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Non-pharmacological treatments for ADHD may involve behavioural, psychological, social, educational and lifestyle interventions.1-7

Figure: Non-pharmacological therapies. Figure developed from multiple sources.1-7

Non-pharmacological treatments: a lifespan approach

A lifespan approach

Non-pharmacological interventions should become increasingly focused on the individual as patients mature and become ‘agents of implementation’ in their care.8 Psychosocial interventions play a particularly important role during key life transitions, e.g. the transition between adolescence and adulthood.9 Treatments should be modified for key developmental stages, reflecting both the most problematic behavioural symptoms at that stage in time, and the patient’s level of understanding.8

Figure: Non-pharmacological treatments: a lifespan approach. Reproduced with kind permission from Young S and Amarasinghe JM. J Child Psychol Psychiatry 2010; 51: 116-133.8

Non-pharmacological treatments: a lifespan approach

Parent-led behavioural therapy

Parent-led behavioural therapy aims to treat the core symptoms of ADHD and associated oppositional and non-compliant behaviour.2,10 It combines behaviour management techniques with novel therapeutic elements based on developmental models of social and cognitive development.2

Classroom-led behavioural therapy

Classroom-led behavioural therapies are delivered in a real-world situation that provides training on the expected behaviour, within the context in which it is required.11 These interventions can be delivered by mainstream teachers following appropriate training, and combine behaviour modification and cognitive behavioural modification techniques.11,12

Cognitive behavioural therapy (CBT)

CBT consists of self-instructional training administered on an individual or group basis. It helps the patient to:

  • Develop a more planned and reflective approach to thinking and behaving, including social interactions.3
  • Adopt a more reflective, systematic and goal-oriented approach to everyday tasks, activities and problem solving, including academic functioning.13

Regular sessions of CBT have been shown to reduce ADHD symptoms in children, adolescents and adults.14-23

Psychoeducation

Psychoeducation can be viewed as the provision of information regarding ADHD to individuals with the disorder and their families/people close to them.24-27

Psychoeducation programmes are not based on CBT approaches, or parent-led behaviour training, but are designed to inform patients and relatives about ADHD and its treatment, to help facilitate understanding and handling of the condition.25

Figure: Psychoeducation – overview. Figure developed from multiple sources.9,24-27

Psychoeducation overview

Figure: Types of psychoeducation. Reproduced with kind permission from Ferrin M and Taylor E. Future Neurol 2011; 6: 399-413.25

Neurofeedback

Neurofeedback typically involves computer-based exercises, which provide feedback regarding attention levels to enable behavioural training.4,28

Patients’ brain activities are measured by electroencephalogram whilst performing a task, usually a computer game, in which patients receive points when their brain activity shows positive changes.5,28

This gives immediate feedback to patients on their level of attention during a task.4 Patients are then trained to monitor and change their brainwave patterns.4

Exercise and diet

Current recommendations, including National Institute of Health and Care Excellence (NICE) guidelines, advocate the importance of regular exercise, a balanced diet and good nutrition for children, adolescents and adults with the disorder.1

  1. NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed February 2019.
  2. Daley D, van der Oord S, Ferrin M, et al. Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains. J Am Acad Child Adolesc Psychiatry 2014; 53: 835-847.
  3. Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder — first upgrade. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1): I/7-I/30.
  4. Steiner NJ, Frenette EC, Rene KM, et al. In-school neurofeedback training for ADHD: sustained improvements from a randomized control trial. Pediatrics 2014; 133: 483-492.
  5. Meisel V, Servera M, Garcia-Banda G, et al. Neurofeedback and standard pharmacological intervention in ADHD: a randomized controlled trial with six-month follow-up. Biol Psychol 2013; 94: 12-21.
  6. Sonuga-Barke EJ, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 2013; 170: 275-289.
  7. Cairncross M, Miller CJ. The effectiveness of mindfulness-based therapies for ADHD: a meta-analytic review. J Atten Disord 2016; Epub ahead of print.
  8. Young S, Amarasinghe JM. Practitioner review: Non-pharmacological treatments for ADHD: a lifespan approach. J Child Psychol Psychiatry 2010; 51: 116-133.
  9. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Fourth Edition. Toronto, ON; CADDRA, 2018.
  10. Thompson MJ, Laver-Bradbury C, Ayres M, et al. A small-scale randomized controlled trial of the revised new forest parenting programme for preschoolers with attention deficit hyperactivity disorder. Eur Child Adolesc Psychiatry 2009; 18: 605-616.
  11. Miranda A, Presentación MJ, Soriano M. Effectiveness of a school-based multicomponent program for the treatment of children with ADHD. J Learn Disabil 2002; 35: 546-562.
  12. Hodgson K, Hutchinson AD, Denson L. Nonpharmacological treatments for ADHD: a meta-analytic review. J Atten Disord 2014; 18: 275-282.
  13. Prevatt F, Yelland S. An empirical evaluation of ADHD coaching in college students. J Atten Disord 2015; 19: 666-677.
  14. Vidal R, Castells J, Richarte V, et al. Group therapy for adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2015; 54: 275-282.
  15. Pettersson R, Söderström S, Edlund-Söderström K, et al. Internet-based cognitive behavioral therapy for adults with ADHD in outpatient psychiatric care: a randomized trial. J Atten Disord 2017; 21: 508-521.
  16. Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 2010; 304: 875-880.
  17. Virta M, Vedenpaa A, Gronroos N, et al. Adults with ADHD benefit from cognitive-behaviorally oriented group rehabilitation: a study of 29 participants. J Atten Disord 2008; 12: 218-226.
  18. Solanto MV, Marks DJ, Mitchell KJ, et al. Development of a new psychosocial treatment for adult ADHD. J Atten Disord 2008; 11: 728-736.
  19. Solanto MV, Marks DJ, Wasserstein J, et al. Efficacy of meta-cognitive therapy for adult ADHD. Am J Psychiatry 2010; 167: 958-968.
  20. Knouse LE, Teller J, Brooks MA. Meta-analysis of cognitive-behavioral treatments for adult ADHD. Journal of consulting and clinical psychology 2017; 85: 737-750.
  21. Fehlings DL. Attention deficit hyperactivity disorder: does cognitive behavioral therapy improve home behavior? J Dev Behav Pediatr 1991; 12: 223-228.
  22. Hoekzema E, Carmona S, Tremols V, et al. Enhanced neural activity in frontal and cerebellar circuits after cognitive training in children with attention-deficit/hyperactivity disorder. Hum Brain Mapp 2010; 31: 1942-1950.
  23. Hoekzema E, Carmona S, Ramos-Quiroga JA, et al. Training-induced neuroanatomical plasticity in ADHD: a tensor-based morphometric study. Hum Brain Mapp 2011; 32: 1741-1749.
  24. Montoya A, Colom F, Ferrin M. Is psychoeducation for parents and teachers of children and adolescents with ADHD efficacious? A systematic literature review. Eur Psychiatry 2011; 26: 166-175.
  25. Ferrin M, Taylor E. Child and caregiver issues in the treatment of attention deficit-hyperactivity disorder: education, adherence and treatment choice. Future Neurol 2011; 6: 399-413.
  26. Ferrin M, Moreno-Granados JM, Salcedo-Marin MD, et al. Evaluation of a psychoeducation programme for parents of children and adolescents with ADHD: immediate and long-term effects using a blind randomized controlled trial. Eur Child Adolesc Psychiatry 2014; 23: 637-647.
  27. Ferrin M, Perez-Ayala V, El-Abd S, et al. A randomized controlled trial evaluating the efficacy of a psychoeducation program for families of children and adolescents with ADHD in the United Kingdom: results after a 6-month follow-up. J Atten Disord 2016; Epub ahead of print.
  28. Bink M, van Nieuwenhuizen C, Popma A, et al. Behavioral effects of neurofeedback in adolescents with ADHD: a randomized controlled trial. Eur Child Adolesc Psychiatry 2015; 24: 1035-1048.
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