Are Nonpharmacologic Treatments for ADHD Useful?
There are several very effective ADHD medications, and treatment guidelines from professional organizations view these drugs as the first line of treatment for people with ADHD symptoms. (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 “natural remedies for ADHD.”
What are these non-pharmacologic treatments and do they work?
My upcoming 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; http://www.cebm.net/).
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 (CBT) 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.
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 is about 0.9, which is derived from a very strong evidence base. The effects of dietary treatments on symptoms of adult ADHD 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.
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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.