April 9, 2025

From Meds to Mindfulness: What Actually Works for Adult ADHD?

A new large-scale study has shed light on which treatments for attention-deficit/hyperactivity disorder (ADHD) in adults are most effective and best tolerated. 

Researchers analyzed 113 randomized controlled trials involving nearly 15,000 adults diagnosed with ADHD. These studies included medications (like stimulants and atomoxetine), psychological therapies (such as cognitive behavioral therapy), and newer approaches like neurostimulation.

The Findings

Stimulant medications (lisdexamfetamine and methylphenidate) as well as selective norepinephrine reuptake inhibitors (SNRI) (atomoxetine) were the only treatments that consistently reduced core ADHD symptoms—both from the perspective of patients and clinicians. It may be worth noting that atomoxetine, while effective, was less well tolerated, with more people dropping out due to side effects.

Psychological therapies such as CBT, mindfulness, and psychoeducation showed some benefits, but mainly according to clinician ratings—not necessarily from the patients themselves. Neurostimulation techniques like transcranial direct current stimulation also showed some improvements, but only in limited contexts and with small sample sizes.  

Conclusion 

So, what does this mean for people navigating ADHD in adulthood? Stimulant medications remain the most effective treatment for managing ADHD symptoms day-to-day but nonstimulant medication are not far behind, which is good given the problems we’ve had with stimulant shortages. This study also supports structured psychotherapy as a viable treatment option, especially when used in conjunction with medication. 

The study emphasizes the importance of ongoing, long-term research and the need for treatment plans that are tailored to the individual ADHD patient– Managing adult ADHD effectively calls for flexible, patient-centered care.

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Struggling with side effects or not seeing improvement in your day-to-day life? Dive into a step-by-step journey that starts with the basics of screening and diagnosis, detailing the clinical criteria healthcare professionals use so you can be certain you receive an accurate evaluation. This isn’t just another ADHD guide—it’s your toolkit for getting the care you deserve. This is the kind of care that doesn’t just patch up symptoms but helps you unlock your potential and build the life you want. Whether you’ve just been diagnosed or you’ve been living with ADHD for years, this booklet is here to empower you to take control of your healthcare journey.

Proceeds from the sale of this book are used to support www.ADHDevidence.org.

Get the guide now– Navigating ADHD Care: A Practical Guide for Adults

Ostinelli EG, Schulze M, Zangani C, Farhat LC, Tomlinson A, Del Giovane C, Chamberlain SR, Philipsen A, Young S, Cowen PJ, Bilbow A, Cipriani A, Cortese S. Comparative efficacy and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: a systematic review and component network meta-analysis. Lancet Psychiatry. 2025 Jan;12(1):32-43. doi: 10.1016/S2215-0366(24)00360-2. PMID: 39701638.

Related posts

Are Nonpharmacologic Treatments for ADHD Useful?

Are Nonpharmacologic Treatments for ADHD Useful?

There are several very effective drugs for ADHD, and those treatment guidelines from professional organizations view these drugs as the first line of treatment for people with ADHD. The only exception is for preschool children where medication is only the first line of treatment for severe ADHD; the guidelines recommend that other preschoolers with ADHD be treated with non-pharmacologic treatments, when available. Despite these guidelines, some parents and patients have been persuaded by the media or the Internet that ADHD drugs are dangerous and that non-drug alternative are as good or even better. Parents and patients may also be influenced by media reports that doctors overprescribe ADHD drugs or that these drugs have serious side effects. Such reports typically simplify and/or exaggerate results from the scientific literature. Thus, many patients and parents of ADHD children are seeking non-drug treatments for ADHD. What are these non-pharmacologic treatments and do they work? My next series of blogs will discuss each of these treatments in detail. Here I'll give an overview of my evidenced-based taxonomy of non-pharmacologic treatments for ADHD described in more detail in a book I recently edited (Faraone, S. V. &Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatry Clin N Am 23, xiii-xiv.). I use the term "evidence-based" in the strict sense applied by the Oxford Center for Evidenced Based Medicine (OCEBM; http://www.cebm.net/). Most of the non-drug treatments for ADHD fall into three categories: behavioral, dietary, and neurocognitive. Behavioral interventions include training parents to optimize methods of reward and punishment for their ADHD child, teaching ADHD children social skills, and helping teachers apply principles of behavior management in their classrooms. Cognitive behavior therapy is a method that teaches behavioral and cognitive skills to adolescent and adult ADHD patients. Dietary interventions include special diets that exclude food coloring or eliminate foods believed to cause ADHD symptoms. Other dietary interventions provide supplements such as iron, zinc, or omega-3 fatty acids.  The neurocognitive interventions typically use a computer-based learning setup to teach ADHD patients cognitive skills that will help reduce ADHD symptoms. There are two metrics to consider when thinking about the evidence base for these methods. The first is the quality of the evidence. For example, a study of 10 patients with no control group would be a low-quality study, but a study of 100 patients randomized to either a treatment or control group would be of high quality and the quality would be even higher if the people's rating patient outcomes did not know who was in each group. The second metric is the magnitude of the treatment effect. Does the treatment dramatically reduce ADHD symptoms, or does it have only a small effect? This metric is only available for high-quality studies that compare people treated with the method and people treated with a 'control' method that is not expected to affect ADHD. I used a statistical metric to quantify the magnitude of the effect. Zero means no effect, and larger numbers indicate better effects on treating ADHD symptoms. For comparison, the effect of stimulant drugs for ADHD is about 0.9, which is derived from a very strong evidence base.  The effects of dietary treatments are smaller, about 0.4 to 0.5, but because the quality of the evidence is not strong, these results are not certain and the studies of food color exclusions apply primarily to children who have high intakes of such colorants. In contrast to the dietary studies, the evidence base for behavioral treatments is excellent, but the effects of these treatments on ADHD symptoms are very small, less than 0.1.  Supplementation with omega-3 fatty acids also has a strong evidence base, but the magnitude of the effect is also small (0.1 to 0.2). The neurocognitive treatments have modest effects on ADHD symptoms (0.2 to 0.4) but their evidence base is weak. This review of non-drug treatments explains why ADHD drug treatments are usually used first. The evidence base is stronger, and they are more effective in reducing ADHD symptoms. There is, however, a role for some non-drug treatments. I'll be discussing that in subsequent blog posts. See more evidence-based information about ADHD at www.adhdinadults.com

May 17, 2021

ADHD Treatment Decision Tree

ADHD Treatment Decision Tree

If you've ever wondered how experts make treatment recommendations for patients with ADHD, take a look at this ADHD treatment decision tree that my colleagues and I constructed for our "Primer" about ADHD,http://rdcu.be/gYyV.  

Although a picture is worth a thousand words, keep in mind that this infographic only gives the bare bones of a complex process. That said, it is telling that one of the first questions an expert asks is if the patient has a comorbid condition that is more severe than ADHD. The general rule is to treat the more severe disorder first and after that condition has been stabilized plan a treatment approach for the other condition. Stimulants are typically the first-line treatment due to their greater efficacy compared with non-stimulants.

When considering any medication treatment for ADHD safety is the first concern, which is why medical contraindications to stimulants, such as cardiovascular issues or concerns about substance abuse, must be considered. For very young children (preschoolers) family behavior therapy is typically used before medication. Clinicians also must deal with personal preferences.  Some parents and some adolescents and adults with ADHD simply don't want to take stimulant medications for the disorder. When that happens, clinicians should do their best to educate them about the costs and benefits of stimulant treatment.

If, as is the case for most patients, the doctor takes the stimulant arm of the decision tree, he or she must next decide if methylphenidate or amphetamine is more appropriate. Here there is very little guidance for doctors. Amphetamine compounds are a bit more effective, but can lead to greater side effects.  Genetic studies suggest that a person's genetic background provides some information about who will respond well to methylphenidate, but we are not yet able to make very accurate predictions. After choosing the type of stimulant, the doctor must next consider what duration of action is appropriate for each patient.

There is no simple rule here; the choice will depend upon the specific needs of each patient. Many children benefit from longer-acting medications to get them through school, homework, and late afternoon/evening social activities. Likewise for adults. But many patients prefer shorter-acting medications, especially as these can be used to target specific times of day and can also lower the burden of side effects.  

For patients taking down the non-stimulant arm of the decision tree, duration is not an issue but the patient and doctor must choose from among two classes of medications norepinephrine reuptake inhibitors or alpha-2-agonists. There are not a lot of good data to guide this decision but, again, genetics can be useful in some cases. Regardless of whether the first treatment is a stimulant or a non-stimulant, the patient's response must be closely monitored as there is no guarantee that the first choice of medication will work out well. In some cases, efficacy is low, or adverse events are high. Sometimes this can be fixed by changing the dose, and sometimes a trial of a new medication is indicated.

If you are a parent of a child with ADHD or an adult with ADHD, this trial-and-error approach can be frustrating. But don't lose hope. In the end, most ADHD patients find a dose and a medication that works for them. Last but not least, when medication leads to a partial response, even after adjusting doses and trying different medication types, doctors should consider referring the patient for a non-pharmacologic ADHD treatment.

You can read details about these in my other blogs, but here the main point is to find an evidence-based treatment. For children, the biggest evidence base is for behavioral family therapy. For adults, cognitive behavior therapy (CBT) is the best choice.  Except for preschoolers, the experts I worked with on this infographic did not recommend these therapies before medication treatment. The reason is that the medications are much more effective, and many non-pharmacologic treatments (such as CBT) have no data indicating they work well in the absence of medication.

April 3, 2021

Mindfulness-Based Cognitive Therapy for Adults with ADHD

Mindfulness-Based Cognitive Therapy for Adults with ADHD

A Dutch study compared the efficacy of mindfulness-based cognitive therapy (MBCT) combined with treatment as usual (TAU), with TAU-only as the control group. MBCT consisted of an eight-week group therapy consisting of meditation exercises (body scan, sitting meditation, mindful movement), psychoeducation about ADHD, and group exercises. TAU consisted of usual treatment in the Netherlands, including medications and other psychological treatments. Sixty individuals were randomly assigned to each group. MBCT was taught in subgroups of 8 to 12 individuals. Patients assigned to TAU were not brought together in small groups. Baseline demographic and clinical characteristics were closely matched for both groups.

Outcomes were evaluated at the start, immediately following treatment, and again after 3 and 6 months using well-validated rating scales. Following treatment, the MBCT + TAU group outperformed the TAU group by an average of 3.4points on the Conner's Adult Rating Scale, corresponding to a standardized mean difference of .41. Thirty-one percent of the MBCT + TAU group made significant gains, versus 5% of the TAU group. 27% of MBCT +TAU patients scored a symptom reduction of at least 30 percent, as opposed to only 4% of TAU patients. Three and six-month follow-up effects were stable, with an effect size of .43.

The authors concluded, "that MBCT has significant benefits to adults with ADHD up to 6 months after post-treatment, about both ADHD symptoms and positive outcomes." Yet in their section on limitations, they overlook a potentially important one. There was no active placebo control. Those who were undergoing TAU-only were aware that they were not doing anything different from what they had been doing before the study. Hence, no substantial placebo response would be expected from this group during the intervention period (post-treatment they were offered an opportunity to undergo MBCT). Moreover, MBCT + TAU participants were gathered into small groups, whereas TAU participants were not. We, therefore, have no way of knowing what effect group interaction had on the outcomes because it was not controlled for. So, although these results are intriguing and suggest that further research is worthwhile, the work is not sufficiently rigorous to definitively conclude that MBCT should be prescribed for adults with ADHD.

June 8, 2021

The Role of Serotonin in ADHD and Its Many Comorbidities

Serotonin is a key chemical in the body that helps regulate mood, behavior, and also many physical functions such as sleep and digestion. It has also been linked to how ADHD (attention-deficit/hyperactivity disorder) develops in the brain. This study looks at how serotonin may be involved in both the mental health and physical health conditions that often occur alongside ADHD.

It is well-established that ADHD is more than just trouble focusing or staying still. For many, it brings along a host of other physical and mental health challenges. It is very common for those with ADHD to also have other diagnosed disorders. For example, those with ADHD are often also diagnosed with depression, anxiety, or sleep disorders. When these issues overlap, they are called comorbidities. 

A new comprehensive review, led by Dr. Stephen V. Faraone and colleagues, delves into how serotonin (5-HT), a major brain chemical, may be at the heart of many of these common comorbidities.

Wait! I thought ADHD had to do with Dopamine–Why are we looking at Serotonin?

Serotonin is a neurotransmitter most often linked to mood, but its role in regulating the body has much broader implications. It regulates sleep, digestion, metabolism, hormonal balance, and even immune responses. Although ADHD has long been associated with dopamine and norepinephrine dysregulation, this review suggests that serotonin also plays a central role, especially when it comes to comorbid conditions.

The Study:

  • Objective: To systematically review which conditions commonly co-occur with ADHD and determine whether serotonin dysfunction might be a common thread linking them.

  • Method: The authors combed through existing literature up to March 2024, analyzing evidence for serotonin involvement in each comorbidity associated with ADHD.

  • Scope: 182 psychiatric and somatic conditions were found to frequently occur in people with ADHD.

Key Findings

  • 74% of Comorbidities Linked to Serotonin: Of the 182 comorbidities identified, 135 showed evidence of serotonergic involvement—91 psychiatric and 44 somatic (physical) conditions.

  • Psychiatric Comorbidities: These include anxiety disorders, depression, bipolar disorder, and obsessive-compulsive disorder—all of which have long-standing associations with serotoninergic dysfunction.

  • Somatic Comorbidities: Conditions like irritable bowel syndrome (IBS), migraines, and certain sleep disorders also showed a significant serotonergic link.

This research suggests that serotonin dysregulation could explain the diverse and sometimes puzzling range of symptoms seen in ADHD patients. It supports a more integrative model of ADHD—one that goes beyond the brain’s attention, reward and executive control circuits and considers broader physiological and psychological health.

future research into the role of serotonin could help develop more tailored interventions, especially for patients who don't respond well to stimulant medications. Future studies may focus on serotonin’s role in early ADHD development and how it interacts with environmental and genetic factors.

The Take-Away: 

This study is a strong reminder that ADHD is a complex, multifaceted condition. Differential diagnosis is crucial to properly diagnosing and treating ADHD. Clinicians' understanding of the underlying link between ADHD and its common comorbidities may help future ADHD patients receive the individualized care they need. By shedding light on serotonin’s wide-reaching influence, this study may provide a valuable roadmap for improving how we diagnose and treat those with complex comorbidities in the future. 

July 14, 2025

Undiagnosed ADHD May Be Undermining Diabetes Control in Adults with Type 1 Diabetes

Our recent study, published in the Journal of Clinical Medicine, aims to shed light on an under-recognized challenge faced by many adults with Type 1 diabetes (T1D): attention-deficit/hyperactivity disorder (ADHD) symptoms.

We surveyed over 2,000 adults with T1D using the Adult Self-Report Scale (ASRS) for ADHD and analyzed their medical records. Of those who responded, nearly one-third met the criteria for ADHD symptoms—far higher than the general population average. Notably, only about 15% had a formal diagnosis or were receiving treatment.

The findings are striking: individuals with higher ADHD symptom scores had significantly worse blood sugar control, as indicated by higher HbA1c levels. Those flagged as "ASRS positive" were more than twice as likely to have poor glycemic control (HbA1c ≥ 8.0%). They also reported higher levels of depressive symptoms.

As expected, ADHD symptoms decreased with age but remained more common than in the general public. No strong links were found between ADHD symptoms and other cardiometabolic issues.

This study highlights a previously overlooked yet highly significant factor in diabetes management. ADHD-related difficulties—such as forgetfulness, inattention, or impulsivity—can make managing a complex condition like T1D more difficult. The researchers call for more screening and awareness of ADHD in adults with diabetes, which could lead to better mental health and improved blood sugar outcomes.

Takeaway: If you or a loved one with T1D struggles with focus, organization, or consistent self-care, it may be worth exploring whether ADHD could be part of the picture. Early identification and support are crucial to managing this common comorbidity. 

July 10, 2025

Norwegian Population Study Finds ADHD Associated with Much Higher Odds of Contact with Child Welfare Services

Background:

This nationwide population study by a Norwegian team aimed to evaluate the relationship between ADHD and various types of child welfare services contacts over a long-term period of up to 18 years among children and adolescents aged 5 to 18 years diagnosed with ADHD, in comparison to the general population within the same age group. 

Norway has a single-payer national health insurance system that fully covers virtually the entirety of its population. In combination with a system of national population and health registers, this facilitates nationwide population studies, overcoming the limitations of relying on population sampling. 

Study:

The study population included all 8,051 children and adolescents aged 5 to 18 who were diagnosed with ADHD for the first time in the Norwegian Patient Registry between 2009 and 2011. 

The study also included a comparison sample of 75,184 children and adolescents aged 5–18 with no child welfare services contact during 2009–2011. 

The interventions delivered by child welfare services in Norway are largely divided into two primary categories: supportive intervention and out-of-home placement. 

Supportive interventions include improving parenting skills, promoting child development, providing supervision and control, facilitating cooperation with other services, assessments and treatments by other institutions, and offering housing support. 

Norway uses foster homes or child welfare institutions as a last resort. When supportive interventions fail to meet the child’s needs, the child welfare services can temporarily place the child in these facilities. If parents disagree, the county social welfare board decides based on a municipal request. 

The team adjusted for potential confounders: sex, age, parental socioeconomic status (father’s and mother’s education and income level), and marital status. 

Results:

With these adjustments, children and adolescents diagnosed with ADHD were over six times more likely to have any contact with child welfare services than their general population peers. This was equally true for males and females.  

Children and adolescents diagnosed with ADHD were also over six times more likely to receive supportive interventions from child welfare services. Again, there were no differences between males and females. 

Finally, children and adolescents diagnosed with ADHD were roughly seven times more likely to have an out-of-home placement than their general population peers. For males this rose to eight times more likely. 

Conclusion:

The team concluded, “This population-based study provides robust evidence of a higher rate and strong association between ADHD and contact with CWS [Child Welfare Service] compared to the general population in Norway.” 

July 8, 2025