Efficacy of non-pharmacological interventions on executive functions in children and adolescents with ADHD: A systematic review and meta-analysis

An Adolescent with Undiagnosed Inattentive-Type Attention Deficit-Hyperactivity Disorder and Comorbid Migraine: A Case Report

ABSTRACT

Patients with attention deficit-hyperactivity disorder (ADHD) commonly exhibit symptoms such as difficulty paying attention and focusing, trouble controlling their behavior, and hyperactivity. Comorbidities frequently occur with ADHD, including a variety of psychiatric issues, medical conditions, and learning disorders. The lack of adequate pediatric mental health resources highlights the critical need for experienced nurses and NPs to play a pivotal role in diagnosing and treating ADHD, ensuring timely care for young patients. This article presents a case study of an adolescent with ADHD with inattention and migraine, but not hyperactivity or impulsivity. The patient was not diagnosed until adolescence, causing frustration for the patient and the family, and resulting in academic failure. An NP diagnosed the patient and treated him with the stimulant methylphenidate, which resulted in a positive academic outcome and improved quality of life. It is critical to identify, diagnose, and treat ADHD early and appropriately for optimal patient outcomes. This is especially true for adolescents with previously undiagnosed inattentive-type ADHD.

Network meta-analysis of the effects of long-term non-pharmacologic treatment on inhibitory control in children and adolescents with attention deficit hyperactivity disorder

OBJECTIVE

To conduct a network meta-analysis comparing the effects of various long-term non-pharmacological treatments on inhibitory control in children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD) to provide theoretical support for non-pharmacological interventions in ADHD management.

METHODS

Randomized controlled trials (RCTs) on the effects of long-term non-pharmacological treatments on inhibitory control in children and adolescents with ADHD published up to November 11, 2024, were searched in databases such as CNKI, Web of Science, APA PsycInfo, Embase, PubMed and Cochrane Library.

RESULTS

A total of 42 studies, including seven non-pharmacological types, were included, involving 1981 children and adolescents with ADHD, with a mean age of 10.04 ± 1.82 years. Both traditional and network meta-analyses based on post-test data revealed that physical exercise, cognitive training, behavior therapy, and neurofeedback significantly improved inhibitory control (P < 0.05), with physical exercise showing the best improvement (SUCRA: 85.9 %). At the same time, board games, EMG feedback, and meditation had no significant effect (P > 0.05). Follow-up analysis showed that behavior therapy and cognitive training had a good maintenance effect (P < 0.05), with behavior therapy demonstrating the best sustained effect (SUCRA: 95.1 %). In contrast, physical exercise, board games, and neurofeedback showed diminishing effects over time and had no significant long-term effect (P > 0.05).

CONCLUSION

Existing evidence shows that physical exercise, cognitive training, behavior therapy, and neurofeedback all have a positive effect on improving inhibitory control in children and adolescents with ADHD, with physical exercise showing the best effect, though with poor maintenance, while cognitive training and behavior therapy had a slightly lower effect, but their maintenance was better.

Internet-based behavioural parent training intervention for children with attention-deficit/hyperactivity disorder: A randomized clinical trial

BACKGROUND

Behavioral parent training (BPT) is recognized as a significant non-pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD). However, there is limited empirical evidence of its effectiveness within the Chinese context, particularly for online BPT. This study evaluates the efficacy of an 8-session internet-based BPT (I-BPT) program in improving ADHD symptoms and mental health outcomes for children and parents, compared to routine clinical care (RCC).

METHODS

Participants included 120 children with ADHD and their parents, recruited from the Wuhan Mental Health Centre between March and September 2023. They were randomly assigned to either the I-BPT+RCC (N = 60) or RCC (N = 60) group, with assessments conducted at baseline and after two months. Child-related outcomes measured were ADHD symptoms, depressive symptoms, anxiety symptoms and functional impairment. Parent-related outcomes included depressive symptoms, anxiety symptoms and parental stress. Analyses of covariance (ANCOVA) were used to compare the efficacy of I-BPT+RCC with the RCC alone.

RESULTS

The I-BPT+RCC group showed significant improvements in total ADHD symptoms (F=6.84, P = 0.010), inattention (F=4.82, P = 0.030), hyperactivity/impulsivity (F=4.83, P = 0.030), and child depressive symptoms (F=8.56, P = 0.004) compared to the RCC group. Parental stress also significantly decreased in the I-BPT+RCC group (F=5.95, P = 0.016).

CONCLUSIONS

Overall, the I-BPT significantly enhanced health outcomes for children with ADHD and their parents. These findings highlight the potential of I-BPT as an effective and accessible treatment option for a broader patient population.

The impact of physical activity on inhibitory control of adult ADHD: a systematic review and meta-analysis

Objective

We aimed to Investigate physical activity's effects on inhibitory control in adult attention deficit hyperactivity disorder (ADHD).The benefits of physical activity on the inhibitory control of adult ADHD were explored in the hope of providing some suggestions for approaches to treating adult ADHD.

Methods

We searched the databases PubMed, Web of Science, CNKI and Wanfang for randomised controlled trials (RCTs) of the effect of physical activity on inhibitory control in adults with ADHD, using PRISMA guidelines. We used used the Cochrane Bias Risk Assessment Criteria to assess the methodological quality of the included studies. Finally, we performed a heterogeneity analysis and a potential publication bias analysis using Revman 5.4.

Results

A total of eight articles, 14 studies, and 373 experimental subjects were included in the systematic review and meta-analysis. The meta-analysis results showed that both acute exercise (standard mean deviation (SMD) = -0.65, 95% confidence interval (CI) = -1.10,-0.2, P = 0.005) and chronic exercise (SMD = -1.77, 95% CI = -2.84, -0.69, P = 0.0001) have a positive effect on the inhibitory control of adult ADHD. Pilates (SMD = -2.22, 95% CI = -2.97, -1.47, P < 0.0001), Tai Chi (SMD = -2.20, 95% CI = -6.25, -1.8, P = 0.25), cycling (SMD = -0.67, 95% CI = -1.27, -0.08, P = 0.03), vibration training (SMD = -0.67, 95% CI = -1.39, -0.05, P = 0.07), yoga (SMD = 0.01, 95% CI = -0.50, -0.48, P = 0.97), and other different exercise styles have significant differences in their effects on adult ADHD inhibitory control.

Conclusions

Physical activity has a beneficial effect on inhibitory control in adults with ADHD. However, more research is needed to examine the beneficial effects of different types of physical activity, intervention modalities, and dose-response effects of intensity.

Registration

This review was registered with INPLASY (registration number: 202490109).

Short-term and long-term effect of non-pharmacotherapy for adults with ADHD: a systematic review and network meta-analysis

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) is a lifelong neurodevelopmental condition with a global prevalence of 2.5% to 6.7% among adults. Non-pharmacological interventions have demonstrated effectiveness both as standalone treatments and adjuncts to pharmacotherapy in managing adult ADHD. Nevertheless, the comparative efficacy of these interventions, particularly with respect to diverse ADHD-related outcomes and their long-term impacts, remains insufficiently investigated.

Objective

This study aims to evaluate and compare the short-term and long-term effects of various non-pharmacological therapies on core ADHD symptoms (inattention, hyperactivity, and impulsivity) and emotional disorders (depression and anxiety) in adults with ADHD and to rank these therapies accordingly.

Methods

A systematic search was conducted for relevant randomized controlled trials (RCTs) in the Web of Science, PubMed, Cochrane Library, and EMBASE databases from inception to Sep 2024. Researchers independently screened and extracted data, and the analysis was performed using R version 4.3.2. Cochrane Risk of Bias tool version 2 (ROB2) and Confidence in Network Meta-Analysis (CINeMA) were used to assess the risk of bias and the certainty of the evidence. Standardized mean differences were estimated using network meta-analyses with random effects.

Results

A total of 37 RCTs involving 2,289 participants and 10 non-pharmacological therapies were included. The risk of bias was classified as low in 24.3%, unclear in 27%, and high in 48.6%, while the CINeMA assessment indicated that confidence in the evidence was "very low" or "low" for most of the remaining treatments. Cognitive behavioral therapy (CBT) showed significantly greater effectiveness than the control group/condition in both the short-term (SMD: -4.43, 95%CI: -5.50 to -3.37) and long-term (SMD: -3.61, 95%CI: -4.66 to -2.56) core symptoms. Additionally, CBT shows both short-term and long-term efficacy for depression (SMD: -4.16, 95%CI: -5.51 to -2.81; SMD: -3.89, 95%CI: -5.95 to -1.83) and anxiety (SMD: -2.12, 95%CI: -3.18 to -1.07; SMD: -7.25, 95%CI: -10.57 to -3.94).

Conclusion

CBT may be the most effective intervention for adults with ADHD and associated emotional disorders, while Mindfulness-based Cognitive Therapy (MC) is recommended as a preferable option for those without comorbidities. Caution is needed in interpreting our results, and high-quality RCTs are urgently required for more reliable insights.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier CRD42024432912.

Comparative effectiveness of physical activity interventions on cognitive functions in children and adolescents with Neurodevelopmental Disorders: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Physical activity (PA) interventions have been shown to yield positive effects on cognitive functions. However, it is unclear which type of PA intervention is the most effective in children and adolescents with Neurodevelopmental Disorders (NDDs). This study aimed to compare the effectiveness of different types of PA interventions on cognitive functions in children and adolescents with NDDs, with additional analyses examining intervention effects across specific NDD types including attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).

METHODS

In this systematic review and network meta-analysis, seven databases (Web of Science, PubMed, Medline, APA PsycINFO, Embase, CINAHL, and SPORTDiscus) for randomized controlled trials from database inception to September 2023 were searched. Randomized controlled trials comparing the effectiveness of PA intervention with any non-pharmacological treatment or control group on cognitive functions in children and adolescents diagnosed with NDDs aged 5-17 years were included. Frequentist network meta-analyses were performed based on standardized mean differences (SMD) using random effects models to examine post-intervention differences in cognitive functions, including attention, memory, and executive functions. Intervention dropout was assessed as a measure of treatment acceptability.

RESULTS

Thirty-one randomized controlled trials (n = 1,403, mean age 10.0 ± 1.9 years) with 66 arms were included in the network. Mind-body exercise (MBE; SMD = 1.91 for attention; 0.92 for executive functions), exergaming (SMD = 1.58 for attention; 0.97 for memory; 0.94 for executive functions), and multi-component physical activity (MPA; SMD = 0.79 for executive functions) were associated with moderate to substantial cognitive improvements compared with usual care, whereas the effectiveness of aerobic exercise (AE) was non-significant. Exergaming (SMD = 0.78, 95%CI 0.12 to 1.45) and MPA (SMD = 0.64, 95%CI 0.11 to 1.18) were more effective than AE for executive functions. When analyzing specific NDD types, exergaming lost its superiority over usual care for attention and memory in ADHD, nor for executive functions in ASD. Instead, MPA demonstrated significant benefits across these domains and populations. The certainty of evidence for these comparisons was very low to low. No significant differences in acceptability were observed among MBE, exergaming, and MPA.

CONCLUSIONS

The findings in this study suggest that MBE, exergaming, and MPA were effective interventions for improving domain-specific cognitive functions in children and adolescents with NDDs. AE demonstrated non-significant effectiveness for all outcomes. MBE emerges as particularly advantageous for attention. MPA yielded consistent improvements in memory and executive functions across NDD types. Further high-quality randomized controlled trials of direct comparisons are needed to confirm and expand on the findings from this NMA.

TRIAL REGISTRATION

PROSPERO CRD42023409606.

Comparative Efficacy of Neurofeedback Interventions for Attention-Deficit/Hyperactivity Disorder in Children: A Network Meta-Analysis

OBJECTIVE

This study aimed to synthesize and encapsulate findings from recent research (May 1, 2018 to August 1, 2023) on neurofeedback interventions for children diagnosed with attention deficit hyperactivity disorder (ADHD).

METHODS

A comprehensive search was conducted across major databases and platforms, including randomized controlled trials s focusing on children aged 5-11 years with ADHD. The inclusion was broad, not restricted by ADHD subtype, gender, IQ, socioeconomic status, or coexisting conditions.

RESULTS

From the study screening process, 13 studies were included in the network meta-analysis, involving 1370 children. Most neurofeedback therapies surpassed placebo in ADHD symptoms. In the acceptability outcome, five neurofeedback therapies (HEG, SCP training, TBR training, SMR training, and active control) outperformed the inactive control, physical activity, and EMG therapies.

CONCLUSIONS

The potential efficacy of nonpharmacological interventions in ADHD management among children is illuminated. The findings advocate for a holistic, child-centered approach, emphasizing the need for further in-depth research to understand and refine these interventions.

Cognitively combined/engaged physical activity for the executive function, symptomology, and motor competence of children and adolescents with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis

BACKGROUND

Cognitively combined/engaged physical activity (CC/CE-PA) has been used as an intervention for children/adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHOD

This review aimed to quantify the effects of CC/CE-PAs on enhancing executive and physical function and alleviating ADHD symptoms in children/adolescents with ADHD. An extensive literature search of online databases identified 32 studies (75 % high-quality studies), of which 22 (pooled n=968) were included in the meta-analysis.

RESULTS

The included studies covered five PA types with varying intervention periods, frequencies, and exercise durations. The CC/CE-PAs showed an overall significant effect on improving executive function (standardized mean difference [SMD]: 1.10) and motor competence (SMD: 0.52) and alleviating ADHD symptoms (SMD: -0.75). Program design and participants' medication status were found to significantly moderate the effect of CC/CE-PA.

CONCLUSION

More evidence is needed to support the effect of CC/CE-PA by comparing it with other interventions and using a rigorous experimental design.

Impact of a physical exercise intervention on psychological resilience and mental ill-being in medical-naïve children with attention-deficit/hyperactivity disorder: a pilot randomised controlled trial

The study aimed to evaluate whether a 12-week physical exercise intervention would improve psychological resilience and mental ill-being (e.g. internalising and externalising symptoms) in medical-naïve children with Attention-Deficit/Hyperactivity Disorder (ADHD). In a parallel two-group randomised controlled trial (RCT) design, 30 children between 8-12 years (Mage = 8.62 ± 1.37) formally diagnosed with ADHD were assigned to a 12-week physical exercise intervention group (three sessions per week for 60 mins, moderate-to-vigorous physical activity [MVPA] intensity) or a control group (treatment as usual). Psychological resilience was measured by a self-reported Chinese version of the 25-item Connor-Davidson Resilience Scale, and mental ill-being was assessed by a parent-reported Chinese version of the 113-item Achenbach's Child Behavior Checklist. The 12-week physical exercise intervention with MVPA level revealed a significant improvement in psychological resilience (F = 4.82, p = .038) and a significant reduction in internalising symptoms (e.g. anxiety/depressed, withdrawn/depressed, and somatic complaints) (F = 7.11, p = .013) and externalising symptoms (e.g. rule-breaking behaviour and aggressive behaviour) (F = 21.09, p < .001) in the intervention group but not in the control group. Moderate correlations were revealed between the changes in psychological resilience and the changes in internalizing (r = -.557, p = .031) and externalising symptoms (r = -.647, p = .009) in the intervention groups (n = 15). The findings of this study provide initial support for the efficacy of physical exercise intervention on psychological resilience and mental ill-being and for the potential mechanisms of psychological resilience under the effects of exercise-induced mental ill-being improvements in children with ADHD.

Training of Awareness in ADHD: Leveraging Metacognition

Attention deficit hyperactivity disorder (ADHD) is a disorder that is prevalent in children and adults, with significant impact on life outcomes. Common treatment strategies include a combination of pharmacological and psychosocial interventions which have recognized limits to their effectiveness. Consequently, there exists interest in additional non-pharmacological interventions. In the current minireview we aim to complement existing surveys by focusing on a complementary approach, namely rooted in metacognition or the training of awareness. We review programs that incorporate metacognitive training of awareness in skill-training, psychosocial interventions, and mindfulness, and discuss existing assessments of metacognitive ability in ADHD. Existing data suggest that metacognitive approaches have potential in supporting symptom management in ADHD, with gains in objective assessments in near and far transfer tasks in educational research and high satisfaction from parents. Further research is warranted in assessment of the relative contribution of metacognitive elements relative to other treatment components, objective assessments of outcomes in psychosocial interventions, and efficacy in adult interventions.

Mechanisms Linking Physical Activity With Mental Health in Children and Adolescents With Neurodevelopmental Disorders: A Systematic Review

INTRODUCTION

Physical activity (PA) is a promising way to improve mental health in children and adolescents with neurodevelopmental disorders (NDDs). However, the underlying mechanisms remain unclear. The current review aimed to explore the potential neurobiological, psychosocial, and behavioral mechanisms between PA interventions and mental health in children and adolescents with NDDs.

METHODS

Web of Science, PsycINFO, SPORTDiscus, MEDLINE, CINAHL, and ERIC were searched from inception to June 2023. Randomized controlled trials/quasi-experimental designs applying PA interventions and reporting at least one mental health outcome and at least one potential mechanism in children and adolescents with NDDs were included. The best evidence synthesis rating system was adopted to determine the strength and consistency of potential mechanisms and was performed in 2024.

RESULTS

In total, 45 studies were included, 29 of which were randomized controlled trials and 16 were quasi-experimental, with a total of 1,751 participants. According to the best evidence synthesis rating system, neurobiological (theta activity and P3 amplitude), psychosocial (social skills and social participation), and behavioral (motor skills and sleep) mechanisms were the frequently examined and consistent mechanisms through which PA affected mental health in children and adolescents with NDDs. However, evidence regarding P3 latency, beta activity, and physical self-concept was insufficient.

DISCUSSION

Future PA interventions could consider neurobiological (theta activity and P3 amplitude), psychosocial (social skills and social participation), and behavioral (motor skills and sleep) mechanisms. Alternatively, PA can be developed as an adjunctive approach with interventions that specifically focus on these mechanisms to enhance mental health in children and adolescents with NDDs.

Main focus of parents of children with attention deficit hyperactivity disorder and the effectiveness of early clinical screening

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common mental and behavioral disorder among children.

AIM

To explore the focus of attention deficit hyperactivity disorder parents and the effectiveness of early clinical screening.

METHODS

This study found that the main directions of parents seeking medical help were short attention time for children under 7 years old (16.6%) and poor academic performance for children over 7 years old (12.1%). We employed a two-stage experiment to diagnose ADHD. Among the 5683 children evaluated from 2018 to 2021, 360 met the DSM-5 criteria. Those diagnosed with ADHD underwent assessments for letter, number, and figure attention. Following the exclusion of ADHD-H diagnoses, the detection rate rose to 96.0%, with 310 out of 323 cases identified.

RESULTS

This study yielded insights into the primary concerns of parents regarding their children's symptoms and validated the efficacy of a straightforward diagnostic test, offering valuable guidance for directing ADHD treatment, facilitating early detection, and enabling timely intervention. Our research delved into the predominant worries of parents across various age groups. Furthermore, we showcased the precision of the simple exclusion experiment in discerning between ADHD-I and ADHD-C in children.

CONCLUSION

Our study will help diagnose and guide future treatment directions for ADHD.

Establishing Reference Values for a New Computerized Cognitive Function Test Program for Children

OBJECTIVE

To establish reference values for the computerized cognitive test and evaluate cognitive function improvements across different age groups, we introduce the computerized Cognitive Function Test program (eCFT), specifically designed for children. We aimed to establish eCFT reference values and assess cognitive function improvements across different age groups.

METHODS

We included children aged 3-6 years with confirmed normal cognition based on the Korean Developmental Screening Test for Infants and Children and Kaufman Assessment Battery for Children-II. The eCFT consists of 8 subtests for visual perception, attention, memory, and executive function.

RESULTS

A total of 66 participants (36 males and 30 females) with an average age of 4.4 years participated. The age 6 group consistently outperformed both age group 3 and 4 in terms of correct responses. With regard to the completed stage, the "selective auditory stimulus" test findings were 2.0 and 3.9 for the age 3 and age 6 groups, respectively (p<0.05). The "trail-making" test findings were 1.7, 2.1, 2.6, and 2.8, respectively (between ages 3 and 6, p<0.01; between ages 4 and 6, p<0.05); moreover, the age 5 group surpassed the age 3 group (2.6 and 1.7, respectively, p<0.05).

CONCLUSION

The eCFT is an easily accessible tool to evaluate cognitive function in young children. We introduce reference values with a cutoff range for preschool-aged children, enabling early intervention for those with cognitive impairment. Given its accessibility and relatively short evaluation time, the eCFT has potential for clinical use.

Limited usefulness of neurocognitive functioning indices as predictive markers for treatment response to methylphenidate or neurofeedback@home in children and adolescents with ADHD

Introduction

Earlier studies exploring the value of executive functioning (EF) indices for assessing treatment effectiveness and predicting treatment response in attention-deficit/hyperactivity disorder (ADHD) mainly focused on pharmacological treatment options and revealed rather heterogeneous results. Envisioning the long-term goal of personalized treatment selection and intervention planning, this study comparing methylphenidate treatment (MPH) and a home-based neurofeedback intervention (NF@Home) aimed to expand previous findings by assessing objective as well as subjectively reported EF indices and by analyzing their value as treatment and predictive markers.

Methods

Children and adolescents (n = 146 in the per protocol sample) aged 7-13 years with a formal diagnosis of an inattentive or combined presentation of ADHD were examined. We explored the EF performance profile using the Conners Continuous Performance Task (CPT) and the BRIEF self-report questionnaire within our prospective, multicenter, randomized, reference drug-controlled NEWROFEED study with sites in five European countries (France, Spain, Switzerland, Germany, and Belgium). As primary outcome for treatment response, the clinician-rated ADHD Rating Scale-IV was used. Patients participating in this non-inferiority trial were randomized to either NF@home (34-40 sessions of TBR or SMR NF depending on the pre-assessed individual alpha peak frequency) or MPH treatment (ratio: 3:2). Within a mixed-effects model framework, analyses of change were calculated to explore the predictive value of neurocognitive indices for ADHD symptom-related treatment response.

Results

For a variety of neurocognitive indices, we found a significant pre-post change during treatment, mainly in the MPH group. However, the results of the current study reveal a rather limited prognostic value of neurocognitive indices for treatment response to either NF@Home or MPH treatment. Some significant effects emerged for parent-ratings only.

Discussion

Current findings indicate a potential value of self-report (BRIEF global score) and some objectively measured neurocognitive indices (CPT commission errors and hit reaction time variability) as treatment markers (of change) for MPH. However, we found a rather limited prognostic value with regard to predicting treatment response not (yet) allowing recommendation for clinical use. Baseline symptom severity was revealed as the most relevant predictor, replicating robust findings from previous studies.

Executive control training for adolescents with ADHD: Study protocol for a randomised controlled trial

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental conditions diagnosed during childhood and adolescence. In addition to the commonly observed symptoms of inattention, hyperactivity, and impulsivity, individuals with ADHD often experience impairments in executive functions (EFs). Goal management training (GMT) is a cognitive remediation intervention targeting EFs, with empirical support from studies with adult populations, including ADHD. The objective of the upcoming trial is to assess the effectiveness of GMT for adolescents with ADHD.

METHODS

This pre-registered protocol outlines a multi-centre randomised controlled trial (RCT) comparing GMT to treatment as usual (TAU) to improve EFs. We aim to recruit 120 participants, aged 12 to 18 years, recently diagnosed with ADHD. Participants will be randomly allocated to the group-based GMT intervention in addition to TAU, or the TAU condition, through block randomisation with site stratification. GMT will be delivered in groups of four to six participants, with weekly two-hour sessions for seven weeks, complemented by separate parent and teacher sessions. TAU is standard community mental health treatment. The primary outcome measure will be parent-reported EF assessed with the Behaviour Rating Inventory of Executive Function 2 (BRIEF-2). Secondary outcomes will include ADHD symptom measures, social functioning, quality of life, and neuropsychological tests (attention span, inhibition, working memory, and visuo-motor speed). The outcome assessments will be conducted at baseline, 12 weeks, 12 months, and 24 months post-treatment.

CONCLUSION

The study findings will contribute to determine the effectiveness of a non-pharmacological ADHD treatment, including outcome trajectories up to 24 months post-treatment.