Nonpharmacological treatments
13 April 2020
Behavioral and psychosocial treatments

Behavioral interventions are used to identify and provide positive reinforcement of adaptive coping behaviors to reduce problem behaviors. Behavior parent training and social skills training are one of the primarily recommended alternatives to medication management of ADHD. They are usually regarded as first-line treatments for very young children or those with mild to moderate ADHD. They are also the standard addon to medication treatment for severe presentations at any age. In summary, most guidelines recommend behavioral interventions for ADHD in any situation, either alone or in combination with medication treatment and these are the most frequently used nonpharmacological treatment among children and adolescents.

The efficacy of behavioral therapy in the treatment of ADHD is a matter of controversy. Current appraisals of the available evidence do not agree on whether the balance of evidence supports or refutes the efficacy of psychosocial treatments for ADHD. One meta-analysis concluded that behavioral treatments were effective for ADHD, and a review for the Agency for Health Care Research and Quality concluded that the A. Caye et al. evidence for positive effects of behavioral treatment on preschool children was strong enough to guide clinical practice. However, a Cochrane systematic review and meta-analysis of randomized trials concluded that while BPT may have a positive effect on the behavior of children and adolescents with ADHD, the evidence is not strong enough to guide clinical practice. A separate Cochrane meta-analysis concluded that the evidence was insufficient to support social skills training for adolescents. Several clinical guidelines have recommended both BPT and social skills as behavioral treatments. Some of these discrepancies may be explained by the type of rater considered by reviews. Two recent meta-analyses identified a moderate and statistically significant pooled effect size for behavioral therapies on ADHD symptoms when all probably unblinded raters were included but that this effect was not maintained when considering only probably blinded raters. The same group did, however, confirm that behavioral therapies were effective in improving positive parenting and conduct problems of children with ADHD, even on blinded ratings.
Nonpharmacologic treatments for Attention-Deficit/Hyperactivity Disorder:
✔ Behavioral and psychosocial treatments;
✔ Cognitive training;⠀
✔ Neurofeedback.
Cognitive training

Cognitive training strategies aim to reduce ADHD symptoms by improving performance in specific neuropsychological functions associated with ADHD (e.g., attention, inhibitory control, and working memory). Cognitive training programs are usually delivered through electronic interfaces such as computers or mobile phones and are designed to be appealing to the user (i.e., resembling videogames). Performance is continually reassessed so that training is adaptive.
A recent meta-analysis evaluated the effects, across 16 randomized clinical trials, for probably blinded and potentially unblinded raters separately. The conclusions match those of previous meta-analyses, indicating moderate efficacy in improving the neuropsychological functions targeted by the intervention but a less clear effect on symptoms. The effect size for total ADHD symptoms and inattentive symptoms was moderate and significant when rated by a potentially un-blinded rater. The estimates decreased when outcomes were rated by a probably blinded rater. Of note, the effect size was much larger for programs that included multiple process training (i.e., targeting more than one executive functioning) compared to those that focused on just on the cognitive process. However, for the multiple process studies only potentially unblinded ratings were available. In summary, the evidence so far available suggests that cognitive training has no effect on core ADHD symptoms or other functional outcomes for ADHD patients.


Neurofeedback (NF), or electroencephalogram (EEG) biofeedback, is a relatively new, noninvasive approach for treating multiple brain-related conditions.

Caye, A., Swanson, J. M., Coghill, D., & Rohde, L. A. (2018). Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Molecular Psychiatry. doi:10.1038/s41380-018-0116-3

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