BACKGROUND AND AIM: The use of acupuncture is becoming increasingly popular in the management of attention-deficit/hyperactivity disorder (ADHD). This systematic review consolidates evidence on acupuncture's efficacy and safety for treating ADHD in children and adolescents. METHODS: Controlled clinical trials assessing acupuncture against waitlist-control, placebo or active controls, or as an adjunct treatment were systematically searched across seven databases from inception to November 2024. Cochrane criteria were adhered to. RESULTS: We reviewed 25 studies with 1,758 participants. None compared acupuncture to placebo or behavioral therapy. Subdomain analysis of the Conners' Parent Rating Scale indicated that acupuncture and Methylphenidate had comparable effects on Conduct Problems [SMD = 0.03, 95%CI (-0.93, 0.99), p = 0.95] and Learning Problems [SMD = 0.29, 95%CI (-0.38, 0.97), p = 0.39], but acupuncture was more effective in controlling Impulsive/Hyperactive symptoms [SMD = -1.71, 95%CI (-2.08, -1.35), p <
0.01]. Insufficient sample size prevented confirmation of potential false positives. Acupuncture was safer and reduced Methylphenidate-related side-effects, including appetite loss, sleep disturbances, dry mouth, abdominal pain, and constipation. Acupuncture combined with behavioral therapy outperformed behavioral therapy alone in improving Psychosomatic symptoms [SMD = -0.88, 95%CI (-1.54, -0.23), p <
0.01]. In the Integrated Visual and Auditory Continuous Performance Test, ADHD patients receiving acupuncture alongside conventional care performed better than those receiving conventional care alone. Nevertheless, the methodological quality of the included trials was very low to low, with significant bias risk, and 88% lacked follow-up. CONCLUSIONS: Acupuncture may offer an alternative for children and adolescents with ADHD who are intolerant to medication (primarily Methylphenidate). When combined with medication or behavioral therapy, it appeared more effective in ameliorating hyperactivity/impulsivity, inattention and conduct problems than standard treatments alone. It is also safe and well-tolerated. However, the supporting evidence is of low quality, and well-designed randomized controlled trials are needed. Thus, it is premature to recommend acupuncture as an alternative or adjunctive therapy for ADHD management.