New Tool Summarizes the Evidence for ADHD Treatment Options

Source: 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.Investigators from multiple institutions conducted a systematic review of meta-analyses assessing the short-, medium-, and long-term effectiveness, tolerability, and acceptance of drug and nondrug treatments for attention deficit/hyperactivity disorder (ADHD) in individuals from multiple age groups, ie, an 'umbrella review.' A standardized process was used to identify metaanalyses that compared a specific treatment to a passive control (eg, placebo) for patients with ADHD. Data extracted from the selected meta-analyses included age group of participants, intervention, outcomes, duration of follow-up, tolerability (participants dropping out because of side effects), and acceptability (participants dropping out for any reason). Outcomes were classified as short-term (up to 12 weeks), medium-term (26 weeks), or long-term (52 weeks). A primary outcome was ratings of severity of ADHD symptoms. Ratings from parents/caregivers, clinicians, teachers, or self-report were analyzed separately. The other primary outcomes were acceptability and tolerability. The results from the included meta-analyses were re-estimated, and effect size metrics of different treatments were harmonized to allow comparison. In addition, a systematic process was used to rate the certainty of the evidence as high, moderate, low, or very low.Results from 115 meta-analyses that evaluated 221 unique combinations of participant group, interventions, comparators, and out-comes were included in the umbrella review. A total of 31 treatments were assessed. In children and adolescents there was moderate or greater certainty that ADHD symptoms improved in the short term with methylphenidate (standardized mean difference across all rating groups SMD, >0.75). A large effect size on ADHD symptoms was noted in the short term with amphetamine (SMD, 1.02), based on clinician ratings, with a lower effect size when rated by parents or teachers (SMD, <0.6). Other medications associated with improvement in the short term included alpha-2 agonists (clinician raters SMD, 0.64), atomoxetine (clinician raters SMD, 0.53), and viloxazine (mixed raters SMD, 0.38). Among non-drug treatments, acupuncture and cognitive behavioral therapy had large effect sizes, but the certainty of the evidence was low or very low. In adults, methylphenidate (SMD 0.34) and atomoxetine (SMD 0.37) were effective in the short term, based on self-report, and with high certainty; cognitive behavioral therapy (SMD, 0.53) was effective in the short term, based on clinician rating, with moderate certainty. There was no intervention in any age group for which there was moderate or high certainty of effectiveness in the medium or long term. In children and adolescents, amphetamines had worse tolerability than placebo, but the tolerability of atomoxetine or methylphenidate was not significantly different from that of placebo. Methylphenidate had higher acceptability than placebo, with no significantly better acceptability for amphetamines or atomoxetine. In adults, both methylphenidate and atomoxetine had worse tolerability than placebo.The authors conclude that there was evidence of short-term efficacy of methylphenidate, amphetamines, atomoxetine, and viloxazine for treatment of ADHD symptoms in children and adolescents.Dr Goyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.ADHD is estimated to affect almost 10% of children in the United States and is among the most common mental health diagnoses managed within pediatric primary care.1,2 Medication management is an important aspect of ADHD care,1 with many factors influencing treatment decisions, including family preferences, treatment goals, child age, co-morbidities, and insurance coverage. To support clinical decision-making in the context of these practical considerations, the AAP has developed a clinical practice guideline and process of care algorithm for the primary care setting, recommending methylphenidate and amphetamine compounds as first-line medications given existing efficacy and safety data, but also emphasizing the role of behavioral and school-based interventions.2The goal of the current study was to develop a continuously updated web platform that synthesizes current evidence for ADHD treatment,3 utilizing the umbrella review, evaluation, analysis, and communication hub (U-REACH) framework.4 The investigators concluded there was moderate to high certainty evidence for the short-term efficacy of alpha-2 agonists, amphetamines, atomoxetine, methylphenidate, and viloxazine in managing pediatric ADHD, with methylphenidate demonstrating efficacy the most consistently. Cognitive behavioral therapy was associated with large effect sizes, but certainty of the evidence was low. Overall, these findings support current AAP recommendations and reflect the breadth of options to navigate in shared decision-making for ADHD management.The U-REACH platform, designed with input from clinicians and people with lived experience of ADHD, is publicly available online.5 Users can filter study results by patient population and/or treatment option. While plain language summaries are provided, the information is limited to results of the pooled analyses and does not address considerations of cost, contraindications, or specific side-effect profiles. Whether patients or clinicians will utilize the platform in real-time clinical decision-making remains to be seen.Pooled analyses supports the short-term efficacy of methylphenidate and other commonly used medications to treat pediatric ADHD.