Non-pharmacological interventions for attention-deficit hyperactivity disorder in children and adolescents

Abstract

Attention-deficit hyperactivity disorder (ADHD) affects approximately 5% of children and adolescents globally and is associated with negative life outcomes and socioeconomic costs. First-generation ADHD treatments were predominantly pharmacological; however, increased understanding of biological, psychological, and environmental factors contributing to ADHD has expanded non-pharmacological treatment possibilities. This Review provides an updated evaluation of the efficacy and safety of non-pharmacological treatments for paediatric ADHD, discussing the quality and level of evidence for nine intervention categories. Unlike medication, no non-pharmacological treatments showed a consistent strong effect on ADHD symptoms. When considering broad outcomes (eg, impairment, caregiver stress, and behavioural improvement), multicomponent (cognitive) behaviour therapy joined medication as a primary ADHD treatment. With respect to secondary treatments, polyunsaturated fatty acids showed a consistent modest effect on ADHD symptoms when taken for at least 3 months. Additionally, mindfulness and multinutrient supplementation with four or more ingredients showed modest efficacy on non-symptom outcomes. All other non-pharmacological treatments were safe; clinicians might tolerate their use but should educate families of childrenand adolescents with ADHD on the disadvantages, including costs, burden to the service user, absence of proven efficacy relative to other treatments, and delay of proven treatment.

Figure 1:. A theoretical model of factors that influence ADHD severity and the treatments that target them

ADHD treatments and the mechanisms that they are proposed to target are illustrated. Level of evidence for the effect of treatments on targets are summarised in the appendix (pp 120–237). BT=behaviour therapy. GABA=γ-aminobutyric-acid.

Figure 2:. Venn diagrams representing components of behaviour therapy interventions

Operant reinforcement was present in almost all behaviour therapy packages (90·2%), as was parent skills training (82·4%). Youth (55·9%) and teacher (18·6%) skills training were less common. Youth skills training included social (30·4%), problem-solving (30·4%), organisation (28·4%), and metacognitive (13·7%) skills. Motivational interviewing, an engagement strategy, was bundled into 6·9% of packages. On average, treatments possessed approximately three components. Numbers indicate the number of intervention packages that have that component.