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Which non-pharmacological therapies are available for ADHD?

It is recommended that non-pharmacological interventions are focused on the individual with ADHD as they mature and become ‘agents of implementation’ in their care.1 Non-pharmacological treatments for ADHD may involve behavioural, psychological, social, educational and lifestyle interventions (Figure 1).2-8 Non-pharmacological treatments may be modified for key developmental stages, reflecting both the most problematic behavioural symptoms at that stage in time, and the individual’s level of understanding (Figure 2).1

Figure 1: Examples of non-pharmacological therapies for ADHD. Figure developed from multiple sources.2-8

Examples of non-pharmacological therapies for ADHD

Figure 2: Non-pharmacological treatments for ADHD: a lifespan approach. Reproduced with permission from Young S and Amarasinghe JM. J Child Psychol Psychiatry 2010; 51: 116-133.1

A lifespan approach to non-pharmacological treatments for ADHD

Non-pharmacological treatments for ADHD may be modified across the lifespan to reflect the most problematic behavioural symptoms and the individual’s level of understanding.1

What is parent-led behavioural therapy for ADHD?

Parent-led behavioural therapy aims to treat the core symptoms of ADHD and associated oppositional and non-compliant behaviour.3,9 This therapy combines behaviour management techniques with novel therapeutic elements based on developmental models of social and cognitive development.3 Parents are taught behavioural strategies to address parent‒child interactions, promote positive behaviour and reduce problematic behaviour.10 Parent-led behavioural therapy for ADHD is either group-based or led by a therapist on an individual basis, and can be performed in the home or in an outpatient setting.9-12 There are several manual-based models for parent-led behavioural therapy, including the Positive Parenting Program, the Incredible Years® programme and Parent-Child Interaction Therapy.10,12

What is classroom-led behavioural therapy for ADHD?

The classroom presents a number of demands that children with ADHD may struggle with, such as: following rules; interacting with peers; avoiding interruption of the teacher and peers; engaging in teaching activities; and self-organisation.13 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.13 These interventions can be delivered by mainstream teachers following appropriate training, and combine behaviour modification and cognitive behavioural modification techniques.13,14

What is cognitive behavioural therapy for ADHD?

Cognitive behavioural therapy involves self-instructional training administered in a group or individual basis, to help the individual with ADHD to develop a more planned and reflective approach to thinking and behaving, including social interactions.4 Cognitive behavioural therapy can also help individuals with ADHD adopt a more reflective, systematic and goal-oriented approach to everyday tasks, activities and problem solving, including academic functioning.15

What is psychoeducation for ADHD?

Psychoeducation can be viewed as the provision of information regarding ADHD to individuals with the disorder and their families or the people close to them.16-19 Psychoeducation may be provided using books or other forms of text and Internet resources.17 The media may be recognised as an effective tool to transmit information and attitudes, but can also be a source of false beliefs and expectations.17 The aim of a psychoeducation programme is to: provide clear information at a level that this appropriate for the recipient; include the individual with ADHD, their family and their broader environment; and promote education as an active and ongoing process where attitudes are shaped and changed by the information provided.17 The use of psychoeducation programmes may help families and people with ADHD become active decision-makers in their therapy.17

What is neurofeedback for ADHD?

Neurofeedback typically involves computer-based exercises, which provide feedback regarding attention levels to enable behavioural training.5,20

Brain activities of the individual with ADHD are measured by electroencephalogram whilst performing a task, usually a computer game, in which individuals receive points when their brain activity shows positive changes.6,20 Neurofeedback gives immediate feedback on attention levels during a task.5 Individuals with ADHD are then trained to monitor and change their brainwave patterns.5

What exercise and diet interventions are available for ADHD?

Current recommendations, including the National Institute of Health and Care Excellence (NICE) guidelines 2018, advocate the importance of regular exercise and a balanced diet and good nutrition in children, adolescents and adults with ADHD.2 Some studies have assessed the effects of dietary interventions for the management of ADHD symptoms – such as restriction or elimination diets, or dietary supplementation with iron, vitamins, minerals and omega-3/6 fatty acids.7,21-29

  1. Young S, Amarasinghe JM. Practitioner Review: Non-pharmacological treatments for ADHD: a lifespan approach. J Child Psychol Psychiatry 2010; 51: 116-133.
  2. NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed January 2021.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Cairncross M, Miller CJ. The effectiveness of mindfulness-based therapies for ADHD: a meta-analytic review. J Atten Disord 2020; 24: 627-643.
  9. 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.
  10. Loren RE, Vaughn AJ, Langberg JM, et al. Effects of an 8-session behavioral parent training group for parents of children with ADHD on child impairment and parenting confidence. J Atten Disord 2015; 19: 158-166.
  11. Daley D, O’Brien M. A small-scale randomized controlled trial of the self-help version of the New Forest Parent Training Programme for children with ADHD symptoms. Eur Child Adolesc Psychiatry 2013; 22: 543-552.
  12. Mulqueen JM, Bartley CA, Bloch MH. Meta-analysis: parental interventions for preschool ADHD. J Atten Disord 2013; 19: 118-124.
  13. 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.
  14. Hodgson K, Hutchinson AD, Denson L. Nonpharmacological treatments for ADHD: a meta-analytic review. J Atten Disord 2014; 18: 275-282.
  15. Prevatt F, Yelland S. An empirical evaluation of ADHD coaching in college students. J Atten Disord 2015; 19: 666-677.
  16. 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.
  17. 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.
  18. 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.
  19. 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 2020; 24: 768-779.
  20. 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.
  21. Kean JD, Sarris J, Scholey A, et al. Reduced inattention and hyperactivity and improved cognition after marine oil extract (PCSO-524®) supplementation in children and adolescents with clinical and subclinical symptoms of attention-deficit hyperactivity disorder (ADHD): a randomised, double-blind, placebo-controlled trial. Psychopharmacology (Berl) 2017; 234: 403-420.
  22. Assareh M, Davari Ashtiani R, Khademi M, et al. Efficacy of polyunsaturated fatty acids (PUFA) in the treatment of attention deficit hyperactivity disorder. J Atten Disord 2017; 21: 78-85.
  23. Barragán E, Breuer D, Döpfner M. Efficacy and safety of omega-3/6 fatty acids, methylphenidate, and a combined treatment in children with ADHD. J Atten Disord 2017; 21: 433-441.
  24. Konofal E, Lecendreux M, Deron J, et al. Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol 2008; 38: 20-26.
  25. Rucklidge JJ, Frampton CM, Gorman B, et al. Vitamin-mineral treatment of attention-deficit hyperactivity disorder in adults: double-blind randomised placebo-controlled trial. Br J Psychiatry 2014; 204: 306-315.
  26. Johnson M, Mansson JE, Ostlund S, et al. Fatty acids in ADHD: plasma profiles in a placebo-controlled study of omega 3/6 fatty acids in children and adolescents. Atten Defic Hyperact Disord 2012; 4: 199-204.
  27. Stevenson J, Buitelaar J, Cortese S, et al. Research review: the role of diet in the treatment of attention-deficit/hyperactivity disorder–an appraisal of the evidence on efficacy and recommendations on the design of future studies. J Child Psychol Psychiatry 2014; 55: 416-427.
  28. Pelsser LM, Frankena K, Toorman J, et al. Diet and ADHD, reviewing the evidence: a systematic review of meta-analyses of double-blind placebo-controlled trials evaluating the efficacy of diet interventions on the behavior of children with ADHD. PLoS One 2017; 12: e0169277.
  29. Huss M, Volp A, Stauss-Grabo M. Supplementation of polyunsaturated fatty acids, magnesium and zinc in children seeking medical advice for attention-deficit/hyperactivity problems – an observational cohort study. Lipids Health Dis 2010; 9: 105.
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