillic acid in cerebral spinal fluid were positively correlated with the amount of hyperactivity in boys. 62 A recent genetic study found that alleles of the gene encoding dopamine beta hydroxylase, an enzyme that breaks down dopamine, may be related to the expression of ADHD. 76 Further support for dopamine dysfunction in ADHD comes from a functional MRI study that found children with ADHD had reduced activity in the frontal-striatal regions and impaired performance on response inhibition tasks. 77 Additionally, methylphenidate, which acts on the dopamine transporter (DAT), increased both frontal-striatal activity and performance on response inhibition tasks. A study using single PET-CT found that adults with ADHD had increased levels of striatal DAT compared to normal controls, which may lead to decreased availability of striatal dopamine in ADHD. 78

Research on the role of the basal ganglia in ADHD has primarily focused on the caudate. 79 The caudate has been implicated in a complex loop , receiving information from the association cortices and indirectly sending it via the thalamus to the prefrontal cortex. 80 Studies have found neuroanatomical differences in the caudate of children with ADHD with mixed results. 56 , 62 ,69, 81-83 Found that boys with ADHD had a smaller right caudate; recently, this finding was not replicated in ADHD girls. 69 In boys with ADHD, smaller right caudate volumes were found to significantly correlate with poor accuracy on sensory selection tasks, and left and right caudate volumes were negatively correlated with mean reaction times. 81 Conflicting results found ADHD adolescents had larger right caudate than normal adolescents, and the right caudate volume was associated with poorer performance on attention tasks and higher ratings of hyperactivity and impulsivity. 83 Another study found that children with ADHD had smaller left caudate volumes. 73 , 82 More recently, Manor et al . 56 reported that boys with ADHD were found to have a decreased volume of the left head of the caudate. These children were also more likely to show a reversed caudate asymmetry when compared to healthy controls, with the left being smaller than right. Moreover, a significant relationship between the reduction in left caudate volume and performance on behavioral inhibition tasks was found. In addition, children displaying reversed caudate asymmetry (L<R) were more likely to perform poorly on tasks of behavioral inhibition and attention regardless of group membership. 56 , 81 It has been also previously found that reversed caudate asymmetry was related to deficits in response execution tasks in ADHD. This evidence suggests that asymmetry of the caudate regardless of volume has important implications in attention and behavioral control. Finally, functional imaging studies have found decreases in blood flow to the caudate in ADHD. 62 , 84

Role of the putamen

The role of the putamen has also been studied as an etiological factor for the ADHD. 85 The putamen is hypothesized to be part of the motor loop because it receives information from the sensory-motor cortex and then sends it indirectly back to the premotor regions of the frontal cortex. Based on the putamen’s anatomical connections and function, a role for the putamen in ADHD is possible although currently unclear because of equivocal evidence. 80 There are relatively few studies investigating the neuroanatomical role of the putamen in ADHD. 69 Another study have not found volumetric differences in the putamen between children with ADHD and healthy controls. 62 In addition, they found that the volume of the putamen did not correlate with performance on response inhibition tasks. However, two studies suggest that the putamen may actually be important in the expression of ADHD symptomology. Researchers found that the ADHD diagnosis was significantly associated with the titer of two ant streptococcal antibodies. 86

In addition, they found that higher antibodies titers were associated with larger volumes in the left putamen and right globus pallidus in children with ADHD. 86 Although this study found structural evidence for the role of the putamen in ADHD, the second study demonstrates functional differences in the putamen of children with ADHD. Recent advances in functional MRI technology have provided new methods to investigate blood flow to various regions of the brain. Functional MRI relaxometry allows researchers to investigate the resting or steady state conditions and medication-related changes and were able to indirectly assess blood volume to the striatum (caudate and putamen). 75 They found that blood flow to both sides of the putamen was decreased in ADHD children compared to normal children. In addition, they found that blood flow to the left was more decreased than blood flow to the right side. They found no differences in blood flow to the thalamus and caudate, although there was a non-significant trend in the right caudate. Methylphenidate administration significantly altered the blood flow to the right and left putamen, and changes were correlated to the child’s unmedicated state.

There were no significant differences in blood flow to the caudate off or on medication. Filipek et al . 75 found strong associations between measures of activity and inattention with T2-RT measures in the putamen. They propose that ADHD symptoms are closely related to functional abnormalities in the putamen, which is closely involved in the control of motor behavior. These hypotheses lay the foundation for our study of the neuroanatomy of the putamen in children with ADHD. Investigators in their study using magnetic resonance imaging scans of boys in residential treatment with symptoms of ADHDand psychopathic traits found no differences in the total, left and right putamen volumes across the ADHD or control group. A significant reversal of asymmetry across groups was found; children with ADHD more frequently had a smaller left putamen than right. In contrast, the control group more frequently has a smaller right than left putamen.

Several studies have examined cerebral blood flow using single-photon emission computed tomography (SPECT) in children with ADHD and normal children. 68 , 72 They have consistently shown decreased blood flow to the prefrontal regions (most recently in the right frontal area), and to pathways connecting these regions with the limbic system via the striatum and specifically its anterior region known as the caudate, and with the cerebellum. 87 , 88

Neuropsychology of attention deficit hyperactivity disorder

Studies examining the neuropsychology of ADHD provide an opportunity to understand the relationship between underlying biological processes and symptoms of ADHD. For many years it was accepted that symptoms of ADHD were the result of cognitive dysregulation. 89 The behavior of a child with ADHD resulted from insufficient forethought, planning and control. 90 Evidence to support this view point came from many studies using neuropsychological tests which demonstrated that children with ADHD performed less well on these tests than did matched controls to match familiar figures, children with ADHD demonstrated more impulsive responding and higher error rates than did matched controls. 91 , 92

Cognitive dysregulation

A summary of ADHD as a disorder of cognitive dysregulation suggested that the relationship between biology and behavior in children with ADHD was mediated by inhibitory dysfunction. 93 In contrast to the dominant view, researchers offered an alternative view of ADHD, not as a disorder of cognitive dysregulation, but as a motivational style. This viewed ADHD as a functional response by the child, aimed at avoiding delay. This alternative viewpoint of ADHD was based on other studies, 92 which showed that most of the neuropsychological evidence to support ADHD as a result of cognitive dysregulation was confounded by delay. To demonstrate this, researchers got children with ADHD and match control children to participate in the matching familiar figures test, and found the same results as previous studies. 92 Children with ADHD made more impulsive responses and more errors. However, researchers pointed out that all these studies involved trial constraints where as soon as one trial ended the next began and were confounded with delay. 92 In order words, children with ADHD made more impulsive responses because it allowed them to complete the task quicker and therefore escape delay. When researchers re-ran their study under time constraint (for a fixed period of time where early or impulsive responses had no influence on delay), children with ADHD performed no differently from controls. 92 Results of these studies lead to the development of the delay aversion hypothesis, 94 which characterized the influence of delay on behavior dependent upon whether the child has control over their environment or not. When the child is in control of their environment they can choose to minimize delay by acting impulsively, e.g. by skipping the queue at the end of the slide! When the child is not in control of their environment, or at least where they are expected to behave in certain ways or face sanctions, the child would choose to distract themselves from the passing of time. For example, in a classroom context during literacy lessons the child could achieve this either by daydreaming (inattention) or by fidgeting (hyperactivity). A summary of ADHD as a motivational style suggests that the relationship between biology and behavior in ADHD is mediated by delay aversion.

Traditionally these two different accounts of ADHD have both sought to independently explain the disorder. However, a study by Sonuga-Barke et al . 95 compared the measurement of both of these hypotheses in a head-to-head study. Results of this study showed that measures used to test each hypothesis were uncorrelated, demonstrating that they measured different constructs. Both sets of measures were correlated with ADHD, and when combined were highly diagnostic, correctly distinguishing 87.5 of cases from non-cases. These results suggested that both accounts appeared to help to explain ADHD, but that neither explanation was the single theory of ADHD which both theoretical camps had been searching for. Based on these findings, researchers proposed his dual pathway model of ADHD. 93 This model proposed two possible routes between biology and ADHD behavior. The first one is through cognitive dysregulation and another via motivational style. Clinically the dual pathway model suggests that there may be merit in targeting different sub-types with specific treatments, as well as allowing the development of novel interventions, perhaps aimed at desensitizing delay. Some have suggested ways in which the greater understanding about the influence of delay aversion on the development of ADHD could be used to develop alternative interventions. 93 , 96 These suggestions include the use of delay fading, a technique to systematically reorganize the child’s delay experience, as a means of increasing tolerance for delay, and reducing ADHD symptoms.

Some studies have not found a greater incidence of prenatal (pregnancy or birth complications) in children with ADHD compared to normal children whereas others have found a slightly higher prevalence of unusually short or long labor, fetal distress, low forceps delivery, and toxemia or eclampsia in children with ADHD. 97 Nevertheless, though children with ADHD may not experience greater pregnancy complications, prematurity, or lower birth-weight as a group, children born prematurely or who have markedly lower birth-weights are at high risk for later hyperactivity or ADHD.

Researchers found that smoking and maternal stress during the pregnancy is associated with onset of ADHD during early childhood. Similarly observed that parental smoking during pregnancy predicts non-responsiveness to intervention targeting ADHD symptoms in elementary school children. Hartsough et al . observed that behavioral symptoms of ADHD were predicted by a lower ponderal index (kg/m 3 ), 98 a smaller head circumference, and a smaller head-circumference-to-length ratio. Length of gestation, mother’s age, tobacco and alcohol during pregnancy and pre-pregnancy, body mass index or parity, the monthly gross income of family, child’s BMI at the age of five or six years or gender didn’t have any significant effect on the behavioral symptoms of ADHD at the age of five or six.

Exposure to environmental toxins

Exposure to environmental toxins specifically lead has also been reviewed as a causal factor for ADHD. An amazing variety of toxins extent in the modern environment have deleterious effects on the central nervous system that range from severe organic destruction to subtle brain dysfunction. 99 , 100 Toxic metals are ubiquitous in the modern environment, as are organohalide pesticides, herbicides, and fumigants, and a wide range of aromatic and aliphatic solvents. 101 All these categories of environmental pollutants have been linked to abnormalities in behavior, perception, cognition, and motor ability that can be subtle during early childhood but disabling over the long term. 102 Children exposed acutely or chronically to lead, arsenic, aluminum, mercury, or cadmium are often left with permanent neurological sequelae that include attentional deficits, emotional lability, and behavioral reactivity. 101 Elevated body lead burden has been shown to have a small but consistent and statistically significant relationship to the symptoms of ADHD. 103 , 104 However, even at relatively high levels of lead, fewer than 38% of children in one study were rated as having the behavior of hyperactivity on a teacher rating scale, 104 implying that most lead-poisoned children do not develop symptoms of ADHD. And most children with ADHD likewise, do not have significantly elevated lead burdens. 105

Environmental influences

Environmental influences on ADHD have also been reviewed extensively. Attention deficit hyperactivity disorder is best viewed as a gene × environment interaction. 106 Children who have a genetic predisposition will express the disorder when put in the correct environment, typically one characterized by chaotic parenting. 107 The best evidence for environmental influences on ADHD come from intervention studies which have demonstrated improvements in ADHD symptoms, when parents have been taught alternative parenting skills. 108 , 109 Results of these studies do not necessarily imply that parents of children with ADHD are bad parents. In fact, influence of parenting on ADHD is best viewed from an interactionist viewpoint. The relationship between ADHD and parenting may result from both negative aspects of the child influencing the parents’ behavior, and negative aspects of the parents influencing the child’s behavior. Studies examining mother-child interaction have found that children with ADHD are less often on task, less compliant, less responsive and more active than controls; researchers investigated both mother-son and father-son interactions and found that parents of boys with ADHD were more demanding, aversive and power assertive; 110-112 while the findings of Buhrmester et al. 113 have demonstrated that mothers of children with ADHD have been found to be more negative, controlling, intrusive and disapproving, and less rewarding and responsive than mothers of children without ADHD.

Research finds that ADHD affects the interactions of children with their parents, and hence the manner in which parents may respond to these children. 114 Those with ADHD are more talkative, negative and defiant; less compliant and cooperative; more demanding of assistance from others; and less able to play and work independently of their mothers. 115-118 Their mothers are less responsive to the questions of their children, more negative and directive, and less rewarding of their children’s behavior. 107 , 116 Mothers of children with ADHD have been shown to give both more commands and more rewards to sons with ADHD than to daughters with the disorder, 119 , 120 but also to be more emotional and acrimonious in their interactions with sons. 112 Children and teens with ADHD seem to be nearly as problematic for their fathers as their mothers. 112 , 118 , 121 Contrary to what may be seen in normal mother-child interactions, the conflicts between children and teens with ADHD (especially boys) and their mothers may actually increase when fathers join the interactions. 112 , 121 So while parents of children with ADHD may engage in less than optimal parenting, it is easy to see how such responses might have evolved.

In addition, genetic studies highlight the familial basis of ADHD. 122 , 123 Children with ADHD are more likely to have a parent with ADHD. ADHD symptoms in parents usually interfere with consistent and appropriate parenting. Researchers found that ADHD in parents prevented effective parental monitoring and consistent use of constructive parenting techniques. 124 Other researchers found that parental ADHD symptoms were associated with lax discipline, 125 while Harvey et al. 126 found that high ADHD symptoms in mothers were a barrier to successful psychosocial intervention for pre-school children with ADHD.

Most widely researched and commonly prescribed treatments for ADHD are the psychostimulants, including methylphenidate, amphetamine, and pemoline. 2 , 127 Several studies have demonstrated the short-term efficacy of stimulant compared to placebo conditions in improving both core ADHD symptoms and important ancillary features of the disorder. 128 Controlled studies of stimulants have shown their effect on reducing interrupting in class, reducing task-irrelevant activity in school, improving performance on spelling and arithmetic tasks, improving sustained attention during play, and improving parent-child interaction.

Meaningful effects have been documented across a wide array of outcome domains, cognitive attentional performance, school behavior, and learning, parent-child interactions, interaction with peers, and with a wide variety of assessment approaches, direct observations of behavior in natural and laboratory settings, and objective laboratory performance. 129

Diet is another environmental influence, often cited by parents as having an adverse influence on the ADHD symptoms of their child. 130 Specifically, food additives, refined sugars and fatty acid deficiencies have all been associated with ADHD symptoms. 131

However, the majority of this literature comes from older studies, with a variety of methodological problems, and small sample sizes. 131 In fact, a large recent randomized control trial examined the influence of food colorings and benzoate preservatives on pre-school hyperactivity. Results demonstrated a general adverse effect of food coloring and benzoate preservatives on hyperactive behavior of preschool children, based on parental reports, but not on simple clinic assessment. Children with high levels of hyperactivity were no more vulnerable to this effect than children with low levels of hyperactivity. 132 While improving children’s diet might impact on their general health and improve their overall behavior, the clinical importance of dietary change as a means of remediating ADHD remains doubtful. 133

Co-morbidity

ADHD appears to be associated with a wide variety of other psychiatry problems, which are often co-morbid with it. ADHD co-occurs with other childhood disorders far more often than it appears alone. 134 Notable associations exist with Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), tic disorder, mood disorder, autism spectrum disorder, specific learning disorder such as dyslexia, 135 , 136 depression and anxiety. About 50-60% of children with ADHD meet criteria for ODD, even in the pre-school period. 137 Busch and colleagues (2002) reported that ADHD children in primary care settings were significantly more likely than non-ADHD clinic controls to demonstrate mood disorders (57%) such as depression, multiple anxiety disorders (31%), and substance use disorders (11.5%). However, in the recent British Child Mental Health Survey, 138 anxiety was not associated with ADHD when adjustment was made for the presence of a third disorder. It is widely accepted that ADHD is a co-morbid disorder. Copeland et al. 135 point out that co-morbidity can mean a common underlying etiology which leads to two or more different disorders, or that one disorder leads to another, or even that two unrelated disorders co-occur. The term co-morbid also implies that their entities are morbid conditions, i.e. diseases. High rates of comorbidity with either other neurodevelopmental disorders ( e.g ., mental retardation, and learning disabilities) or psychiatric disorders ( e.g ., anxiety) make delineation of the phenotype difficult. 139

Some studies found that 47% children with ADHD have co-morbid ODD, 140-142 27% have anxiety disorder and 7% have mood disorder. 38% of children with ADHD were found to have CD and 13% have depression. In fact, the vast majority of co-morbidities with ADHD represent functional impairments and symptoms, which are not rooted in specific diseases. 135 Studies of clinic-referred children with ADHD find that between 54% and 67% will meet criteria for a diagnosis of ODD by 7 years of age or later. ODD is a frequent precursor to CD, a more severe and often (though not always) later occurring stage of ODD. 143. The co-occurrence of CD with ADHD may be 20-50% in children and 44-50% in adolescence with ADHD. 144 By adulthood, up to 26% may continue to have CD, while 12–21% will qualify for a diagnosis of antisocial personality disorder (ASPD).

In addition to associations with other psychiatric disorders children with ADHD are also more likely than their non-ADHD counterparts to experience a substantial array of developmental, social and health risks. It therefore seems important to discuss associated problems along with co-morbidity.

Motor coordination

Children with ADHD often demonstrate poor motor co-ordination or motor performance and balance. 145-147 Substantial evidences have been observed for problems in motor development and motor execution children with ADHD. 148 Clinical and epidemiological studies report that 30% to 50% of children with ADHD suffer from motor coordination problems. 146 These percentage are dependent of the type of motor assessment, referral sources and the cut-off points used. 149-151 As noted by Needleman et al ., 105 children with ADHD display greater difficulties with the development of motor coordination, planning and execution of complex, lengthy tasks, and novel chains of goal directed responses.

Academic functioning

Children with ADHD have an impaired academic functioning and are usually at an educational disadvantage upon school entry. 152 , 153 ADHD children are more likely than their non-ADHD peers to demonstrate difficulties with basic mathematics and pre-reading skills during their first year at school. 147 , 154 , 155 Executive academic functions were found to be core deficits specific to ADHD. Girls with ADHD were found to be less impaired than boys with ADHD. 156 Even pre-school children with ADHD demonstrate educational disadvantage, DuPaul et al . 157 demonstrated that their sample of pre-school ADHD children demonstrated deficits in pre-academic skills even prior to formal school entry. The pre-school ADHD children in their sample scored on average one standard deviation lower on the Battelle Developmental Index, 158 than did their non-ADHD control group. Researchers emphasized the importance of look away behavior (inattention) as a major reason for poor academic achievement. 159

Clinic-referred children with ADHD often present with lower scores on intelligence tests than control groups, specifically verbal intelligence with differences ranging from 7 to 10 standard score points. 160 Studies with community samples of ADHD children have also demonstrated negative associations between ADHD and intelligence. 161 , 162

Children with ADHD demonstrate serious difficulties with psychosocial functioning. Social adjustment is often given little attention on assessment protocols, given its designation as an associated feature of ADHD. 15 However, the high levels of disruptive behavior demonstrated by ADHD children increases the likelihood of negative reactions from parent, teachers and also peers. 163 In addition, negative social interactions with peers ultimately lead to peer’s rejection, 164 because these social difficulties are often resistant to psychosocial and pharmacological treatment, 165 they are expected to continue into adolescence, and even adulthood when criteria for the disorder may no longer be met. 166 The patterns of disruptive, intrusive, excessive, negative, and emotional social interactions that have been found between children with ADHD and their parents, have also been found to occur in the children’s interactions with teachers and peers. 157 , 167 , 168 It should come as no surprise, then, that those with ADHD receive more correction, punishment, censure, and criticism than other children from their teachers, as well as more school suspensions and expulsions, particularly if they have ODD/CD. 168 , 169 In their social relationships, children with ADHD are less liked by other children, have fewer friends, and are overwhelmingly rejected as a consequence, 170 particularly if they have comorbid conduct problems. 107 , 125 , 171 , 172 Another research study demonstrated that the co-occurrence of conduct disorder and anxiety disorder with ADHD in childhood predicted a more severe course for ADHD in adolescence. 173

Unintentional physical injury

Children with ADHD appear to be at a greater risk for unintentional physical injury and accidental poisoning. 157 , 174 In one of the first studies of the issue, Stewart and colleagues found that four times as many hyperactive children as control children (43% vs . 11%) were described by parents as accidentprone. Later studies have also identified such risks; up to 57% of children with hyperactivity or ADHD are said to be accident-prone by parents, relative to 11% or fewer of control children. 175 , 176 Most studies find that children with ADHD experience more injuries of various sorts than control children. In one study, 16% of the hyperactive sample had at least four or more serious accidental injuries (broken bones, lacerations, head injuries, severe bruises, lost teeth, etc.), compared to just 5% of control children. 2 , 177 found that 68% of children with DSM-IV-TR ADD, compared to 39% of control children, had experienced physical trauma sufficient to warrant sutures, hospitalization, or extensive/painful procedures. Several other studies likewise found a greater frequency of accidental injuries than among control children. Researchers found that children with ADHD were at a greater risk for suffering fractures, 178 most likely as a result of hyperactive and impulsive behavior. Children with AD/HD are also more likely than their non-ADHD counterparts to be injured as pedestrians, to inflict injuries to themselves, to sustain injuries to multiple body regions and to experience head injury. 179 Knowledge about safety does not appear to be lower in these children; implying interventions aimed at increasing knowledge about safety may have little impact. 180

Sleep disturbances

Studies report an association between ADHD and sleep disturbances found that sleep problems occurred twice as often in ADHD as in control children. 181-184 The problems are mainly more behavioral and include settling difficulties, a longer time to fall asleep, and instability of sleep duration, tiredness at awakening or frequent night waking. The direction of effect, between ADHD and sleep problems is unclear. It is possible that sleep difficulties increase ADHD symptoms during the daytime, as the research on normal children implies. 105 Yet some research finds that the sleep problems of children with ADHD are not associated with the severity of their symptoms; this suggests that the disorder, not the impaired sleeping, is what contributes to impaired daytime alertness, inattention, and behavioral problems. 184 , 185

While knowledge about the associations between ADHD and other related variables is useful in terms of diagnostic profiles, less is known about the impact of related variables on the long-term outcome for the disorder. Even less is known about the specificity of these associated problems to ADHD. In the preschool years a wealth of evidence now exists comparing the symptoms of pre-school ADHD symptoms to its school-aged counterpart. Children with a pre-school variant of ADHD present with the same symptom structure, 186 , 187 similar associated impairment and developmental risk, 187 and similar patterns of neuropsychology. 188 Despite the similarities between pre-school ADHD and school-aged ADHD, little is known about what constitutes impairment during the pre-school years although school readiness should be what clinicians focus on. And even less is known about the relationship between early hyperactivity and later expression of the ADHD disorder. 189

While originally conceived of as a disorder of childhood and adolescence, evidence suggests scientific merit and clinical value in examining ADHD in adulthood, 40 , 189 as well as the pre-school period. 189 ADHD symptoms have been shown to persist into later life with up to 40% of childhood cases continuing to meet full criteria in the adult years. 190 , 191 Adult ADHD appears to share many characteristics of the childhood disorder. Similar to their childhood counterparts, adults with ADHD display impairment in the interpersonal, vocational and cognitive domains. 192-194 The adult and childhood disorders also appear to share a common neuropathology, 195 , 196 and demonstrate a similar response to treatment. 197

Conclusions

We have discussed two different possible causes of ADHD in neurological research. The top down theory says that ADHD begins with frontal and pre-frontal lobe dysfunction. The other theory says that the sub-cortical regions, the thalamus and the hypothalamus are responsible for ADHD. Neuro-imaging doesn’t show abnormality in the thalamus, but does show changes in the frontal and prefrontal area. Researchers agree that genetic factors are a strong contribution to the occurrence of ADHD.

DSM-IV has an aura of scientific legitimacy, many authors have written about its shortcomings in terms of reliability and validity. 198 , 199 The primary function and goal of the DSM, 200 is to lend credibility to the claim that certain (mis) behaviors are mental disorders and that such disorders are medical diseases. Although the DSM-IV is often used when discussing mental illnesses, be it in a research setting or a clinical practice setting. Researchers apply points out that such extensive use does not in itself guarantee either its validity or reliability. 201 The DSM-IV is purely descriptive and presents no new scientific insights about the causes of the many mental disorders it lists. Despite a wide level of acceptance, ADHD is not an uncontested condition. 202 For example, another researcher has argued that ….the working dogma that ADHD is a disease or neurobehavioral condition does not at this time hold up . 203 , 204 A more recent perspective presented by Lollar has also stated that there are no valid neurological markers for the diagnosis of ADHD. 205 Additionally, Shaw et al . 206 observe that there is currently no verifiable objective evidence to support the claims of ADHD advocates. Given the lack of validity as a medical condition, it is important to ask why the label of ADHD is applied, and under what conditions?

Another researcher found no association between DAT1 and ADHD. 207 Another gene for which there have been many studies is the dopamine receptor D4, DRD4, on chromosome 11. Another researchers found no evidence of an association between ADHD and DRD4. 208 Environmental effects could also include child-specific experiences of salient environmental influences such as maternal lifestyle or parenting. 209 Childhood ADHD symptoms do remit across time for some, 4 , 210 but not all children. 209

Some of the controversial treatments have involved dietary management, herbs and antioxidants. The removal of artificial food colorings and preservatives from the diet is an indispensable and practicable clinical intervention in ADHD, but rarely is sufficient to eliminate symptomatology. 102 Up to 88 percent of ADHD children react to these substances in sublingual challenge testing, but in blinded studies no child reacted to these alone. Allergies to the foods themselves must also be identified and eliminated. 211 Sugar intake makes a marked contribution to hyperactive, aggressive, and destructive behavior. 212 , 213-222 Overall body of evidence currently does not support dietary use as sole therapy for ADHD. There is a group of children with ADHD who do not respond well to treatment. More resources should be made available to help them, through clinical research and clinical-based treatment. 214

The actual degree to which genetic heritability may predispose to childhood onset of ADHD is still an open question. 102 Population studies indicate attentional problems, conduct problems, and emotional problems tend to cluster within families. 215 , 223 , 224 Genetics and environment are notoriously difficult to separate within the family unit, and researchers suggested the genetic predisposition to ADHD might fuel a negative family atmosphere that exacerbates latent ADHD in the child, 102 , 225 , 226

It is unknown whether the association of motor coordination problems with ADHD is comparable across ages. The limitation in daily life caused by poor motor performance varies with age. 146 Four to six years old children mainly have problems with dressing, use of scissors, drawing, trying shoelaces, and riding a bike. Children seven to ten years old encounter difficulties in writing, dressing, swimming, constructional play, ball skills and outdoor play, while eleven to nineteen year olds have problems of clumsiness in writing, drawing, ball skills, poor table manners and tool use. 218

Research on long term effects and safety of ADHD medications has been especially lacking. 36 , 219 According to researchers of a study of psychotropic drugs used with preschoolers, earlier ages of initiation and longer duration of treatment means that the possibility of adverse effects on the developing brain cannot be ruled out . Another research study of longer term ADHD treatments suggested the side effects such as depression, worrying, and irritability from ADHD medications. 227 , 228 In some of these children, drug therapy is insufficient because of persistent symptoms of coexisting conditions. 228 , 229 Future studies will be needed to define the subgroups clearly. There is much to learn about it.