Execution Functioning & ADHD
Behavioural inhibition is the brain’s ability to pause before acting.
This brief pause allows the executive functioning system to organise thoughts, regulate emotions, evaluate consequences, resist distractions, and guide behaviour towards future goals rather than immediate impulses.
When behavioural inhibition is less effective, immediate events have a much stronger influence on behaviour than future intentions. Interest, novelty, urgency, emotional significance, and immediate reward tend to override long-term priorities.
Executive functioning can be thought of as the brain’s self-management system. It allows us to regulate ourselves across time in order to achieve future goals.
Executive functioning enables us to:
- Pause and think before acting.
- Sustain attention despite distractions.
- Hold information in mind (working memory).
- Plan and organise activities.
- Prioritise competing demands.
- Estimate and manage time effectively.
- Delay gratification.
- Regulate emotions.
- Monitor our own behaviour.
- Solve problems flexibly.
- Persist with repetitive or difficult tasks.
- Work consistently towards long-term goals.
People with ADHD generally understand what they need to do. The difficulty lies in consistently activating and maintaining these executive functions, particularly when tasks are repetitive, routine, or provide little immediate reward.
Executive dysfunction
Executive functioning refers to the brain’s capacity for self-regulation—the ability to direct behaviour towards future goals by managing time, organising actions, inhibiting impulses, generating motivation, and regulating emotions.
Executive functions represent the brain’s “management system.” Rather than reflecting intelligence or knowledge, these functions enable an individual to coordinate thoughts, emotions, behaviour, and motivation in pursuit of long-term objectives.
Self-Management to Time
Self-management to time refers to the ability to perceive, estimate, monitor and use time to guide future behaviour. Individuals with severe executive dysfunction frequently experience “time blindness,” whereby future events exert considerably less influence over present behaviour than they do for most people.
Individuals experiencing this degree of difficulty commonly struggle to estimate how long activities will take, prioritise tasks according to deadlines, pace themselves appropriately, and maintain awareness of the passage of time during activities.
Planning ahead becomes extremely difficult because future events fail to exert sufficient influence on present behaviour.
Clinically, this often presents as chronic lateness or, conversely, excessive overcompensation by arriving unusually early due to fear of being late. There may be marked difficulty meeting deadlines, allocating adequate time for tasks, transitioning between activities, and anticipating future consequences.
Daily functioning frequently becomes reactive rather than proactive, with behaviour driven by immediate demands rather than long-term planning.
Self-Organisation and Problem Solving
This executive function refers to the ability to organise information, develop plans, sequence complex activities, solve problems efficiently, prioritise competing demands, and adapt strategies when circumstances change.
Individuals with this level of difficulty frequently experience substantial problems breaking larger tasks into manageable steps, maintaining organised systems, planning projects, remembering multiple components of tasks, and efficiently solving everyday problems.
Planning often becomes inconsistent and inefficient. Tasks may be approached without a clear strategy, important steps overlooked, and priorities frequently change according to what is most immediately stimulating rather than what is most important.
Multi-step activities can quickly become overwhelming, particularly when several demands compete simultaneously.
Although many individuals develop highly structured external systems such as calendars, reminders, lists, and routines, these often function as compensatory strategies rather than evidence of intact executive functioning.
Considerable mental effort may be required simply to maintain an organisational system that others manage more automatically.
Self-Restraint
Self-restraint represents the ability to inhibit immediate behavioural, cognitive and verbal responses.
It encompasses impulse control, delaying gratification, interrupting automatic reactions, thinking before acting, and suppressing responses that are inappropriate within a given context.
Difficulties in this domain affect virtually every aspect of self-control.
Individuals may experience marked difficulty interrupting conversations, waiting their turn, resisting impulses, delaying decisions, or preventing immediate emotional or behavioural reactions.
Thoughts are frequently expressed before they have been fully evaluated, resulting in comments or actions that are later regretted.
There may be impatience in queues, traffic, meetings, or social interactions, together with a tendency to make rapid decisions without fully considering future consequences.
Importantly, these behaviours are not typically deliberate or oppositional.
Rather, they reflect reduced inhibitory control arising from executive dysfunction. The capacity to pause, mentally evaluate options, and intentionally choose a response is substantially compromised.
Self-Motivation
Self-motivation refers to the capacity to generate internal motivation sufficient to begin, sustain and complete tasks, particularly when activities are repetitive, effortful, delayed in reward, or lacking immediate interest.
Individuals often know exactly what they need to do but experience extreme difficulty translating intention into action when immediate reinforcement is absent.
Individuals with severe impairment in this domain frequently struggle to initiate important tasks despite fully understanding their importance.
Motivation becomes disproportionately dependent upon immediate interest, novelty, urgency, challenge, or external accountability.
Activities that lack these characteristics are often postponed repeatedly despite significant consequences.
Task initiation may occur only when deadlines become imminent or external pressure becomes unavoidable.
Once immediate stimulation diminishes, maintaining effort becomes increasingly difficult.
As a consequence, work may accumulate until urgency produces sufficient activation to complete tasks under considerable stress.
From a neuropsychological perspective, this reflects reduced capacity to use internal representations of future rewards to sustain present effort.
Motivation remains largely dependent upon external sources of stimulation rather than internally generated drive.
Self-Regulation of Emotions
Self-regulation of emotions refers to the capacity to inhibit, modulate and recover from emotional responses in order to maintain behaviour consistent with long-term goals.
Individuals commonly experience emotions that are rapid in onset, intense in magnitude, and difficult to modify once activated.
Emotional responses frequently occur before conscious reflection, making it challenging to pause, evaluate the situation objectively, and respond proportionately.
Clinically, this may present as heightened frustration, irritability, impatience, sensitivity to criticism, emotional overwhelm, rapid mood shifts, reduced tolerance for stress, and prolonged recovery following emotionally
significant events.
Emotional responses often interfere with problem solving, decision-making, communication, and interpersonal relationships.
The difficulty lies not in experiencing emotions, but in managing their intensity, duration, and behavioural expression.
Impairment in this domain can significantly affect occupational functioning, intimate relationships, parenting, social interactions, and overall psychological wellbeing.
Dopamine
Interest-Based Attention
Attention in ADHD is not absent—it is interest-based rather than importance-based.
The ADHD brain naturally allocates attention towards activities that provide stronger dopamine signalling, including those that are:
- Interesting
- Novel
- Challenging
- Urgent
- Emotionally significant
- Immediately rewarding
In contrast, routine, repetitive, administrative, or delayed-reward tasks generate weaker dopamine signalling, making them much harder to initiate, sustain, and complete—even when the person fully understands their importance.
For this reason, many people with ADHD describe their difficulty as not deciding what to do, but consistently doing what they already know needs to be done.
In ADHD, differences in dopamine and noradrenaline signalling affect the brain networks responsible for executive functioning, motivation, attention and reward processing.
Dopamine Signalling Is Less Efficient
Dopamine helps the brain determine:
- What is important
- What deserves attention
- What is rewarding
- Whether effort is worth investing
Underactivation of the Reward System
- Reduced activation occurs when rewards are delayed.
- Immediate rewards are valued much more highly than future rewards.
- Interest drops quickly when novelty disap
ADHD is not caused by a simple lack of dopamine.
Current research suggests that the brain uses dopamine and noradrenaline less efficiently.
This reflects differences in how these neurotransmitters
are released, transmitted, received by brain cells and recycled.
This altered chemical communication, known as dopamine signalling, describes how dopamine carries messages between brain cells.
When dopamine signalling is less efficient, the brain finds it harder to activate and coordinate the networks responsible for attention, planning, motivation and self-regulation.
These differences primarily affect interconnected brain networks involving the prefrontal cortex, anterior cingulate cortex, basal ganglia, thalamus, and the brain’s reward pathways.
Together, these regions help us decide what is important, regulate behaviour, sustain mental effort, learn from experience and work towards future goals.
As a result, people with ADHD may find it more difficult to:
□ Sustain attention.
□ Initiate tasks.
□ Maintain motivation.
□ Regulate emotions.
□ Inhibit impulsive responses.
□ Plan and organise.
□ Hold information in working memory.
□ Persist with repetitive or low-interest activities.
□ Complete tasks that have delayed rewards.
Dopamine plays an important role in:
□ Motivation.
□ Attention regulation.
□ Working memory.
□ Decision-making.
□ Identifying what is important.
□ Initiating behaviour.
□ Sustaining mental effort.
□ Reinforcement learning.
□ Goal-directed behaviour.
□ Interest and curiosity.
□ Behavioural activation.
□ Movement.
Dopamine helps the brain to:
□ Identify what is important.
□ Focus attention on relevant information.
□ Decide whether something is worth the effort.
□ Anticipate future rewards.
□ Allocate mental effort.
□ Initiate action.
□ Sustain motivation over time.
□ Learn from rewards and consequences.
□ Adapt behaviour based on previous experiences.
When dopamine signalling is less efficient, the brain does not automatically assign the same level of importance to every task.
Activities that are repetitive, delayed, or offer little immediate reward may generate a weaker motivational signal, making them feel unusually difficult to start or continue.
In contrast, tasks that are novel, highly interesting, urgent or personally meaningful produce a stronger dopamine response and are often much easier to engage with.
This is why many people with ADHD describe themselves as being interest-based rather than importance-based in how they direct their attention.
Importantly, this does not mean that people with ADHD lack motivation. Rather, the brain’s motivational system is regulated differently.
Interest, novelty, challenge, urgency and immediate feedback activate these networks far more effectively than tasks that are routine or provide rewards only in the distant future.
Dopamine release is influenced by:
□ Novel experiences.
□ Curiosity.
□ Interest.
□ Achievement.
□ Anticipation of reward.
□ Immediate rewards.
□ Urgency.
□ Positive feedback.
□ Progress towards a goal.
□ Learning something new.
Self Management to Time
Executive Functioning : Self-Management to Time
Self-management to time is the executive function that enables an individual to use their awareness of time and future consequences to regulate behaviour in the present.
Supports the ability to:
□ Sense the passage of time.
□ Estimate how long tasks will take.
□ Plan for future events.
□ Prioritise competing demands.
□ Meet deadlines.
□ Work steadily towards long-term goals.
□ Delay immediate gratification.
□ Use future goals to guide present behaviour.
Leads to difficulty with:
□ Underestimating how long tasks will take.
□ Missing deadlines.
□ Forgetting appointments.
□ Forgetting future intentions.
□ Rushing tasks and making careless mistakes.
□ Difficulty completing lengthy tasks.
□ Poor planning of multi-step activities.
□ Difficulty completing responsibilities.
□ Difficulty organising behaviour around long-term goals.
□ Estimating how long tasks will take accurately.
□ Planning ahead for future events and commitments.
□ Prioritising tasks according to their importance and urgency.
□ Meeting deadlines consistently.
□ Anticipating future consequences when making decisions.
□ Maintaining awareness of the passage of time (“time blindness”).
□ Allocating sufficient time to complete work accurately.
□ Pacing work appropriately to balance speed and accuracy.
Sustaining Future Reward
One important function of self-management to time is the ability to mentally hold a future reward in mind while completing work in the present.
An important function of self-management to time is the ability to mentally hold a future reward in mind while working in the present.
Future Rewards
In ADHD, delayed rewards often lose their motivational value much more rapidly than immediate rewards.
Individuals commonly experience:
□ Future rewards feeling psychologically distant.
□ Immediate stimulation being more motivating than future outcomes.
□ Difficulty sustaining effort towards delayed rewards.
□ Reliance on urgency to initiate tasks.
□ Preference for immediate rather than delayed gratification.
Professor Russell Barkley describes ADHD as involving a reduced capacity to use internal information about the future to regulate behaviour in the present.
Time Blindness
Time blindness refers to reduced awareness of the passage of time and difficulty using time as an internal guide for behaviour.
It commonly includes difficulty:
□ Perceiving the passage of time.
□ Estimating how long tasks will take.
□ Planning across time.
□ Organising behaviour towards future goals.
Many adults with ADHD experience:
□ Future events feeling psychologically distant.
□ Deadlines not feeling real until they become urgent.
□ Hours passing without awareness.
□ Underestimating task duration.
□ Difficulty valuing future rewards.
□ Time blindness.
□ Chronic lateness.
□ Procrastination.
□ Poor scheduling.
□ Poor prioritisation.
□ Difficulty delaying gratification.
□ Reduced future-oriented thinking.
□ Reliance on urgency.
□ Last-minute task completion.
Self Restraint
Executive Functioning: Self-Restraint
Self-restraint refers to the brain’s ability to inhibit an immediate thought, emotion, or behaviour long enough to consider consequences, alternative responses, and future goals.
Without the ability to pause, the brain has less opportunity to engage planning, working memory, emotional regulation, and problem-solving.
Reduced self-restraint affects the brain’s ability to pause before
responding.
Rather than reflecting a lack of intelligence or motivation, these difficulties arise from reduced inhibitory control within the brain’s executive functioning networks.
Cognitive Impulsivity
□ Makes decisions without pausing to think.
□ Responds before fully considering the situation.
□ Speaks without considering the impact of their words.
□ Makes important decisions impulsively without considering long-term consequences.
□ Feels compelled to express every thought or opinion immediately.
Behavioural Impulsivity
□ Acts before thinking through the consequences.
□ Has difficulty inhibiting automatic behavioural responses.
□ Has difficulty waiting for their turn during conversations and group activities.
□ Interferes with other people’s activities without being invited or when it is not appropriate.
□ Interrupts or takes over tasks that other people are completing.
Verbal Impulsivity
□ Speaks before thinking.
□ Has difficulty allowing other people opportunities to contribute during conversations.
□ Talks excessively during conversations.
□ Has difficulty stopping talking when it is appropriate to do so.
□ Has difficulty respecting other people’s personal, conversational, and social boundaries.
Distractability
Why Background Sound Can Improve Concentration in ADHD
Many people with ADHD find that background sound improves their ability to concentrate. Rather than being distracting, certain types of sound can provide the level of stimulation that helps the brain maintain alertness and sustain attention.
The ADHD brain seeks optimal stimulation
ADHD is associated with less efficient dopamine and noradrenaline signalling within the brain’s attention and executive functioning networks.
When environmental stimulation is too low, the brain may struggle to maintain an optimal level of alertness.
As a result:
□ Silence may provide insufficient stimulation to sustain attention.
□ The mind may wander more easily.
□ Internal thoughts become increasingly distracting.
□ The brain seeks alternative sources of stimulation.
Providing a moderate level of background sound may help increase cortical arousal and maintain an optimal level of attention.
This concept is consistent with the Optimal Stimulation Theory of ADHD.
Background sound may increase dopamine signalling
Certain forms of background sound, particularly predictable and enjoyable sounds, may help activate the brain’s reward and attention networks.
Potential benefits include:
□ Increasing motivation to begin tasks.
□ Improving task engagement.
□ Reducing the urge to seek stimulation elsewhere (such as checking a phone or changing activities).
□ Supporting sustained attention during repetitive or low-interest tasks.
Background sound helps reduce internal distraction
ADHD involves difficulty filtering both external and internal distractions.
When the environment is completely quiet:
□ Internal thoughts may become more intrusive.
□ Daydreaming and mind wandering may increase.
□ Worries or unrelated thoughts may compete for attention.
Consistent background sound provides a stable sensory input that may reduce awareness of distracting internal thoughts, allowing attention to remain on the task.
Rhythm supports sustained attention
Predictable rhythmic sounds may help regulate attention by supporting synchronisation within the brain’s attention networks.
Many individuals with ADHD find that steady rhythms improve:
□ Sustained attention.
□ Working memory.
□ Mental endurance.
□ Task persistence.
For this reason, many people prefer:
□ Instrumental music.
□ Lo-fi beats.
□ Brown noise.
□ White noise.
□ Rain or nature sounds.
Music with lyrics may be less helpful during reading or writing tasks because spoken words compete with the brain’s language processing systems.
Sound reduces boredom
One of the defining characteristics of ADHD is that attention is influenced more by interest, novelty, reward, and urgency than by importance alone.
Tasks that are:
□ Boring.
□ Repetitive.
□ Slow.
□ Mentally demanding.
□ Low in immediate reward.
are more likely to result in reduced attention and motivation.
Appropriate background sound can increase the level of stimulation sufficiently to make these tasks easier to initiate and sustain.
A Simple Analogy
A useful way to understand this is to think of the ADHD brain as an engine that naturally idles at a lower speed.
- Silence may provide too little stimulation, allowing attention to drift.
- Appropriate background sound acts like a gentle accelerator, increasing alertness and helping the brain maintain focus without becoming overwhelmed.
While not every person with ADHD finds background sound helpful, many discover that the right type of predictable, non-intrusive auditory stimulation improves concentration, reduces mind wandering, and makes sustained mental effort easier.
Delayed Rewards
Dopamine helps the brain assign value to outcomes and sustain behaviour when rewards are delayed.
In ADHD, immediate events—something interesting, novel, urgent, emotionally intense, or rewarding now—can have disproportionately strong influence compared with distant goals.
This can look like:
- knowing a task matters but being unable to begin it
- losing motivation when a reward is delayed
- choosing immediate relief over a longer-term benefit
- becoming highly productive when a deadline creates urgency
- finding routine, repetitive tasks unusually effortful
- needing novelty, feedback, accountability, or immediate consequences to stay engaged
Different Reward System
- Novelty captures attention more easily
- Urgency increases motivation
- Immediate rewards feel more compelling
- Repetitive tasks feel painful
Attention or behaviour is driven by :
- Interest
- Novelty
- Urgency
- Reward
- Easy tasks
- Instant gratification
- Fear of negative consequences
- Important & urgent tasks
Less responsive to delayed rewards
- Immediate rewards feel more motivating than future rewards
- Urgency activates motivation more effectively than importance
- Boring or repetitive tasks can feel extremely difficult to start
- Motivation may disappear quickly when interest fades
Working Memory
What is Working Memory?
Working memory is the brain’s mental workspace. It is the ability to hold information in mind for a short period of time while using or manipulating that information to complete a task.
Unlike long-term memory, which stores information for days or years, working memory only keeps information active for a few seconds unless you actively rehearse or use it.
Think of working memory as the RAM in a computer.
- Long-term memory is the hard drive where information is stored.
- Working memory is the RAM where information is temporarily held while you work with it.
If the brain’s “RAM” becomes overloaded or inefficient, information is easily lost before the task is finished.
Everyday examples of working memory
Working memory allows you to:
- Remember a phone number long enough to dial it.
- Follow multi-step instructions without forgetting the next step.
- Keep track of what someone is saying during a conversation.
- Perform mental arithmetic.
- Remember why you walked into a room.
- Hold your place while reading.
- Remember what you intended to say while someone else is talking.
- Cook a meal while keeping track of several steps at once.
What happens in ADHD?
In ADHD, working memory is often less efficient because the brain has difficulty keeping information active in awareness.
This can lead to:
- Forgetting what you were doing after an interruption.
- Losing track of conversations.
- Walking into a room and forgetting why.
- Frequently misplacing belongings.
- Needing to write everything down.
- Forgetting appointments despite intending to remember.
- Losing your place during reading or paperwork.
- Difficulty following multi-step instructions.
- Starting a task and forgetting the original goal.
- Feeling mentally overloaded when several things require attention simultaneously.
Importantly, this is not a problem with intelligence. Many people with ADHD have excellent reasoning ability, but their “mental workspace” has a reduced capacity or is more easily disrupted by distraction.
What parts of the brain are involved?
Working memory relies on a network of brain regions, including:
- Dorsolateral Prefrontal Cortex (DLPFC): Holds and manipulates information “online.”
- Frontoparietal Network: Directs attention and coordinates information.
- Anterior Cingulate Cortex (ACC): Monitors performance and helps maintain focus.
- Basal Ganglia (especially the Caudate): Helps update and filter information entering working memory.
- Cerebellum: Contributes to timing and sequencing of cognitive processes.
These regions communicate using neurotransmitters such as dopamine and noradrenaline, both of which help maintain stable attention and keep relevant information active.
Working memory is primarily supported by a network of brain regions, rather than a single area. In ADHD, several of these regions function less efficiently, particularly when dopamine and noradrenaline signalling is reduced.
1. Prefrontal Cortex (Main Working Memory Centre)
The prefrontal cortex, especially the dorsolateral prefrontal cortex (DLPFC), is the brain’s main “working memory system.”
It is responsible for:
- Holding information in mind for short periods.
- Keeping attention focused on relevant information.
- Planning and organising.
- Mentally manipulating information (for example, doing calculations in your head).
- Resisting distractions while remembering what you were doing.
In ADHD, this region is often less active and has less efficient dopamine and noradrenaline signalling, making it harder to keep information “online.”
2. Anterior Cingulate Cortex (ACC)
The anterior cingulate cortex helps:
- Maintain attention.
- Detect errors.
- Monitor performance.
- Decide what information is important enough to keep active.
When the ACC is less efficient, attention is more easily diverted, and information being held in working memory can be lost.
3. Basal Ganglia
The basal ganglia, particularly the caudate nucleus, act as a gatekeeper.
They help:
- Filter out irrelevant information.
- Select what should enter working memory.
- Support smooth communication between the prefrontal cortex and the rest of the brain.
Differences in this network are consistently found in ADHD.
4. Parietal Cortex
The parietal cortex works with the prefrontal cortex to:
- Store information temporarily.
- Maintain spatial information.
- Support mental calculations.
- Help keep track of multiple pieces of information.
5. Cerebellum
Although traditionally associated with movement, the cerebellum also contributes to:
- Timing.
- Sequencing.
- Mental coordination.
- Keeping cognitive processes running smoothly.
It helps the working memory system operate efficiently.
Think of working memory as a team:
- Prefrontal cortex = the manager that holds information in mind.
- Anterior cingulate cortex = the supervisor that keeps attention on the task.
- Basal ganglia = the gatekeeper that decides what information gets through.
- Parietal cortex = the temporary storage area.
- Cerebellum = the timing coordinator that keeps everything running smoothly.
In ADHD, these regions still work, but communication between them is often less efficient because dopamine and noradrenaline signalling is less effective.
As a result, information is more easily lost from working memory, particularly during distractions, interruptions, or tasks that are repetitive or uninteresting.
This network-based explanation is well supported by modern neuroimaging research and aligns with current models of ADHD as a disorder of frontostriatal and frontoparietal brain networks.
Working Memory
- Working memory is the brain’s ability to hold information in mind and use it over short periods of time.
- It acts like a mental workspace that helps us follow instructions, complete tasks, and keep track of what we are doing.
How Dopamine Affects Working Memory
- Helps the prefrontal cortex maintain information “online.”
- In ADHD, less efficient dopamine signalling can make information fade more quickly, resulting in forgetfulness, distractibility, and difficulty completing complex tasks.
In ADHD:
- Information is more easily lost from conscious awareness.
- Difficulty holding multiple pieces of information in mind at once.
- Forgetting what you were about to say or do.
- Losing track of tasks after interruptions.
- Difficulty following multi-step instructions.
- Frequently misplacing items and forgetting appointments.
- Increased reliance on reminders, notes, and external prompts.
Brain Regions Involved:
- Prefrontal Cortex (PFC) – temporarily stores and manipulates information.
- Frontostriatal Networks – support attention and task maintenance.
- Dopamine Pathways – help keep information active and available in working memory.
Working Memory Difficulties in ADHD
Attention & Concentration
- Losing track of conversations
- Forgetting what someone just said
- Difficulty following lengthy discussions
- Needing instructions repeated
- Losing focus after interruptions
- Forgetting what was being done before becoming distracted
- Reading without retaining information
- Difficulty taking notes while listening
Planning & Organisation
- Difficulty holding multiple steps in mind
- Forgetting parts of a plan
- Losing track of priorities
- Difficulty organising complex tasks
- Forgetting deadlines and appointments
- Struggling to anticipate future needs
- Difficulty coordinating several tasks simultaneously
Task Completion
- Starting tasks and forgetting to finish them
- Forgetting the next step in a sequence
- Leaving tasks partially completed
- Moving between tasks without completing either
- Difficulty following recipes, instructions, or procedures
- Forgetting why a task was started
Time Management
- Forgetting scheduled commitments
- Losing track of time
- Underestimating how long tasks will take
- Missing deadlines
- Forgetting future intentions
- Difficulty planning ahead
Memory & Recall
- Frequently misplacing items
- Forgetting names shortly after hearing them
- Forgetting phone numbers, passwords, or codes
- Forgetting what was needed from a shop
- Walking into a room and forgetting why
- Forgetting what you intended to say mid-conversation
- Losing thoughts before expressing them
Emotional Regulation
- Difficulty remembering coping strategies when upset
- Reacting impulsively before considering consequences
- Difficulty holding perspective during emotional situations
- Becoming overwhelmed when managing multiple demands
- Increased frustration when information is lost
Self-Monitoring
- Forgetting personal goals
- Losing track of progress on tasks
- Difficulty monitoring performance
- Forgetting mistakes and repeating them
- Difficulty evaluating behaviour in real time
Social Functioning
- Forgetting details from conversations
- Forgetting birthdays or important events
- Losing track of conversational topics
- Interrupting because of fear of forgetting a thought
- Difficulty remembering social commitments
- Missing social cues while trying to hold information in mind
Learning & Academic Performance
- Difficulty following multi-step instructions
- Forgetting information while solving problems
- Difficulty performing mental calculations
- Poor retention of newly learned material
- Difficulty taking information from one context and applying it to another
- Problems with note-taking while listening
Everyday Life Examples
- Forgetting keys, phone, wallet, glasses, medications
- Leaving items behind when leaving home
- Starting household chores and becoming distracted
- Forgetting items on a shopping list
- Missing bills or paperwork
- Difficulty managing finances
- Forgetting where objects were placed moments earlier
Rejection Sensitivity
Rejection Sensitivity Explained
Rejection sensitivity (often termed Rejection Sensitivity Dysphoria, RSD) is
A pattern of intense emotional pain and rapid mood shifts
Triggered by perceived or actual rejection, criticism, or failure.
Test for Rejection Sensitivity
❑ Rejection sensitive dysphoria (RSD) is an intense vulnerability to the perception — not necessarily the reality — of being rejected, teased, or criticised by important people in your life.
❑ The response is well beyond all proportion to the nature of the event that triggered it.
❑ Rejection sensitive dysphoria is not a formal diagnosis, but rather one of the most common and disruptive manifestations of emotional dysregulation a but under-researched and oft-misunderstood symptom of ADHD, particularly in adults.
❑ RSD is a brain-based symptom that is likely an innate feature of ADHD.
❑ Often, this intense emotional reaction is hidden from other people. People experiencing it don’t want to talk about it because of the shame they feel over their lack control, or because they don’t want people to know about this intense vulnerability.
❑ RSD causes extreme emotional pain that may also be triggered by a sense of failure, or falling short — failing to meet either your own high standards or others’ expectation.
❑ Dysphoria is the Greek word meaning unbearable; its use emphasise the severe physical and emotional pain suffered by people with RSD when they encounter real or perceived rejection, criticism, or teasing.
What RSD looks like
❑ A Disproportionate emotional response (e.g., shame, sadness, anger) to minor criticism or neutral feedback
❑ A Rapid onset and intensity, often described as overwhelming or unbearable
❑ Threat-based interpretation of social cues (e.g., assuming disapproval or abandonment)
❑ Behavioural consequences: avoidance, people-pleasing, withdrawal, rumination, or sudden anger
Why it occurs in ADHD
❑ Emotion regulation deficits: ADHD involves reduced top-down modulation from prefrontal networks, limiting the ability to dampen emotional responses once triggered.
❑ Heightened limbic reactivity: Increased sensitivity of threat-detection systems (e.g., amygdala) amplifies perceived social threat.
❑ Learning history: Repeated experiences of criticism, failure, or misunderstanding (especially in undiagnosed ADHD) condition strong emotional responses to feedback.
❑ Dopaminergic vulnerability: Fluctuations in reward and motivation systems increase sensitivity to social evaluation.
Rejection Sensitivity Resources
Deficient Emotional Self Regulation in ADHD Video by Dr Barkley
An ADHD guide to Emotional Dysregulation & Rejection Sensitivity Dysphoria
By Dr William Dodson Video
Rejection Sensitivity & Social Anxiety By Dr Sharon Saline Video
The 7 Truths about Emotions & ADHD Video by Dr William Dobson
Managing Rejection Sensitivities in Real Time video By Dr Sharon Saline
How ADHD shapes perception, motivations & emotions Video
by Dr William Dobson
Managing big emotions in ADHD Video by Dr Sharon Saline
Article: 3 Defining Features of ADHD That Everyone Overlooks
Article: Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings
Article: Rejection Sensitivity Is Worse for Girls and Women with ADHD
Article: How ADHD Ignites RSD: Meaning & Medication Solutions
Article: New Insights Into Rejection Sensitive Dysphoria
Article: RSD Vs Bipolar Disorder
How RSD presents
Internalised RSD:
Presents as sudden, intense sadness that can imitate a major mood disorder, sometimes with suicidal ideation. This rapid shift in mood is often misdiagnosed as rapid-cycling bipolar disorder or major depressive episodes.
Externalised RSD:
Manifests as instantaneous rage toward the person or situation perceived as rejecting
Can be mistaken for anger dysregulation or oppositional behaviour .
Anticipatory RSD:
Leads individuals to constantly scan for potential rejection, even when uncertain.
May resemble social phobia, though the core fear is different
Social Anxiety Vs Rejection Sensitivity:
Social phobia: fear of public humiliation or negative scrutiny.
RSD: fear of losing love, approval, or respect.
Subjective Experience:
People often struggle to put RSD into words. They describe it as Intense, Awful, Terrible, Overwhelming
The emotional reaction is consistently tied to a perceived or real loss of approval, love, or respect.
Procrastination
Procrastination is putting off tasks that you intend to do, often until the last minute, even though you know delaying them may cause stress, problems, or missed opportunities.
In ADHD, this usually happens because the brain has difficulty getting started, maintaining motivation, or managing time, rather than because the person does not care.
1. Interest-Based Procrastination
- Tasks are delayed because they are boring, repetitive, or lack immediate reward.
- People often have little difficulty starting tasks they find interesting or stimulating.
2. Urgency-Seeking Procrastination
- Tasks are postponed until a deadline creates enough pressure to activate attention and motivation.
- Often described as, “I work best under pressure.”
3. Task Initiation Procrastination
- Difficulty starting tasks despite knowing they are important.
- Individuals often feel mentally “stuck” rather than unwilling.
4. Overwhelm Procrastination
- Large or complex tasks feel unmanageable, making it difficult to know where to begin.
- Frequently associated with planning and organisational difficulties.
5. Emotional Avoidance Procrastination
- Tasks are delayed because they evoke anxiety, fear of failure, perfectionism, or rejection sensitivity.
- Particularly common in adults who have experienced repeated criticism or negative experiences related to ADHD.
Why adults with ADHD procrastinate
Difficulty starting tasks
The brain has difficulty generating enough motivation to start tasks that are:
❑ Boring
❑ Repetitive
❑ Complex
❑ Mentally demanding
❑ Lacking immediate reward
❑ Low in interest
❑ Low in novelty (new)
❑ Prediction the activity will be time consuming
❑ Requires significant reading
❑ Important & not urgent
❑ Longer deadlines
❑ Repetitive activities
❑ Monotonous or boring activities
❑ Complex, requires concentration before starting
❑ Requires sustained mental effort or concentration
❑ Multi-step tasks
❑ Poorly defined activities
❑ Desire for task to be completed perfectly (perfectionism)
The problem is starting, not necessarily completing the task once engaged.
❑ Do the easiest or nicest things first of all
❑ Often postpone boring or difficult tasks
❑ Postpone tasks so that deadlines are missed
❑ Avoid monotonous work, such as administration
❑ Do not like reading due to mental effort
❑ Avoidance of tasks that require a lot of concentration
Reward Prediction Difficulties
The brain has difficulty assigning value to rewards that are distant in time.
This can contribute to:
❑ Procrastination
❑ Difficulty initiating boring tasks
❑ Interest-based attention
❑ Reliance on urgency or novelty
❑ Rapid loss of motivation
❑ Difficulty maintaining effort toward long-term goals
Neurodivergent Trauma
Articles on Neurodivergent Insights
Neurodivergent trauma describes the traumatic impact that can arise when autistic, ADHD, or AuDHD individuals repeatedly experience environments that do not accommodate their neurological differences.
While neurodivergence itself is not traumatic, ongoing experiences of misunderstanding, exclusion, sensory overload, social rejection, and pressure to conform can contribute to chronic stress and, for some people, symptoms of trauma or complex trauma.
According to studies by Adler et al., (2004) and Kessler et al. (2006), ADHD is actually a risk factor for developing PTSD. But there are a few other factors that contribute to this overlap too.
People with ADHD are at a higher risk for experiencing traumatic events in the first place (Ford et al., 2009). The nervous systems are more sensitive, which means that traumatic events can hit us even harder and make us more likely to develop PTSD (Biederman et al., 2012),
According to Crenshaw and Mayfield, (2021), early life trauma can act as a trigger for those who are genetically predisposed to ADHD.
Autism and trauma often co-occur, yet this intersection remains under-researched and seldom highlighted in clinical training. Autistic people are at a significantly higher risk of developing PTSD after experiencing trauma due to several factors that intertwine their neurobiology with their social experiences.
A recent study highlighted that even when criteria A of PTSD (Big T Trauma) is not met, Autistic people will often develop PTSD symptoms (Rumball et al., 2020).
While there are several factors, here are a few of the reasons Autistic people may be more vulnerable to developing PTSD following a traumatic experience.
□ We have more vulnerable neurobiology (more reactive nervous systems)
□ Increased risk of victimisation
□ Sensitive sensory profiles that encode memory with more intensity
□ The chronic stress and invalidation of navigating an allistic world.
Chronic Invalidation:
Many neurodivergent people experience repeated misunderstanding, criticism, bullying, social rejection, or pressure to behave in neurotypical ways. Over time, these experiences can contribute to persistent feelings of shame, hypervigilance, low self-worth, and difficulties trusting others.
Sensory Overload:
Everyday environments containing bright lights, loud noise, crowded spaces, unexpected touch, or strong smells may repeatedly overwhelm the nervous system. Frequent sensory overload can contribute to chronic stress, fatigue, emotional dysregulation, and heightened threat responses.
Masking:
Many autistic and AuDHD individuals consciously or unconsciously suppress natural ways of communicating, moving, or responding in order to fit social expectations. Although masking may reduce social conflict in the short term, maintaining it over long periods has been associated with increased anxiety, depression, exhaustion, autistic burnout, and reduced wellbeing.
Repeated Social Rejection:
Many neurodivergent people experience repeated experiences of being excluded, criticised, misunderstood, or feeling “different.” Over time, these experiences can increase sensitivity to rejection, reduce self-confidence, and contribute to chronic stress and trauma-related symptoms. This is particularly relevant for individuals with ADHD who experience significant rejection sensitivity.
Emotional Presentation
Anxiety & ADHD
Bipolar Affective Disorder (BPAD) & ADHD
Bipolar Affective Disorder (BPAD) & ADHD
Lifetime co-occurring psychiatric disorders in newly diagnosed adults with
ADHD and Autism Spectrum Disorder. (2020)
Video : Anxiety & ADHD: How they are related By Dr Barkley
Perfectionism & ADHD & Anxiety By Dr Sharon Saline video
Emotional Dysregulation & Rejection Sensitivity Dysphoria
By Dr William Dodson Video (60 mins)
ADHD & Social Anxiety
By Dr Sharon Saline
Article: Females with ADHD: a lifespan approach in girls and women.
BMC Psychiatry (2020)
Article: Annual Research Review: ADHD in girls and women: underrepresentation,
longitudinal processes, and key directions.
Stephen P. Hinshaw. Journal of Child Psychology and Psychiatry (2021)
Article: Adverse experiences of women with undiagnosed ADHD and the invaluable role of diagnosis.
Holden, E., Kobayashi-Wood, H. Sci Rep 15, 20945 (2025).
Article: ADHD and Sex Hormones in Females: A Systematic Review .
J Atten Disord. 2025 Apr 18;29(9):706–723.
Article : Exploring Female Students’ Experiences of ADHD and its Impact on Social, Academic, and Psychological Functioning.
J Atten Disord. 2023 Aug;27(10):1129-1155.
ADHD in women and girls is frequently overlooked when anxiety or depression is present, because ADHD symptoms—especially inattention, restlessness, and emotional lability—are misattributed to the mood or anxiety disorder. Women with ADHD have a high likelihood of also experiencing anxiety disorders (generalised anxiety disorder, social anxiety, panic disorder, or phobias).
Studies estimate that 25–50% of women with ADHD meet criteria for at least one anxiety disorder at some point. Undiagnosed and untreated ADHD can frequently lead to a secondary presentation of general anxiety , triggered by the consequences , in home and work life, of challenges with procrastination, distractibility, time management, planning and setting and following through on priorities.
Frequently Woman are often treated first for anxiety and/or depression, delaying recognition of the under diagnosed ADHD.
Bipolar Affective Disorder (BPAD) & ADHD
Bipolar Affective Disorder (BPAD) & ADHD
Bipolar Affective Disorder (BPAD) & ADHD
This section is included to explain where misdiagnosis can occur. Misdiagnosis of Bipolar Affective Disorder when it may be ADHD.
The principle difference is that ADHD symptoms are contextual and situational, whereas bipolar symptoms are not triggered by any external factors. In a stimulating and positive environment, people with ADHD remain in a good internal state. If the environment is not stimulating enough, they can become bored or agitated. People with ADHD always experience life in this manner. Their sensibility and orientation toward the world is the same, even when they move through mood states of different intensities. Patients with ADHD can more often control their feelings by changing their environment and stimuli.
Depressive bipolar symptoms, on the other hand, can feel like a dark cloud emerging from an internal emotional state. No situational reasons trigger these feelings of depression; patients just wake up feeling fundamentally different when depressed and not depressed
At RMC we have an in depth understanding of the difference in both presentations.
Dr Lewis has a specialisation in the psychiatric treatment of combined ADHD and Bipolar Affective Disorder, and has 27 years of experience of psychiatric treatment of Bipolar 1 disorder and Bipolar 2 disorder.
An ADHD guide to Emotional Dysregulation & Rejection Sensitivity Dysphoria
By Dr William Dodson Video
Bipolar was formerly called manic-depressive illness or manic depression.
Bipolar Affective Disorder & ADHD share 14 features in common.Two studies, the STAR*D program
and the STEP-BD program, both found a tremendous overlap between the disorders.
For clients with bipolar disorder, there is a 40% chance of having ADHD as well.
ADHD:
With adult ADHD, you see a very di!erent pattern; the moods of an individual with
ADHD are clearly triggered. The ADHD symptoms of rejection sensitive dysphoria, for example,
is triggered by the perception that a person has been rejected, teased, or criticised.
An observer might not be able to point out the trigger, but the individual
with ADHD can say, “When my mood shifts, I can always see a trigger.
My mood matches my perception of the trigger.” In technical terms, ADHD moods are “congruent.”
Mood changes are instantaneous and intense in individuals with ADHD, much
more so than in a neuro-typical person.
ADHD moods rarely persist for more than a few hours. It is extremely
rare for them to last two weeks. Typically, the mood can be altered by
the person with ADHD finding a new interest or occupation that
captures their interest and distracts them from the intense emotion.
Bipolar Mood Disorder:
Unlike ADHD, bipolar is a classic mood disorder that has a life of its own separate from
the events of a person’s life, outside of the person’s conscious will and control.
Bipolar moods aren’t necessarily triggered by something; they just come and they stay.
Usually, the onset is very gradual over a period of weeks to months.
To meet the bipolar definition, the mood must be continuously present for at least
two weeks and then its resolution must be gradual over a period of weeks to months.
Depression and anxiety are often the most visible coexisting conditions experienced by women who have ADHD. Both conditions can be present as separate disorders or as the result of struggling with undiagnosed or poorly treated ADHD for a very long time.
The two conditions frequently prompt women to seek medical and mental health care and can lead to a diagnosis of ADHD.
When treating a woman or girl who has ADHD and a co-occurring condition, the clinician or treatment specialist needs to address the condition causing the most difficulty at that moment, especially conditions that can be life-threatening if untreated.
ADHD Burnout
Understanding ADHD Burnout: Causes, Symptoms, and Coping Strategies
Living with ADHD (Attention Deficit Hyperactivity Disorder) means navigating a brain that works differently. While it comes with strengths—like creativity, energy, and unique problem-solving—it also brings daily challenges around focus, organization, and emotional regulation. Add in the constant pressure to keep up in a fast-paced world, and many people with ADHD eventually hit a wall: ADHD burnout.
This type of burnout is often misunderstood, but it’s a very real and overwhelming experience.
Let’s dive into what it is, why it happens, and how to recover when you feel completely drained.
What Is ADHD Burnout?
ADHD burnout is a state of mental, emotional, and physical exhaustion. It happens when someone with ADHD pushes themselves too hard—often trying to meet external expectations—while also managing the everyday demands that ADHD makes harder.
Some of the key drivers include:
- Constant overwhelm from tasks that feel impossible to finish
- Pressure to “keep up” with neurotypical peers
- The heavy mental load of masking symptoms in work or social settings
- Lack of rest, self-care, or proper support
Over time, this pressure adds up, leaving you feeling depleted, stuck, and hopeless.
Causes of ADHD Burnout
There isn’t just one reason ADHD burnout happens—it’s usually a mix of factors. Here are some of the most common:
Cognitive Overload
Because ADHD impacts executive function, everyday tasks like planning, prioritizing, or meeting deadlines require extra effort. That constant mental strain leads to fatigue.
Hyperfocus (and the Crash After)
When someone with ADHD locks into a task, they can work for hours straight—forgetting meals, breaks, or rest. Eventually, the body and brain crash, creating burnout.
Inconsistent Motivation
Tasks that feel boring can be almost impossible to start, while interesting ones may lead to overwork. That rollercoaster creates stress and imbalance.
Social and Emotional Stress
ADHD often comes with feeling misunderstood, judged, or “not enough.” Social interactions can feel draining, and emotional stress compounds the burnout cycle.
Masking
Trying to hide ADHD traits in professional or social settings takes huge effort. Over time, that performance is exhausting.
Sleep Struggles
Many people with ADHD wrestle with insomnia, racing thoughts, or irregular sleep patterns. Poor rest makes recovery from burnout even harder.
Signs and Symptoms of ADHD Burnout
ADHD burnout can look different for everyone, but some common signs include:
- Emotional exhaustion – feeling empty, drained, or numb
- Difficulty prioritizing – getting stuck, unable to decide what to do first
- Physical fatigue – tired no matter how much you rest
- Impulsivity – turning to quick “escapes” like shopping, eating, or scrolling
- Social withdrawal – avoiding people because it feels overwhelming
- Brain fog – struggling to concentrate, even on things you enjoy
- Mood swings or irritability – snapping over small things
- Declining performance – work, school, or relationships start to suffer
- Hopelessness – believing you’ll never “catch up”
Coping Strategies: How to Recover from ADHD Burnout
The good news is: recovery is possible. It takes patience, self-compassion, and strategies that work with your ADHD brain—not against it. Here are some steps to help you reset:
1. Recognize the Signs Early
Burnout sneaks up on you. Noticing the red flags (irritability, brain fog, emotional fatigue) gives you a chance to pause before things get worse.
2. Lower the Bar
Set realistic expectations. Perfectionism and impossible standards feed burnout—aim for “good enough” instead of “perfect.”
3. Use ADHD-Friendly Tools
- Break tasks into smaller steps
- Use timers (Pomodoro method works well)
- Create visual reminders like task boards or sticky notes
4. Build in Breaks
Schedule downtime the way you would schedule a meeting. Your brain needs recovery time.
5. Practice Self-Compassion
ADHD isn’t about laziness or weakness—it’s neurological. Speak to yourself kindly and give yourself permission to rest.
Causes of ADHD
Prenatal and Early Life Risk Factors of ADHD: What Research Says — and What Parents Can Do.
Additude Article September 2025
For most people with ADHD, many genetic and environmental risk factors accumulate to cause the disorder (Faraone et al., 2015).
The environmental risks for ADHD exert their effects very early in life, during the fetal or early postnatal period. In rare cases, however, ADHD-like symptoms can be caused by extreme deprivation early in life (Kennedy et al., 2016), a single genetic abnormality (Faraone and Larsson, 2018), or traumatic brain injury early in life (Stojanovski et al., 2019).
These findings are helpful to understand the causes of ADHD but are not useful for diagnosing the disorder.
The associations between aspects of the environment and the onset of ADHD have attained a very high level of evidential support. Some have strong evidence for a causal role but, for most, the possibility remains that these associations are due to correlated genetic and environmental effects.
For this reason, we refer to features of the pre- and post-natal environments that increase risk for ADHD as correlates, rather than causes.
The genetic and environmental risks described below are not necessarily specific to ADHD.
ADHD can also be the result of rare single gene defects (Faraone and Larsson, 2018) or abnormalities of the chromosomes (Cederlof et al., 2014). When the DNA of 8000+ children with autism spectrum disorder (ASD) and/or ADHD and 5000 controls was analyzed, those with ASD and those with ADHD had an increased rate of rare genetic mutations compared with controls (Satterstrom et al., 2019).
A review of 37 twin studies from the United States, Europe, Scandinavia, and Australia found that genes and their interaction with the environment must play a substantial role in causing ADHD (Faraone and Larsson, 2018; Larsson et al., 2014a; Pettersson et al., 2019).
In a genomewide study, an international team analysed DNA from over 20,000 people with ADHD and over 35,000 without ADHD from the United States, Europe, Scandinavia, China, and Australia. They identified many genetic risk variants, each having a small effect on the risk for the disorder (Demontis et al., 2019).
This study confirmed a polygenic cause for most cases of ADHD, meaning that many genetic variants, each having a very small effect, combine to increase risk for the disorder. The polygenic risk for ADHD is associated with general psychopathology (Brikell et al., 2020) and several psychiatric disorders (Lee et al., 2019a,b
Family, twin, and DNA studies show that genetic and environmental influences are partially shared between ADHD and many other psychiatric disorders (e.g. schizophrenia, depression, bipolar disorder, autism spectrum disorder, conduct disorder, eating disorders, and substance usedisorders) and with somatic disorders (e.g. migraine and obesity) (Demontis et al., 2019) (Faraone and Larsson, 2018) (Ghirardi et al., 2018) (Lee et al., 2019a,b) (Lee et al., 2013) (Anttila et al., 2018; Tylee et al., 2018) (van Hulzen et al., 2017) (Vink and Schellekens, 2018) (Brikell et al., 2018) (Chen et al., 2019a) (Yao et al., 2019).
However, there is also a unique genetic risk for ADHD.
Evidence of shared genetic and environmental risks among disorders suggest that these disorders also share a pathophysiology in the biological pathways that dysregulate neurodevelopment and create brain variations leading to disorder onset.
Very large studies of families suggest that ADHD shares genetic or familial causes with autoimmune diseases (Li et al., 2019), hypospadias (Butwicka et al., 2015), and intellectual disability (Faraone and Larsson, 2018).
ADHD Brain
References
Foundational ADHD Neurobiology
- Russell A. Barkley (2015). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed.). Guilford Press.
- Russell A. Barkley (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65–94.
Dopamine and ADHD
- Nora D. Volkow, Wang, G. J., Newcorn, J., et al. (2011). Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway. Molecular Psychiatry, 16(11), 1147–1154.
- Nora D. Volkow, Wang, G. J., Kollins, S. H., et al. (2009). Evaluating dopamine reward pathway in ADHD: Clinical implications. JAMA, 302(10), 1084–1091.
- Philip Asherson, Buitelaar, J., Faraone, S. V., & Rohde, L. A. (2016). Adult ADHD and comorbid disorders: Clinical implications of a dimensional approach. BMC Psychiatry, 16, 301.
Salience, Motivation and Reward Processing
- Edmund Sonuga-Barke (2005). Causal models of ADHD: From common simple deficits to multiple developmental pathways. Biological Psychiatry, 57(11), 1231–1238.
- Edmund Sonuga-Barke (2011). Neuropsychological heterogeneity in ADHD: Reward and motivational pathways. Behavioral Brain Research, 215(1), 1–8.
- Samuele Cortese, Kelly, C., Chabernaud, C., et al. (2012). Toward systems neuroscience of ADHD: A meta-analysis of functional MRI studies. American Journal of Psychiatry, 169(10), 1038–1055.
Executive Functioning and Dopamine Networks
- Adele Diamond (2005). Attention-deficit disorder and the prefrontal cortex. In Development and Psychopathology, 17(3), 807–825.
- Adele Diamond (2013). Executive functions. Annual Review of Psychology, 64, 135–168.
- Arnsten, A. F. T. (2009). The emerging neurobiology of attention deficit hyperactivity disorder: The key role of the prefrontal association cortex. Journal of Pediatrics, 154(5), I–S43.
Current Consensus Reviews
- Faraone, S. V., Asherson, P., Banaschewski, T., et al. (2021). The World Federation of ADHD International Consensus Statement: 208 evidence-based conclusions about ADHD. Neuroscience & Biobehavioral Reviews, 128, 789–818.
- Cortese, S., Adamo, N., Del Giovane, C., et al. (2018). Comparative efficacy and tolerability of medications for ADHD in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727–738.