there is good evidence for the use of behavioural therapies in adhd. they are the recommended first-line treatment in those who have mild symptoms or who are preschool-aged. psychological therapies used include: psychoeducational input, behavior therapy, cognitive behavioral therapy, interpersonal psychotherapy, family therapy, school-based interventions, social skills training, behavioural peer intervention, organization training, and parent management training. neurofeedback has greater treatment effects than non-active controls for up to 6 months and possibly a year following treatment, and may have treatment effects comparable to active controls (controls proven to have a clinical effect) over that time period. despite efficacy in research, there is insufficient regulation of neurofeedback practice, leading to ineffective applications and false claims regarding innovations. parent training may improve a number of behavioural problems including oppositional and non-compliant behaviours. there is little high-quality research on the effectiveness of family therapy for adhd—but the existing evidence shows that it is similar to community care, and better than placebo. adhd-specific support groups can provide information and may help families cope with adhd. social skills training, behavioural modification, and medication may have some limited beneficial effects in peer relationships. stable, high-quality friendships with non-deviant peers protect against later psychological problems. stimulants methylphenidate and amphetamine or its derivatives are first-line treatments for adhd as they are considered the most effective pharmaceutical treatments. about 70 percent respond to the first stimulant tried and as few as 10 percent respond to neither amphetamines nor methylphenidate. stimulants may also reduce the risk of unintentional injuries in children with adhd. magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with adhd. a 2018 review found the greatest short-term benefit with methylphenidate in children, and amphetamines in adults. the likelihood of developing insomnia for adhd patients taking stimulants has been measured at between 11 and 45 percent for different medications, and may be a main reason for discontinuation. other side effects, such as tics, decreased appetite and weight loss, or emotional lability, may also lead to discontinuation. stimulant psychosis and mania are rare at therapeutic doses, appearing to occur in approximately 0.1% of individuals, within the first several weeks after starting amphetamine therapy. the safety of these medications in pregnancy is unclear. symptom improvement is not sustained if medication is ceased. the long-term effects of adhd medication have yet to be fully determined, although stimulants are generally beneficial and safe for up to two years for children and adolescents. regular monitoring has been recommended in those on long-term treatment. there are indications suggesting that stimulant therapy for children and adolescents should be stopped periodically to assess continuing need for medication, decrease possible growth delay, and reduce tolerance. although potentially addictive at high doses, stimulants used to treat adhd have low potential for abuse. treatment with stimulants is either protective against substance abuse or has no effect.: 12 the majority of studies on nicotine and other nicotinic agonists as treatments for adhd have shown favorable results; however, no nicotinic drug has been approved for adhd treatment. caffeine was formerly used as a second-line treatment for adhd. it is considered less effective than methylphenidate or amphetamine but more so than placebo for children with adhd. pseudoephedrine and ephedrine do not affect adhd symptoms. modafinil has shown some efficacy in reducing the severity of adhd in children and adolescents. it may be prescribed off-label to treat adhd. non-stimulants there are a number of non-stimulant medications, such as viloxazine, atomoxetine, bupropion, guanfacine, amantadine (effective in children and adolescents but still not been seen for adults), and clonidine, that may be used as alternatives, or added to stimulant therapy. there are no good studies comparing the various medications; however, they appear more or less equal with respect to side effects. for children, stimulants appear to improve academic performance while atomoxetine does not. atomoxetine, due to its lack of addiction liability, may be preferred in those who are at risk of recreational or compulsive stimulant use, although evidence is lacking to support its use over stimulants for this reason.: 13 evidence supports its ability to improve symptoms when compared to placebo. amantadine was shown to induce similar improvements in children treated methylphenidate, with less frequent side effects. a 2021 retrospective study showed showed that amantadine may serve as an effective adjunct to stimulants for adhd–related symptoms and appears to be a safer alternative to second- or third-generation antipsychotics. there is little evidence on the effects of medication on social behaviours. antipsychotics may also be used to treat aggression in adhd. guidelines guidelines on when to use medications vary by country. the united kingdom's national institute for health and care excellence recommends use for children only in severe cases, though for adults medication is a first-line treatment. conversely, most united states guidelines recommend medications in most age groups. medications are especially not recommended for preschool children. underdosing of stimulants can occur, and can result in a lack of response or later loss of effectiveness. this is particularly common in adolescents and adults as approved dosing is based on school-aged children, causing some practitioners to use weight-based or benefit-based off-label dosing instead. exercise regular physical exercise, particularly aerobic exercise, is an effective add-on treatment for adhd in children and adults, particularly when combined with stimulant medication (although the best intensity and type of aerobic exercise for improving symptoms are not currently known). the long-term effects of regular aerobic exercise in adhd individuals include better behaviour and motor abilities, improved executive functions (including attention, inhibitory control, and planning, among other cognitive domains), faster information processing speed, and better memory. parent-teacher ratings of behavioural and socio-emotional outcomes in response to regular aerobic exercise include: better overall function, reduced adhd symptoms, better self-esteem, reduced levels of anxiety and depression, fewer somatic complaints, better academic and classroom behaviour, and improved social behaviour. exercising while on stimulant medication augments the effect of stimulant medication on executive function. it is believed that these short-term effects of exercise are mediated by an increased abundance of synaptic dopamine and norepinephrine in the brain. diet dietary modifications are not recommended as of 2019 by the american academy of pediatrics, the national institute for health and care excellence, or the agency for healthcare research and quality due to insufficient evidence. a 2013 meta-analysis found less than a third of children with adhd see some improvement in symptoms with free fatty acid supplementation or decreased eating of artificial food colouring. these benefits may be limited to children with food sensitivities or those who are simultaneously being treated with adhd medications. this review also found that evidence does not support removing other foods from the diet to treat adhd. a 2014 review found that an elimination diet results in a small overall benefit in a minority of children, such as those with allergies. a 2016 review stated that the use of a gluten-free diet as standard adhd treatment is not advised. a 2017 review showed that a few-foods elimination diet may help children too young to be medicated or not responding to medication, while free fatty acid supplementation or decreased eating of artificial food colouring as standard adhd treatment is not advised. chronic deficiencies of iron, magnesium and iodine may have a negative impact on adhd symptoms. there is a small amount of evidence that lower tissue zinc levels may be associated with adhd. in the absence of a demonstrated zinc deficiency (which is rare outside of developing countries), zinc supplementation is not recommended as treatment for adhd. however, zinc supplementation may reduce the minimum effective dose of amphetamine when it is used with amphetamine for the treatment of adhd. prognosis adhd persists into adulthood in about 30–50% of cases. those affected are likely to develop coping mechanisms as they mature, thus compensating to some extent for their previous symptoms. children with adhd have a higher risk of unintentional injuries. effects of medication on functional impairment and quality of life (e.g. reduced risk of accidents) have been found across multiple domains. rates of smoking among those with adhd are higher than in the general population at about 40%. individuals with adhd are significantly overrepresented in prison populations. although there is no generally accepted estimate of adhd prevalence among inmates, a 2015 meta-analysis estimated a prevalence of 25.5%, and a larger 2018 meta-analysis estimated the frequency to be 26.2%. adhd is more common among longer-term inmates; a 2010 study at norrtälje prison, a high-security prison in sweden, found an estimated adhd prevalence of 40%. epidemiology main article: epidemiology of attention deficit hyperactive disorder percent of people 4–17 ever diagnosed in the us as of 2011 adhd is estimated to affect about 6–7% of people aged 18 and under when diagnosed via the dsm-iv criteria. when diagnosed via the icd-10 criteria, rates in this age group are estimated around 1–2%. children in north america appear to have a higher rate of adhd than children in africa and the middle east; this is believed to be due to differing methods of diagnosis rather than a difference in underlying frequency. as of 2019, it was estimated to affect 84.7 million people globally. if the same diagnostic methods are used, the rates are similar between countries. adhd is diagnosed approximately three times more often in boys than in girls. this may reflect either a true difference in underlying rate, or that women and girls with adhd are less likely to be diagnosed. rates of diagnosis and treatment have increased in both the united kingdom and the united states since the 1970s. prior to 1970, it was rare for children to be diagnosed with adhd, while in the 1970s rates were about 1%. this is believed to be primarily due to changes in how the condition is diagnosed and how readily people are willing to treat it with medications rather than a true change in how common the condition is. it was believed changes to the diagnostic criteria in 2013 with the release of the dsm-5 would increase the percentage of people diagnosed with adhd, especially among adults. due to disparities in the treatment and understanding of adhd between caucasian and non-caucasian populations, many non-caucasian children go undiagnosed and unmedicated. it was found that within the us that there was often a disparity between caucasian and non-caucasian understandings of adhd. this led to a difference in the classification of the symptoms of adhd, and therefore, its misdiagnosis. it was also found that it was common in non-caucasian families and teachers to understand the symptoms of adhd as behavioural issues, rather than mental illness. crosscultural differences in diagnosis of adhd can also be attributed to the long-lasting effects of harmful, racially targeted medical practices. medical pseudosciences, particularly those that targeted african american populations during the period of slavery in the us, lead to a distrust of medical practices within certain communities. the combination of adhd symptoms often being regarded as misbehaviour rather than as a psychiatric condition, and the use of drugs to regulate adhd, result in a hesitancy to trust a diagnosis of adhd. cases of misdiagnosis in adhd can also occur due to stereotyping of non-caucasian individuals. due to adhd's subjectively determined symptoms, medical professionals may diagnose individuals based on stereotyped behaviour or misdiagnose due to differences in symptom presentation between caucasian and non-caucasian individuals. history timeline of adhd diagnostic criteria, prevalence, and treatment hyperactivity has long been part of the human condition. sir alexander crichton describes "mental restlessness" in his book an inquiry into the nature and origin of mental derangement written in 1798. he made observations about children showing signs of being inattentive and having the "fidgets". the first clear description of adhd is credited to george still in 1902 during a series of lectures he gave to the royal college of physicians of london. he noted both nature and nurture could be influencing this disorder. alfred tredgold proposed an association between brain damage and behavioural or learning problems which was able to be validated by the encephalitis lethargica epidemic from 1917 through 1928. the terminology used to describe the condition has changed over time and has included: minimal brain dysfunction in the dsm-i (1952), hyperkinetic reaction of childhood in the dsm-ii (1968), and attention-deficit disorder with or without hyperactivity in the dsm-iii (1980). in 1987,