Cookie Preferences
By clicking, you agree to store cookies on your device to enhance navigation, analyze usage, and support marketing. More Info
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
April 9, 2025
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.
-----
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.
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.
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
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.
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.
Stimulant medications, such as methylphenidate (Ritalin) and amphetamines (Adderall), are among the most widely prescribed drugs in the world. In the United States alone, prescription rates have climbed more than 50% over the past decade, driven largely by growing awareness of ADHD in both children and adults. Yet stimulants also have a long history of non-medical use, and concerns about their psychological risks persist among patients, families, and clinicians alike.
Two major studies now offer the clearest picture yet of what that risk actually looks like, and who it may affect.
The Background:
Before turning to the research, it helps to understand the landscape. A notable share of stimulant users misuse their medication: roughly one in four takes it in ways other than prescribed, and about one in eleven meets criteria for Prescription Stimulant Use Disorder (PSUD). Counterintuitively, most people with PSUD aren’t obtaining drugs illicitly — they’re misusing their own prescriptions.
This distinction between therapeutic and non-therapeutic use turns out to be critical when evaluating psychosis risk.
The Study:
A comprehensive meta-analysis by Jangra and colleagues pooled data across more than a dozen studies to compare psychotic outcomes in people using stimulants therapeutically versus non-therapeutically. The contrast was striking.
Among therapeutic users (more than 220,000 individuals taking stimulants at prescribed doses under medical supervision), psychotic episodes occurred in roughly one in five hundred people. When symptoms did appear, they typically emerged after prolonged treatment or in individuals with pre-existing psychiatric vulnerabilities, and they usually resolved when the medication was stopped.
Among non-therapeutic users (over 8,000 participants across twelve studies, many using methamphetamine or high-dose amphetamines), nearly one in three experienced psychotic symptoms. These episodes tended to be more severe, involving persecutory delusions and hallucinations, with faster onset and a greater likelihood of recurrence or persistence.
The biology underlying this difference is well understood. When stimulants are taken orally at guideline-recommended doses, they produce moderate, gradual changes in neurotransmitter activity central to attention and executive functions. The brain tolerates these changes relatively well. Non-therapeutic use, by contrast, often involves much higher doses that are frequently delivered through non-oral routes such as injection or smoking. This produces a rapid, excessive surge in dopamine activity, which is precisely the neurochemical pattern associated with psychotic symptoms.
The takeaway here is not that therapeutic stimulant use is risk-free, but that risk is strongly modulated by dose, route of administration, and individual psychiatric history. Clinicians are advised to monitor patients with pre-existing mood or psychotic disorders, particularly carefully.
A Nationwide Study Focuses on Methylphenidate Specifically:
Where the meta-analysis cast a wide net, a large-scale population study by Healy and colleagues drilled into a specific and clinically pressing question: does methylphenidate (the most commonly prescribed ADHD medication, also known as Ritalin) increase the risk of developing a psychotic disorder?
To find out, the researchers analyzed Finland's national health insurance database, tracking nearly 700,000 individuals diagnosed with ADHD. Finland's single-payer system made this kind of comprehensive, long-term tracking possible in a way that fragmented healthcare systems rarely allow.
Critically, the team adjusted for a range of confounding factors that have clouded previous research, including sex, parental education, parental history of psychosis, and the number of psychiatric visits and diagnoses prior to the ADHD diagnosis itself (a proxy for illness severity). After these adjustments, they found no significant difference in the risk of schizophrenia or non-affective psychosis between patients treated with methylphenidate and those who remained unmedicated. This held true even among patients with four or more years of continuous methylphenidate use.
The Take-Away:
When considered together, these studies offer meaningful reassurance without encouraging complacency.
For patients and families weighing ADHD treatment, the evidence suggests that methylphenidate used as prescribed does not increase psychosis risk, even over years of use. The rare cases of stimulant-associated psychosis in therapeutic settings are typically linked to high doses, pre-existing vulnerabilities, or both, and tend to resolve with discontinuation.
For clinicians, the findings reinforce the importance of baseline psychiatric assessment before initiating stimulant therapy, ongoing monitoring in patients with mood or psychotic disorder histories, and clear patient education about the risks of dose escalation or non-oral use.
The picture that emerges is one of a meaningful distinction between a medication used carefully within its therapeutic window and a drug misused outside of it. This distinction matters enormously when communicating risk to patients, policymakers, and the public.
ADHD is commonly treated with medication, but these treatments frequently cause side effects such as reduced appetite and disrupted sleep. Psychological and behavioral therapies exist as alternatives, but they tend to be expensive, hard to scale, and generally do little to address the motor difficulties that many children with ADHD experience — things like clumsy movement, poor handwriting, or difficulty with coordination.
Physical exercise has attracted attention as a more accessible option. But research findings have been mixed, partly because studies vary so widely in how exercise is delivered and what outcomes they measure. This meta-analysis, drawing on 21 studies involving 850 children and adolescents aged 5–20 with a clinical ADHD diagnosis, tries to cut through that noise.
Two types of motor skills
The researchers separated motor skills into two broad categories:
The Data:
Gross motor skills (16 studies, 613 participants)
Overall, exercise produced medium-to-large improvements in gross motor skills. The strongest gains were in:
No significant gains were found in balance or flexibility.
Fine motor skills (13 studies, 553 participants):
Exercise also produced medium-to-large improvements in fine motor skills, specifically:
The Results: What Kind of Exercise Works Best?
Two factors stood out consistently across both gross and fine motor skills: session length and frequency.
The type of exercise mattered; structured programs with clear motor-skill components (rather than unstructured physical activity) yielded stronger results.
These results are not without caveats, however. The authors urge caution in interpreting these findings. A few key limitations include:
The Bottom Line
This meta-analysis provides tentative moderate evidence that structured physical exercise can meaningfully support motor skill development in children and adolescents with ADHD — particularly when sessions run longer than 45 minutes and occur at least three times a week. The benefits appear most robust for object control, locomotion, handwriting, and manual dexterity.
That said, the evidence base still has real gaps. The authors call for better-designed, fully randomized controlled trials with consistent methods, standardized ways of measuring exercise intensity, and greater inclusion of children and adolescents who are not on medication — all of which would help clarify when, how, and for whom exercise works best.
Treatment guidelines for childhood ADHD recommend medications as the first-line treatment for most youth with ADHD. Still, concerns about side effects and long-term outcomes have increased interest in non-pharmacological approaches. Researchers at Saudi Arabian Armed Forces hospitals recently conducted a network meta-analysis comparing several interventions, including mindfulness-based therapy, cognitive behavioral therapy, behavioral parent training, neurofeedback, yoga, virtual reality programs, and digital working memory training.
Although the authors aimed to “provide a rigorous methodological approach to combine evidence from multiple treatment comparisons,” the study illustrates several pitfalls that arise when network meta-analysis is applied to a thin and heterogeneous evidence base.
What Network Meta-analysis Can and Cannot Do:
Network meta-analysis extends conventional meta-analysis by combining:
When the evidence network is large and well-connected, this approach can provide useful estimates of comparative effectiveness among many treatments.
This method is not always best, however, as many networks are sparse. This is especially true in areas such as complementary or behavioral therapies. In sparse networks, estimates rely heavily on indirect comparisons, and single studies can exert disproportionate influence over the results.
Conventional meta-analysis focuses on heterogeneity, meaning differences in results across studies within the same comparison.
Network meta-analysis must additionally evaluate consistency, whether the direct and indirect evidence agree.
However, when comparisons are supported by only one or two studies and the network is weakly connected, statistical tests for heterogeneity and consistency have very little power. In practice, this means the analysis often cannot detect problems even if they are present.
Sparse networks also make publication bias difficult to evaluate. This concern is particularly relevant in fields dominated by small trials and emerging therapies.
Why Such Treatment Rankings Are Appealing, but Potentially Problematic:
Many network meta-analyses summarize results using SUCRA, which estimates the probability that each treatment ranks best.
SUCRA, or Surface Under the Cumulative Ranking, is a key statistical metric in network meta-analyses. It is used to rank treatments by efficacy or safety. This is achieved by summarizing the probabilities of a treatment's rank into a single percentage, where a higher SUCRA value indicates a superior treatment. Ultimately, SUCRA helps pinpoint the most effective intervention among the ones compared.
Again, in well-supported networks, SUCRA can provide a useful summary of comparative effectiveness. But in sparse networks, rankings can create an illusion of precision, because treatments supported by a single small study may appear highly ranked simply due to random variation.
What Did this New Network Meta-analysis Study?
The study includes 16 trials with a total of 806 participants. But the structure of the evidence network is far weaker than this headline number suggests.
Based on the underlying studies:
This produces a very thin network, in which several interventions rely entirely on single studies.
Another challenge is that the included trials measure different outcomes. Some evaluate ADHD symptom severity, while others measure parental stress.
When studies use different outcome scales, meta-analysis typically relies on standardized measures such as the standardized mean difference to allow comparisons across studies. However, the analysis reports only mean-average differences, making it difficult to interpret the relative effect sizes.
Study Issues (including Limited Evidence and Risk of Bias):
The intervention supported by the largest number of studies (family mindfulness-based therapy) was one of the two approaches reported as producing statistically significant results. The other was BrainFit, which is supported by only a single previous trial.
Despite this limited evidence base, the study ranks interventions using SUCRA:
Notably, none of the runner-up interventions demonstrated statistically significant efficacy.
The authors acknowledge methodological limitations in the included studies:
“Blinding of participants and personnel (performance bias) exhibited notable concerns, as blinding for active treatment was not applicable in most studies.”
Such limitations are common in behavioral intervention trials, but they further increase uncertainty in already small evidence networks.
Conclusions:
The study ultimately concludes:
“This network meta-analysis supports MBT and BPT as effective non-pharmacological treatments for ADHD.”
However, the evidence underlying these claims is limited. Some analyses rely on very small numbers of studies and participants, and the network structure depends heavily on indirect comparisons.
Network meta-analysis can be a powerful tool when applied to a large, consistent, and well-connected body of evidence. When the evidence base is sparse, however, the resulting rankings and comparisons may appear statistically sophisticated while resting on a fragile evidentiary foundation.
_logo%201.svg)
