Attention deficit/hyperactivity disorder (ADHD) is characterized by persistent and impairing inattention, hyperactivity, impulsivity, or a combination of these symptoms. It is estimated to occur in 5% of children, and symptoms persist into adulthood in up to 70% of cases. ADHD frequently co-occurs with mood disorders, anxiety disorders, substance use disorders, and impairments, including emotional dysregulation and executive dysfunction. These challenges cause poor academic performance, compromised social relationships, greater exposure to physical harm and road accidents, and reduced quality of life. The disorder is also associated with a substantial economic burden.
ADHD can be treated with both stimulant and non-stimulant medications: methylphenidate and amphetamines, atomoxetine, bupropion, clonidine, guanfacine, and viloxazine. Non-pharmacological approaches include behavioural therapies, diet, and neurofeedback. Current clinical guidelines generally suggest the use of stimulant drugs, followed by non-stimulants, as a rule in combination with behavioural or cognitive behavioural interventions. Nevertheless, despite the large number of meta-analyses of randomised controlled trials, most of them lack clinical applicability. Many of these focus on narrow outcomes, report conflicting findings, or lack a systematic assessment of the evidence. Dissemination remains limited, and individuals with ADHD have expressed a need for clear, accessible online resources that present reliable evidence, especially on non-pharmacological treatments and strategies for managing comorbid conditions.
To provide comprehensive and accessible evidence, the researchers utilized an umbrella review adopting the U REACH framework. The review was pre-registered and performed in line with the existing methodological principles. Searches of  PubMed, Embase, Emcare, PsycInfo, Web of Science, and Cochrane Library until 19 January 2025 were performed to identify systematic reviews that contained randomised controlled trials that used Diagnostic and Statistical Manual of Mental Disorders III or ICD 9 through 11 to diagnose ADHD. There were no language or age limitations applied. Outcomes were ADHD symptom severity (parent, clinical, teacher, self-report, or mixed rater) and acceptability, tolerability, functioning, comorbid symptoms, quality of life, suicidal ideation or behaviour, reduced appetite, and sleep problems. At about 12 weeks, short-term outcomes were evaluated, and at about 26 or 52 weeks, medium to long-term outcomes were evaluated.
A total of 414 full-text articles were screened, and 115 were eligible articles, 221 unique combinations of participants, interventions, comparators, and outcomes. Each combination was re-estimated using the most recent methodologically robust meta-analysis, which produced 221 new analyses based on 47 reports, with moderate to high certainty.
Alpha-2 agonists, amphetamines, atomoxetine, methylphenidate, and viloxazine induced medium to large-scale short-term changes in ADHD symptoms in children and adolescents. Methylphenidate reported consistent, significant improvements across raters, with the standardised mean difference more than 0.75, and a 95% confidence interval (CI) of 0.56 to 1.03. Such drug treatments were not as easily tolerated as a placebo, but not highly significant with methylphenidate or atomoxetine.
Amphetamines, atomoxetine, cognitive behavioural therapy, and methylphenidate of high-quality trials demonstrated medium effect sizes with moderate certainty among adults. The risk ratios between tolerability to methylphenidate, amphetamines, and atomoxetine were lower than placebo, which ranged from 0.50 (95% CI: 0.36–0.69), 0.40 (95% CI: 0.22–0.72), and 0.45 (95% CI: 0.35–0.58), respectively. The data on some non-drug interventions, such as acupuncture and cognitive behavioural therapy in younger populations and mindfulness in adults, had high effects but lower certainty.
No intervention demonstrated high-certainty long-term efficacy. Overall, this umbrella review provides comprehensive and up-to-date evidence to guide patients, clinicians, and guideline developers in selecting effective strategies for managing ADHD symptoms. The accompanying online platform is intended to support routine use of shared decision-making in clinical practice.
References: Gosling CJ, Garcia-Argibay M, De Prisco M, et al. Benefits and harms of ADHD interventions: umbrella review and platform for shared decision making. BMJ. 2025;391:e085875. doi:10.1136/bmj-2025-085875
