presentation of adhd in adults

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• Diseases & Conditions
• Adult attention-deficit/hyperactivity disorder (ADHD)

Adult attention-deficit/hyperactivity disorder (ADHD) is a mental health disorder that includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior. Adult ADHD can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

Though it's called adult ADHD , symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity may decrease, but struggles with impulsiveness, restlessness and difficulty paying attention may continue.

Treatment for adult ADHD is similar to treatment for childhood ADHD . Adult ADHD treatment includes medications, psychological counseling (psychotherapy) and treatment for any mental health conditions that occur along with ADHD .

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Some people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. Symptoms can range from mild to severe.

Many adults with ADHD aren't aware they have it — they just know that everyday tasks can be a challenge. Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger.

Adult ADHD symptoms may include:

• Impulsiveness
• Disorganization and problems prioritizing
• Poor time management skills
• Problems focusing on a task
• Trouble multitasking
• Excessive activity or restlessness
• Poor planning
• Low frustration tolerance
• Frequent mood swings
• Problems following through and completing tasks
• Trouble coping with stress

What's typical behavior and what's ADHD?

Almost everyone has some symptoms similar to ADHD at some point in their lives. If your difficulties are recent or occurred only occasionally in the past, you probably don't have ADHD . ADHD is diagnosed only when symptoms are severe enough to cause ongoing problems in more than one area of your life. These persistent and disruptive symptoms can be traced back to early childhood.

Diagnosis of ADHD in adults can be difficult because certain ADHD symptoms are similar to those caused by other conditions, such as anxiety or mood disorders. And many adults with ADHD also have at least one other mental health condition, such as depression or anxiety.

When to see a doctor

If any of the symptoms listed above continually disrupt your life, talk to your doctor about whether you might have ADHD .

Different types of health care professionals may diagnose and supervise treatment for ADHD . Seek a provider who has training and experience in caring for adults with ADHD .

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While the exact cause of ADHD is not clear, research efforts continue. Factors that may be involved in the development of ADHD include:

• Genetics. ADHD can run in families, and studies indicate that genes may play a role.
• Environment. Certain environmental factors also may increase risk, such as lead exposure as a child.
• Problems during development. Problems with the central nervous system at key moments in development may play a role.

Risk factors

Risk of ADHD may increase if:

• You have blood relatives, such as a parent or sibling, with ADHD or another mental health disorder
• Your mother smoked, drank alcohol or used drugs during pregnancy
• As a child, you were exposed to environmental toxins — such as lead, found mainly in paint and pipes in older buildings
• You were born prematurely

Complications

ADHD can make life difficult for you. ADHD has been linked to:

• Poor school or work performance
• Unemployment
• Financial problems
• Trouble with the law
• Alcohol or other substance misuse
• Frequent car accidents or other accidents
• Unstable relationships
• Poor physical and mental health
• Poor self-image
• Suicide attempts

Coexisting conditions

Although ADHD doesn't cause other psychological or developmental problems, other disorders often occur along with ADHD and make treatment more challenging. These include:

• Mood disorders. Many adults with ADHD also have depression, bipolar disorder or another mood disorder. While mood problems aren't necessarily due directly to ADHD , a repeated pattern of failures and frustrations due to ADHD can worsen depression.
• Anxiety disorders. Anxiety disorders occur fairly often in adults with ADHD . Anxiety disorders may cause overwhelming worry, nervousness and other symptoms. Anxiety can be made worse by the challenges and setbacks caused by ADHD .
• Other psychiatric disorders. Adults with ADHD are at increased risk of other psychiatric disorders, such as personality disorders, intermittent explosive disorder and substance use disorders.
• Learning disabilities. Adults with ADHD may score lower on academic testing than would be expected for their age, intelligence and education. Learning disabilities can include problems with understanding and communicating.
• Attention-deficit/hyperactivity disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 26, 2019.
• Attention-deficit/hyperactivity disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml. Accessed Jan. 26, 2019.
• AskMayoExpert. Attention-deficit/hyperactivity disorder. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2017.
• What is ADHD? American Psychiatric Association. https://www.psychiatry.org/patients-families/adhd/what-is-adhd. Accessed Jan. 26, 2019.
• ADHD. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/ADHD/Overview. Accessed Jan. 26, 2019.
• Adult ADHD (attention deficit hyperactive disorder). Anxiety and Depression Association of America. https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/adult-adhd. Accessed Feb. 11, 2019.
• Geffen J, et al. Treatment of adult ADHD: A clinical perspective. Therapeutic Advances in Psychopharmacology. 2018;8:25.
• Adult ADHD. American Association for Marriage and Family Therapy. https://www.aamft.org/Consumer_Updates/Adult_ADHD.aspx. Accessed Feb. 11, 2019.
• Kooij JJS, et al. Updated European consensus statement on diagnosis and treatment of adult ADHD. European Psychiatry. 2019;56:14.
• Fields SA, et al. Adult ADHD: Addressing a unique set of challenges. Journal of Family Practice. 2017;66:68.
• Mitchell JT, et al. Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: Current empirical support, treatment overview, and future direction. Cognitive and Behavioral Practice. 2015;22:172.
• Bhagia J (expert opinion). Mayo Clinic, Rochester, Minn. June 13, 2019.
• Hyperthyroidism (overactive). American Thyroid Association. https://www.thyroid.org/hyperthyroidism/. Accessed June 13, 2019.
• Low blood glucose (hypoglycemia). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-hypoglycemia. Accessed June 13, 2019.

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Adult ADHD: A Review of the Clinical Presentation, Challenges, and Treatment Options

The clinical presentation and functional impacts of ADHD in adults vary greatly from their child and adolescent counterparts. Here: latest information on this complex topic.

Table 1 – Stimulant drug therapy options

Table 2 – Nonstimulant drug therapy options

Premiere Date: October 20, 2015 Expiration Date: April 20, 2017

This activity offers CE credits for:

1. Physicians (CME) 2. Other

ACTIVITY GOAL

To recognize the clinical presentation of adult ADHD as well as the associated challenges of assessment and treatment.

LEARNING OBJECTIVES

At the end of this CE activity, participants should be able to:

• Understand the difficulties associated with making an objective assessment of adult ADHD

• Identify the psychiatric conditions frequently comorbid with adult ADHD

• Distinguish which intervention to use when treating an adult patient with a diagnosis of ADHD

TARGET AUDIENCE

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

CREDIT INFORMATION

CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for 1.5 AMA PRA Category 1 Credit™ .

DISCLOSURE DECLARATION

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Jennifer A. Reinhold, PharmD, BCPS, BCPP, has no disclosures to report.

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The inattentive and the hyperactive-impulsive subtypes of ADHD are particularly evident in adults. This inherent heterogeneity complicates the diagnosis and contributes to the lack of uniformly recognized criteria in the adult population. Historically, the diagnostic criteria that were developed based on the traditional childhood presentation have been applied to adult patients. Practitioners have attempted to adapt these criteria to adults in practice, and DSM-5 has also modified some of the qualifiers in order to facilitate the utilization of the criteria in adults. However, the clinical presentation and functional impacts of ADHD in adults vary greatly from their child and adolescent counterparts.

As patients mature and their roles and responsibilities evolve, the functional impairments and symptom presentation evolve in response, thereby presenting a barrier to fulfilling diagnostic criteria. Adults are exposed to a variety of social and professional situations that can provide an opportunity for previously unnoticed symptoms to manifest. Inattentive symptoms may present as difficulty in completing tasks, poor time management, difficulty in sustaining attention in work-related activities, distractibility and forgetfulness, and poor concentration. Occupational performance and professional interpersonal relationships can suffer, and ultimately result in frequent job changes, unemployment, failure to live up to one’s occupational potential, and lower salaries. Moreover, deficits in global performance in the adult patient’s life role, follow-through, and memory can have pervasive effects that extend to those who depend on him or her (eg, children, spouses, employers, friends).

Perhaps the most significant evolution of symptoms occurs in the hyperactivity-impulsivity domain. It is often assumed that these symptoms fade or resolve entirely in adults as they grow older. However, maturation results in a shift in this symptom cluster, and it evolves from behavioral to cognitive-adult patients feel restless as opposed to running around and being disruptive in school. Approximately 90% of adult patients have symptoms of inattention. 1

Challenges in assessing ADHD in adult patients

There are many challenges associated with a diagnosis of ADHD in adults. Objective assessment is difficult because of many factors, including the extensive degree of symptom overlap with other psychiatric diagnoses (eg, psychiatric comorbidities, adaptive compensatory mechanisms, difficulty in assessing functional impact).

Lack of validated diagnostic criteria

The most contemporary multidimensional approach to a relatively objective diagnosis in children and adolescents are DSM-5 criteria, which assess symptoms in all 3 domains. Until the release of DSM-5, there was very little consideration for the assessment of adult patients because DSM criteria had not been validated in the adult population. DSM-5 adapted the previous set of diagnostic criteria to be more accurately applicable to adult symptom presentation. The nomenclature has evolved to reflect more adult-specific situations, such as having difficulty focusing during lectures, avoidance of reviewing lengthy papers, and forgetfulness related to paying bills or keeping appointments.

Revisions that facilitate the application of the criteria to adults are the decrease in the number of required symptoms for adults to fulfill criteria as well as an increase in the age of initial presentation. Previously, adult patients needed to satisfy at least 6 of the 9 inattentive criteria, which is consistent with diagnosis in the pediatric and adolescent population. In DSM-5, adults need to satisfy only 5 of the 9 criteria and children and adolescents still need to satisfy 6 of the 9 inattentive criteria. DSM-IV required that symptoms present before age 7-a challenging retrospective for adult patients who had not previously sought an intervention.

Even with the new criteria, practitioners need to make a retrospective evaluation of the presence of ADHD in childhood in order to establish a diagnosis in adulthood. This was cited as one of the most problematic components of the criteria because many patients could not recall childhood symptoms or they could not produce documentation substantiating a childhood diagnosis. Because ADHD is considered a developmental disorder, the presence of current symptoms as well as a history of previous symptoms (in childhood) needs to be established. Patients with ADHD, however, have impaired short- and long-term memory; therefore, recall bias can affect the accuracy of assessments. The practitioner is faced with the challenge of determining whether this was an established childhood diagnosis, a missed diagnosis in childhood, or a late-onset adult ADHD.

There are a host of validated rating scales for assessing adult patients with suspected ADHD, although each has inherent limitations. The Adult Self-Report Scale (ASRS) is an 18-item screening tool that is based on DSM-IV criteria. Patients rate the items based on the frequency and degree to which they occur. A 6-item version of the ASRS captures abnormalities in the domains related to follow-through, memory, organization, procrastination, restlessness, and hyperactivity.

The Conners Self-Report Scale is a multidimensional assessment scale that both the patient and an observer complete. The long version of this scale has 66 items that assess symptoms consistent with inattention and memory deficits, impulsivity and emotional lability, hyperactivity and restlessness, and problems with self-conceptualization. 2 Having multiple perspectives is ideal in that the observer can contribute critical data that the patient may be either unaware of or not willing to disclose. One of the most significant limitations of self-report scales is that they are generally not sufficient independently to establish a diagnosis in the absence of more objective data or documentation. A 30-item version of the Conners Adult ADHD Self-Report Scale can also be used.

Psychiatric comorbidity and symptom overlap

Another challenge in the evaluation of adult ADHD is the symptom overlap between ADHD and mood and anxiety disorders. Patients with ADHD tend to have high rates of comorbidity with anxiety, depression, and substance abuse disorders, with prevalence rates that are more than double those observed in patients without ADHD. 3-5 In a 2006 study, 87% of adult patients had at least one psychiatric comorbidity and 56% had two. 4 Determining whether ADHD is present alone or whether it is comorbid with another psychiatric disorder is critical-a mood or anxiety disorder may be responsible for the ADHD-like symptoms.

Compared with patients who have a depressive disorder, those with ADHD tend to have more occupational or functional impairment, organizational deficits, and impulsivity issues. The distinction between ADHD and bipolar disorder can be especially challenging, since the manic and hypomanic features of bipolar disorder are similar to the hyperactive and impulsive symptoms associated with ADHD. In patients with ADHD, these symptoms tend to be constant, but in bipolar disorder there is a waxing and waning of manic symptoms interrupted with periods of depression. Patients with bipolar disorder tend to be goal-directed and are usually productive, while patients with ADHD are less able to complete tasks.

Substance use disorders are more common in patients with ADHD, and the clinical course of ADHD tends to be more challenging in this patient population. In patients with an opiate or cocaine addiction, the prevalence of ADHD is as high as 35%; and for alcohol-addicted patients, the ADHD prevalence exceeds 70%. 4,6 Alcohol and certain prescription and illicit drugs can produce symptoms that mirror those of ADHD, which may artificially inflate the prevalence of ADHD in patients with an addiction problem and may not be reflective of the true prevalence.

Compensatory mechanisms

Adult patients may develop and depend on compensatory mechanisms in order to overcome some of the functional impairments associated with ADHD. 4,7 Patients who are highly functioning with higher than average IQs tend to develop useful coping mechanisms to overcome symptoms or to hide them from others. Some patients become compulsive list makers or develop a highly structured daily routine in order to complete tasks and to minimize forgetting details or losing belongings.

6 Challenges in Assessing ADHD in Adult Patients

They may unknowingly rely on coworkers or family members to an inappropriate extent for reminders or assistance in completing tasks or fulfilling responsibilities. Although compensatory mechanisms are generally therapeutic for the patient, they may cloud the clinical picture particularly in cases where the patient does not self-suspect ADHD but rather a family member or the practitioner suspects ADHD.

Engaging in compensatory mechanisms such as relying significantly on others or forgoing sleep to finish tasks may mask the symptoms of ADHD or suggest that a patient is adequately coping when he or she is not. In any case, the use of appropriate compensatory mechanisms should also be taken into consideration when determining whether drug therapy is indicated. Some patients can manage without a clinically significant functional impact by relying on compensatory mechanisms and are able to avoid drug therapy.

Evidence of significant clinical impact

Among the DSM criteria is an item that evaluates the degree of clinical impact of ADHD symptoms on life domains. For a diagnosis of ADHD, there must be clear evidence of significant clinical impact, which can be especially difficult to objectively assess. Failure to demonstrate significant clinical impact precludes a diagnosis of ADHD even if all other criteria are satisfied. Examples of true clinical impact include disciplinary action at work, risk of job loss, relationship discord, or frequent automobile accidents or accidents in the home.

Underdiagnosis vs overdiagnosis

Given the high degree of psychiatric symptom overlap, the realistic possibility of feigning ADHD symptoms, and a general fear of enabling drug addiction or diversion, the underdiagnosis versus overdiagnosis of ADHD in practice has been called into question. There are no available data to quantify this concern, and therefore no support can be lent to the argument of failure to recognize ADHD or misdiagnosis of ADHD. A psychiatric comorbidity and the point of entry into the health care system (primary care versus a psychiatrist) may influence whether ADHD is overdiagnosed or underdiagnosed. The most frequent point of entry into the health care system and the most common place for ADHD to be evaluated and diagnosed is in the primary care setting, where it may be overdiagnosed. However, when patients are seen by a psychiatrist, it usually is the comorbid psychiatric diagnosis that is treated and not ADHD. Thus, ADHD may be underdiagnosed when patients present to a psychiatrist. Given the assertion that ADHD is overdiagnosed in primary care and underdiagnosed by specialists, the true prevalence of ADHD theoretically lies somewhere in between. 8,9

Prescription drug abuse and drug-seeking behavior

According to the most recent survey by the National Institute on Drug Abuse, adults between the ages of 18 and 25 are statistically the most likely to abuse prescription drugs. 10 Adults between the ages of 18 and 22 are the most likely to abuse stimulant medications, with rates in college students double those in non-college students. 11 The majority of adult patients who present with self-suspected ADHD are between the ages of 18 and 24; therefore, the unfortunate but realistic risk of drug seeking must be considered.

A definitive statistic that quantifies the risk and rates of stimulant medication abuse is elusive owing to patient unwillingness to admit abuse or diversion. However, multiple studies have attempted to capture this rate through anonymous surveys and emergency-department visits. Generally stimulants with a rapid onset of effect and shorter half-life are more likely to be abused, since there is a more narrow window between ingesting the drug and realizing the perceived reward. Variability exists within the therapeutic class in terms of abuse potential: rates of abuse of amphetamine salts exceed those of methylphenidate. 12

Establishing a meaningful comparison of the rates of abuse of stimulant medications compared with prescription drugs for other indications is also challenging. Considering the physiologic consequences of abusing stimulants, opioids, or sedative-hypnotics, it may not be surprising that accidental death due to abuse of a prescription drug is by far the highest for the opioids. Prescription opioid-related accidental deaths were more frequent than cocaine, heroin, and stimulant overdoses combined. 13

Treatment modalities

Psychostimulants remain the drug class of choice in treating adults and children with ADHD. Most product formulations available are derived from one of two parent molecules: methylphenidate or amphetamine ( Table 1 ). Pharmacologically, the stimulants inhibit the reuptake of dopamine and norepinephrine, thereby increasing concentrations in the presynaptic cleft. Amphetamines also directly stimulate the release of dopamine and norepinephrine. About 14 products are currently available in the US: some of them are immediate-release and others are extended-release formulations. It is generally recommended that drug therapy, particularly in adults, should consist of an extended-release product in order to maximize compliance and minimize the risk of abuse. Stimulant medications mitigate traditional ADHD symptoms and have demonstrated utility in improving interpersonal relationships, self-esteem, and cognition, as well as alleviating symptoms of comorbid anxiety disorders. 14,15 Stimulants are arguably the most effective in resolving ADHD symptoms and comorbid psychopathology; however, because of the risk of adverse effects and abuse potential, these agents may be underprescribed for adult ADHD. 16

Common, transient adverse effects include sleep disturbance, appetite suppression and associated weight loss, agitation, and nervousness. These are typically minimized by taking the drugs with food and using an extended-release formulation. Serious concerns exist regarding cardiotoxicity. Patients can experience palpitations, tachycardia, and elevations in blood pressure. Serious cardiovascular effects include rhythm disturbances and cardiomyopathy, which precludes use in patients who have an existing cardiovascular abnormality.

Nonstimulants

Owing to their less impressive effectiveness compared with stimulants, the nonstimulant medications tend to be prescribed less frequently among all age groups. Generally, practitioners do not initiate drug therapy with a nonstimulant unless the patient has a contraindication to stimulants (cardiac abnormalities, previous or current substance abuse) or is intolerant to or has failed a trial of a stimulant. Currently, the nonstimulant therapeutic class includes atomoxetine, immediate- and extended-release guanfacine, clonidine, and bupropion (Table 2 ).

Atomoxetine’s efficacy and safety have been demonstrated in adults and children; however, its associated rates of response are less impressive than those of the stimulants. It remains an appropriate option in patients who have contraindications to stimulants or who have a comorbid anxiety disorder, as anecdotal evidence suggests some level of anxiolytic activity.

Bupropion has been evaluated in a small number of studies involving children, adolescents, and adults, in whom its efficacy compared with placebo or with an active stimulant comparator has been established. This is not an approved indication for bupropion in any age group, however. Bupropion may be a therapeutic alternative in adults who have contraindications or are intolerant to stimulant medications, or in patients who have a comorbid depressive illness.

Guanfacine and clonidine are typically reserved for children who also have a hyperactive component. Of the newer extended-release formulations, only extended-release clonidine has an indication for the treatment of adult ADHD.

CASE VIGNETTE

A 42-year-old woman presents to a primary care clinic for an evaluation of her attention issues. Alice’s symptoms became apparent in early grade school, but with extra effort she managed to get good grades throughout elementary school, high school, and college. Lately she has had increasing difficulty in remembering appointments and completing her projects; she has also been losing her belongings, avoiding tasks, getting distracted at meetings, and failing to listen to people when they speak to her. Her direct superior has brought this to her attention and has mentioned possible disciplinary action. Symptoms occur all day, regardless of setting. Her past medical history includes dyslipidemia, anxiety, and gastroesophageal reflux disease. Prescription medications include 20-mg atorvastatin daily, 10-mg escitalopram daily, and 20-mg omeprazole daily. Evaluations for mood and anxiety disorders reveal no additional diagnoses. There is no documented history of or current issues with substance abuse.

Does this patient fulfill DSM-5 diagnostic criteria for ADHD?   Yes . She reports at least 5 symptoms of inattention (remembering appointments, finishing projects, losing belongings, task avoidance, easy distraction, failing to listen to others in conversation). The symptoms (per patient report) began before age 12, occur both at work and at home, and have resulted in functional impairment (evidenced by her supervisor’s threat of disciplinary action). Given her age, it would be difficult to collect collateral supporting information from a teacher or parent, and so the patient report alone will need to be the only account of symptoms. The clinician’s judgment about the validity of these claims will also need to be taken into consideration. If possible, an attempt could be made to discuss these issues with the patient’s husband or work supervisor in order to acquire different perspectives and additional supporting information. Other psychiatric diagnoses and substance abuse issues are ruled out; therefore, the ADHD symptoms are not better explained by another psychiatric disorder.

Is this patient a candidate for a pharmacotherapeutic intervention?   Yes. Current treatment guidelines recommend initiating drug therapy in adults as a first-line treatment.

Is this patient a candidate for non-drug therapy?   Yes, if necessary. There is no treatment guideline that specifically recommends non-drug therapy for adult patients because there is a lack of efficacy data to support it. However, if the patient complains of specific symptoms that may be behavior-mediated (such as time management or procrastination-related symptoms), counseling or other workshop-based interventions may help her to manage these symptoms more effectively and may eventually reduce her dependence on drug therapy for the monotherapy of ADHD.

What pharmacotherapeutic intervention(s) would be most appropriate? Consistent with the domestic guidelines for the management of ADHD in children, the National Institute for Health and Care Excellence guidelines in Europe recommend initiating a stimulant medication as first-line therapy. None of the stimulants are considered superior with regard to safety or efficacy in adults or children. However, a long-acting formulation is generally preferred because of the reduced likelihood of abuse. This patient has no history of substance abuse, but use of longer-acting formulations will minimize any risk.

Longer-acting products tend to have a smoother onset and offset of action compared with immediate-release agents, which produce a noticeable onset in most patients. A longer-acting product will reduce the pill burden and will require less frequent dosing-an advantage for someone who needs coverage throughout the day.

If this patient has a contraindication to stimulants, what is the next most appropriate intervention? Contraindications to stimulants generally include cardiovascular issues such as arrhythmias, uncontrolled hypertension, or concomitant administration of other drugs that can be arrhythmogenic. In the setting of a contraindication, the nonstimulants could be considered. Atomoxetine is generally used first because its efficacy data are more robust than that of clonidine, guanfacine, and bupropion.

If this patient had a comorbid diagnosis of depression or anxiety, how might the treatment plan for ADHD be different? Depending on the severity of symptoms, the practitioner may choose to treat the mood or anxiety disorder first. This depends on which symptoms are most distressing and which are causing the most functional impairment. Improvement in a comorbid mood and/or anxiety disorder may also indirectly improve ADHD symptoms because patients who are euthymic and not anxious may be better equipped to deal with the ADHD symptoms. Assuming that the comorbid diagnosis is depression, a stimulant and an antidepressant could be initiated, but not at the same time in order to gauge which drug resulted in the resolution of which symptoms.

Bupropion might be a possible intervention if a reduction in pill burden is important. Bupropion is not indicated for ADHD, but there is some evidence to support its use. Assuming that the comorbidity is anxiety, the initiation of a stimulant may or may not worsen symptoms. This is highly patient-specific and will depend on whether the anxiety is worsening the ADHD or vice versa. It may be advisable to initiate medication therapy for the anxiety first and once improved or resolved, initiate drug therapy carefully for the ADHD and monitor for worsening of anxious symptoms.

Historically considered a diagnosis of childhood, ADHD persists into adulthood for a vast majority of patients. Secondary to the absence of validated screening tools for adults, the pervasive symptom overlap with other psychiatric illnesses, frequent comorbidity with other psychiatric diagnoses, feigned ADHD, and the risk of drug diversion or abuse, diagnosis in adults has proven to be challenging. However, utilizing the available diagnostic criteria, gathering as much data as possible from as many sources as possible, considering the possible influence of other psychiatric comorbidities, and being diligent in assessing risk of abuse, the diagnosis of ADHD in an adult can be achieved responsibly and with minimal risk.

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Disclosures:

Dr Reinhold is Associate Professor of Clinical Pharmacy in the department of pharmacy practice/pharmacy administration at The Philadelphia College of Pharmacy at the University of the Sciences in Philadelphia.

References:

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2. Taylor A, Deb S, Unwin G. Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): a systematic review. Res Dev Disabil . 2011;32:924-938.

3. Haavik J, Halmøy A, Lundervold AJ, Fasmer OB. Clinical assessment and diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Rev Neurother . 2010;10:1569-1580.

4. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry . 2006;163:716-723.

5. McGough JJ, Smalley SL, McCracken JT, et al. Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families. Am J Psychiatry . 2005;162:1621-1627.

6. Levin FR. Diagnosing attention-deficit/hyperactivity disorder in patients with substance use disorders. J Clin Psychiatry . 2007;68(suppl 11):9-14.

7. Santosh PJ, Sattar S, Canagaratnam M. Efficacy and tolerability of pharmacotherapies for attention-deficit hyperactivity disorder in adults. CNS Drugs . 2011;25:737-763.

8. Fayyad J, De Graaf R, Kessler R. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry . 2007;190:402-409.

9. Ginsberg Y, Quintero J, Anand E, et al. Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. Prim Care Companion CNS Disord . 2014;16.

10. US Department of Health and Human Services. National Institute on Drug Abuse. Stimulants . October 2011. http://www.drugabuse.gov/publications/research-reports/prescription-drugs/stimulants . Accessed September 1, 2015.

11. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. 2013.

. Accessed August 31, 2015.

12. Romach MK, Schoedel KA, Sellers EM. Human abuse liability evaluation of CNS stimulant drugs. Neuropharmacol . 2014;87:81-90.

13. Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug Alcohol Depend . 2013;131:263-270.

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16. Greenhill LL, Pliszka S, Dulcan MK, et al. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry . 2002;41(suppl 2):26S-49S.

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Attention-Deficit/Hyperactivity Disorder

What is adhd.

Attention-deficit/hyperactivity disorder (ADHD) is marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. People with ADHD experience an ongoing pattern of the following types of symptoms:

• Inattention means a person may have difficulty staying on task, sustaining focus, and staying organized, and these problems are not due to defiance or lack of comprehension.
• Hyperactivity means a person may seem to move about constantly, including in situations when it is not appropriate, or excessively fidgets, taps, or talks. In adults, hyperactivity may mean extreme restlessness or talking too much.
• Impulsivity means a person may act without thinking or have difficulty with self-control. Impulsivity could also include a desire for immediate rewards or the inability to delay gratification. An impulsive person may interrupt others or make important decisions without considering long-term consequences.

What are the signs and symptoms of ADHD?

Some people with ADHD mainly have symptoms of inattention. Others mostly have symptoms of hyperactivity-impulsivity. Some people have both types of symptoms.

Many people experience some inattention, unfocused motor activity, and impulsivity, but for people with ADHD, these behaviors:

• Are more severe
• Occur more often
• Interfere with or reduce the quality of how they function socially, at school, or in a job

Inattention

People with symptoms of inattention may often:

• Overlook or miss details and make seemingly careless mistakes in schoolwork, at work, or during other activities
• Have difficulty sustaining attention during play or tasks, such as conversations, lectures, or lengthy reading
• Not seem to listen when spoken to directly
• Find it hard to follow through on instructions or finish schoolwork, chores, or duties in the workplace, or may start tasks but lose focus and get easily sidetracked
• Have difficulty organizing tasks and activities, doing tasks in sequence, keeping materials and belongings in order, managing time, and meeting deadlines
• Avoid tasks that require sustained mental effort, such as homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers
• Lose things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones
• Be easily distracted by unrelated thoughts or stimuli
• Be forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments

Hyperactivity-impulsivity

People with symptoms of hyperactivity-impulsivity may often:

• Fidget and squirm while seated
• Leave their seats in situations when staying seated is expected, such as in the classroom or the office
• Run, dash around, or climb at inappropriate times or, in teens and adults, often feel restless
• Be unable to play or engage in hobbies quietly
• Be constantly in motion or on the go, or act as if driven by a motor
• Talk excessively
• Answer questions before they are fully asked, finish other people’s sentences, or speak without waiting for a turn in a conversation
• Have difficulty waiting one’s turn
• Interrupt or intrude on others, for example in conversations, games, or activities

Primary care providers sometimes diagnose and treat ADHD. They may also refer individuals to a mental health professional, such as a psychiatrist or clinical psychologist, who can do a thorough evaluation and make an ADHD diagnosis.

For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind typical development for their age. Stress, sleep disorders, anxiety, depression, and other physical conditions or illnesses can cause similar symptoms to those of ADHD. Therefore, a thorough evaluation is necessary to determine the cause of the symptoms.

Most children with ADHD receive a diagnosis during the elementary school years. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before age 12.

ADHD symptoms can appear as early as between the ages of 3 and 6 and can continue through adolescence and adulthood. Symptoms of ADHD can be mistaken for emotional or disciplinary problems or missed entirely in children who primarily have symptoms of inattention, leading to a delay in diagnosis. Adults with undiagnosed ADHD may have a history of poor academic performance, problems at work, or difficult or failed relationships.

ADHD symptoms can change over time as a person ages. In young children with ADHD, hyperactivity-impulsivity is the most predominant symptom. As a child reaches elementary school, the symptom of inattention may become more prominent and cause the child to struggle academically. In adolescence, hyperactivity seems to lessen and symptoms may more likely include feelings of restlessness or fidgeting, but inattention and impulsivity may remain. Many adolescents with ADHD also struggle with relationships and antisocial behaviors. Inattention, restlessness, and impulsivity tend to persist into adulthood.

What are the risk factors of ADHD?

Researchers are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other disorders, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors that might raise the risk of developing ADHD and are studying how brain injuries, nutrition, and social environments might play a role in ADHD.

ADHD is more common in males than females, and females with ADHD are more likely to primarily have inattention symptoms. People with ADHD often have other conditions, such as learning disabilities, anxiety disorder, conduct disorder, depression, and substance use disorder.

How is ADHD treated?

While there is no cure for ADHD, currently available treatments may reduce symptoms and improve functioning. Treatments include medication, psychotherapy, education or training, or a combination of treatments.

For many people, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Sometimes several different medications or dosages must be tried before finding the right one that works for a particular person. Anyone taking medications must be monitored closely by their prescribing doctor.

Stimulants. The most common type of medication used for treating ADHD is called a “stimulant.” Although it may seem unusual to treat ADHD with a medication that is considered a stimulant, it works by increasing the brain chemicals dopamine and norepinephrine, which play essential roles in thinking and attention.

Under medical supervision, stimulant medications are considered safe. However, like all medications, they can have side effects, especially when misused or taken in excess of the prescribed dose, and require an individual’s health care provider to monitor how they may be reacting to the medication.

Non-stimulants. A few other ADHD medications are non-stimulants. These medications take longer to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD. Doctors may prescribe a non-stimulant: when a person has bothersome side effects from stimulants, when a stimulant was not effective, or in combination with a stimulant to increase effectiveness.

Although not approved by the U.S. Food and Drug Administration (FDA) specifically for the treatment of ADHD, some antidepressants are used alone or in combination with a stimulant to treat ADHD. Antidepressants may help all of the symptoms of ADHD and can be prescribed if a patient has bothersome side effects from stimulants. Antidepressants can be helpful in combination with stimulants if a patient also has another condition, such as an anxiety disorder, depression, or another mood disorder. Non-stimulant ADHD medications and antidepressants may also have side effects.

Doctors and patients can work together to find the best medication, dose, or medication combination. To find the latest information about medications, talk to a health care provider and visit the FDA website  .

Psychotherapy and psychosocial interventions

Several specific psychosocial interventions have been shown to help individuals with ADHD and their families manage symptoms and improve everyday functioning.

For school-age children, frustration, blame, and anger may have built up within a family before a child is diagnosed. Parents and children may need specialized help to overcome negative feelings. Mental health professionals can educate parents about ADHD and how it affects a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other.

All types of therapy for children and teens with ADHD require parents to play an active role. Psychotherapy that includes only individual treatment sessions with the child (without parent involvement) is not effective for managing ADHD symptoms and behavior. This type of treatment is more likely to be effective for treating symptoms of anxiety or depression that may occur along with ADHD.

Behavioral therapy is a type of psychotherapy that aims to help a person change their behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a person how to:

• Monitor their own behavior
• Give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting

Parents, teachers, and family members also can give feedback on certain behaviors and help establish clear rules, chore lists, and structured routines to help a person control their behavior. Therapists may also teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

Cognitive behavioral therapy helps a person learn how to be aware and accepting of one’s own thoughts and feelings to improve focus and concentration. The therapist also encourages the person with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.

Family and marital therapy can help family members and spouses find productive ways to handle disruptive behaviors, encourage behavior changes, and improve interactions with the person with ADHD.

Parenting skills training (behavioral parent management training) teaches parents skills for encouraging and rewarding positive behaviors in their children. Parents are taught to use a system of rewards and consequences to change a child’s behavior, to give immediate and positive feedback for behaviors they want to encourage, and to ignore or redirect behaviors they want to discourage.

Specific behavioral classroom management interventions and/or academic accommodations for children and teens have been shown to be effective for managing symptoms and improving functioning at school and with peers. Interventions may include behavior management plans or teaching organizational or study skills. Accommodations may include preferential seating in the classroom, reduced classwork load, or extended time on tests and exams. The school may provide accommodations through what is called a 504 Plan or, for children who qualify for special education services, an Individualized Education Plan (IEP). 

To learn more about the Individuals with Disabilities Education Act (IDEA), visit the  U.S. Department of Education’s IDEA website  .

Stress management techniques can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behavior.

Support groups can help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.

The National Resource Center on ADHD, a program of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD®) supported by the Centers for Disease Control and Prevention (CDC), has information and many resources. You can reach this center online   or by phone at 1-866-200-8098.

Learn more about psychotherapy .

Tips to help kids and adults with ADHD stay organized

Parents and teachers can help kids with ADHD stay organized and follow directions with tools such as:

• Keeping a routine and a schedule. Keep the same routine every day, from wake-up time to bedtime. Include times for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or a bulletin board. Write changes on the schedule as far in advance as possible.
• Organizing everyday items. Have a place for everything, (such as clothing, backpacks, and toys), and keep everything in its place.
• Using homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home necessary books.
• Being clear and consistent. Children with ADHD need consistent rules they can understand and follow.
• Giving praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior and praise it.

For adults:

A professional counselor or therapist can help an adult with ADHD learn how to organize their life with tools such as:

• Keeping routines.
• Making lists for different tasks and activities.
• Using a calendar for scheduling events.
• Using reminder notes.
• Assigning a special place for keys, bills, and paperwork.
• Breaking down large tasks into more manageable, smaller steps so that completing each part of the task provides a sense of accomplishment.

How can I find a clinical trial for ADHD?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage : Information about participating in clinical trials
• Clinicaltrials.gov: Current Studies on ADHD  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country
• Join a Study: Children - ADHD : List of studies being conducted on the NIH Campus in Bethesda, MD

Where can I learn more about ADHD?

Free brochures and shareable resources.

• Attention-Deficit/Hyperactivity Disorder in Children and Teens: What You Need to Know : This brochure provides information about attention-deficit/hyperactivity disorder (ADHD) in children and teens including symptoms, how it is diagnosed, causes, treatment options, and helpful resources. Also available en español .
• Attention-Deficit/Hyperactivity Disorder in Adults: What You Need to Know : This brochure provides information about attention-deficit/hyperactivity disorder (ADHD) in adults including symptoms, how ADHD is diagnosed, causes, treatment options, and resources to find help for yourself or someone else. Also available en español .
• Shareable Resources on ADHD : These digital resources, including graphics and messages, can be used to spread the word about ADHD and help promote awareness and education in your community.
• Mental Health Minute: ADHD : Take a mental health minute to learn about ADHD.
• NIMH Expert Discusses Managing ADHD : Learn the signs, symptoms, and treatments of ADHD as well as tips for helping children and adolescents manage ADHD during the pandemic.

Federal resources

• ADHD   : CDC offers fact sheets, infographics, and other resources about the signs, symptoms, and treatment of children with ADHD.
• ADHD   : (MedlinePlus – also available  en español   .)

Research and statistics

• Journal Articles   : This webpage provides information on references and abstracts from MEDLINE/PubMed (National Library of Medicine).
• ADHD Statistics : This web page provides statistics about the prevalence and treatment of ADHD among children, adolescents, and adults.

Last Reviewed: September 2023

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What are the symptoms of adult ADHD, and what are the diagnostic criteria?

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition that causes people to become impulsive and hyperactive and pay less attention to everyday activities.

Healthcare professionals typically diagnose ADHD during childhood, but the condition can persist into adulthood.

According to the Anxiety and Depression Association of America (ADAA), 60% of children with ADHD in the United States grow into adults with ADHD.

They also note that under 20% of adults with ADHD receive a diagnosis or treatment, and that around a quarter of these adults seek medical help.

This article will discuss what adult ADHD is, its causes and symptoms, how doctors diagnose and treat it, and whether or not any other conditions may coexist with ADHD.

What is ADHD?

ADHD, which some people may also know as ADD, is a neurodevelopmental condition that causes inattention, impulsivity, and hyperactivity.

The Royal College of Psychiatrists state that ADHD tends to improve as a person grows up. For example, a person will typically become less hyperactive over time. However, they may still have difficulty concentrating, be impulsive, and take risks.

As a result, an adult with ADHD may find it difficult to learn, work, and get along with others. Adults with ADHD may also be more likely to experience anxiety, depression , and low self-esteem.

According to the Royal College of Psychiatrists , some symptoms of ADHD in adults include:

• becoming easily distracted and finding it difficult to pay attention, especially when bored
• finding it difficult to listen to other people, including interrupting and finishing their sentences
• finding it difficult to follow instructions
• finding it difficult to organize and finish activities
• becoming restless and unable to sit still
• being forgetful
• becoming irritable, impatient, or frustrated easily
• finding stressors difficult to deal with
• being impulsive

According to the Centers for Disease Control and Prevention (CDC) , healthcare professionals will diagnose adults with ADHD based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition ( DSM-5 ), which is a book that outlines the symptoms of mental health conditions.

Based on which symptoms a person experiences, a doctor will decide which of the three types of ADHD a person has. This might be:

• Predominantly inattentive presentation: An individual may find it difficult to finish a task, pay attention to detail, or follow instructions. They may also find that they are easily distracted.
• Predominantly hyperactive-impulsive presentation: An individual may talk a lot and fidget. They may feel restless and find it difficult to wait their turn.
• Combined presentation: An individual may experience the symptoms of the above two types equally.

To receive a diagnosis of adult ADHD, a person will have to show five or more of the following symptoms for at least 6 months (which are typically inappropriate for that adult’s developmental level).

Inattentive presentation

They may often:

• fail to pay close attention to details or make careless mistakes in work or other activities
• have difficulty paying attention to tasks and activities
• not appear to listen when a person speaks to them directly
• not finish chores or duties in the workplace
• have difficulty organizing activities and tasks
• avoid, or be reluctant to do, tasks that require mental effort over a long period of time
• lose things necessary for tasks and activities
• get easily distracted
• become forgetful in daily activities

Hyperactive-impulsive presentation

• fidget with their feet or hands or not be able to sit still
• stand up when remaining seated is expected
• become restless
• be unable to quietly take part in leisure activities
• be very active and “on the go”
• interrupt questions
• have difficulty waiting their turn
• interrupt others

Other criteria

As well as experiencing some of the above symptoms, they must also:

• have experienced several inattentive or hyperactive-impulsive symptoms before the age of 12
• experience these symptoms in at least two settings, such as at home and at work
• show that there is evidence that these symptoms are interfering with their daily activities
• show that these symptoms are not the result of another mental health condition, such as anxiety or depression

According to the National Institute of Mental Health (NIMH) , once a healthcare professional diagnoses ADHD, they are likely to prescribe medication and refer a person for therapy.

The following sections will discuss these treatments in more detail.

Medication usually consists of either stimulants or non-stimulants.

Stimulants increase the amount of dopamine and norepinephrine in the brain. These are two chemicals that make it easier for people to think and pay attention.

However, stimulants may not be suitable for people with high blood pressure , seizures, liver or kidney diseases, or anxiety disorders.

Non-stimulants take longer to work than stimulants, but they also improve focus and attention and reduce impulsivity.

Some doctors may prescribe both stimulants and non-stimulants to the same person to increase their effectiveness.

Doctors may also refer a person for therapy.

Behavioral therapy and cognitive behavioral therapy aim to help a person change their behavior patterns and teach them methods to reinforce their desired behaviors.

Doctors may also suggest that a person joins a support group.

The CDC explain that researchers are still unsure about what causes ADHD.

However, there is increasing evidence to suggest that genetics may play a part in who develops this condition and who does not.

As well as genetics, the following factors may increase the chance of a person having ADHD:

• brain injury
• exposure to environmental factors such as lead during pregnancy or at a young age
• alcohol and tobacco use during pregnancy
• low birth weight
• premature birth

The CDC also suggest that there is currently no research that conclusively confirms that factors such as watching too much television, consuming too much sugar, or certain parenting practices cause ADHD.

Although these factors may make the symptoms worse, there is not enough evidence to say that these are main causes of ADHD.

Coexisting conditions

According to one 2017 article, there are several conditions that adults with ADHD may also have.

Bipolar disorder

According to the NIMH , bipolar disorder and ADHD can coexist.

Bipolar disorder is a condition that causes people to be restless, talkative, and distractible. They may also have periods of depressive and manic moods.

The 2017 article states that between 9.5% and 21.2% of adults with bipolar disorder also have adult ADHD, and that between 5.1% and 47.1% of adults with ADHD have bipolar disorder.

Researchers suggest that having either ADHD or bipolar disorder under the age of 18 increases the likelihood that people will develop the other condition over time.

Depression is another condition that commonly coexists with ADHD.

Some research has suggested that between 18.6% and 53.3% of adults with ADHD also experience depression.

Adults with both ADHD and depression self-report that their quality of life is lower than that of those with depression alone.

Learn more about ADHD and depression here.

Adults with ADHD are more likely to also have anxiety than those who do not have ADHD.

The ADAA state that 50% of adults with ADHD also experience an anxiety disorder.

Adults with ADHD who also have a social phobia, such as fear when meeting or talking to people, are more common than adults with ADHD who also experience a panic disorder.

Substance use

According to the 2017 article , use of alcohol, nicotine, cannabis, or cocaine is one of the most common coexisting conditions with adult ADHD.

Some researchers suggest that substance use is twice as common in adults with ADHD as it is with those who do not have this condition.

The most common type of substance use among people with ADHD is cigarette use.

Adults with ADHD tend to have a stronger dependence on nicotine than adults who do not have ADHD.

People with ADHD are also more likely to use substances to manage their mood or help them sleep than people without this condition.

Personality disorder

The same 2017 study reports that more than 50% of adults with ADHD also have personality disorders , and that 25% of adults with ADHD have two or more personality disorders.

When to see a doctor

A person should see a doctor if they believe that they are experiencing any of the symptoms of ADHD and it is interfering with their daily activities.

Doctors can diagnose and manage the symptoms of ADHD so that people can carry on their daily activities without interruption.

ADHD is a neurodevelopmental condition that causes inattentiveness, hyperactivity, and impulsivity.

Doctors can diagnose ADHD if a person experiences enough of the symptoms outlined in the DSM-5 , which is a book that details the symptoms of various mental health conditions.

Once a doctor has diagnosed ADHD, they can work with individuals to help them manage and treat the symptoms.

There are several other coexisting conditions that a person with ADHD may have. These include bipolar disorder, depression, and substance use.

A person should see a doctor if they believe that they are experiencing any symptoms of ADHD and those symptoms are interfering with their daily activities.

Doctors will prescribe medications, refer a person to therapy, or both.

Last medically reviewed on August 31, 2020

• Mental Health

How we reviewed this article:

• Adult ADHD (attention deficit hyperactive disorder). (n.d.). https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/adult-adhd
• Attention-deficit/hyperactivity disorder. (2019). https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml
• Attention-deficit/hyperactivity disorder (ADHD). (2020). https://www.cdc.gov/ncbddd/adhd/index.html
• Bipolar disorder. (2018). https://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml
• Crimlisk, H., & Nicoll, T. (2020). ADHD in adults. https://www.rcpsych.ac.uk/mental-health/problems-disorders/adhd-in-adults
• Katzman, M. A., et al. (2017). Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567978/

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Treatment and Management of ADHD in Adults

Management approach and treatment options.

The primary goal of treatment is to minimize the impact of ADHD symptoms on patient function while maximizing the patient’s ability to compensate or cope with any remaining difficulties. Not all symptoms can be resolved with treatment; it is important to manage expectations of treatment and to promote a sense of responsibility and personal agency in patients. 

Overview of Treatment Recommendations for Adults ADHD outlines a general approach to treating ADHD in adults. Briefly, treatment of ADHD in adults includes:

• Stratification by ADHD with and without co-existing mental health conditions
• Non-pharmacological treatment options
• Medication management of symptoms
• Psychoeducation and effective coping strategies for the patient and family
• Vocational and/or educational accommodations
• Family therapy for adults with ADHD who are parents or have difficulties in relationships
• Drug contracts for patients at high risk of substance abuse
• Ongoing monitoring for adverse effects
• Treatment response monitoring Vigilance for any patterns of medication misuse as a necessary part of stimulant prescribing

Evidence-Based Non-Pharmacological Treatments

Cognitive behavioral therapy (cbt).

Cognitive Component: Focused on identifying and modifying “thinking errors” or “thought distortions” so that the patient’s thoughts are more aligned with success and confidence.

Behavioral Component: Involves engineering the environment to be more conducive to concentration and focus, and learning what reinforces and maintains problem behaviors, and constructive behaviors so that constructive changes can be implemented that support the patient’s ability to function well. It includes training in skills to promote relaxation and quiet the mind; communication skills training and exposure therapy, which helps a patient, overcome certain fears and avoidance. It also includes behavioral rehearsal, behavioral practice, and role-playing.

Meta-Cognitive Therapy

Metacognitive therapy is as a type of therapy that involves changing how people think rather than what they are thinking about. Metacognitive therapy suggests stepping back from specific thoughts and instead understand one’s own thinking style. Changing one’s own patterns or style of thinking could have a broad impact on how one manages their life. In this way, metacognitive therapy is distinct from cognitive behavioral therapy, which focuses more on the content of people's thoughts. In people with attention deficit hyperactivity disorder (ADHD), problems with metacognition more often encompass difficulty in planning or executing tasks. The goal of metacognitive therapy in ADHD is to improve organization skills, planning, time management, and resolve thinking distortions that lead to negative moods and the perception of limited options.

ADHD and Exercise

There is no research looking at exercise and adults with ADHD, but there is some research showing improvement of ADHD with exercise on children and adolescents. There is not enough research to conclude what type, intensity, or duration is best. Exercise is an important part of a healthy lifestyle, and should be recommended for both health and possible ADHD benefits. When patients fail to get regular exercise, it could be an indication that ADHD is affecting their organizational skills.

Pharmacological Treatments

Currently, two classes of FDA-approved medications are used for ADHD treatment: stimulant and non-stimulant. 

Methylphenidate and amphetamine are the two most commonly used stimulant medications for treatment of ADHD in adults ( FDA-Approved Stimulant Medications for Adult ADHD ). They both affect dopamine and norepinephrine reuptake in certain parts of the brain and, as a result, increase the amount of these neuro - transmitters to facilitate brain functioning. While methylphenidate and amphetamine have different mechanisms of action in the brain, they generally have a similar effect in terms of improvement of ADHD symptoms.

View a general overview on medication treatments for ADHD and how the medications work.

Non-stimulants

Atomoxetine (Strattera) is currently the only non-stimulant approved by the FDA for the treatment of ADHD in adults ( FDA-Approved Non-Stimulant Medications for Adult ADHD ). It is a potent selective norepinephrine reuptake inhibitor. It lacks the abuse potential of stimulants and is not a controlled Schedule II drug. The effects of atomoxetine take longer to achieve. Some people report small changes in hyperactivity and impulse control within two weeks, but it may take 4 to 8 weeks for the drug to achieve maximum effectiveness.

Treatment Monitoring

It is suggested that all adults with a new ADHD diagnosis, uncontrolled symptoms or any change in medication should be seen within 30 days and monthly there after until the symptoms and function improve. When symptoms and function improve, visits every 3-6 months are recommended. 

At the follow up visit, consider the following:

• Review target symptoms and function 
• Review medication use and effects, considering any dose or time of administration modifications (inquire about how long the effects last and any changes in symptoms or medications effects during a day)
• Monitor for treatment adherence and side effects
• Monitor vital signs
• Review information from informants (when available)
• Adjust therapy
• Provide patient education and advice 
• Monitor for signs of substance abuse/dependence

About 60% of adults experience improvements in quality of life and symptom reduction in response to treatment. Comorbid conditions such as mood and anxiety disorders are also highly treatable. 

Treatment Discontinuation

There is no evidence from controlled trials to indicate how long the patient with ADHD should be treated with medications. Trials of off medications and “medication holidays” can be used to assess the patient's functioning without pharmacotherapy. Improvement may be sustained when the drug is either temporarily or permanently discontinued. The evidence on effectiveness and safety of these methods is lacking in adults. 

There is a documented withdrawal syndrome for stimulant medications. The initial phase (crash) of withdrawal syndrome occurs as the stimulant effects wear off. Symptoms may include:

• Prolonged sleeping
• Depressed mood
• Irritability
• Some cravings (not usually severe in this initial phase).

The initial phase may last one to two days and then is followed by a longer period of several days to weeks of dysphoria (unpleasant or negative mood states). This can start within a few hours to several days of stopping use of the stimulant, in addition to at least two of the following symptoms:

• Difficulty sleeping (insomnia) or excessive sleeping (hypersomnia)
• Feelings of fatigue
• Unpleasant and very vivid dreams
• Psychomotor agitation (e.g., jitteriness, nervousness, moving quickly, edginess, etc.) or psychomotor retardation (e.g., slowed reflexes, moving as if one feels they are weighted down, moving like one is in slow motion, etc.)

Psychotic symptoms may emerge during the first one to two weeks, particularly if they were present during times of use.

Amphetamine withdrawal is largely psychological, but may be difficult to manage, particularly for friends and family members, due to mood swings.

An inpatient setting may be necessary if the patient has significant psychotic symptoms, in which case a referral to mental health services is appropriate.

No medication has been demonstrated to be effective in alleviating amphetamine withdrawal, but some medications may be useful with some symptoms.

Patients should drink at least 2-3 liters of water per day during stimulant withdrawal. Multivitamin supplements containing B group vitamins and vitamin C are recommended. Symptomatic medications should be offered as required for aches, anxiety and other symptoms

If patients are significantly distressed or agitated, presenting a danger to themselves or others, short-term use of benzodiazepines (diazepam 5 to 10mg QID PRN) and antipsychotics (olanzapine 2.5-5mg BD PRN) for control of irritability and agitation can be helpful, particularly in the inpatient setting. Care should be taken to limit access to large quantities of medications and to avoid development of benzodiazepine dependence. These medications should be prescribed for a maximum of seven to 10 days.

The goal of treatment during withdrawal is supportive care and counselling 1 .

Team-based Care and Referrals

Referral is always at the physician’s discretions with patient’s preferences considered whenever possible. During assessment and diagnosis process, consider referral to a psychiatrist or mental/behavioral health professionals in the following several presentations and co-conditions:

• Extreme or severe dysfunction
• Suicidal or homicidal ideationsSubstance use or dependence
• Extreme psychosocial stressors or recent traumatic events
• Previous treatment failures
• Atypical presentation – if presentation as brand-new symptoms this is not ADHD; even if not diagnosed as a child the symptoms must concur 

During treatment and monitoring, consider referral to a psychiatrist in the following situations:

• Poor or no treatment effect after repeated medication adjustments
• Resistant mood or anxiety disorder
• Active substance use and dependence

View team-based care patient resources

Tips and Resources for Patients

Most adult patients with ADHD can benefit from education about ADHD, skill building trainings and adjuvant psychotherapy. A variety of self-help resources such as books, websites and apps exist for adults with ADHD. Several tips and resources for the patients are summarized in the patient handout, Managing Adult ADHD .

1. Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings . Geneva: World Health Organization; 2009. 4, Withdrawal Management.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood, and it’s usually diagnosed in kids. But ADHD tends to be underdiagnosed in women and people of color , which can lead to some people reaching adulthood before realizing they may have the condition. 

Busy Philipps is one of them. The actress recently revealed that she was diagnosed with ADHD after going to a doctor’s appointment for her daughter. “My older daughter was having some issues in school and we took her to be evaluated. And literally in the evaluation, my ex-husband, Marc , we were looking at each other because everything the doctor was asking Birdie and talking about, I was like, ‘But that’s me. That’s what I have,’” the 44-year-old told Us Weekly . 

Philipps said she felt like “there was something wrong” with her before her diagnosis, only to learn that her challenges with completing tasks and scheduling were likely due to ADHD. “There are ways to deal with it, there are medications. It has changed my life,” she said.

Philipps isn’t the only person who has been through this. Over the past few years, “there has been a significant increase in people seeking an ADHD diagnosis,” says Justin A. Barterian, PhD, a psychologist and assistant professor at the Ohio State University – Wexner Medical Center. “There currently seems to be less stigma surrounding ADHD and other mental health disorders in our culture today, leading some individuals who meet criteria for ADHD to seek a diagnosis for the first time,” he adds.

But Barterian says that there are also “misleading” social media and influencer accounts that “misrepresent” symptoms of the condition, “leading to many thinking they have the disorder while not meeting full criteria.”

All of this has raised a lot of questions about adult ADHD, along with how it’s diagnosed. Specialists who treat these patients break it down.

How is ADHD different in adults vs. kids?

ADHD is the same condition in children and adults, but it can present differently in grown-ups, says Joshua M. Langberg, PhD, a licensed clinical psychologist in the Rutgers Graduate School of Applied and Professional Psychology and director of the Center for Youth Social Emotional Wellness . 

“ADHD in childhood is often characterized by high levels of inattention, hyperactivity, and impulsivity,” he says. “In contrast, ADHD in adulthood is primarily defined by difficulties with inattention, concentration, organization, and time-management.”

While hyperactivity is more obvious in kids who experience it, it tends to create internal feelings of restlessness in adults, Langberg says. “Although ADHD symptoms may not be as visible to others in adulthood, they are just as important and impairing,” he says. “Difficulties with sustained attention, attention to detail, and with organization and planning can lead to significant problems with post-secondary education achievement, occupational functioning, and with relationships.”

Symptoms of ADHD in adults

People with ADHD have a pattern of struggling with certain symptoms. Those include inattention, which is having trouble paying attention; hyperactivity, or having too much energy; and impulsivity, which is acting without thinking or having trouble with self-control, says Dr. James McGough , a professor of clinical psychiatry and co-director of the ADHD Clinic at UCLA.

People with ADHD may have mostly symptoms of inattention or mostly symptoms of hyperactivity-impulsivity, while some will have both types of symptoms, the National Institute of Mental Health (NIMH) says. 

People with inattentive ADHD may struggle with these tasks, according to NIMH:

• Paying close attention to details
• Paying attention for long tasks, like preparing reports, completing forms, or reviewing long papers
• Listening closely when spoken to directly
• Following instructions and finishing duties at work
• Organizing tasks and activities
• Managing time
• Doing tasks that require sustained attention

They may also lose things like keys, wallets, and phones, get distracted easily, and be forgetful with things like paying bills, keeping appointments, or returning calls. 

Those with hyperactivity and inactivity may have these symptoms, according to NIMH:

• Extreme restlessness and trouble sitting still for long periods of time
• Fidgeting with or tapping hands or feet or squirming in seat
• Struggling to do quiet leisure activities
• Talking excessively
• Answering questions before they’re asked completely
• Having trouble waiting in line
• Interrupting others

But Hillary Ammon , PsyD, a clinical psychologist at the Center for Anxiety & Women’s Emotional Wellness , stresses that all adults experience some of these symptoms here and there. “Every now and then, it may be hard to accomplish everything you wish to accomplish, or find yourself being forgetful,” she says. “It may not be ADHD, but instead, you may have too much on your plate at one time and it’s causing forgetfulness or mistakes.”

People with ADHD will often have a chronic history of having running to-do lists, with little success in getting the list done, consistently choosing fun over boring tasks, having actual consequences for mistakes or not completing tasks, or procrastinating tasks that seem “too big” or “overwhelming,” Ammon says. 

But if you suddenly start having symptoms of ADHD, it’s unlikely to be due to the disorder, McGough says. “You don’t make it to age 50 as a partner in a law firm and suddenly have ADHD,” he says. “That would be hard to believe.” 

How is adult ADHD diagnosed?

An adult ADHD diagnosis usually starts with someone realizing that they’re struggling, McGough says. “Some people who are more intelligent or who have a family with more resources may make it to college or beyond without realizing something is going on,” he says. But suddenly being faced with more challenging life situations can bring those issues to light.

“I’ve had people come in who are starting medical school or law school who were smart or supported enough in the past that this was never an issue before,” McGough says. 

Doctors will typically ask a lot of questions during an initial meeting, says Dr. Shazia Savul , a psychiatrist at Penn Medicine. “We ask them what’s going on currently and the difficulty they’re having,” she says. People with ADHD tend to have issues across several areas of life—work, academics, and relationships—and hearing how things are going in those areas can be enlightening for doctors, she says. 

But doctors also will want to know about your past. “We will also ask about if they were having these problems growing up—if they had similar symptoms in elementary or middle school,” Savul says. 

Savul points out that factors like significant depression or severe anxiety can also mimic the symptoms of ADHD, making it important to rule those out, too. “People smoking marijuana frequently will start to have symptoms very similar to ADHD as well,” Savul says. “We have to take these things into account.”

While your doctor may have you fill out questionnaires, you should also expect an in-person or virtual meeting that will last a few hours, Langberg says. “The clinician’s primary job is to determine why symptoms of inattention are concerning and whether they are best attributed to ADHD, anxiety, depression, sleep, stress, changes in context, etc,” he says. “There is a diagnostic manual that clinicians use, and in order to meet criteria for ADHD, specific and well-defined symptom thresholds need to be met currently and in childhood.”

Langberg stresses that there is no single test for ADHD. “If someone tells you that they can look at your blood type or brain waves or performance on a computer task and use that information alone to diagnose ADHD, they are not following recommended or best-practice procedures and they are not operating in an ethical manner,” he says. 

What is treatment like for adult ADHD?

Treatment for adult ADHD is similar for kids and adults, Barterian says. That includes using stimulant medications like amphetamine/dextroamphetamine salts (Adderall) or lisdexamfetamine (Vyvanse, Elvanse), which come with possible side effects including headaches, anxiety,  and trouble sleeping, per the Mayo Clinic .

Other options include non-stimulant medications, Savul says, and medication-free treatments. 

“Adults may also benefit from cognitive behavioral therapy targeted at addressing skills deficits related to executive functioning,” Barterian says. “Skills learned through therapy can help an individual with ADHD learn to modify their environment to reduce impairment associated with ADHD symptoms.”  

If you suspect that you have ADHD, doctors stress the importance of getting evaluated by a licensed mental healthcare provider. “Sometimes I see anxiety misdiagnosed as ADHD,” Ammon says. “To clarify, individuals can have both anxiety and ADHD. However, I have assessed clients who suspected they had ADHD when in reality the root of their procrastination habits was actually anxiety-driven. That is why proper assessment is so important.”

If you’re given an ADHD diagnosis, McGough says the proper treatment can be life-changing. “I have one friend who got on the right ADHD medication and got a glowing review at work. Lawyers will say, ‘I now have triple the billings,’” he says. “These are very observable outcomes.”

Savul agrees that the proper treatment can make a big impact. “The majority of patients are responsive,” she says. “They feel better about themselves, they start functioning better in professional and academic life. We have a lot of stories of people doing well after they started treatment.”

Most Popular

Clinical presentations of adult patients with ADHD

Affiliation.

• 1 Combined Psychiatry and Neurology/Adult ADHD Program, New York University School of Medicine, New York 10016, USA. [email protected]
• PMID: 15046529

Attention-deficit/hyperactivity disorder (ADHD) persists into adulthood in an increasingly recognized number of individuals with childhood onset. The symptoms of adult ADHD are similar to the restlessness, distractibility, and impulsivity central to childhood ADHD, but expression of symptoms changes as the individual matures. A childhood history of ADHD is requisite for a diagnosis of adult ADHD, although full DSM-IV criteria for the childhood disorder need not be met as long as significant symptoms and impairment occurred. Three case reports described here illustrate the migration of symptoms and the use of retrospective reporting and rating scales to determine a diagnosis of adult ADHD. These reports also stress the high probability of comorbid disorders and family aggregation of ADHD, as well as the likelihood that the adult with ADHD has developed coping mechanisms to compensate for his or her impairment.

• Aging / psychology*
• Attention Deficit Disorder with Hyperactivity / diagnosis
• Attention Deficit Disorder with Hyperactivity / genetics
• Attention Deficit Disorder with Hyperactivity / psychology*
• Attention Deficit Disorder with Hyperactivity / therapy
• Comorbidity
• Diagnosis, Differential
• Middle Aged

ADHD Combined Type: Symptoms and How to Cope

Attention deficit hyperactivity disorder (ADHD) combined presentation can mean losing concentration one minute and feeling impulsive the next.

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder. Its symptoms are usually first noticed during childhood when hyperactive or inattentive behaviors begin to show. Sometimes, both types of behaviors are seen, and the diagnosis is ADHD combined type.

What is ADHD combined presentation?

ADHD combined presentation is diagnosed when you’ve persistently experienced both of these types of ADHD symptoms for at least 6 months:

• hyperactivity and impulsivity
• inattention

Hyperactivity and impulsivity

Examples of hyperactivity and impulsivity behaviors include:

• restlessness
• difficulty sitting for lengthy periods
• nonstop talking
• interrupting conversations
• low impulse control
• behaviors that may put your and other people’s safety in jeopardy
• difficulty relaxing or engaging in quiet activities

Inattention

Examples of ADHD inattention symptoms include:

• forgetfulness
• procrastination
• frequently losing items like keys, your wallet, glasses, or phone
• hesitant to do tasks requiring prolonged mental effort
• mental and physical disorganization
• not following through on instructions or directions
• jumping from task to task without completing any
• making careless mistakes
• daydreaming
• not paying attention when spoken to

Other types of ADHD

According to the Diagnostic and Statistical Manual of Mental Disorders, 5 th edition, text revision (DSM-5-TR) , ADHD can present in several forms , including combined presentation. The diagnosis will depend on which symptoms are more dominant.

• inattention presentation : symptoms primarily of inattention
• hyperactivity and impulsivity presentation : symptoms related to low impulse control and hyperactivity

When you meet the diagnostic criteria for both of these types of ADHD, you’ll receive the ADHD combined presentation diagnosis.

Severity levels

All three types of ADHD can present with distinct levels of severity, according to the DSM-5.

• Mild: Symptoms meet the minimum diagnostic requirements, with few other symptoms seen. Impairment is minimal.
• Moderate: There are numerous dominant symptoms, and impairment is more than mild.
• Severe: Many symptoms beyond basic diagnosis surface, or several with noticeable severity or symptoms cause significant trouble socially and at work.

Treatment options for ADHD combined type

If you live with ADHD combined presentation, treatment and management will likely focus on hyperactivity, impulsivity, and inattention. Your health team may start by addressing the behaviors affecting you the most.

For example, if paying attention at school is a significant problem but hyperactivity and impulsivity aren’t as severe, your health team may focus on helping you manage inattention.

Medication approaches

Stimulants are the go-to medications for treating ADHD symptoms.

Why stimulants are effective in ADHD treatment isn’t clear , but evidence suggests the medications improve dopamine and norepinephrine production in the brain. This, in turn, increases focus and impulse control.

Only two stimulant medications are used for ADHD:

• methylphenidate (Ritalin, Focalin, Concerta)
• amphetamine (Adderall, Evekeo, Vyvanse)

Stimulants can help reduce the symptoms of ADHD combined presentation because they help with hyperactivity, impulsivity, and inattention.

Still, the medications carry some side effects, including:

• mood changes
• development of tics (uncontrollable, sudden movements or behaviors)
• withdrawal symptoms as the medication wears off
• sleep problems
• changes in appetite

If tic development is a concern, your health team may opt for one of two types of nonstimulant medications for ADHD:

• alpha-2 agonists (clonidine, guanfacine)
• norepinephrine reuptake inhibitors (atomoxetine)

Behavioral approaches

Medication may not be enough to manage ADHD . Most mental health professionals use a “multimodel” approach — in addition to medication, they may recommend cognitive behavioral therapy and ADHD coaching .

Complementary or home remedies to treat ADHD often lack enough scientific evidence to prove their effectiveness. Still, some information indicates they may work for some people.

For ADHD, complementary practices may include:

• sensory integration training
• dietary management
• interactive metronome training
• electroencephalograms biofeedback
• vision therapy
• thyroid treatment

Is ADHD combined type a disability?

ADHD, regardless of presentation, is considered a disability under the Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973 (Section 504).

It may mean you could qualify for government assistance as well as learning accommodations set forth by the Individuals with Disabilities Education Act (IDEA).

5 tips for managing ADHD combined presentation

Guidance from a healthcare team is essential to manage ADHD, particularly in severe cases. But self-care is also important.

Consider these tips to manage ADHD combined type:

1. Creating routines that work for you

Starting your day with a written plan can help you find a routine that speaks to your specific ADHD symptoms. The plan could involve scheduling meal breaks, chore goals, and routine tasks like taking out the garbage.

2. Decreasing the weight

It’s OK to pass along responsibility. For example, if you find it challenging to pay your bills on time, using auto-pay features or having a family member take on that role may help.

3. Minimizing distractions

If you need to get something done, minimizing your distractions may help. This might mean turning off your phone while you do a project or moving to an area of the house where there’s little clutter.

4. Allowing yourself to move

It’s OK to take a break from a task for a moment. Just because you know you live with symptoms of ADHD doesn’t mean you have to force yourself to never move a muscle.

Scheduling breaks and setting a timer for them can indulge your urge to be active without leading you down a path of distraction.

5. Making use of technology

People with ADHD with combined presentation symptoms may benefit from technology. You can use electronic reminders, planners, and apps to help you stay on task .

Also, hyperactivity and impulsivity symptoms may benefit from mental strengthening games and programs designed with the ADHD brain in mind.

Let’s recap

ADHD combined presentation involves symptoms of the other types of ADHD: hyperactivity, impulsivity, and inattention.

Like other forms of ADHD, the combined type can range in severity, and your treatment options may involve both medication and psychotherapy.

Self-care and a holistic approach can help prevent ADHD combined type from significantly impacting your life.

Last medically reviewed on June 6, 2022

4 sources collapsed

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) text revision. Arlington, VA: American Psychiatric Association.
• Hawk Jr LW, et al. (2018). How do stimulant treatments for ADHD work? Evidence for mediation by improved cognition. https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.12917
• Information and technical assistance on the Americans with Disabilities Act. (n.d.). https://www.ada.gov/
• Section 504, Rehabilitation Ac of 1973. (n.d.). https://www.dol.gov/agencies/oasam/centers-offices/civil-rights-center/statutes/section-504-rehabilitation-act-of-1973

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

Susan young.

1 Psychology Services Limited, PO 1735, Croydon, London, CR9 7AE UK

2 Department of Psychology, Reykjavik University, Reykjavik, Iceland

Nicoletta Adamo

3 Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK

4 Service for Complex Autism and Associated Neurodevelopmental Disorders, South London and Maudsley NHS Foundation Trust, Michael Rutter Centre, London, UK

Bryndís Björk Ásgeirsdóttir

Polly branney.

5 Oxford ADHD and Autism Centre, Oxford, UK

Michelle Beckett

6 ADHD Action, Harrogate, North Yorkshire, UK

William Colley

7 CLC Consultancy, Perth, UK

Sally Cubbin

8 Manor Hospital, Oxford, UK

Quinton Deeley

9 National Autism Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, Beckenham, UK

10 Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology, and Neuroscience, London, UK

Emad Farrag

11 South London & Maudsley NHS Foundation Trust, Maudsley Health, Abu Dhabi, UAE

Gisli Gudjonsson

12 Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

13 Independent Consultant in Child and Adolescent Psychiatry, Private Practice, London, UK

Jack Hollingdale

14 Michael Rutter Centre, South London and Maudsley Hospital, London, UK

15 Koc University, Istanbul, Turkey

16 ADHD Foundation, Liverpool, UK

Peter Mason

17 ADHD and Psychiatry Services Limited, Liverpool, UK

Eleni Paliokosta

18 Tavistock and Portman NHS Foundation Trust, London, UK

Sri Perecherla

19 St Thomas’ Hospital London, London, UK

Jane Sedgwick

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

Caroline Skirrow

21 Cambridge Cognition, Cambridge, UK

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

Kevin Tierney

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

Kobus van Rensburg

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

Emma Woodhouse

25 Compass, London, UK

Associated Data

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

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

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

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

Conclusions

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

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

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

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

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

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

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

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

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

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

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

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

• 1.1 Presentation in females and what might trigger referral?
• 1.2 Considering sex differences when conducting ADHD assessments
• 2.1 Pharmacological
• 2.2 Non-pharmacological
• 3.1 Educational considerations
• 3.2 Other multi-agency considerations

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

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

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

Results and consensus outcome

Presentation of adhd in females.

Although much of the scientific literature indicates an overlap in the clinical presentation of males and females with ADHD, the available evidence often draws on predominantly male samples [ 39 ] due to the higher prevalence of ADHD in males [ 4 ]. Some sex differences have been reported, which are described below, and briefly summarised in Table ​ Table1 1 .

Summary of key points for detection of ADHD in females

ADHD symptoms

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

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

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

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

Comorbidity

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

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

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

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

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

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

Associated features, functional problems and impairments

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

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

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

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

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

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

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

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

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

Triggers for referral

There are multiple potential triggers that may prompt the referral of females for assessment, shown in Table ​ Table2. 2 . Some of these triggers are indicative of other associated conditions and it is the clustering of multiple trait-like symptoms that are pervasive and impairing that is informative, rather than state-like symptoms showing situational change. The decision to refer would also be strongly supported if there is a first-degree relative with ADHD.

Co-occurring functional problems, features or conditions commonly seen in girls and women with ADHD

Legend: Co-occurring functional problems, associated features or conditions commonly seen in addition to ADHD symptoms in girls and women with ADHD, presented along with age-ranges for detection. These may serve as triggers to help to identify individuals who may require assessment for ADHD

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

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

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

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

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

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

For both males and females, a comprehensive assessment should be completed to accurately capture the symptoms of ADHD across multiple settings, their persistence over time and associated functional impairments. High rates of comorbidity are typically present. The assessment process is typically tripartite involving the use of rating scales, a clinical interview and ideally objective information from informants or school reports. Key recommendations for enhancing diagnostic assessment in girls and women are provided in Table ​ Table3 3 .

Enhancing ADHD diagnostic assessment in females: consensus recommendations

Rating Scales

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

While rating scales are useful aids for clinical assessment and treatment monitoring, findings should be interpreted cautiously if they are used for screening purposes as they are non-specific markers of potential problems [ 110 ]. Rigid adherence to cut-offs may lead to a high proportion of false positives and negatives. There are many rating scales available with varying merits and limitations and some are yet to be updated to reflect revisions to diagnostic criteria. Where possible both informant- and patient-rated scales should be obtained. Rating scales in common use are presented in Table ​ Table4 4 .

Clinical assessment resources which are in common use for ADHD

Rating scale norms are predominantly from male or mixed samples, which may disadvantage their use in females, although some provide female-specific norms (see Table ​ Table4). 4 ). Where female norms are not available, greater emphasis should be placed on collateral information (e.g. parental and school reports). The Nadeau and Quinn checklists may also be used as indication of possible ADHD in girls and women [ 126 , 127 ], providing structured self-enquiry of ADHD symptoms and associated problems, including a range of difficulties such as learning problems, social/interpersonal and behavioural problems.

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

The clinical interview

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

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

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

Semi-structured clinical diagnostic interviews are helpful as they guide the healthcare practitioner to complete a comprehensive developmental and clinical interview, whilst allowing for individual differences to be considered. For example, symptoms relating to excessive talking, blurting out answers, fidgeting, interrupting and/or intruding on others have been reported as more frequently endorsed by women than men with ADHD [ 53 , 55 ] and may be more sensitive to the presentation in females. Small modifications may help to capture more female-centric behaviour (e.g. ‘excessive talking and giggling’ instead of ‘excessive talking’) [ 133 ]. Commonly used diagnostic interviews are presented in Table ​ Table4. 4 . There are three clinical interviews that prompt the assessor to consider the presence of co-existing conditions (which may differ between males and females); ACE, ACE+ [ 134 ] and the DAWBA [ 118 ].

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

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

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

Objective assessments

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

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

Interventions and Treatments

Prompt identification and treatment of ADHD is recommended, as there is evidence of long-term functional benefits associated with treatment [ 137 , 138 ]. ADHD is typically treated with psychoactive medication, psychoeducation and therapeutic interventions at all ages, and a stronger treatment effect has been reported with multi-modal treatment [ 138 ]. A brief summary of treatment recommendations is presented in Table ​ Table5 5 .

Treating ADHD in girls and women: key consensus recommendations

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

Pharmacological management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Non-pharmacological management

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

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

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

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

Primary age

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

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

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

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

Secondary age

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Multi-agency liaison

This section addresses issues that arise at a broader institutional level. Primarily, support for females with ADHD may be improved through the psychoeducation and training of individuals who work within these institutions. Some may act as referral gatekeepers and, as such, they have the potential to support or hinder the referral process and to positively or negatively influence the progress of young people and adults within these institutions. A brief summary of multi-agency liaison recommendations is presented in Table ​ Table6 6 .

Multi-agency liaison for ADHD in girls and women: key recommendations

Educational considerations and adjustments

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

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

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

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

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

All educational staff should be trained in how to screen females for ADHD and how to make onward referrals for treatment, if indicated. School staff should be trained on the importance of early detection, educational needs and interventions and support strategies that can improve educational outcomes. Training sessions should raise awareness of the current bias towards males in the clinical referral process. Teaching staff may not be as aware of the benefits of referral and ADHD treatment in girls [ 45 ], and children with the inattentive subtype [ 204 ]. Addressing gender-specific ADHD issues, and gender expectations and stereotypes may help staff to better identify affected females. If ADHD is suspected, schools may consider adopting sensitive screening tools for ADHD (Table ​ (Table4) 4 ) or broader mental health problems (e.g. the SDQ [ 116 ]). These tend to be cost-effective, quick and reliable, and can help to identify vulnerable girls and young women. Difficulties can arise in maintaining medication treatment programmes in school and staff should be mindful that children may find this stigmatising, especially those who require short-acting medications to be dispensed at school.

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

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

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

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

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

Occupational considerations and adjustments

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

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

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

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

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

Health and social care

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

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

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

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

Criminal justice system

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

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

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

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

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

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

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

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

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

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

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

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

Acknowledgements

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

Abbreviations

Authors’ contributions.

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

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

Availability of data and materials

Ethics approval and consent to participate.

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

Consent for publication

Not applicable

Competing interests

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

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Symptoms - Attention deficit hyperactivity disorder (ADHD)

Symptoms of attention deficit hyperactivity disorder (adhd).

The symptoms of attention deficit hyperactivity disorder (ADHD) can be categorised into 2 types of behavioural problems:

• inattentiveness (difficulty concentrating and focusing)
• hyperactivity and impulsiveness

Many people with ADHD have problems that fall into both these categories, but this is not always the case.

For example, around 2 to 3 in 10 people with the condition have problems with concentrating and focusing, but not with hyperactivity or impulsiveness.

This form of ADHD is also known as attention deficit disorder (ADD). ADD can sometimes go unnoticed because the symptoms may be less obvious.

ADHD is more often diagnosed in boys than girls. Girls are more likely to have symptoms of inattentiveness only, and are less likely to show disruptive behaviour that makes ADHD symptoms more obvious. This means girls who have ADHD may not always be diagnosed.

Symptoms in children and teenagers

The symptoms of ADHD in children and teenagers are well defined, and they're usually noticeable before the age of 6. They occur in more than 1 situation, such as at home and at school.

Children may have symptoms of both inattentiveness and hyperactivity and impulsiveness, or they may have symptoms of just 1 of these types of behaviour.

Inattentiveness (difficulty concentrating and focusing)

The main signs of inattentiveness are:

• having a short attention span and being easily distracted
• making careless mistakes – for example, in schoolwork
• appearing forgetful or losing things
• being unable to stick to tasks that are tedious or time-consuming
• appearing to be unable to listen to or carry out instructions
• constantly changing activity or task
• having difficulty organising tasks

Hyperactivity and impulsiveness

The main signs of hyperactivity and impulsiveness are:

• being unable to sit still, especially in calm or quiet surroundings
• constantly fidgeting
• being unable to concentrate on tasks
• excessive physical movement
• excessive talking
• being unable to wait their turn
• acting without thinking
• interrupting conversations
• little or no sense of danger

These symptoms can cause significant problems in a child's life, such as underachievement at school, poor social interaction with other children and adults, and problems with discipline.

Related conditions in children and teenagers with ADHD

Although not always the case, some children may also have signs of other problems or conditions alongside ADHD, such as:

• anxiety disorder  – which causes your child to worry and be nervous much of the time; it may also cause physical symptoms, such as a rapid heartbeat, sweating and dizziness
• oppositional defiant disorder (ODD) – this is defined by negative and disruptive behaviour, particularly towards authority figures, such as parents and teachers
• conduct disorder – this often involves a tendency towards highly antisocial behaviour, such as stealing, fighting, vandalism and harming people or animals
• sleep problems – finding it difficult to get to sleep at night, and having irregular sleeping patterns
• autistic spectrum disorder (ASD)  – this affects social interaction, communication, interests and behaviour
• dyspraxia – a condition that affects physical co-ordination
• epilepsy  – a condition that affects the brain and causes repeated fits or seizures
• Tourette's syndrome  – a condition of the nervous system, characterised by a combination of involuntary noises and movements (tics)
• learning difficulties – such as dyslexia

Symptoms in adults

In adults, the symptoms of ADHD are more difficult to define. This is largely due to a lack of research into adults with ADHD.

As ADHD is a developmental disorder, it's believed it cannot develop in adults without it first appearing during childhood. But symptoms of ADHD in children and teenagers often continue into adulthood.

The way in which inattentiveness, hyperactivity and impulsiveness affect adults can be very different from the way they affect children.

For example, hyperactivity tends to decrease in adults, while inattentiveness tends to remain as the pressures of adult life increase.

Adult symptoms of ADHD also tend to be far more subtle than childhood symptoms.

Some specialists have suggested the following as a list of symptoms associated with ADHD in adults:

• carelessness and lack of attention to detail
• continually starting new tasks before finishing old ones
• poor organisational skills
• inability to focus or prioritise
• continually losing or misplacing things
• forgetfulness
• restlessness and edginess
• difficulty keeping quiet, and speaking out of turn
• blurting out responses and often interrupting others
• mood swings, irritability and a quick temper
• inability to deal with stress
• extreme impatience
• taking risks in activities, often with little or no regard for personal safety or the safety of others – for example, driving dangerously

Related conditions in adults with ADHD

As with ADHD in children and teenagers, ADHD in adults can occur alongside several related problems or conditions.

One of the most common is depression. Other conditions that adults may have alongside ADHD include:

• personality disorders  – conditions in which an individual differs significantly from the average person in terms of how they think, perceive, feel or relate to others
• bipolar disorder  – a condition affecting your mood, which can swing from one extreme to another
• obsessive compulsive disorder (OCD)  – a condition that causes obsessive thoughts and compulsive behaviour

The behavioural problems associated with ADHD can also cause problems such as difficulties with relationships and social interaction.

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Understanding ADHD Inattentive Type

Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Ann-Louise T. Lockhart, PsyD, ABPP, is a board-certified pediatric psychologist, parent coach, author, speaker, and owner of A New Day Pediatric Psychology, PLLC.

Delmaine Donson / Getty Images

Comparing ADHD Types

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental "disorder" that impacts the way the brain functions. We put the word disorder in quotation marks because while ADHD is a disorder in the DSM-5, it is more commonly viewed by physicians and neurodivergent individuals as having a brain that simply works differently than neurotypicals.

An estimated 5% of people around the world live with ADHD, which starts in childhood but often persists into adulthood.

We will always encourage people with ADHD to embrace those ways of thinking and characteristics that make them unique. Still, there are certain stressors and symptoms caused by ADHD that can be managed so that you can be the best version of your neurodivergent self.

ADHD is typically characterized by two types of traits or characteristics :

• Traits of inattention: These characteristics or behaviors can make it hard for the person to pay attention or stay organized.
• Traits of hyperactivity and impulsivity: These characteristics or behaviors can make it difficult for the person to sit still, causing them to move around constantly. They may have difficulty controlling their impulses and behaviors.

There are three types of ADHD, which are distinguished based on the characteristics or behaviors the person has:

• ADHD inattentive type: This type of ADHD is characterized by characteristics or behaviors of inattention. People with this type of ADHD may have few or no hyperactivity and impulsivity traits. This form of ADHD is sometimes referred to as attention deficit disorder (ADD) , although the term ADD is an outdated one that is not used anymore.
• ADHD hyperactive/impulsive type: This type of ADHD is characterized by characteristics or behaviors of hyperactivity and impulsivity. People with this type of ADHD may have few or no symptoms of inattention.
• ADHD combined type: People who have ADHD combined type have characteristics or behaviors of inattention as well as those of hyperactivity and impulsivity. This is the most common type of ADHD. 

Up to 30% of people with ADHD have inattentive type ADHD. A 2014 study notes that ADHD inattentive type is more subtle than the other types of ADHD, so it can be harder to detect. For instance, students with this type of ADHD may be less disruptive in the classroom than children who also have characteristics of hyperactivity and impulsivity.

This article explores the characteristics, causes, diagnosis, and treatment of inattentive type ADHD.

Characteristics of ADHD Inattentive Type

Children or adults with ADHD inattentive type primarily display traits of inattention, which include:

• Having difficulty focusing on tasks at school or work
• Not paying close attention to detail, which can result in careless mistakes in schoolwork or work assignments
• Being disorganized, resulting in missed appointments and deadlines
• Getting distracted easily
• Leaving tasks such as assignments, chores, or other activities incomplete
• Frequently losing personal belongings and valuables
• Forgetting things often
• Failing to follow through on instructions and appearing not to listen when spoken to directly
• Avoiding tasks that require sustained focus for longer periods of time

Children and teenagers below the age of 17 need to have at least six of these traits in order to be diagnosed with ADHD inattentive type. Those above the age of 17 need to have had at least five of these traits.

In addition to characteristics of inattention, people with ADHD inattentive type may also have a few characteristics of hyperactivity and impulsivity, which include:

• Fidgeting, tapping, or squirming while seated
• Having difficulty remaining seated, in class or at work for instance
• Pacing, or in children, running around or climbing instead of staying seated
• Making a lot of noise while playing or participating in leisure activities
• Constantly feeling restless and being on the go, as though powered by a motor
• Talking too much
• Responding to questions before they’re asked, speaking out of turn, or finishing other peoples’ sentences
• Being unable to wait their turn patiently
• Interrupting, intruding on, or taking over others’ conversations or activities

Causes of ADHD Inattentive Type

ADHD is characterized by low levels of the chemical dopamine in the brain, as well as lower metabolism levels in areas of the brain that are responsible for attention, impulse control, and movement.

The exact causes of these differences in the brain are unknown; however, these are some factors that may contribute to the development of this condition:

• Genetic factors: ADHD can be genetically inherited; a child may be more likely to have it if one of their parents or relatives has it.
• Environmental factors: Exposure to environmental toxins may play a role in the development of ADHD. For instance, a 2016 study found that exposure to lead can cause ADHD in children.
• Early life factors: Premature birth, alcohol or tobacco use during pregnancy, and traumatic events or injuries in early life may contribute to the development of ADHD.

Diagnosing ADHD Inattentive Type

ADHD inattentive type can be diagnosed by a mental healthcare provider such as a psychiatrist or psychologist . A primary care physician, family doctor, or pediatrician can provide a reference to a healthcare provider who specializes in ADHD.

The diagnostic process may involve:

• A detailed personal and family medical history
• A standard rating scale or checklist of symptoms and their severity 
• An interview with the healthcare provider
• Interviews with the child’s family members or teachers
• Other psychological tests, blood work, physical exams, or imaging scans required to rule out other conditions or confirm the diagnosis

The healthcare provider will determine whether the person’s symptoms meet the diagnostic criteria for ADHD inattentive type laid out in the American Psychiatric Association’s Diagnostic and Statistical Manual :

• The person has had the symptoms for over six months.
• The person has had many of the symptoms since before they were 12.
• The symptoms are present in two or more settings, such as school/work, home, social settings, or while doing other activities.
• The symptoms significantly interfere with the person’s ability to function.
• The symptoms are not better explained by another mental health condition .

It’s important to note that a person’s characteristics or symptoms of ADHD may change over time, as they get older. Therefore, the type of ADHD they have can also change. So, even though they may currently have ADHD inattentive type, that could change in future.

Treating ADHD Inattentive Type

Once again, having ADHD does not mean anything is wrong with you, or that you have something to be cured. However, treatment can help people with ADHD inattentive type manage some of the more challenging characteristics and reduce their difficulties, particularly those related to work or school, where focus is required. Treatment options include medication and therapy.

There are several FDA-approved medications that can treat people ages six and above. These are some of the types of medications that may be prescribed to treat ADHD inattentive type:

• Stimulants: These are the most widely used medications in the treatment of ADHD. Stimulants work by increasing the levels of the chemicals dopamine and norepinephrine in the brain, in order to help with attention and cognition.
• Non-stimulants: These medications take longer to work than stimulants but they can also help with the symptoms of ADHD inattentive type. Non-stimulant medication may be prescribed in combination with stimulants, if stimulants are ineffective, or if stimulants cause too many side effects.
• Antidepressants: Depending on the person’s symptoms, side effects, and any other health conditions they might have, their healthcare provider may also prescribe antidepressant medication. Antidepressants can be particularly helpful if the person also has a mood or anxiety disorder.

Therapy can help people with ADHD inattentive type improve their focus and manage their condition better. These are some forms of therapy that may be helpful:

• Behavioral therapy , which helps people monitor and change their behavior.
• Cognitive-behavioral therapy , which helps people become more aware of their thought processes and teaches them how to improve their focus and concentration.
• Family and marital therapy , which helps partners and family members learn how to support the person with ADHD inattentive type and improve their interactions with them.
• Parenting skills training , which is also known as behavioral training for parents. It can teach parents whose children have ADHD how to encourage positive behaviors in their children and discourage negative behaviors.
• Support groups , which can help people with ADHD and their parents or families connect with others who share their experiences.

Coping With ADHD Inattentive Type

These are some steps that can help people with ADHD inattentive type cope with the condition :

• Reduce distractions: Switch off the television, maintain a clean workspace, and limit other noises and distractions while trying to work, to help improve focus.
• Break up lengthy tasks: Tasks that require sustained attention may be daunting for people with ADHD inattentive type. Dividing the task into smaller chunks can make it more manageable.
• Budget enough time: It can be helpful to start on schoolwork or work assignments in advance, with plenty of activity breaks scheduled in between. 
• Build a routine: It can be helpful to build and maintain a daily routine, to encourage consistency.
• Follow a healthy lifestyle: Eat a nutritious diet , get sufficient sleep, and exercise regularly.

Keep in Mind

ADHD inattentive type is a condition that can make it difficult for a person to focus and concentrate, affecting their performance at work or school. Recognizing the more difficult-to-live-with symptoms of this condition and seeking treatment for it can help improve their ability to function on a day-to-day basis.

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By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

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Doctors Are Still Figuring Out Adult A.D.H.D.

It’s one of the most common psychiatric disorders in adults. Yet there are no U.S. guidelines for diagnosing and treating patients beyond childhood.

By Christina Caron

Just before Katie Marsh dropped out of college, she began to worry that she might have attention deficit hyperactivity disorder.

“Boredom was like a burning sensation inside of me,” said Ms. Marsh, who is now 30 and lives in Portland, Ore. “I barely went to class. And when I did, I felt like I had a lot of pent-up energy. Like I had to just move around all the time.”

So she asked for an A.D.H.D. evaluation — but the results, she was surprised to learn, were inconclusive. She never did return to school. And only after seeking help again four years later was she diagnosed by an A.D.H.D. specialist.

“It was pretty frustrating,” she said.

A.D.H.D. is one of the most common psychiatric disorders in adults. Yet many health care providers have uneven training on how to evaluate it, and there are no U.S. clinical practice guidelines for diagnosing and treating patients beyond childhood.

Without clear rules, some providers, while well-intentioned, are just “making it up as they go along,” said Dr. David W. Goodman, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine.

This lack of clarity leaves providers and adult patients in a bind.

“We desperately need something to help guide the field,” said Dr. Wendi Waits, a psychiatrist with Talkiatry, an online mental health company. “When everyone’s practicing somewhat differently, it makes it hard to know how best to approach it.”

Can A.D.H.D. symptoms emerge in adulthood?

A.D.H.D. is defined as a neurodevelopmental disorder that begins in childhood and is typically characterized by inattention, disorganization, hyperactivity and impulsivity. Patients are generally categorized into three types: hyperactive and impulsive, inattentive, or a combination of the two.

The latest data suggest that about 11 percent of children ages 5 to 17 in the United States have been diagnosed with A.D.H.D. And about 4 percent of adults are estimated to have the disorder. But as recently as two decades ago, most mental health providers “didn’t really believe in adult A.D.H.D.,” Dr. Goodman said.

Now, for the most part, that’s no longer the case. And during the pandemic, stimulant prescriptions, primarily used to treat A.D.H.D., “sharply increased,” particularly among young adults and women, according to a study published in JAMA Psychiatry in January.

When diagnosing the condition, providers rely on the D.S.M.-5., the American Psychiatric Association’s official manual of mental disorders, which contains a somewhat arbitrary requirement: In order to meet the diagnostic criteria for A.D.H.D., significant symptoms, such as continual forgetfulness and talking out of turn, should be present in at least two settings before age 12.

But sometimes, older patients either do not recall childhood symptoms or say that those symptoms were mild. Judy Sandler, 62, who lives in Lincolnville, Maine , was not diagnosed with A.D.H.D. until her mid-50s, after retiring from her job as a teacher: It was the first time in her life she felt like she couldn’t get anything done. She wanted to write, but when she would sit down to focus, she immediately had the urge to get up and do something else: “I’ll just do the laundry,” she would think. “And then go walk the dog.”

During her working years, she benefited from a “hyper-structured” schedule — up until retirement. “All of a sudden, I felt like the rug had been pulled out,” she said.

Patients like Ms. Sandler fall into a gray area. She did not recall having significant symptoms in school or at home, rather she indicated that her symptoms became most problematic later in life. Her husband of 33 years, however, had noticed symptoms for years: She was often forgetful, for example, and found it challenging to slow down.

“There’s a lot more subtlety in making this diagnosis — especially in high-functioning, bright people — than just a symptom checklist,” Dr. Goodman said.

Is the D.S.M. missing symptoms?

The D.S.M. lists nine symptoms of inattention and nine symptoms of impulsivity-hyperactivity that are used to evaluate whether an adult or a child has A.D.H.D.

The D.S.M. does not formally include symptoms related to emotional dysregulation, which is when someone has difficulty managing their mood. It also does not officially mention deficits of executive functioning, or problems with planning, organization and self-regulation. But studies have found that these are some of the most common symptoms that adults with A.D.H.D. experience, said Russell Ramsay, a psychologist who treats adult A.D.H.D.

When the D.S.M.-5 was published in 2013, there was not enough high-quality research to support the addition of these symptoms, Dr. Goodman said. But experts say they are still useful to consider when assessing someone.

Dr. Goodman is working with Dr. Ramsay and other A.D.H.D. specialists from around the world to develop the first U.S. guidelines for diagnosing and treating adults with A.D.H.D., in collaboration with the American Professional Society of A.D.H.D. and Related Disorders.

There is an urgency to do so, in part because of new research that has emerged in the last decade. In addition, while adult A.D.H.D . is often undiagnosed and untreated, some people might be getting diagnosed who don’t actually have the disorder — and given medication they don’t truly need, Dr. Goodman said.

The new guidelines, which are expected to be available for public comment later this year, will aim to create a more uniform process for diagnosing adults, but the D.S.M. will continue to be the “gold standard” for providers, Dr. Ramsay said.

“It’s not wrong,” he added. “It’s just incomplete.”

Is it A.D.H.D or something else?

For adults, a proper A.D.H.D. diagnosis typically requires several steps: an interview with the patient, a medical and developmental history, symptom questionnaires and, if possible, conversations with other people in the patient’s life, like a spouse.

“There are no shortcuts,” said Dr. Lenard A. Adler, a professor of psychiatry at the N.Y.U. Grossman School of Medicine, while speaking to hundreds of providers at the American Psychiatric Association conference in early May. “This isn’t easy.”

While everybody has some trouble paying attention or is restless from time to time, he added, it’s really how pervasive and significant the symptoms are and how consistent and impairing they’ve been throughout the patient’s life that helps doctors decide if an A.D.H.D. diagnosis is appropriate.

But several factors can make it tricky.

People who consider themselves heavy users of digital technology are more likely to report A.D.H.D. symptoms, research suggests .

There’s a “chicken or the egg” dilemma, Dr. Waits said. Are people with A.D.H.D. drawn to using digital technology more than the average person? Or did their A.D.H.D. develop because of their technology use?

People with A.D.H.D. are also likely to have another coexisting condition , like substance use disorder, depression or anxiety, which can make it challenging for both doctors and patients to understand if their symptoms are a result of A.D.H.D., particularly if the symptoms overlap.

Ms. Marsh, who had been diagnosed with depression as a teenager and took up to 10 different medications to treat it without much success, finally received an A.D.H.D. diagnosis after visiting a psychologist in her hometown. This time, the practitioner took the time to talk with her parents and her partner, and then did a fresh analysis of the test results that had been deemed inconclusive four years earlier.

After Ms. Marsh began therapy and started taking the stimulant Focalin, the difference in how she felt was “insane,” she said. Her depression improved as well.

“I could keep track of things in my brain easier,” she added. “I’ve just been able to do a lot more things because I have the motivation for it.”

Christina Caron is a Times reporter covering mental health. More about Christina Caron

Understanding A.D.H.D.

The challenges faced by those with attention deficit hyperactivity disorder can be daunting. but people who are diagnosed with it can still thrive..

Millions of children in the United States have received a diagnosis of A.D.H.D . Here is how their families can support them .

The condition is also being recognized more in adults . These are some of the behaviors  that might be associated with adult A.D.H.D.

Since a nationwide Adderall shortage started, some people with A.D.H.D. have said their medication no longer helps with their symptoms. But there could be other factors at play .

Everyone has bouts of distraction and forgetfulness. Here is when psychiatrists diagnose it as something clinical .

The disorder can put a strain on relationships. But there are ways to cope .

Though meditation can be beneficial to those with A.D.H.D., sitting still and focusing on breathing can be hard for them. These tips can help .

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CDC report finds 1 in 9 American kids has been diagnosed with ADHD

Maria Godoy

Ayesha Rascoe

A new CDC report finds that in 2022, over 7 million children and adolescents in the U.S. had gotten an ADHD diagnosis at some point in their lives. That’s 1 out of every 9 kids. And it's a million more kids than in 2016.

Copyright © 2024 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

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Health Warnings on Sugar-Sweetened Beverages: Simulation of Impacts on Diet and Obesity Among U.S. Adults

Add to collection, downloadable content.

• Affiliation: Gillings School of Global Public Health, Department of Health Behavior
• Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
• Affiliation: Gillings School of Global Public Health, Department of Nutrition
• Introduction: Overconsumption of sugar-sweetened beverage (SSB) is a significant contributor to obesity. Policymakers have proposed requiring health warnings on SSBs to reduce SSB consumption. Randomized trials indicate that SSB warnings reduce SSB purchases, but uncertainty remains about how warnings affect population-level dietary and health outcomes. Methods: This study developed a stochastic microsimulation model of dietary behaviors and body weight using the 2005–2014 National Health and Nutrition Examination Surveys, research on SSB health warnings, and a validated model of weight change. In 2019, the model simulated a national SSB health warning policy's impact on SSB intake, total energy intake, BMI, and obesity among U.S. adults over 5 years. Sensitivity analyses varied assumptions about: (1) how warning efficacy changes over time, (2) the magnitude of warnings’ impact on SSB intake, and (3) caloric compensation. Results: A national SSB health warning policy would reduce average SSB intake by 25.3 calories/day (95% uncertainty interval [UI]= −27.0, −23.6) and total energy intake by 31.2 calories/day (95% UI= −32.2, −30.1). These dietary changes would reduce average BMI by 0.64 kg/m2 (95% UI= −0.67, −0.62) and obesity prevalence by 3.1 percentage points (95% UI= −3.3%, −2.8%). Obesity reductions persisted when assuming warning efficacy wanes over time and when using conservative estimates of warning impact and caloric compensation. Benefits were larger for black and Hispanic adults than for white adults, and for adults with lower SES than for those with higher SES. Conclusions: A national SSB health warning policy could reduce adults’ SSB consumption and obesity prevalence. Warnings could also narrow sociodemographic disparities in these outcomes.
• Body Weight
• controlled study
• body weight
• caloric intake
• health education
• Young Adult
• stochastic model
• Models, Theoretical
• health care planning
• food packaging
• body weight change
• United States
• Public Policy
• theoretical model
• computer simulation
• food preference
• Food Preferences
• young adult
• health care policy
• health disparity
• sensitivity analysis
• Nutrition Surveys
• Socioeconomic Factors
• consumer attitude
• Middle Aged
• socioeconomics
• Energy Intake
• Black person
• middle aged
• Food Labeling
• Sugar-Sweetened Beverages
• Computer Simulation
• public policy
• Consumer Behavior
• sugar-sweetened beverage
• fluid intake
• adverse event
• Health Status Disparities
• health survey
• https://doi.org/10.17615/zb56-2w78
• https://doi.org/10.1016/j.amepre.2019.06.022
• In Copyright
• American Journal of Preventive Medicine
• National Institutes of Health, NIH
• National Institute of Child Health and Human Development, NICHD, (T32HD007168)
• University of the North Carolina Royster Society of Fellows
• National Rosacea Society, NRS, (CPC P2C HD050924, T32 HD091058)
• Elsevier Inc.

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