Autonomously self-navigating clinical assistance systems (ASCAS) seem highly promising for improving clinical workflows. There is great potential for easing staff workload and improving overall efficiency by reducing monotonous and physically demanding tasks. However, a seamless integration of such systems into complex human-supervised clinical workflows is challenging. As of yet, guiding principles and specific approaches for solving this problem are lacking.We propose to treat ASCAS orchestration as a scheduling problem. However, underlying objectives and constraints for this scheduling problem differ considerably from those found in other domains . We analyze the clinical environment to deduce unique needs and conclude that existing scheduling approaches are not sufficient to overcome these challenges.human precedence, command structure, emergency context and immediacy, that govern the integration of self-navigating assistance systems into clinical workflows. Based on these results, we propose our approach, namely Auto-Navigation Task Scheduling for Operating Rooms (ANTS-OR), for solving the ASCAS orchestration problem in a surgical application scenario, employing a score-based scheduling strategy.We present four guiding principles, namely The proposed approach is a first step toward addressing the ASCAS orchestration problem for the OR wing. We are currently advancing and validating our concept using a simulation environment and aim at realizing a dynamic end-to-end ASCAS orchestration platform in the future. Mobile self-navigating robotic technology has successfully been applied to various domains, including logistics , housekeGARMI , Twendy-One [Care-O-bot [Moxi  and RIBA [autonomously self-navigating clinical assistance systems (ASCAS) will play a crucial role in making clinical workflows more efficient, safe and ergonomic. Possible applications are manifold and include simple fetching of materials, assisting in repositioning of patients, device control, documentation tasks, inventory management and more. In particular, we envision ASCAS as a central component of the fully assisted OR environment of the future. Within such an environment, robotic team members collaborate closely and continuously with their human counterparts to guarantee patient safety and improve patient outcome, while making surgical processes more robust and efficient. Prospectively, this might lead to a partial or even complete merging of robotic and human spheres of influence within the clinic. This is in stark contrast to most industrial and domestic scenarios where robotic machines are usually operating in highly optimized but delimited environments, commonly called envelopes, to complete subtasks of the production workflow in an unhampered manner.First concepts for domestic care—e.g., endy-One  and Carere-O-bot —as well and RIBA —have beeConsequently, fundamental challenges must be addressed before a broad integration of ASCAS to the clinic can become a reality. We need to find means to seamlessly integrate these systems into complex clinical workflows. Guiding principles for achieving this in a safe, ethical and economic way that leaves clinicians in control of the workflow while maximizing productivity are needed.Auto-Navigation Task Scheduling for Operating Rooms (ANTS-OR) for ASCAS orchestration across multiple operating rooms.In this short communication, we aim at providing such principles, to govern human–machine collaboration in the clinic and leverage the full potential of ASCAS regarding workflow optimization. As a further key contribution, we apply our principles to a surgical application scenario and utilize them to derive an explicit scheduling strategy named n ASCAS deployed within a clinical unit . Each ASCAS offers a set of tasks that it can perform . Multiple ASCAS may offer the same type of task. The execution of a task takes a certain—in general unknown—amount of time and may require a change of location beforehand. Tasks may be assigned or canceled at any time by members of the clinical staff or by clinical information systems. The execution of a task may depend on the completion of another task, and thus underlie precedence relations, or depend on other preconditions. The overall goal is an optimal exploitation of the available ASCAS resources regarding one or more objectives .The ASCAS orchestration problem may be described as follows: There are scheduling problems that are common in many different domains including logistics, operational research, manufacturing and computer multitasking. Many variants of these problems have been described to address unique constraints or objectives associated with different contexts [dynamic nature, since new tasks may be assigned at any time. Special consideration must also be given to objectives and constraints of the scheduling. As in the manufacturing or logistics domain, time- and cost-related objectives must be considered, though other factors, such as patient welfare, patient outcome and staff ergonomics, are of higher relevance. Tasks in the ASCAS orchestration problem are also subject to certain constraints, introduced by clinical command structures, emergency situations and precedence relations between tasks. Due to these unique and partly indistinct objectives and constraints, developing solutions to ASCAS orchestration based on known optimal or suboptimal scheduling algorithms is not straightforward.Clearly, this is closely related to contexts . The ASCLaws of Robotics, we propose a set of fundamental principles that must be considered by any approach dealing with ASCAS orchestration. These principles aim at reflecting the unique requirements associated with clinical environments and describe the governing rules of human–machine collaboration in a simple and solution-independent manner. Based on these results, we propose our ANTS-OR approach for solving the ASCAS orchestration problem in a surgical application scenario, employing a score-based scheduling strategy.Inspired by Isaac Asimov’s famous P1) Human Precedence: The clinical staff must remain in control of the workflow (P1a) and be aware of all autonomously performed actions and their consequences (P1b). In modern clinics, processes are not only controlled by human beings but also by clinical information systems. In the future, these systems might be capable of (semi-)autonomously assigning tasks to ASCAS resources: For example, a bed transportation robot might be dispatched to transfer the next patient from ward to operating room, as soon as the end of the previous surgery has been registered in the clinical information system. With the advent of AI-driven workflow recognition technology, the influence of autonomous decision systems might increase even more: imagine a workflow recognition engine—e.g., tracking the progress of a surgical intervention—assigning ASCAS tasks on the fly to offer automated context-dependent support for the surgical team. While these new technologies seem promising for improving clinical efficiency, it is vital to ensure that human staff remains in control of the process at any time.(P2) Command Structure: Decisions made by senior team members supersede decisions made by subordinates. Clinical workflows and decision-making processes are grounded on clear hierarchies that allow for efficient collaboration, especially in frequently occurring critical and time-sensitive situations. These command structures must be conserved when dealing with ASCAS orchestration, e.g., by attaching a higher priority to tasks assigned by senior staff members than to tasks assigned by subordinates.(P3) Emergency Context: Measures dealing with emergency situations must be executed with maximum priority. Time-sensitive situations, e.g., when dealing with emergencies or adverse events, are occurring frequently in clinical units. These situations demand immediate measures to avoid or minimize severe consequences for the patient. Thus, tasks that are assigned in an emergency context or are inherently emergency related must be executed with minimal delay. Other upcoming tasks that are not emergency related must stand back until the critical situation has been resolved.(P4) Immediacy: Timespan between task assignment and start of execution must be minimized. Even in a non-emergency context, immediate execution of newly assigned tasks is desired in clinical workflows. In contrast to, e.g., the manufacturing domain, tasks are normally not associated with a precise due date or deadline but are supposed to be processed as soon as possible after being released (assigned). One can define the current idle time for each released task as difference between the current time and the task’s release time. We propose that a task should gain priority in ASCAS scheduling with increasing idle time.. Tasks may be assigned or canceled by the surgical staff or by the workflow assistance engine at any time.We make the following simplifying assumptions: Firstly, tasks are non-preemptive. Secondly, there are no precedence relations or other preconditions. Thus, assigning a task implies that it is execution ready. Thirdly, traveling durations are known for all relevant ASCAS routes.ANTS-OR score,Command level Fig. ,Fig. 2CoEmergency level Fig. ,Fig. 3EmIdle time function,Task release time,Balancing weights.Figure command and emergency levels depicted in Figs. To address ASCAS orchestration principles P2) and P3), we introduced the  and (P3), we intrAs shown in Fig. Since (P4) requires idle times to be as short as possible, we incorporated the time-dependent function The factors After scoring, tasks in the global list are sorted by score. Starting from the top of the global list, the scheduler now tries to match tasks from the global list with ASCAS systems based on individual capabilities and current occupation. In case that more than one ASCAS is available and capable of executing the task, the candidate with the shortest traveling duration to task location is chosen in order to improve overall throughput.T1 with the goal of modifying the position of the OR table to prepare for wound closure. In OR 2, the surgical team is currently facing a severe bleeding during a partial hepatectomy. An ASCAS task T2 is assigned by the attending surgeon with the goal of fetching new blood bags. OR 3 is currently being prepared for an upcoming surgery by the nursing team. The ASCAS is ordered to reset the surgical devices (task T3). In OR 4, a port implantation is being performed by a surgical resident under the supervision of an attending surgeon. The resident orders the ASCAS to fetch suture material (task T4).The following example illustrates the concept described above for a simple scenario: Let’s suppose four operating rooms are being in use within an OR wing. The human staff members are supported by a single multifunctional ASCAS that is able to fetch supplies as well as operate medical devices. In OR 1, a laparoscopic cholecystectomy  is conducted, while the surgical workflow is tracked and assisted by an AI algorithm. Just now, this algorithm has assigned a new task Provided that all tasks have been assigned at the same time, Table T2, which is reasonable, since it is originating from a high-ranking team member and dealing with an emergency situation. Other tasks have to stand back until the execution of T2 is finished.Thus, the highest score value is obtained for task The proposed scheduling approach ANTS-OR is a first step toward addressing the ASCAS orchestration problem for the OR wing. We are currently evaluating our concept using a simulation environment, where we benchmark different assisted and non-assisted scenarios to fine-tune and validate the algorithm. Besides improving our score-based approach, we aim at exploring and adapting known optimal and suboptimal scheduling algorithms to realize a dynamic end-to-end ASCAS orchestration platform in the future.


AimExecutive function (EF) is considered a core attention deficit hyperactivity disorder (cADHD) symptom in adults and, more recently, sluggish cognitive tempo (SCT). Despite considerable controversy around the role of SCT symptoms in the diagnosis of attention deficit hyperactivity disorder (ADHD), some scholars have suggested that SCT symptoms are a subset of the ADHD syndrome, whereas others have suggested that SCT is an entirely unique type of attention disorder. Therefore, we looked to characterize the impact of treatment as usual (TAU) with medication and psychoeducation on the functional impairments related to EF and SCT, and related functional impairments in adults with ADHD. We aim to clarify if the combination of TAU and modular ADHD therapy (TAUTx) further improves these symptoms. The goal is to assess the validity of self-reporting assessment of symptoms adopted in the present for the monitoring of treatment in this population. MethodsWe implemented the inclusion and exclusion criteria at the onset of the clinic. This prospective cohort case series study is designed to see the difference with self-reporting scales for EF, SCT, and cADHD symptoms in TAU and TAUTx. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist was used to provide transparency in reporting the data.ResultsAdults with ADHD showed a significant improvement with TAU in EF (p=0.001), cADHD (p=0.007), and SCT (p=0.002). Furthermore, TAUTx improved areas of EF (p=0.001), cADHD (p=0.004), and SCT (p=0.002). We saw a significant benefit from starting/optimizing medications in the treatment of ADHD along with psychoeducation. Self-reporting scales appeared to be reliable for monitoring the symptoms of ADHD and related dysfunction and were consistent with the Clinical Global Impressions Scale.ConclusionsAdult ADHD patients reported significant benefit from TAU for aspects of impairment in EF and SCT. They require ongoing medication prescribing and “tailoring” through optimization. Psychoeducation is an effective form of therapy in these patients with or without the addition of adult ADHD modular therapy. Self-reporting is valid for monitoring and providing transparency in patient care. Background/rationaleThe prevalence of adult attention deficit hyperactivity disorder (ADHD) can be 2.9-16.4% . ADHD caStandardized screening can assess the functional aspects of ADHD and their comorbidities. These screening tools can monitor and assess the baseline of parameters that can contribute to the impairment in ADHD. Though the functional aspects include EF and ADHD scores, one of the known confounders in the diagnoses of ADHD in children is sluggish cognitive tempo (SCT) , which rWhile some scholars have suggested that SCT symptoms are a subset of the ADHD syndrome -8, otherIt is not uncommon to find monitoring of the treatment of children and adolescents with ADHD in academic and community settings. However, it is rare in the treatment of adults with ADHD. Studies with long-term treatment outcomes in adults with ADHD have shown limited conclusions but are in favor of treatment rather than non-treatment -12. The MethodsOn entry to the clinic, all participants underwent a self-reported narrative psychiatric assessment and a structured or semi-structured standardized interview for ADHD: DIVA (Diagnostic Interview for ADHD in adults) 2.0  and ACE Validity and cost-effective were part of the decision-making in choosing self-reporting forms for adults with ADHD. Forms used for the functional impairments of EF, core ADHD (cADHD), and sluggish cognitive were Barkley Deficits in Executive Function-Scale (BDEFS-LA)  and BarkThe study design compared the groups using self-rating scales of different functional impairments seen in ADHD. The BDEFS-LA subscales were as follows: self-management to time, self-organization/problem solving, self-motivation, self-regulation of emotions, total EF, and ADHD-EF index. The last index subscale shows the likelihood that the respondent has ADHD. The BAARS-IV subscales were as follows: inattention, hyperactivity, impulsivity, total scores, symptom scores, and SCT. Manuals published by both BDEFS and BAARS had data for the Reliable Change Index (RCI), which was referenced for these participants.. The Adult ADHD Self-Report scale version 1.1 was used to monitor weekly progress during the therapy.Recruitment of subjects was stopped in October 2019. The two groups were as follows: group I/TAUTx with 14 subjects who received the treatment arm of medication, psychoeducation (PE), and adult ADHD therapy (Tx), and group II/TAU with 18 subjects who received medication initiation/optimization and PE. Self-reports at baseline entry into the clinic, at medication optimization with PE, and at the end of Tx were collected. Data were collected of the known variables in ADHD, such as substance use, sleep disorders, medical and psychiatric contributors, and the age of onset, to provide further explanations of the results.Inclusion and exclusion criteriaThe inclusion criteria were a diagnosis of ADHD and 18 years of age or above. The exclusion criteria were active mood disorder, suicide ideation, and schizophrenia spectrum. Substance use disorder was part of the exclusion criteria for all therapy cases, but its minimal use with efforts to decrease/abstain was included in the medication and PE group.Statistical methodsAll data analysis was performed using IBM SPSS software, Version 25 . The Wilcoxon signed-rank test  was usedSettingParticipants aged 18-70 years who were referred to and comprehensively evaluated at a specialty service for ADHD at a tertiary referral medical center in an urban setting were included. The referrals to the clinic came from community primary care clinics through a standard intake process prior to assignment to the specialty clinics at the tertiary center from September 2018 to February 2020. The clinic saw 113 patients during that period. All patients were asked to fill out the self-report forms. There was a waitlist created for the patients interested in engaging in therapy and the first-come base criterion was used. The recruitment was ongoing and discontinued in October 2019. This was a consultation and treatment model clinic and all subjects were regularly followed up. The clinic was discontinued in February of 2020 with a three-month notice and a referral to community caregivers to all participants. The primary author collected data at entry to the clinic, three to six months after the first entry into the clinic, and at the end of therapy. IRB approval for a chart review was obtained.Figure Demographics of participantsTable Table Normalization and reliable change index as published for these forms (BDEFS-LA/BAARS-IV) showed a normalization of symptoms for most of the subjects in areas of EF, cADHD, and SCT. Of the group that had reliability scores consistent with published data (N=14), 100% of them had a difference of more than 54 points in EF and 71% had had a difference of more than 2 points in SCT. In the group that had unreliability scores consistent with published data (N=10), the difference in scores was less than 32 points in EF and less than 2 in the SCT group. Of the subjects that showed the unreliable scores, 80% of them were on three different medications.The Clinical Global Impressions Scale (CGI) pre- and post-score differences are shown in Figure Sleep disorders were common (69%) in this cohort. Out of those, the sleep disorders were obstructive sleep apnea (14%), initial insomnia (52%), initial and middle insomnia (17%), and narcolepsy (3%). Substance abuse disorders in the past of 48% remitted to 3% with treatment. Of those who used substances, marihuana/cannabinoids versus alcohol was their drug of choice by 58% and 42%, respectively.The results were consistent for both genders in the group that underwent ADHD therapy. The subjective reporting of improvement from the therapy was greater in males than females. Among the females, 14.2% reported minimal benefit in follow-up notes but reported functional improvement that was statistically significant in the self-report. All of them reported subjectively, with minimal to no positive effect from the module (distractibility delay), with 86.7% reporting subjective improvement with the addition of adult ADHD therapy.Figures To the best of our knowledge, this is the first time a study has shown that self-reporting of SCT and EF is associated with each other and improves with medication and psychoeducation. Medication initiation/optimization with psychoeducation with or without modular ADHD therapy improves the symptoms and the functional aspect of all the symptoms of subjects recruited for EF and SCT. The results of the response to treatment of EF and SCT in a clinically referred sample of adults with ADHD supported an association between core symptoms, EF and SCT, and treatment .Self-report rating scales, as reported previously, are reliable and valid assessments in the treatment response and monitoring of patients . ModularThe difference in treatment response is remarkable when we looked at medication in combination, such as bupropion versus atomoxetine in TAU versus TAUTx group . Studies on bupropion have inconsistent results, but the studies have been small , and theObservational psychiatric studies can be meaningful if there is a discussion of bias to provide transparency. Awareness and attempts to eliminate it are more meaningful in presenting data . This stInter-rater reliability was 90-100%, and collateral information when available was obtained. This prevented confounders in diagnosis. Choosing evidence-based modular therapy facilitated the decrease in subjective and the variables in the relationship between the therapist and unconscious bias. However, this bias is helpful in translating it to real life practice. It was a conscious effort to include equal amounts of males and females but did not include the transgender population, as they did not take part in the therapy. Understanding why this population did not take part may help us understand if cross-cultural bias was present. The subjects had a college education and employment at the time of the study. This does not represent the people who did not complete their education or the unemployed. Substance use was an exclusion criterion for therapy, which may not generalize to the population.Adult ADHD is commonly treated in the community by an adult psychiatrist or a family physician, but in this study an experienced child and adolescent psychiatrist treated them. Medications are not tolerated by all individuals , and theIn conclusion, medication initiation and optimization help EF, SCT, and cADHD symptoms that impair adults with ADHD. Given our initial specific aims, the most noteworthy finding to emerge from this study is the significant relationship between the response to the treatment of the SCT and EF. The nature of the responses to the treatment is consistent with the hypothesis that there is a close correlation between these different dimensions. These findings can help the physician be less hesitant to prescribe or continue medications. It may help set standards for treatment recommendations for psychoeducation and medication monitoring and may improve the distractibility delay module of therapy.


No differences emerged in internalizing problems (p > 0.05) across groups. CBCL is a useful measure to study the psychopathological conditions as well as emotional and behavioral profiles associated with ASD, ADHD, and the co-occurrence of ADHD and ASD. The identification of psychopathological and behavioral profiles associated with ASD and ADHD is crucial to perform specific and individualized treatments. Our preliminary findings suggested the existence of an intermediate and independent phenotype between ADHD and ASD that seems to be defined by the externalizing problems. Internalizing problems do not significantly differ between the combined phenotype and the two groups.Comorbidity between attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) is a frequently reported condition. However, the clinical overlaps between the two disorders are not well characterized. The Child Behavior Checklist (CBCL) is a well-documented measure of emotional and behavioral problems in children and adolescents. The aim of the present study was to evaluate whether CBCL scales were able to detect psychopathological comorbidities as well as emotional and behavioral profiles across three groups of children with ASD, ADHD, and with the co-occurrence of both disorders. The results show that around 30% of participants with ASD exhibited internalizing problems, which was in line with previous findings. Co-occurrence condition showed a clinical intermediate phenotype: relative to ADHD and ASD, youths with co-occurrence of ADHD and ASD phenotype showed respectively lower ( Attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are common neurodevelopmental disorders  that freAttention deficit/hyperactivity disorder is a prevalent and persistent psychiatric disorder that emerges in childhood as a complex of symptoms characterized by developmentally inappropriate and impairing levels of hyperactivity, impulsivity, and/or inattention . PolanczAutism spectrum disorder is characterized by persistent deficits in social communication and social interaction across multiple contexts as well as restricted, repetitive patterns of behavior, interests, or activities . The lasBoth conditions are characterized by a high rate of psychiatric comorbidities. These affect around 80% of youth with ADHD , and appDespite significant overlap in symptoms, the previous diagnostic criteria  which may explain what symptom associated with ASD and ADHD is the most disabling. In the next studies, reports from teachers and interviews led by clinicians will be included to integrate parent’s reports and as a measure of the adaptive behaviors.In summary, results suggested that CBCL has been confirmed to be a very accurate instrument to detect the psychopathological, symptoms, and emotional and behavioral profile of the associated comorbidities in children and adolescents with ASD, ADHD, and the co-occurrence condition.Our preliminary findings suggested the existence of an intermediate and independent phenotype between ADHD and ASD that seems to be defined through the externalizing symptom dimensions.Further studies are needed to analyze the overlap of symptoms in the three groups with dimensional analyses and in order to reinforce the current results.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by The Ethics Committee of the IRCCS Bambino Gesù Children’s Hospital of Rome. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.AC participated the design, coordination of the study and interpretation of the data, performed the measurement, drafted, and revised the manuscript. EF conceived the study, participated in its design and interpretation of the data, performed the statistical analysis, and helped to draft and revise the manuscript. SG, EN, and GV participated in the design of the study, performed the measurement, and helped to draft and revise the manuscript. SV participated in the design of the study and coordination, interpretation of the data, and helped to draft the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Research on the predominantly inattentive attention-deficit/hyperactivity disorder (ADHD-PI) subtype/presentation is important given its high prevalence, but paradoxically it is under-recognized and undertreated. The temporal stability of the inattention symptom could impact the high worldwide prevalence of ADHD-PI. Some evidence suggests differences in the nature of attentional deficit in ADHD-PI vs. that in other subtypes. Impairments in neuropsychological, neurocognitive, and social functioning are also evident in ADHD-PI, which could be specific to the subtype , or differ from others in severity. Neuroimaging studies have also revealed ADHD-PI-specific neuropathological abnormalities and those that are shared with other subtypes. ADHD-PI is highly comorbid with learning and internalizing  disorders. There is no solid evidence for ADHD-PI-specific genetic etiologies and differential responses of subtypes to ADHD medications. Translational studies have used the Wistar Kyoto/NCrl substrain which requires further characterizations as an ADHD-PI model. Overall, ADHD-PI research has been conducted in the context of the Diagnostic and Statistical Manual, which arguably does not conform to the widely recognized “dimensional” view of ADHD. The Research Domain Criteria has been proposed to provide a novel framework for understanding the nature of neuropsychiatric illnesses and ultimately improve their diagnosis and treatment. Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent, childhood-onset neurodevelopmental disorder which is characterized by developmentally extreme and impairing symptoms that include inattention, motor hyperactivity, and impulsivity, with difficulties that often continuing into adulthood ,2. The iThe terminology and diagnostic criteria for ADHD, similar to other neuropsychiatric disorders, have been improved and developed over the past 50 years, in response to the evolving understanding and conceptualization of the core deficits of the disorder ,5. The cSince its first appearance in the DSM, there have been controversies surrounding the ADHD-PI subtype of ADHD ,6. For iThe DSM-5 criteria for ADHD also reflect a change in the ADHD subtype nosology  in view of the observed instability of ADHD symptoms over time within individuals across their lifespan ,13. For Regardless of the current view, the neurobiological underpinnings of the ADHD subtypes/presentations have still been actively explored. Furthermore, a long-standing debate has been whether the subtypes are categorically different disorders that necessitate distinct nomenclature, distinct clinical entities, or conceptually meaningful extremes of the ADHD continuum ,16,17. AWe reviewed over 100 articles which explored the behavioral and neurocognitive impairments, comorbid features, neurobiology, genetics, and pharmacotherapy of ADHD-PI. The following two strategies were used to identify the articles: systematic search from the two electronic databases (EMBASE and PubMed) and hand search of the reference lists of the included studies. The key terms used for the literature search are listed in During the first stage, any duplicates were discarded, and titles and abstracts were subsequently assessed for their relevance as per the inclusion and exclusion criteria. Papers were rejected outright if (1) they were not published in the English language; (2) were reviews, commentaries, case reports, and editorials; and (3) discussed themes unrelated to or beyond the scope of this study. Two reviewers (M.P. and C.G.T.) separately screened the titles and abstracts for inclusion or exclusion. When consensus on the eligibility of an article could not be achieved, a third reviewer (ID) was involved in the discussion. Full documents were obtained for the remaining records and checked against the eligibility criteria. Papers were rejected at this stage if ADHD-PI was not determined using the DSM or ICD-10, or if ADHD-PI was diagnosed using earlier versions of the DSM (DSM-II or DSM-III). Those which did not report quantitative data were also not included. The papers that met the eligibility requirements were included and discussed in this review. Three authors  independently extracted the information from the included studies. The data extracted from the articles, e.g., author, year of publication, study design and setting, clinical tool used, main findings, etc. were listed in a custom data extraction form that conformed with PRISMA guidelines .A comprehensive meta-analysis of 86 ADHD studies in children and adolescents and 11 studies in adults throughout the world reported that the ADHD-PI, as defined by the DSM-IV, was the most prevalent subtype in community samples . AccordiThe symptoms of the ADHD-PI include failing to give close attention to details, difficulty sustaining attention in tasks, not following through on instructions and failure to finish chores or duties in the workplace, difficulty in listening to instructions and organizing tasks, avoiding tasks that require sustained effort, losing things, being easily distracted, and forgetfulness in daily activities . While bThe inattentive behavior and attention problems are complex and postulated to be related to abnormalities in neurocognitive functions ,34. AtteAbnormalities in executive functions can occur in various neurocognitive functions such as focusing and sustaining attention . While tNeuropsychological processes such as working memory and processing speed are also relevant to the presentation of ADHD symptoms . WorkingDespite the fact that many studies reported neuropsychological and neurophysiological differences between ADHD-PI and ADHD-C, it is worth noting that a previous meta-analysis of empirical data revealed findings that did not support neuropsychological distinctions between the two subtypes . It was With regard to social functioning, individuals with ADHD-PI often struggle socially and have problems with social perception. A previous study that compared the social functioning of patients with ADHD-PI and those with ADHD-C found impaired assertiveness in ADHD-PI youths, whereas those with ADHD-C showed deficits in self-control . DiffereIn summary, the accumulating evidence suggests a difference in the nature of attentional deficit in ADHD-PI as compared with other subtypes. Neuropsychological, neurocognitive, and social functioning are also evident in ADHD-PI, which could be specific to the subtype , or differ from others only in severity . In general, the small sample sizes of the above-described studies prevent the generalizability of the findings to the clinical setting. To fully establish ADHD-PI-specific behavioral, neuropsychological, and social functioning impairments, future work should include other ADHD subtypes/presentations  in the assessments. However, recruiting ADHD-HI patients in ADHD studies is a challenge given that they are less frequent in samples as compared with other ADHD subtypes/presentations .The comorbidity of ADHD with other childhood-onset neurodevelopmental disorders and psychiatric disorders is substantial . While eRegarding substance use, stronger relationships between hyperactive/impulsive symptoms with substance use and abuse/dependence were observed in a number of studies . This isMoreover, individuals with ADHD-PI were more likely to have comorbid learning disabilities and long-term academic impairments. In some instances, these learning problems were worse in ADHD-PI as compared with other ADHD subtypes ,82,83. AOther comorbidities reported in the literature include disruptions in sleeping patterns such as sleep impairment, sleepiness, and poor sleep functioning ,90,91,92Taken together, ADHD-PI is highly comorbid with learning and internalizing  disorders. Further longitudinal and cohort studies to explore the development of these comorbidities across age groups could provide important clinical information about the converging etiologies, as well as in designing potential interventions. It is noteworthy, however, that the overlap between ADHD-PI and anxiety disorders could be a contributing factor to the misdiagnosis or overdiagnosis of ADHD-PI ,95. TherThe advent of neuroimaging studies paved the way for a deeper understanding of the neurobiological bases of ADHD. Moreover, neuroimaging has also been used to explore neuropathological similarities or distinctions between ADHD subtypes/presentations ,100. TheFunctional neuroimaging studies, which allow noninvasive measurements of brain functions, have provided further insights into the neurobiology of ADHD-PI and other subtypes/presentations . The groIn an fMRI auditory oddball attention task, which measures attentional orienting and updating of contextual information in working memory , ADHD-PIDysfunctions in reward and motivation and susceptibility to drug addiction also characterize ADHD ,122,123.Recently, functional and structural connectivity analyses have been employed to understand brain connectivity features of the different ADHD subtypes/presentations. The findings from these studies seemed to suggest distinctive neural networks that were altered in the ADHD presentations ,127. ClaThe adoption of diffusion tensor imaging (DTI) in ADHD studies also provided important information with regard to the structural and white matter connectivity defects in the ADHD subtypes ,133,134.A structural connectome study of ADHD-PI and ADHD-C subtypes revealed network organization differences in the context of preserved volume . SignifiIn summary, neuroimaging studies have provided indispensable information to improve our understanding of the neurobiological substrates of ADHD-PI and other ADHD subtypes/presentations. Inadequate sample sizes, methodological heterogeneity, and poor reproducibility remain the big challenges in neuroimaging studies, in general, which could be addressed by collaborative multicenter research . MoreoveSimilar to other psychiatric disorders, the pathophysiology of ADHD likely involves the interplay between genetic and environmental risk factors . The genSLC6A3/DAT1), dopamine receptors , and ADHD [DAT1 gene, in particular, a haplotype rs27048 (C)/rs429699 (T) to be significantly associated with the inattentive subtype and severity [DRD4 polymorphism association with inattention than hyperactive-impulsive symptoms of ADHD [DRD4 [DRD5 has been associated with both ADHD-PI and ADHD-C subtypes [Association studies have been conducted to identify ADHD susceptibility genes including those that are associated with ADHD subtypes. In particular, subtype-specific genetic analyses have been performed with the primary goal of reducing inter-study heterogeneity and, ultimately, finding ADHD candidate genes . Compelland ADHD . A familseverity . No alle of ADHD ,155. MorHD [DRD4 . In contsubtypes .MspI polymorphism at the adrenergic α2A receptor (ADRA2A) gene and the inattention symptom have been reported in a cohort of Brazilian youths with ADHD [ADRA2A-1291 C > G polymorphism [ADRA2A-1291 C > G polymorphism in a nonreferred sample of children with ADHD-PI [ADRA2A and ADHD-PI, and improvement of inattention symptoms ascribed to methylphenidate treatment.The noradrenergic system, which underscores behavioral activation, alertness, and attention, is another widely explored neurotransmitter system in ADHD pathology. Associations between the ith ADHD ,158. Mormorphism . Follow- ADHD-PI . Aside f ADHD-PI  that preCOMT), monoamine oxidase (MAO), dopa decarboxylase (DDC)) of these neurotransmitters were also explored for their involvement in ADHD-PI. On the one hand, molecular genetic studies, in a Chinese Han population, showed that genes encoding serotonergic receptor 5-HT1B and cholinergic receptor CHRNA4 were predominantly associated with ADHD-PI, as well as COMT, MAO-A, and DDC [5-HTR2C and 5-HT1D, noradrenergic receptor ADRA2C, dopaminergic receptor-associated gene DRD3, and norepinephrine transporter gene NET1 were primarily linked with ADHD-C [Aside from dopamine and norepinephrine, other neurotransmitter systems have also been implicated in ADHD, for instance, serotonergic and cholinergic systems. Genes associated with receptors and transport, as well as synthesis and metabolism , was linked with ADHD in European populations [BAIAP2 was also reported with childhood ADHD in Chinese Han descent, especially for the ADHD-PI [It is important to note that not only neurotransmitter systems are affected in ADHD, but also those that regulate other neural processes and functions . Recentlulations . Moreove ADHD-PI .The above-mentioned findings indicate appreciable development in the identification of genetic etiologies of ADHD-PI. This is important progress but cause-and-effect relationships must be established. The contribution of other genes involved in more basic processes  in the pathology of ADHD-PI must also be investigated ,170. In Treatment options for ADHD include behavior therapy and medications, for example, widely used stimulants such as methylphenidate and amphetamine, as well as non-stimulants, for example, atomoxetine. Studies that examine the effects of ADHD medications on the different ADHD subtypes/presentations are few in number. The majority of these studies investigated response to psychostimulants, especially methylphenidate. Stein and colleagues  reportedThe response to methylphenidate in adults with ADHD was also examined. In one of these studies, dexmethylphenidate extended release (ER) was reported to be efficacious in improving ADHD symptoms as compared with a placebo . AnalysiThe effects of chronic treatment of methylphenidate  on blood levels of neurosteroids ) as well as their daily fluctuations in ADHD children were examined in order to discover a potential mechanism underlying the therapeutic effect of this drug. Methylphenidate induced the doubling of allopregnanolone levels in ADHD-PI children without depressive symptoms. The drug did not differently alter DHEA levels in the two ADHD subtypes. The authors of the study concluded that the distinct responses of allopregnanolone and DHEA to methylphenidate suggest the differentiation of effects of pharmacologic manipulations on attention and impulse control. Furthermore, allopregnanolone has been suggested to be a biological marker for ADHD-PI . The samLisdexamfetamine is a prodrug of D-amphetamine and a widely used ADHD medication. In a group of adults with ADHD, lisdexamfetamine was found to be effective in reducing ADHD symptoms in participants with ADHD-C, ADHD-HI, and ADHD-PI . In lineAtomoxetine is a nonstimulant approved by the U.S. FDA for use in adults with ADHD. The overall effect size of this drug in ADHD is moderate. Moreover, large, placebo-controlled trials of atomoxetine treatment in adults and young adults with ADHD, adults with ADHD comorbid social anxiety disorder, or alcohol substance use disorders revealed similar extent of ADHD symptom alleviation in adults with ADHD-PI or ADHD-HI . The resOverall, the responses to stimulant and non-stimulant ADHD treatments do not seem to vary across ADHD subtypes/presentations ,183,184.Animal models of human diseases are commonly used to gain insights into the pathogenesis of disorders and to disentangle the effects of therapeutic regimens. Although animal models cannot truly mimic all aspects of human psychiatric disorders, they can provide insights into disorders that are impossible to be obtained from human studies due to some limitations . In partTH), DAT1, and the solute carrier family 9 (sodium/hydrogen exchanger) member 9  [Sagvolden et al. were the first to propose an animal model of ADHD-PI, i.e., the adolescent Wistar Kyoto WKY/NCrl substrain , provided that the Wistar Kyoto rat, or the WKY/NHsd  was used as a control (for review see ). The imor NHE9) ,190. Behor NHE9) . In contor NHE9) . Furtheror NHE9) ). There or NHE9) ,193,194.or NHE9) ,195. Nevor NHE9)  or repreor NHE9) ,198. In or NHE9)  in the Yor NHE9) . Attentior NHE9) . Future or NHE9)  and to dDAT and TH gene expression was in the substantia nigra (SN) or ventral tegmental area (VTA) of WKY/NCrl and SHR/NCrl were increased as compared with the WKY/NHsd, indicating that dopamine synthesis and reuptake are elevated in these two strains as compared with a control. However, different from the SHR/NCrl, the breakdown of dopamine was not accelerated and the excitatory DRD1 drive to the SN/VTA was not increased in WKY/NCrl [In view of the proposed role of dopamine in ADHD, Roessner et al.  examinedWKY/NCrl . Using lWKY/NCrl , which iWKY/NCrl  found deWKY/NCrl ,195. TheWKY/NCrl  also shoWKY/NCrl . These dCreg1, Thrsp, and Zeb2), synaptic transmission , neurological system process , and immune response  [Thrsp) gene in the striatum of mice produced inattention as measured by the novel object recognition and the Y-maze tasks [As noted earlier, Franke et al. erstwhile suggested the involvement of more basic neuronal processes in ADHD ,170. We and Mx2) . Our recze tasks . The expze tasks . More stAs noted earlier, differences in inattention profiles between individuals with ADHD-C and ADHD-PI have been proposed. Recent studies showed differences in stimulus control between WKY/NCrl and SHR/NCrl, which was suggested to support the above proposal . In partThe above-described findings point to the promise and potentiality of the WKY/NCrl as an animal model of ADHD-PI. In addition to further behavioral, genetic, and neurobiological characterizations, the effects of ADHD treatments should be investigated in this model to verify its predictive validity. Moreover, to satisfy face validity, female WKY/NCrl animals should also be included in future studies. It is notable that the WKY/NCrl has also been used as an animal model of depression and anxiety-related behaviors ,207. TheAs noted earlier, the DSM-5 and ICD-11 conceptualize ADHD as a categorical diagnosis, which has been criticized because of the widely supported “dimensional” view of ADHD. Accordingly, ADHD is best understood as the extreme end of a continuum, and that ADHD patients differ from those without ADHD by “degree” rather than in kind . Due to As a prevalent but under-recognized ADHD subtype/presentation and given the temporal stability of the inattention symptom as compared with other ADHD symptoms, the ADHD-PI and the neurobiological underpinnings of the inattention symptom warrant further investigation. There has been some progress, but much remains to be done in order to obtain a more thorough understanding of the nature of ADHD-PI and the inattention symptom. Indeed, some significant strides were found in some areas, for example, neuroimaging research, but the clinical implications of the findings from these studies are hampered by the inherent limitations of the approach, the small sample size in these studies, etc. . With inTranslational research on ADHD-PI is still in its infancy. The WKY/NCrl is not a perfect ADHD-PI model and more characterizations are required to verify that it fulfills the requirements of a reliable and valid animal model of psychiatric disorders . Modelin


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.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 . It is ADHD is present in childhood and symptoms tend to decline with increasing age , with coPsychiatric comorbidity is very common, which may complicate identification and treatment . In chilPrevalence of ADHD is estimated at 7.1% in children and adolescents , and 2.5This 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 , 26. WhiComprehensive views of the aetiology of ADHD incorporate biological, environmental and cultural perspectives and influences . SubstanThere 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 , 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 , and gender to define a social role and cultural-social properties . Howeverwww.UKADHD.com). Meeting attendees included experts in ADHD across a range of mental health professions, including healthcare specialists , 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 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  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: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.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  due to tResearch 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 , 21. By 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 . HyperacPeople may experience and respond to the same behaviour of males and females in different ways due to gender-related behavioural expectations . For exaLess 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 , 49.Externalising problems are more prevalent in males with ADHD , manifesCompared with males with ADHD, internalising disorders  are more often reported in females , 53, 56.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 , 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 , 61, a mConsensus 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 , and chrYoung people with ADHD are at greater risk for tobacco and alcohol use in mid adolescence . In adulIn both children and adults ADHD is commonly accompanied by emotional lability and emotion dysregulation problems  –74. DiffCognitive problems are well established in ADHD –80, spanA similar level of social impairment has been identified for ADHD males and females , 40, 82.Children with ADHD are more likely to experience rejection and unpopularity and have fewer friendships than their peers  and sociThere is some evidence to suggest that elevated symptoms of ADHD are associated with excessive internet use in children and adolescents , as wellThroughout 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 . For exaA 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 , albeit Studies specifically reporting driving problems in women with ADHD have shown no significant association between ADHD and driving outcomes , 104. HoDelinquency 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 , 106. A There are multiple potential triggers that may prompt the referral of females for assessment, shown in Table The stereotype of the ADHD ‘disruptive boy’  is likelIt is important to be mindful that environmental demands  increase in number, scope and complexity with age and level of independence, whilst support resources decline . Many yoThese 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 . The devDifficulty 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 . Those wFor 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 Rating scales can obtain perspectives from different informants  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 . Rigid aRating scale norms are predominantly from male or mixed samples, which may disadvantage their use in females, although some provide female-specific norms .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  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 , which typically peak in adolescence and early adulthood , 129. SuSince heritability of ADHD is high, ranging between 70-80% in both children and adults , it is iSemi-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 , 55 and 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  the individual well during their childhood, it may be helpful to obtain information from an informant who currently knows the individual well  in order to supplement self-reported information with a secondary perspective. If available, reports from childhood  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 . 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 . It is nWhenever possible, the assessor should obtain collateral information from independent sources. This may include direct observations in a specific setting . 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+])  and the Prompt identification and treatment of ADHD is recommended, as there is evidence of long-term functional benefits associated with treatment , 138. ADIn 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.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 . A systeTreatment recommendations do not differ by sex and differ only modestly by age . The ovThe 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  have been noted in stimulant treated ADHD populations , 147, alWhilst 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  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 –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  if they emerge. Side effects of stimulants need to be considered, particularly the side effect of appetite suppression if eating disorders are a concern .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 , 160. ChWhilst 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  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  with the environment . If ADHDHistorically, 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 . NeverthWomen 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 , there iPrescribers 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.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 –170. ResMeta-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 , and orgMeta 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 , 176. BeThe 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 . RegularADHD 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 , 180. WhThere 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 , enuresiBoth 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 . Two specific programmes have been developed for young children with cognitive, emotional, social and/or behavioural problems; one for individual delivery  and the 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 , 186. ThProblems 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  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 . For teeBehavioural 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  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 . This mImpulsive 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 .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 . 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 .The bulk of household, and parental and caring duties are often borne by women –192, refHowever, at the same time harsh, lax or negative parenting styles have been identified to be elevated in mothers with ADHD . MothersWomen 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.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 ADHD is associated with low educational attainment and academic underachievement , 195. InYoung 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 , 99, 199Externalising 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 , 203. FeIndividuals 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  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 , and chiMany 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 . 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 ).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 . Career https://www.gov.uk/disabled-students-allowances-dsas), which can fund assistive technology (e.g. speech to text software), specialist mentoring  and “academic coaching”.Guidance for those wishing to embark in further education should take account of the course demands involved . 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/care-to-learn), and Childcare Grants (https://www.gov.uk/childcare-grant).In general young people with ADHD reach or complete higher education at a later age than their peers . This caIn adulthood, ADHD is associated with unemployment or working in unskilled occupations , difficuADHD qualifies as a disability under the UK Equality Act 2010 , becausehttps://www.gov.uk/specialist-employability-support) are available to provide intensive support and training for unemployed people with a disability.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 . 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.On the other hand, disclosing a disability allows for women with ADHD to be treated more favourably under the UK Equality Act 2010 , and benResearch suggests an increased involvement of ADHD children with the social care and foster care systems , 210. EqThe 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  it is alSocial 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.Increased rates of delinquent or criminal behaviour may lead to contact with the criminal justice system . PrevaleEvidence indicates that ADHD treatment is associated with reduced rates of criminality , is toleFemales 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 . In the 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 . This doThere 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  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 . Lack ofFemales 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 . 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  as well as the key healthcare system  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 , 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.