IACAPAP Textbook of Child and Adolescent Mental Health

EXTERNALIZING DISORDERS

Chapter

D.1.1

NON-PHARMACOLOGIC
TREATMENTS FOR ATTENTIONDEFICIT/HYPERACTIVITYDISORDER (ADHD)
Maite Ferrin, Edmund Sonuga-Barke, David Daley,
Marina Danckaerts, Saskia van der Oord, Jan K. Buitelaar
Maite Ferrin MD, PhD
Developmental Brain-Behaviour
Laboratory, Psychology,
University of Southampton,
UK & Huntercombe Hospital,
Maidenhead, UK
Conflict of interest: participatedin “Meeting of Minds VII”,
Stockholm 2015, sponsoredby Shire

Edmund Sonuga-Barke PhD
Developmental Brain-Behaviour
Laboratory, Psychology,
University of Southampton, UK& Department of Experimental
Clinical & Health Psychology,
Ghent University, Belgium

A Card Trick. John George Brown. Joslyn Art Museum, Omaha, NE, US

Conflict of interest: Shire
Pharmaceuticals (speaker fees,
consultancy, advisory board
membership, research support
and conference attendance
funds); Janssen Cilag (speakerfees). Grants awarded from
MRC, ESRC, Wellcome Trust,This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2016. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Ferrin M, Sonuga-Barke E, Daley D, Danckaerts M, van der Oord S, Buitelaar JK. Non-pharmacologic
treatments for attention-deficit/hyperactivity disorder (ADHD). In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental
Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2016.

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IACAPAP Textbook of Child and Adolescent Mental HealthThis chapter complements and should be read in conjunction with
Chapter D.1 of the IACAPAP Textbook. Attention-deficit/hyperactivity disorder(ADHD) is one of the most common psychiatric disorders of childhood, withan estimated prevalence of about 5% in school-age children. Core symptoms
include impaired attention and/or hyperactivity/impulsivity (American Psychiatric
Association, 2013). ADHD often has a chronic course with up to 65 % of affectedindividuals displaying impairing symptoms during adulthood (Faraone et al,2006). ADHD is associated with high levels of both externalizing (oppositional
defiant disorder and conduct disorder) and internalizing (depression and anxiety)comorbidities. ADHD impacts on in multiple domains of functioning across thelifespan, including school and work performance, social relationships, and familyinteractions (Faraone et al, 2006).
Given its impact and associated burden, considerable effort has been
directed at developing effective treatments. Multimodal treatments, which
combine pharmacologic and psychologic approaches, are currently recommended(National Institute for Health and Clinical Excellence, 2008). ADHD
medication—i.e., stimulants (e.g., methyphenidate, d-amphetemine) and nonstimulants (e.g., atomoxetine, guanfacine)—are effective in the short and medium
term in randomized controlled trials in relation to core symptoms, externalizingcomorbidities, and daily functioning (Faraone & Buitelaar, 2010; Banaschewski etal, 2013). Medication can also reduce neuropsychological impairment: executivefunctions, executive and non-executive memory, reaction time, reaction time
variability, response inhibition, aversion to delayed reward, and intrinsic motivation(Ni et al, 2013; Coghill et al, 2013).
Despite its proven short-term efficacy, treatment with medication has several
limitations. These include (Sonuga-Barke et al, 2013):
•
•
•
•
•

Partial or no-response in a proportion of cases
Adverse effects
Questionable long term benefits and costs
Poor adherence, andNegative attitudes of patients, parents, or clinicians to medication.

Limitations of existing pharmacologic treatments highlight the need fortherapeutic innovation to develop effective non-pharmacologic interventions
that improve short and long term outcomes in core symptom domains,neuropsychological deficits and, more generally, in the pattern of impairment(Graham et al, 2011; Cortese et al, 2013). To date, a variety of non-pharmacologicalinterventions are available to treat ADHD including psychologic treatments
and dietary approaches. Effectiveness of some of these therapies has been partly
supported by several systematic reviews and meta-analyses. However, some of thesestudies have significant methodological shortcomings—for example, by including
non-randomized designs, non-ADHD samples, or non-ADHD outcomes—not
allowing firm conclusions to be drawn (Arns et al, 2009; Fabiano et al, 2009;
Bloch & Qawasmi, 2011; Nigg et al, 2012).
In this chapter we describe commonly available non-pharmacologic
approaches, their rationale, delivery, evidence of effectiveness, clinicalconsiderations, and future directions for research and practice. It is important tonote that our findings do not imply recommendation for their use.

Non-pharmacologic Treatments for ADHD

D.1.1

Solent NHS Trust, European
Union, Child Health Research
Foundation New Zealand,
NIHR, Nuffield Foundation,
Fonds Wetenschappelijk
Onderzoek – Vlaanderen(FWO)David Daley
Division of Psychiatry andApplied Psychology, Schoolof Medicine University of
Nottingham, UK & Institute of
Mental Health University of
Nottingham, UK
Conflict of interest: hasprovided educational talks
for Eli Lilly and Shire; hasattended an Eli Lilly advisoryboard; has received support for
educational travel from Eli Lilly,
Shire, and HP Pharma; hasreceived research funding from
Shire; has received royalties
from the sale of the book “Stepby Step Help for Parents ofChildren with ADHD”

Marina Danckaerts MD, PhD
Department of Child andAdolescent Psychiatry,
University Psychiatric Center
KU Leuven, Belgium &Department of Neurosciences,
KU Leuven, Belgium
Conflict of interest: has beena member to the advisoryboard of Shire and Neurotech
Solutions and a speaker for
Shire, Medici and Novartis (noproduct related lectures) overthe past 3 years. Within that
period she received research
grants from Janssen-Cilag,
Shire, EU, FWO and KU
LeuvenSaskia van der Oord PhD
Clinical Psychology,
Psychology & Educational
Sciences, KU Leuven, Belgium
Developmental Psychology,
Psychology, University of
Amsterdam, the Netherlands
Conflict of interest: has been apaid speaker (Shire, MEDICE)
and consultant (Janssen
Cilag). Co-developer/authorof a cognitive training game
“Braingame Brian” and two
cognitive-behavioral treatments“Plan my Life” and “Solution
Focused Treatment”. Grants
received from ZonMW, FWO(G.0738.14), Kinderpostzegels,
Research council KU Leuven(OT/12/096), Achmea, NutsOhra

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IACAPAP Textbook of Child and Adolescent Mental Health

EXCLUSION DIETS AND DIETARY SUPPLEMENTS
There is increasing interest in the relationship between lifestyle, diet andmental health. For example, a report from a prospective birth cohort study describeda significant association between a “Western” dietary pattern—high in fat, refinedsugars, and sodium, and low in fiber, folate, and omega-3 fatty acids—and ADHD
(Howard et al, 2011). This section focuses on four dietary interventions—exclusionof artificial colors and preservatives; restrictive elimination diets/oligo-antigenic
diets; supplementation with omega-3 fatty acids; supplementation with vitamins
and micronutrients—and their clinical relevance for ADHD.

ARTIFICIAL FOOD COLORS AND PRESERVATIVES
Feingold was the first to suggest that allergy to food color additives,
synthetic flavors, and food preservatives could lead to an increase in ADHD
symptoms (Feingold, 1985). He based this on observations that salicylates could
not only cause asthma or eczema but also behavioral reactions, such as an increaseof hyperkinetic behavior, in some patients. Hence, he proposed a diet free of foods
with natural salicylates and synthetic colors and flavors. The supposed mechanism
could be either an allergic reaction or hypersensitivity to salicylates and related
substances.

Jan K. Buitelaar MD PhD
Department of Cognitive
Neuroscience, Donders
Institute for Brain, Cognition
and Behavior, Radboudumc,
and Karakter Child andAdolescent Psychiatry
University Centre, Nijmegen,
The Netherlands
Conflict of interest: has been in
the past 3 years a consultant
to/member of advisoryboard of and/or speaker
for Janssen Cilag, Eli Lilly,
Lundbeck, Roche, Medicew,
Shire, and Servier. Received
research grants from theNetherlands Organization for
Scientific Research (NWO),
ZorgOnderzoek Nederland(ZonMW), European Union,
and NIMH

Acknowledgment:
We thank all the members
of EAGG (European ADHD
Guidelines Group) who
have contributed with theircomments.

Treatment Delivery and Available Treatments
The Feingold program is a form of elimination diet where foods containing
certain additives are replaced with foods free of those additives. When starting
the program, certain foods and non-food items containing aspirin-like chemicals
called salicylates are eliminated and later tested for tolerance. These foods include:
•
•
•
•
•

Artificial colorings (e.g., petrochemical dyes)
Artificial flavors and fragrances
Some preservatives
Artificial sweeteners
And foods and products containing salicylates.

Click on the image to viewa very brief summary of themeta-analysis by SonugaBarke et al (2013) on the
different non-pharmacologic
treatments for ADHD

Initially the diet is used as a diagnostic tool to determine if any of theeliminated items trigger some or all of the problems observed. When successful, it
is continued as a treatment, and can be combined with other medical treatments.

EffectivenessA meta-analysis across 20 studies of elimination diets including 794
participants found a small effect size (0.18) based on parent reports, that decreased
to 0.12 when possible publication bias was taken into account (Nigg et al, 2012).
Effect on teachers’ reports and observer measures was not significant (Nigg et al,2012). About 8% of children with ADHD were estimated to have symptoms
related to food colors. Another meta-analysis of 8 studies including 294 participants
reported a similar effect size (0.32 to 0.42 depending on the informant). However,
the effect size became non-significant when the analysis was limited to studies withfew or no concurrent medication (Sonuga-Barke et al, 2013). There are no longterm studies.

Non-pharmacologic Treatments for ADHD

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•
•

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IACAPAP Textbook of Child and Adolescent Mental Health

THE INTERNATIONAL NUMBERING SYSTEM FOR FOOD ADDITIVES(INS)
This is a European-based naming system for food additives aimed atproviding a short designation for what may be a lengthy chemical name.
It is defined by the Codex Alimentarius of the international food standards
organization. The information is published in the document “Class Names
and the International Numbering System for Food Additives”. The INS isan open list, subject to the inclusion of additional additives or removal ofexisting ones. INS numbers consist of three or four digits. Approved foodadditives are written with a prefix of E on food packaging in the European
Union. Australia and New Zealand do not use a prefix letter. INS numbers
generally correspond to E numbers for the same compound, e.g. INS 102(tartrazine), is also E102. INS numbers are not unique and, in fact, one
number may be assigned to a group of similar compounds. The US does not
use the INS numbering system (Wikipedia).

Clinical Implications
Despite the long-standing controversy on the effects of food colors andpreservatives on ADHD symptoms, the evidence available still has many gaps.
Most if not all studies are of small size, the mechanisms and predictors of response
are unknown, and it is unclear which chemicals and at which dose have a clinicalimpact. Nevertheless, the effect size on ADHD symptoms of exclusion diets issmall, not large enough to justify it being recommended as stand-alone treatment.
It may be a useful adjunctive treatment for some cases.

Benjamin F Feingold MD(1899, 1982) was a US
pediatrician who proposedthat salicylates and foodadditives, such as artificial
colors and artificial flavors,cause hyperactivity inchildren. Eliminating thesefoods (Feingold diet) would
be expected to reduce
hyperactivity.

Decisions to explore the clinical utility of such diets in individual cases
should be weighed against difficulty and expense (e.g., it is hard to implement ina household with several children, requires intrusive monitoring of compliancethat in itself could impact negatively on the parent-child relationship, and it isexpensive to source additive-free foodstuffs).

Future Directions••

There is a need for rigorous large-scale studies on the effects of foodcolors and preservatives on ADHD symptoms and related behaviors
such as aggression, oppositionality and emotional lability
Though the effect size of food exclusion diets is small from a clinicalperspective, it may be substantial from a population-wide, health care,and food policy perspectives. The prevention paradox states that mostcases derive from low-risk individuals and that a rather small protective

Table D.1.1.1 Preservatives to be eliminated from the diet (www.feingold.
com)
ABBREVIATIONNAME

E-NUMBER*

BHA

Butylated hydroxyanisole

E 320

BHT

Butylated hydroxytoluene

E 131

TBHQ

Tertiary butylhydroquinone

E 319*Codes for substances that are permitted as food additives within theEuropean Union and Switzerland (see Box).

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IACAPAP Textbook of Child and Adolescent Mental Healtheffect on the wider population could reduce caseness more often thanan intervention targeting clinical cases or high-risk individuals (Rose,
1981)

RESTRICTIVE ELIMINATION OR OLIGOANTIGENIC DIETS
Adverse physical reactions (e.g., eczema, asthma, allergic rhinitis, andgastrointestinal problems) to some foods have led to the hypothesis that specificfoods might also have an impact on the brain, resulting in adverse behavioral
effects. In oligoantigenic diets the focus is on foods other than artificial colors andpreservatives that may trigger ADHD symptoms in some children by acting asfood antigens or allergens. Foods often found to be allergenic include cow’s milk,cheese, eggs, chocolate, and nuts. Thus, an individually constructed oligoantigenic
or restricted elimination diet might be an effective treatment for ADHD (Nigg etal, 2012; Pelsser et al, 2011).
A typical food allergy is a reaction to foods involving specific antibodies(e.g., IgE). It has been hypothesized that in non-IgE-mediated reactions to food,determination of IgG may be a helpful adjunct, and IgG blood tests are widelyoffered to establish a relationship between foods and ADHD symptoms, especiallyin complementary medicine settings. According to the IgG-ADHD theory, foods
associated with high IgG-levels would result in a significant behavioral deterioration
when eating these foods, while foods associated with low IgG-levels would not.
However, evidence of the value of these tests is lacking. Further, in a restrictedelimination study, worsening of ADHD symptoms occurred independently of
IgG levels of the challenging foods, thus questioning the role of IgG-mediatedmechanisms (Pelsser et al, 2011).

ANTIBODIES
Antibodies are formed fromshort light chains (with low
molecular weight) and long
heavy chains (with highmolecular weight). Of these,
there are five types of heavy
chains, and the type ofantibody is determined bydifferences in these heavy
chains (IgG, IgM, IgA, IgD,
IgE).
IgE is believed to be related
to immunity reactions toparasites and has recently
become known as a key
factor in allergies such as
hay fever.
IgG is the main antibody
in the blood. It is the
only one that can passthrough the placenta, and
IgG transferred from themother’s body protects
a newborn until a week
after birth. IgG is widelydistributed in the blood andtissues, and protects thebody.

Treatment Delivery and Available Treatments
Restrictive elimination diet interventions typically involve a temporary (2-5weeks) total change of diet, in which the child is only allowed to consume a few
hypo-allergenic foods (e.g., rice, turkey, lettuce, pears, and water). If it results ina substantial decrease in ADHD symptoms (i.e., it shows to be “food sensitive”),
a 12-18 month reintroduction phase is conducted to find out which specificfoodstuffs trigger ADHD symptoms. The rationale is that a person may show
adverse reactions to a variety of foods and that it is important to determine theindividual’s susceptibility to the specific foods that cause the adverse reactions.

EffectivenessA meta-analysis reported an effect size of 0.29 across 6 controlled trials
including 195 participants and concluded that about one third of the children
with ADHD show an excellent (>40% symptom reduction) response (Nigg et al,2012). Another meta-analysis estimated an effect size of 1.48 for the most proximal
assessment (by the person applying the treatment). However, effect size dropped to
0.51 when probably blind raters were used (Sonuga-Barke et al, 2013). There wasconsiderable heterogeneity across studies due to different designs and on how strict
was the food elimination. Studies included a small number of participants. There
are no studies reporting medium to long-term effectiveness and cost-effectiveness.

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IACAPAP Textbook of Child and Adolescent Mental Health

Clinical Considerations•••

A strictly supervised elimination diet is a valuable approach to assess
whether ADHD in a given child might be food-sensitive. As IgG blood
tests do not provide information about which foods might provoke
ADHD symptoms, the prescription of diets based on these tests should
be discouragedChildren with ADHD and their parents who are interested inelimination diets need to be supervised closely because adherence tothe diet requires efforts and motivation by the whole family
Implementation of this diet requires a drastic change of lifestyle;success will depend on the family’s organizational skills and parents’level of control over the child’s diet

Future Directions••

Large scale, multisite clinical trials into the feasibility, effectiveness andcost-effectiveness of elimination diets for children with ADHD areneeded. These studies should aim to identify predictors of response
and establish the long-term effectiveness
Future research might also need to target the gut microbiota/brain
connection as a potential mechanism underlying the effects ofelimination diets

SUPPLEMENTATION WITH OMEGA-3 AND OMEGA-6 FATTY
ACIDS
Around 25-30% of all fatty acids in the brain are polyunsaturated. They
play an important role in the structure and function of neuronal cell membranes
in the brain, retina and myelin sheath. Two fatty acids, also called “essential”,
α-linolenic (an omega-3 fatty acid) and linoleic (an omega-6 fatty acid) cannot be
synthesized by humans and need to be acquired through the ingestion of foods (seeFigure D.1.1.1). Whereas α-linolenic is sparsely distributed in soybean, canola,
and flax seeds oil, linoleic acid is more abundant; over 50% of all fatty acids insoybeans, corn and sunflower oil is linoleic. Omega-6 and omega-3 fatty acids are
not interchangeable; the former have anti-inflammatory properties, whereas thelatter is pro-inflammatory.
Several studies have reported lower concentrations of omega-3 fatty acids
in plasma and erythrocyte membranes in children and adults with ADHD
(Bloch 2011). Abnormally low essential fatty acids in children with ADHD
may be due to reduced intake, reduced conversion of essential fatty acids tolong chain polyunsaturated fatty acids, and increased metabolism of long chain
polyunsaturated fatty acids, but none of these alternatives have been properly
studied (Millichap et al, 2012).

Treatment Delivery and Available Treatments
There are numerous commercial products (gels, capsules, and liquids) available
to supplement omega-3 fatty acids in the diet. Most supply eicosapentaenoic acid
(EPA) and docosahexaenoic acid (DHA) (see Figure D.1.1.1) in amounts that vary
up to ten-fold. Additionally, many products also contain other micronutrients orvitamins hypothesized to be deficient in patients with behavior disorders.

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure D.1.1.1 Fatty-acid synthesis pathway

EffectivenessTwo meta-analyses concluded that supplementation with these fatty acids
was associated with a small but reliable reduction of ADHD symptoms, with effectsizes ranging from 0.18 to 0.31 (Sonuga-Barke et al, 2013; Bloch, 2011). Higher
doses of omega-3 supplements were significantly associated with a larger reductionof ADHD symptoms (Bloch, 2012). A third meta-analysis did not find statisticallysignificant differences on parent and teacher ratings of ADHD symptoms between
fatty acids supplementation and placebo (Gilles et al, 2012). None of the studies
monitored plasma levels of free fatty acids. This and other methodologicallimitations should lead to caution when interpreting the significance of theseeffects. There are no studies on the long-term effectiveness and cost-effectiveness.

Clinical Considerations••

The clinical relevance of fatty acid supplementation in treating ADHD
remains unclear. Some researchers have suggested that fatty acidsupplements be considered as an add-on treatment in children whoshow partial response to medication. If so, the recommended doses are
300 to 600 mg/day of omega-3 and 30-60 mg/day of omega-6 fatty
acids for at least 2 or 3 months, or longer if indicated (Millichap et al,2012). Given the low effect sizes, it is important to monitor carefully
whether supplements have any benefit and to continue using them
only if this is the case
Side effects are minor and include fishy taste and odor, stomach upset,loose stools, and nausea.

Future Directions•

There is a need for high-quality, large sample, controlled studies withfatty acid supplementation that include patients with different ages(preschoolers, school age children and adolescents) and monitor theplasma levels of fatty acids at baseline and during treatment.

SUPPLEMENTATION WITH MICRO-NUTRIENTSNeurotransmitter metabolism requires enzymes, and enzyme function
is dependent upon the presence of adequate quantities of multiple coenzymes

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IACAPAP Textbook of Child and Adolescent Mental Health(cofactors), such as vitamins and minerals. Conditions such as ADHD and otherpsychiatric disorders may be associated with metabolic dysfunctions that limit
the availability of vitamin and mineral cofactors and results in slowed metabolic
activity (Kaplan et al, 2007; Ames et al, 2002). This may be remediated bysupplementation with micronutrients. Deficiencies of micronutrients may play arole in the cognitive deficits associated with ADHD (Mikirova et al, 2013; Sarris
et al, 2011; Scassellatti et al, 2012). Further, outside the context of ADHD, thequality of the nutrition in the first years of life is associated with children’s later
cognitive and academic abilities (Nyaradi et al, 2013; Prado & Dewey, 2014).

Treatment Delivery and Available Treatments
There is a multitude of commercially available products that follow a“broad spectrum approach” by providing multi-ingredient and/or multivitaminsupplementation and claim effectiveness in reducing symptoms of ADHD
and other psychiatric conditions such as bipolar illness, anxiety disorders, anddepression.

EffectivenessMicronutrient treatment trials vary but for the most part have focused on single
nutrients such as iron, magnesium and zinc. They have demonstrated modest to
negligible effects (Cortese et al, 2012; Ghanizadeh et al, 2013; Rucklidge etal, 2009). A well-designed, blinded, randomized clinical trial has shown large
improvements in ADHD symptoms in adults after a broad spectrum vitaminmineral treatment (Rucklidge et al, 2014). An open label pilot trial using thesame micronutrient formula in 14 children with ADHD reported significant
improvement in parent reported ADHD symptoms (Gordon et al, 2015).

Clinical Considerations••

Dose and variety of ingredients in micronutrient supplementation may
be important in effecting change in ADHD, but no specific guidance
can be given since data are lacking
Current studies did not raise safety issues, but very high doses canbecome toxic with no associated benefit as demonstrated by earlier
studies that gave mega doses (Arnold et al, 1978)

Future Directions••

Good quality, large controlled studies with micronutrient
supplementation that include patient with different age ranges areneededThese studies should be combined with biochemical assessments toprobe for real deficiencies and to examine the combined effects of
micronutrient supplementation with other dietary interventions

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PSYCHOSOCIAL TREATMENTS
BEHAVIORAL INTERVENTIONS
Psychosocial treatments based on social learning and behavior modification
principles have been widely used, often through parent training-based approaches.
Behavioral interventions can be defined broadly as therapies using learning
principles to target ADHD or ADHD-related behaviors (Sonuga-Barke et al,2013).
Behaviorally focused treatments can be delivered by therapists, parents, orby other “facilitators” (for example teachers). Facilitators are taught to use basic
operant conditioning principles—behavior is modified though positive (e.g.,praise) and negative (e.g., ignoring inappropriate behavior) reinforcement—toshape more appropriate behavior in the child; this is also called “contingency
management”.
A daily report card is an example of a tool based on operant learning
principles; teachers reinforce appropriate behaviors daily by giving feedback (forexample by sticking stars or “smilies” on the report card) for appropriate behaviors
in the school. Moreover, this tool can go between home and school facilitatinginteraction and communication between parents and teachers (see Figure D.1.1.2).
Another objective of these behavior-focused treatments is to reduce
maladaptive behavior. To achieve this, parents and teachers are trained to use amore structured approach when dealing with a child with ADHD about everyday
issues—for example, by giving clear instructions, one instruction at a time, or byproviding in the morning a clear and realistic plan for the day—so that children
know what is expected of them. Finally, an important aspect of these treatments
is to enhance enjoyable parenting and positive interactions between parent andchild, as a negative coercive cycle between parent and child often develops (Van derOord & Daley, 2015). These interventions are typically used for pre-school andprimary school-aged children rather than for adolescents.
Skills-based interventions assume that individuals with ADHD have core
deficits in certain skills (e.g., planning and organization) and seek to enhance theseskills either directly with the individual or through parents and teachers (Evans etal, 2014). These interventions can be provided in the clinic (Abikoff et al, 2015;
Boyer et al, 2015) or the school, mainly through after school programs (Evans etal, 2016) that focus on enhancing skills such as planning, organization, and social
Figure D.1.1.2 Example of a daily report card

Click here for advice toteachers on how to design
daily report cards

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IACAPAP Textbook of Child and Adolescent Mental Healthinteraction. Skills based interventions are useful for both school-age children andadolescents.
Cognitive interventions for ADHD may also target children’s negative
schemas or thoughts, based on the premise that thoughts, feelings and behaviors
are interrelated and that changing one element of this triad will modify the others(Antshel & Olszewski, 2014). They are typically delivered individually and areparticularly useful for adolescents.

Treatment Delivery and Available Treatments

Click on the image to accessa video on parent andteacher training for ADHD

Should behavioral treatments be provided in a group or individually, athome, at school, or in a mental health service? Are there lower-cost alternatives
such as self-help interventions that are effective?

Parent training
The National Institute for Health and Clinical Excellence (2008) of the
UK recommends group behaviorally-focused parent training interventions (seeChapter A.12 of the Textbook). These interventions are effective for children with,or at risk of, ADHD (Webster-Stratton et al, 2011; Jones et al, 2007), but there isno evidence to suggest that group is more effective than individual intervention.
Parents of children with ADHD often display symptoms of ADHD
themselves and may struggle with the organizational challenges of attending
group-based sessions in clinic or community settings. To enhance effectiveness,treatments should be adapted to the needs of the target group, and be provided
in the setting where maladaptive behavior is manifested (Kazdin & Blase, 2011).
An unpublished study by Sonuga-Barke et al compared the relative efficacy ofan individual home-based parenting program for ADHD (New Forest Parenting
Program) with a group-based parenting intervention run in the community(Incredible Years), and with treatment as usual for a large group of hard to engage
and difficult to treat parents of preschool children at risk of ADHD. Results
suggested no clear advantage of the home based intervention in terms of symptom
severity, but the individual intervention was more cost effective. However, theindividual home-based intervention was preferred by parents (see Wymbs et al,2015 for a discussion of parents’ treatment preferences).

School-based interventions
School-based interventions are very diverse and it is a challenge to reachgeneral conclusions. Not all school-based treatments aim at reducing ADHD
symptoms specifically, some seek to deal with the academic problems commonly
shown by children with ADHD.
Specific manipulation of academic instructions and materials can have apositive effect on ADHD children’s learning efficiency (e.g., sitting closer to theteacher, providing shorter assignments, note-taking training, assisted oral reading,
structured schedules and rules, alternating easier with more difficult exercises,
allowing regular breaks, intra-task stimulation by adding colors or highly engaging
stimuli) (Raggi & Chronis, 2006; Schultz et al, 2011). Peer tutoring (i.e., paring
an ADHD pupil with a highly achieving, supportive student) (DuPaul et al, 1998),
as well as computer enhanced learning, applying a multi-sensory approach andNon-pharmacologic Treatments for ADHD

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IACAPAP Textbook of Child and Adolescent Mental Healthimmediate feedback (Clarfield & Stoner, 2005; Ota & DuPaul, 2002) have shown
beneficial effects but have not been studied in controlled designs.
A review of research conducted over 32 years has identified more than
50 studies (including 36 randomized controlled trials) of non-pharmacologicalinterventions in school settings addressing ADHD symptoms (Richardson et al,2015). The majority targeted children at elementary/primary school level. Four
categories of interventions were defined based on common ingredients:
1.
2.
3.
4.

Reward and punishment (contingency management)
Skills training and self-management
Creativity-based therapies andPhysical treatments

Contingency management has been studied the most, followed by academic
skills training, emotional skills training, self-regulation, biofeedback, daily reportcard, social skills training, cognitive skills training, adaptation to the learning
environment, music therapy, motivational beliefs, psychoeducation, play therapy,
and massage. A large proportion of the interventions was delivered by teachers
within the classroom but often mental health providers were involved. The lengthof the intervention varied widely (between 1 and 156 weeks, with a mean of 15.5
weeks). Across all these different interventions there was some beneficial effect on
inattention and hyperactivity/impulsivity assessed with neurocognitive tasks andon teacher-rated inattention (Richardson et al, 2015). However, there was little
effect according to parent-observed ADHD symptoms. There was a small effect on
Figure D.1.1.3 Summary of recommended behavioral interventions for ADHD
throughout the lifespan**M Ferrin, with permission.

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IACAPAP Textbook of Child and Adolescent Mental Healthstandardized achievement tests and on teacher reported externalizing symptoms.

Effectiveness of Behavioral Interventions
Two meta-analyses explored the short-term effectiveness of behavioral
interventions (broadly defined) compared to control conditions (Sonuga-Barke etal, 2013; Daley et al, 2014). Results were presented separately for outcomes that
may be biased towards favorable reporting because of involvement in the treatment(e.g., parent ratings), and for other outcomes that could represent more objective
Figure D.1.1.4		
Child and parents outcomes of behaviouralinterventions in ADHD acording to informant.* MPROX is based on reports
by individuals who may be biased towards favorable reporting because of
involvement in the treatment (e.g., parent ratings); PBLIND is based on
more objective measures (e.g., teacher ratings). Low Meds represents theresults of studies with less than 30% of the children in the sample receiving
medication.

*With permission from Daley et al

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IACAPAP Textbook of Child and Adolescent Mental Healthmeasures (e.g., teacher ratings). Results (see Figure D.1.1.4) showed a significant
improvement in ADHD symptoms when reports from the person applying thetreatment were considered (“most proximal”), but there was no change according
to the more objective informants (“probably blind”). However, both groups ofinformants reported a significant benefit in relation to conduct problems, positiveparenting, and for reduction in negative parenting. Significant effects were also
found on social skills and academic performance; however, blinded outcomes
were not available for these variables. Finally, no impact was found on parental
wellbeing.
Studies exploring the long-term efficacy of behavioral interventions aresparse and typically they are naturalistic follow-ups where other treatments (e.g.,
medication) are often used concurrently. Therefore it is difficult to disentangle
the specific long-term effects of the behavioral interventions. For parent training,
positive effects on parenting behavior and parent reports of child’s behavior are
maintained for up to 3 months to 3 years after treatment, depending on the study(Lee et al, 2012).

Clinical Considerations
•

•
•

•
•

•
•

According to most studies, children with comorbid ODD/CD
and comorbid anxiety disorders are the most likely to benefit
from behavioral interventions
Larger effect sizes were observed in preschoolers and in children
not taking medication (Daley et al, 2014)
Lower parental education, greater parental mental healthproblems and greater child complexity and comorbidity are likely
to be related to worse outcomes (Daley & O’Brien, 2013)
A challenge for behavioral approaches has been to generalize thebenefits from the treatment setting to other settings
Since some reliable effects have been shown on relatively
objective measures of neurocognitive assessments and academic
achievement, these offer some support for the effectiveness of
non-drug treatment in school settings. Because many different
intervention packages or combinations are used, it is impossible
to identify the potentially active ingredients
Barriers are that these treatments are expensive, both in terms oftime and money, and parents need to be motivated
Evidence supports the efficacy of educational interventions
with parents (Ferrin et al, 2014; Ferrin et al, 2016) and of selfhelp interventions either on their own or in combination with
telephone or media support (Sanders et al, 2007). According to a
Cochrane review (Montgomery et al, 2006) self-help interventions
can: (i) reduce the amount of time therapists have to devote toeach case; (ii) increase access to the intervention; (iii) releaseclinician time to concentrate on more complex cases; (iv) reduceor eliminate costs, transport and timing difficulties for families.

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Future Directions
•

•

•

•

More evidence from blind studies is required before behavioral
interventions can be supported as a first-line treatment for core ADHD
symptoms
Despite the many randomized controlled trials assessing schoolinterventions in ADHD—which already show a large improvement
when compared with earlier reviews (DuPaul et al, 1998)—there is aneed for better designed studies (Richardson et al, 2015)
Self-help approaches may work best within a stepped care clinicalmodel, with self-help targeted at parents who are waiting to access faceto-face treatment. Also, self-help could be used in combination with
face-to-face treatment or on a triage basis. It could be offered as an
initial intervention that may be enough for some highly functioning
parents or those with children with less complex problems
More research is needed on how to engage parents in self-help
interventions and to clarify who may benefit the most

COGNITIVE TRAININGADHD is associated with a broad range of neuropsychological impairments
encompassing multiple brain networks known to underpin diverse cognitive andmotivational processes (Willcutt et al, 2008). There has been an increasing interestin, and use of, computer-based cognitive training as a treatment for ADHD
with different approaches used to target different neuropsychological deficits(i.e., working memory, attention, inhibition). Cognitive training is groundedon the notion of neural plasticity and the reorganization of brain structure andfunction in patients experiencing lesion-based deficits and cognitive impairments(Jolles & Crone, 2012; Willis & Schaie, 2009). Models rely on the assumptions
that particular neuropsychological deficits mediate ADHD pathogenesis, andthat repeatedly loading a limited cognitive resource would eventually lead to its
strengthening and improved functioning. However, specific neurobiologic modelsof the effects of cognitive training strategies used with ADHD patients are lacking.

Treatment Delivery and Available Treatments
Cognitive training for ADHD is typically delivered using computers.
Training sessions may be conducted at school, home, or in the clinic. The durationof each session, number, and frequency vary according to the specific protocol
employed—they typically involve a large number of sessions spread over several
weeks. The difficulty level is automatically adjusted by the software on a session by
session basis to match the improving working memory of the subject on each task,
to drive learners to increasingly higher levels of performance as training proceeds.
This includes an individualized reward schedule. Table D.1.1.2 lists commonly
used, computerized cognitive training programs.

Effectiveness
The first controlled trial that examined the benefits of cognitive training for
ADHD was reported by Klingberg and colleagues (2005). They reported a large
positive effect on parent ratings of ADHD but this did not generalize to teacher

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Click on the image to viewan example of how Cogmed,
one of the cognitive training
programs, is supposed to
work.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table D.1.1.2. Commonly used computer-based cognitive training programs*
PROGRAMTARGET FUNCTION

AixTent (CogniPlus)

Attention: selective, divided, focused andconstant

Captain’s Log

Attention, working memory, visuomotor
function, problem solving

Cogmed (RoboMemo)

Visuospatial and spatial-verbal working
memoryCogniPlus

Attention, working memory, visuomotor
function, executive functions, long-term
memoryLocu Tour

Acoustic, visual, and verbal attention,
executive functions, acoustic and visualmemoryPlay Attention

Attention

RehaCom

Attention, memory, executive functions,visuomotor functions

Braingame Brian (in Dutch) Training working memory, inhibition andflexibility*Adapted from Sonuga-Barke et al, 2014. Click on the name of the programto access.

ratings. The meta-analysis by Sonuga-Barke et al (2013) reported data from 126
participants and 123 controls. Overall, there was a moderate and significant effectin favor of the intervention by the end of treatment. However, the effect dropped
substantially and became not significant when ratings by (probably) blind raters
were considered. Similar results were reported in another meta-analysis (Cortese
et al, 2015).

Clinical Considerations•••

There is no definitive evidence of the effectiveness of cognitive training
in ADHD
Cognitive training may improve working memory, however the impact
on academic functioning is not yet determined (Cortese et al, 2015)
Contraindications and side effect of these treatments are not wellknown

Future Directions•••

Approaches targeting multiple neuropsychological processes may
optimize the transfer of effects from cognitive deficits to clinicalsymptoms, but this requires further research
There is a particular need for studies examining the relative valueof combining cognitive training with medication, dietary, or otherpsychological approaches (Vinogradov et al, 2012)
Future research should explore whether cognitive training may also
play a role in early intervention approaches for ADHD

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IACAPAP Textbook of Child and Adolescent Mental Health•

Trials in the future need to compare the response of clinical subtypes
and neuropsychological sub-groups to different forms of training.

NEUROFEEDBACK
Neurofeedback has been seen as a promising treatment for core ADHD
symptoms based on the results of some controlled studies (Arns et al, 2009). The
increasing acceptance of neurofeedback as a treatment for ADHD derives fromobservations of altered brain activation in many children with ADHD detected
in EEG and imaging studies. Neurofeedback is based on the principle that thetypes of waves registered by EEG represent different psychological states, e.g.,whether the individual is concentrating in an activity or distracted, day-dreaming.
By giving real time information about the type of wave observed at any given timeand rewards, children can be taught to produce the brain-wave pattern associatedwith concentrating on a task. This would reduce symptoms of ADHD.
Two different protocols for treatment are available to address deviant corticalactivity in ADHD children:••

EEG frequency band training, which seeks to reduce slow wave activity
and increase faster (alpha wave) activity
Event-related cortical potentials training. Event-related potentials allow
the examination of electrical responses reflecting preparatory and preattentive processes, auditory and visual attention, frontal inhibition,and time processing. A lower amplitude, longer latency and different
topography of the P300 component has been the most replicated finding
in ADHD children when compared to healthy controls (Brandeis et al,2002).The characteristics of P300 and other components of the evoked
potentials have been used for neurofeedback.

Treatment Delivery and Available Treatments
A conventional neurofeedback protocol to reduce inattention and impulsivity
consists of rewarding the suppression of theta activity and enhancement of beta
activity. Using visual feedback, the trainee receives a large amount of rewards
throughout the training. In some programs, the cortical activity is represented
by the height or speed of an object, such as a ball, a plane, or a cartoon charactermoving across the screen. If the EEG activity is regulated in the desired way, theobject rises, falls, or advances more quickly. In other animations, the patient isasked to view a movie, or change the color of an object in the screen by generating
the target brain wave activity. Successful trials are immediately rewarded by a tone,
a smiley face, coins, or points. Individual parameters are adjusted throughout thecourse of the training to ensure positive feedback in some trials, while other trials
operate without feedback in order to extend the results to the everyday life of thepatient.

Effectiveness
Several controlled studies support the short-term improvement in core
symptoms, neuropsychological function, and electrophysiological correlates of
ADHD achieved with neurofeedback (Gevensleven et al, 2012; Fabiano et al,
2009; Nigg et al, 2012; Sonuga-Barke et al, 2013; Micoulaud-Franchi et al, 2014).
However, a more recent meta-analysis has found no reduction in core symptoms
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D.1.1

Click on the image to view
Dr Selim R. Benbadis talking
about whether ADHD canreally be diagnosed by EEG?

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IACAPAP Textbook of Child and Adolescent Mental Health

ELECTROENCEPHALOGRAM (EEG)Electroencephalogram refers to the recording of brain electrical activity. It is
typically obtained by placing electrodes on the scalp, not very differently fromthose used to obtain electrocardiograms. EEG measures voltage fluctuations
resulting from electrical currents in brain regions, not in individual neurons.
Related techniques are evoked potentials or event-related potentials,
which measure stereotyped electrical brain responses to specific sensory,
cognitive, or motor stimuli. Evoked potentials are obtained by averaging EEG
activity triggered by the presentation of a stimulus (visual, somatosensory, or
auditory).
Five frequency bands have been traditionally defined in EEG recordings:
delta (1.5–3.5 Hz), theta (3.5–7.5 Hz), alpha (7.5-12.5 Hz), beta (12.5-30
Hz), and gamma (30-70 Hz). The type of brain activity recorded depends
on many factors, e.g., whether persons are awake or in different stages of
sleep, what they are doing, and if their eyes are open or closed.
Quantitative EEG (qEEG)—also called brain mapping and brain electricalactivity mapping (BEAM)—is a method of analyzing the electricalactivity of the brain to show a topographic display and analysis of brain
electrophysiological data. The clinical significance of the various patternsof brain wave activity is unknown and the value of quantitative EEG in
diagnosis and treatment of ADHD and other conditions has not been
demonstrated unequivocally.
EEG in children differs from adult EEG because of developmental
maturation—lower frequency bands are most prominent during the firstyears of life, decreasing with increasing age. A substantial group of ADHD
children have shown elevated levels of slow wave (delta and theta) activity inthe frontal regions. An increase in the theta/alpha and theta/beta ratios havebeen claimed to be reliable measures of the presence of ADHD (Monastra etal, 1999). However, this has low specificity and the usefulness of the theta/
beta ratio as a specific marker for ADHD has been questioned.
FIGURE D.1.1.5 The picture describes the brain-computer interface
architecture sequence: brain activity monitoring, translation into commands,
electrophysiological signals, commands subject and action feedback.

Non-pharmacologic Treatments for ADHD

D.1.1

P300
The P300 wave (P3 in
the figure below) of anevent related potential hasreceived particular attention
in relation to ADHD. P300
is a positive wave complex
that occurs about 300500 milliseconds after the
stimulus. It is obtained when
the individual’s attention
is focused on a signal thatis rare, especially if thesignal has a motivational oremotional meaning. P300 isthought to reflect processes
involved in stimulus
evaluation or categorization.
It is typically elicited using
the “oddball paradigm”,
in which low-probability
stimuli are mixed withhigh-probability non-target(or standard) items. For
example, in a visual oddballtask, a square (standard)is presented 95% of thetime and a circle (oddball)
5%. When the targets (e.g.,
circles) appear, the subject
must make a response,such as pressing a button
or updating a mental count.
The characteristics of the
P300 wave in this situation
are often used as measuresof cognitive function indecision making.

17

IACAPAP Textbook of Child and Adolescent Mental Healthor in any neuropsychological outcomes explored (e.g., inattention and response
inhibition) (Cortese et al, in press). Results are difficult to interpret because of
the weak experimental design of many studies (e.g., lack of controls, non-random
allocation, or the use of non-blind measures). No differences were observed
when using quantitative EEG or evoked potentials as the basis for biofeedback(Gevensleven et al, 2009). Trials that compared neurofeedback with medication
alone or in combination reported conflicting results (Duric et al, 2012; Meisel etal, 2013; Li et al, 2013; Ogrim et al, 2013).

Clinical Considerations•••

A number of factors might contribute to clinical response, including
training intensity and number of sessions; visual imagery of theindividual; parenting style; use of reinforcement techniques at home;and motivation (effort, attention, and time invested)
Epilepsy might be a contraindication
Potential side effects include headaches and fatigue

Future directions••

The question whether one training protocol is more effective than theother is not yet resolved (Holtmann et al. 2014).
Techniques such as near-infrared spectroscopy and fMRI neurofeedback
may offer advantages in terms of targeting well defined brain regions(Mihara et al, 2012). Notably, real time fMRI may additionally open
the possibility of more rapid learning to regulate deep structures suchas dopaminergic midbrain regions implicated in ADHD (Cortese etal, 2012).

Click on the image to view
how neurofeedback works inpractice••

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Ma Haifang. Children at school.

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IACAPAP Textbook of Child and Adolescent Mental Health

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Non-pharmacologic Treatments for ADHD

D.1.1

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix D.1.1.1
SELF-DIRECTED LEARNING EXERCISES AND SELF-ASSESSMENT
MCQ D.1.1.1
ADHD:

Restrictive elimination diets for

A. Have been shown to be an effective
treatment
B. Have a small effect size on ADHD
symptoms, not large enough to justify
recommending it as a stand-alone
treatment
C. Are only effective in adolescents
D. Are effective on comorbid depressive
symptoms
E. Are simple and cheap to implement

MCQ D.1.1.4		
Psychosocial treatments
based on social learning and behavior
modification principles have been widelyused for ADHD. The intervention most widely
supported by evidence for younger children is:
A.
B.
C.
D.
E.

MCQ D.1.1.5		
Children most likely tobenefit from behavioral interventions are thosewho:

MCQ D.1.1.2 Oligoantigenic diets focus
on foods other than artificial colors andpreservatives that may trigger ADHD
symptoms. Implementation of these diets:

A. Come from lower socio-economic statusfamilies
B. Have parents with mental healthproblems
C. Have comorbid ODD/CD
D. Are older (e.g., adolescents)
E. Have higher levels of family conflict

A. Requires all the family to be on the diet
B. Do not show results for at least 6 months
C. Usually excludes cow’s milk, cheese,
egg, chocolate, rice and nuts
D. Should be tried in all cases
E. Is very effective
MCQ D.1.1.3
ADHD:

Fatty-acid supplementation for

MCQ D.1.1.6 A form of neurofeedback iscalled EEG frequency band training. This
intervention seeks to:

A. Has significant side effects
B. Requires supplementation with omega-3
fatty acids only
C. Requires supplementation with omega-6
fatty acids only
D. Requires supplementation with bothomega-3 and omega-6 fatty acids
E. Has been found to be ineffective

Non-pharmacologic Treatments for ADHD

Contingency management
Skills training
Creativity-based therapies
Self-management
Parent training programs

D.1.1

A. Reduce slow wave activity and increase
faster (alpha wave) activity
B. Modify event-related cortical potentials
C. Help the child control epileptiform EEG
activity
D. Induce brain maturation
E. Increase neuronal metabolism

22IACAPAP Textbook of Child and Adolescent Mental HealthANSWERSMCQ D.1.1.1 Answer: B
MCQ D.1.1.2 Answer: C
MCQ D.1.1.3 Answer: D
MCQ D.1.1.4 Answer: E
MCQ D.1.1.5 Answer: C
MCQ D.1.1.6 Answer: A

Non-pharmacologic Treatments for ADHD

D.1.1

23