are several very effective drugs for ADHD and that treatment guidelines from professional organization view this drugs as the first line of treatment for people with ADHD. The only exception is for preschool children where medication is only the first line treatment for severe ADHD; the guidelines recommend that other preschoolers with ADHD be treated with non-pharmacologic treatments, when available.

Despite these guidelines, some parents and patients have been persuaded by the media or the Internet that ADHD drugs are dangerous and that non-drug alternatives are as good or even better. Parents and patients may also be influenced by media reports that doctors overprescribe ADHD drugs or that these drugs have serious side effects. Such reports typically simplify and/or exaggerate results from the scientific literature. Thus, many patients and parents of ADHD children are seeking non-drug treatments for ADHD.

What are these non-pharmacologic treatments and do they work? My next series of blogs will discuss each of these treatments in detail. Here I’ll give an overview of my evidenced-based taxonomy of nonpharmacologic treatments for ADHD described in more detail in a book I recently edited (Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.). I use the term “evidenced-based” in the strict sense applied by the Oxford Center for Evidenced Based Medicine (OCEBM;

Most of the non-drug treatments for ADHD fall into three categories: behavioral, dietary and neurocognitive. Behavioral interventions include training parents to optimize methods of reward and punishment for their ADHD child, teaching ADHD children social skills and helping teachers apply principles of behavior management in their classrooms. Cognitive behavior therapy is a method that teaches behavioral and cognitive skills to adolescent and adult ADHD patients. Dietary interventions include special diets that exclude food colorings or eliminate foods believed to cause ADHD symptoms. Other dietary interventions provide supplements such as iron, zinc or omega-3 fatty acids. The neurocognitive interventions typically use a computer based learning setup to teach ADHD patients cognitive skills that will help reduce ADHD symptoms.

There are two metrics to consider when thinking about the evidence-base for these methods. The first is the quality of the evidence. For example, a study of 10 patients with no control group would be a low quality study but a study of 100 patients randomized to either a treatment or control group would be of high quality and the quality would be even higher if the people rating patient outcomes did not know who was in each group.

The second metric is the magnitude of the treatment effect. Does the treatment dramatically reduce ADHD symptoms or does it have only a small effect? This metric is only available for high quality studies that compare people treated with the method and people treated with a ‘control’ method that is not expected to affect ADHD.

I used a statistical metric to quantify the magnitude of effect. Zero means no effect and larger numbers indicate better effects on treating ADHD symptoms. For comparison, the effect of stimulant drugs for ADHD is about 0.9, which is derived from a very strong evidence base. The effects of dietary treatments are smaller, about 0.4 to 0.5, but because the quality of the evidence is not strong, these results are not certain and the studies of food color exclusions apply primarily to children who have high intakes of such colorants.

In contrast to the dietary studies, the evidence base for behavioral treatments is excellent but the effects of these treatments of ADHD symptoms is very small, less than 0.1. Supplementation with omega-3 fatty acids also has a strong evidence base but the magnitude of effect is also small (0.1 to 0.2). The neurocognitive treatments have modest effects on ADHD symptoms (0.2 to 0.4) but their evidence base is weak.

This review of non-drug treatments explains why ADHD drug treatments are usually used first. Their evidence base is stronger and they are more effective in reducing ADHD symptoms. There is, however, a role for some non-drug treatments. I’ll be discussing that in subsequent blog posts.

See more evidenced based information about ADHD at

References :
Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.
Faraone, S. V. & Antshel, K. M. (2014). Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD. Child Adolesc Psychiatr Clin N Am 23, 965-72.

Stephen_Faraone_PhD_AIA_2016_XM7MQd.png.jpgMyth: ADHD is caused by poor parenting or teaching.
Parents and teachers are popular targets for those who misunderstand ADHD. This myth posits that ADHD would not exist if parents and teachers were more effective at disciplining and teaching children. From this perspective, ADHD is a failure of society, not a brain disease.
Fact: ADHD occurs when genes and toxic environments harm the brain.
Blaming parents and teachers for ADHD is wrong. We know from research studies that many parents of ADHD children have normal parenting skills and even when we train parents to be better parents, ADHD does not disappear. In fact, many parents of ADHD children have a non-ADHD child that they raised with the same discipline methods. If bad parenting causes ADHD, all of the children in the family should have ADHD. Equally important, decades of research studies have shown that genes and toxic environments cause ADHD by harming the brain. I’m not saying that all parents and teachers are perfect. In fact, by teaching parents and teachers special methods for dealing with ADHD can help children with ADHD.

Myth: Watching Television causes ADHD.
This myth hit the media in 2004 when a research group published a paper suggesting that toddlers who watched too much TV were at risk for attentional problems later in life.
Fact: The study was wrong.
Sometimes researchers get it wrong. But fortunately science is self-correcting; if an incorrect result is published, subsequent studies will show that it is wrong. That’s what happened with the ADHD television study. After the first study made such a media splash, several other researchers did similar studies. They found out that the original study had errors and that watching too much TV does not cause ADHD. But, because the popular media did not pick up the later studies, the myth persists. I’m not recommending that toddlers watch a lot of television, but rest assured that, if they do, it will not cause ADHD.

Myth: Too much sugar causes ADHD.
This idea is based on common sense. Many parents know that when their children and their friends have too much sugary food, they can get very active and out of control.
Fact: Sometimes, common sense is wrong.
As a parent, I thought there was some truth to the sugar myth. But when a colleague, Dr. Wolraich, reviewed the world literature on the topic, he found that there have been many studies of the effect of sugar on children. These studies show that sugar does not affect either the behavior or the thinking patterns of children. Having too much sugar is bad for other reasons, but it does not cause ADHD.

Wolraich, M. L., Wilson, D. B. & White, J. W. (1995). The effect of sugar on behavior or cognition in children. A meta-analysis. JAMA 274, 1617-21.

Stevens, T. & Mulsow, M. (2006). There is no meaningful relationship between television exposure and symptoms of attention-deficit/hyperactivity disorder. Pediatrics 117, 665-72.
Evans, S. W., Langberg, J. M., Egan, T. & Molitor, S. J. (2014). Middle School-based and High School-based Interventions for Adolescents with ADHD. Child Adolesc Psychiatr Clin N Am 23, 699-715.

Pfiffner, L. J. & Haack, L. M. (2014). Behavior Management for School-Aged Children with ADHD. Child Adolesc Psychiatr Clin N Am 23, 731-746. contrast to a large literature demonstrating the effects of medications for adult ADHD, a small but growing literature is beginning to document the value of naturopathic treatments. A good example was recently published by Rucklidge et al. (2014, British Journal of Psychiatry, Epub). These investigators evaluated the efficacy and safety of a micronutrient formula comprised of vitamins and minerals, without omega fatty acids. It is the first double-blind randomized controlled trial to assess the effects of micronutrients (N = 42) compared with placebo (N = 38) on ADHD symptoms. It found that, compared with placebo, the micronutrient formula led to greater improvements in ADHD symptoms for self-ratings and observer-ratings but not for clinician ratings. The effect size of the clinical response ranged from 0.46 to 0.67, which is less than what is typically seen for ADHD medications (Faraone & S. J. Glatt (2010) J Clin Psychiatry 71 754-763). Only 48% of patients in the micronutrient group were rated as improved or very much improved. Although this was greater than the 21% rate in the placebo group, it is about half the response rate seen with stimulant medications. Importantly, the micronutrient and placebo groups did not differ in rates of adverse events. They authors wisely concluded that their results, albeit intriguing, provide only preliminary evidence for the value of micronutrients in treating adult ADHD. This work, and related studies of children and adolescents, will likely motivate more research into micronutrient treatments. Such treatments are especially appealing to patients due to their low side effect burden but given the small evidence based, they should be used with caution if their use will delay the use of treatments whose efficacy has been established. Of note, Rucklidge et al. reported treatment effects after eight weeks. Thus, if patients insist on monotherapy with micronutrients, they should not delay other treatments for longer than eight weeks without evidence that the micronutrients are working.