Non-pharmacological interventions for attention-deficit hyperactivity disorder in children and adolescents

Novel and complementary treatment approaches in attention-deficit/hyperactivity disorder

PURPOSE OF REVIEW

To provide an updated review of novel and complementary treatment approaches for children and adolescents with attention-deficit/hyperactivity disorder.

RECENT FINDINGS

The evidence for complementary attention-deficit/hyperactivity disorder treatments is often promising, but limited to small, unblinded studies. Recent evidence from larger, more rigorous studies reveals that most of these treatments have modest efficacy. Omega-3 polyunsaturated fatty acids, saffron, broad spectrum micronutrients, and physical exercise have potential benefits that seem to outweigh known risks. However, neurofeedback, cognitive training, and trigeminal nerve stimulation need further research to determine whether specific sub-groups of children/adolescents with attention-deficit/hyperactivity disorder would benefit long-term with their associated tolerable risks.

SUMMARY

There is not sufficient evidence for complementary treatments to be recommended as substitutes for first-line pharmacological and psychosocial treatment options. Nonetheless, some adjuvant therapies to currently recommended attention-deficit/hyperactivity disorder treatments can be safe. Physicians should be familiar with existing and emerging complementary treatments to help guide families.

A Young adolescent with undiagnosed ADHD-inattentive presentation and co-morbid anxiety and depression: A case report

This case report discusses a young adolescent with attention deficit hyperactivity disorder (ADHD) - inattentive presentation, and comorbid anxiety and depression that was not diagnosed until age 13. However, most ADHD is diagnosed before age 12. Anxiety and depression are common comorbidities of ADHD that present in primary care and can mimic the symptoms of ADHD. Due to the shortage of trained pediatric behavioral and mental health specialists, primary care pediatric nurse practitioners often diagnose and manage children and adolescents with ADHD and various comorbid conditions. It is essential to look for red flags in young children, especially in ADHD inattentive presentation, because symptoms are often masked and go unrecognized, undiagnosed, and untreated for years, resulting in academic and social problems causing the child and family stress, frustration, and reduced quality of life.

Systematic Review and Meta-Analysis: Do White Noise or Pink Noise Help With Task Performance in Youth With Attention-Deficit/Hyperactivity Disorder or With Elevated Attention Problems?

OBJECTIVE

Public interest in the potential benefits of white, pink, and brown noise for attention-deficit/hyperactivity disorder (ADHD) has recently mushroomed. White noise contains all frequencies of noise and sounds like static; pink or brown noise has more power in the lower frequencies and may sound, respectively, like rain or a waterfall. This meta-analysis evaluated effects on laboratory tasks in individuals with ADHD or elevated ADHD symptoms.

METHOD

Eligible studies reported on participants with diagnosis of ADHD or elevated symptoms of ADHD who were assessed in a randomized trial using laboratory tasks intended to measure aspects of attention or academic work involving attention or executive function while exposed to white, pink, and brown noise and compared with a low/no noise condition. Two authors independently reviewed and screened studies for eligibility. A random-effects meta-analysis was conducted with preplanned moderator analyses of age, diagnostic status, and task type. Publication bias was evaluated. The GRADE tool was used to assess certainty of the evidence. Sensitivity analyses were conducted to evaluate robustness.

RESULTS

Studies of children and college-age young adults with ADHD or ADHD symptoms (k = 13, N = 335) yielded a small but statistically significant benefit of white and pink noise on task performance (g = 0.249, 95% CI [0.135, 0.363], p < .0001). No studies of brown noise were identified. Heterogeneity was minimal, and moderators were nonsignificant; results survived sensitivity tests, and no publication bias was identified. In non-ADHD comparison groups (k = 11, N = 335), white and pink noise had a negative effect (g = -0.212, 95% CI [-0.355, -0.069], p = .0036).

CONCLUSION

White and pink noise provide a small benefit on laboratory attention tasks for individuals with ADHD or high ADHD symptoms, but not for non-ADHD individuals. This article addresses theoretical implications, cautions, risks, and limitations.

PLAIN LANGUAGE SUMMARY

Public interest in the potential benefits of white, pink, and brown noise exposure for enhancing task performance for individuals with attention-deficit/hyperactivity disorder (ADHD) has increased substantially. This systematic review and meta-analysis included 13 studies with 335 participants and found that white/pink noise improved cognitive performance for children and young adults with ADHD or significant ADHD symptoms. In contrast, white/pink noise impaired cognitive performance for individuals without ADHD. Positive effects of noise were small, but these results point to a possible low-cost, low-risk intervention that may benefit youth with ADHD. Additional studies are needed to confirm effects and identify safe and appropriate decibel levels. The potential detrimental effects for individuals without ADHD also requires further study.

STUDY PREREGISTRATION INFORMATION

White Noise for ADHD: A Systematic Review And Meta-analysis; https://www.crd.york.ac.uk/prospero; CRD42023393992.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study

BACKGROUND

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services.

METHODS

TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness.

RESULTS

WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention.

CONCLUSIONS

WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

Settling a distracted globe: An overview of psychosocial and psychotherapeutic treatment of attention-deficit/hyperactivity disorder

While the currently prevailing theory of ADHD postulates a neurobiological background and core deficits of behavioural inhibition and executive functioning as the basis of ADHD symptoms, our current conceptualisation also acknowledges the essential contributory role of psychosocial, ecological, and cognitive factors. Considering the multifactorial background of ADHD, its treatment equally needs to be multifactorial involving, besides pharmacotherapy, skill development and psychotherapy as well, especially if we postulate the increasing contribution of social factors in the background of the increasing burden of ADHD. Pharmacotherapies, including stimulants and non-stimulant ADHD medications applied as first-line treatments have a positive effect on core behavioural symptoms, however, they often do not sufficiently remediate several other symptoms and comorbid disorders, which are consequences of ADHD, especially considering that ADHD persists into adulthood and is present over the whole life span. Furthermore, pharmacological treatment is not sufficient to substitute for the skills needed to manage symptoms and adapt well to the environment. As part of a multimodal treatment approach, psychological therapies for ADHD target, besides core ADHD symptoms, other associated features including emotional dysregulation, personality development, neurocognitive dysfunction, depression, anxiety, and sleep problems. Insufficiently treated ADHD may contribute to psychological and personality developmental problems in children, as well as increased health costs and decreased productivity warranting multimodal treatment to address the areas not sufficiently targeted by ADHD-specific pharmacotherapy.

Evaluating mineral biomarkers as mediators and moderators of behavioural improvements in a randomised controlled trial of multinutrients for children with attention-deficit/hyperactivity disorder

Essential minerals are cofactors for synthesis of neurotransmitters supporting cognition and mood. An 8-week fully-blind randomised controlled trial of multinutrients for attention-deficit/hyperactivity disorder (ADHD) demonstrated three times as many children (age 6-12) had significantly improved behaviour ('treatment responders') on multinutrients (54 %) compared with placebo (18 %). The aim of this secondary study was to evaluate changes in fasted plasma and urinary mineral concentrations following the intervention and their role as mediators and moderators of treatment response. Fourteen essential or trace minerals were measured in plasma and/or urine at baseline and week eight from eighty-six participants (forty-nine multinutrients, thirty-seven placebos). Two-sample t tests/Mann-Whitney U tests compared 8-week change between treatment and placebo groups, which were also evaluated as potential mediators. Baseline levels were evaluated as potential moderators, using logistic regression models with clinical treatment response as the outcome. After 8 weeks, plasma boron, Cr (in females only), Li, Mo, Se and vanadium and urinary iodine, Li and Se increased more with multinutrients than placebo, while plasma phosphorus decreased. These changes did not mediate treatment response. However, baseline urinary Li trended towards moderation: participants with lower baseline urinary Li were more likely to respond to multinutrients (P = 0·058). Additionally, participants with higher baseline Fe were more likely to be treatment responders regardless of the treatment group (P = 0·036.) These results show that multinutrient treatment response among children with ADHD is independent of their baseline plasma mineral levels, while baseline urinary Li levels show potential as a non-invasive biomarker of treatment response requiring further study.

Mapping the evolution of neurofeedback research: a bibliometric analysis of trends and future directions

Introduction

This study conducts a bibliometric analysis on neurofeedback research to assess its current state and potential future developments.

Methods

It examined 3,626 journal articles from the Web of Science (WoS) using co-citation and co-word methods.

Results

The co-citation analysis identified three major clusters: "Real-Time fMRI Neurofeedback and Self-Regulation of Brain Activity," "EEG Neurofeedback and Cognitive Performance Enhancement," and "Treatment of ADHD Using Neurofeedback." The co-word analysis highlighted four key clusters: "Neurofeedback in Mental Health Research," "Brain-Computer Interfaces for Stroke Rehabilitation," "Neurofeedback for ADHD in Youth," and "Neural Mechanisms of Emotion and Self-Regulation with Advanced Neuroimaging.

Discussion

This in-depth bibliometric study significantly enhances our understanding of the dynamic field of neurofeedback, indicating its potential in treating ADHD and improving performance. It offers non-invasive, ethical alternatives to conventional psychopharmacology and aligns with the trend toward personalized medicine, suggesting specialized solutions for mental health and rehabilitation as a growing focus in medical practice.

One year follow-up of participants in a randomised controlled trial of a CBT-based group therapy programme for adolescents diagnosed with ADHD

BACKGROUND

Adolescents with ADHD often struggle on many areas of their lives and have a high risk of adverse outcomes and negative life trajectories. Multimodal treatment including psychosocial interventions is recommended but evidence regarding effect of such interventions is still limited.

MATERIALS AND METHODS

This study was a follow-up study of adolescents participating in a randomised controlled trial (RCT) of a group intervention based on cognitive behavioural therapy (CBT). Participants were adolescents diagnosed with ADHD and still impaired by their symptoms after standard treatment including psychoeducation and medication. All participants were interviewed by telephone one year after inclusion, and outcome measures included both quantitative and qualitative measures.

RESULTS

There were 100 adolescents included in the study. We found no significant differences between treatment and control group on measures of ADHD-symptoms, self-efficacy, overall problems, global psychosocial functioning, or symptom severity at one-year follow-up. Still, participants in the intervention group reported on positive gains and that they learned a lot about ADHD and themselves.

CONCLUSIONS

The intervention delivered in this trial failed to show a treatment effect on symptom level when added to standard care. Participants did however report on positive gains and felt they learned a lot. More research is needed to explore how the programme and delivery of treatment might be improved, and which patients might benefit the most from this type of interventions.

Longitudinal Patterns of Community-Based Treatment Utilization Among Ethnically and Racially Diverse Adolescents with Attention-Deficit/Hyperactivity Disorder

Background: Attention-deficit/hyperactivity disorder (ADHD) treatment utilization among adolescents is highly variable. This article describes pharmacological and nonpharmacological treatment utilization in a community sample of primarily Latinx and/or Black adolescents with ADHD (N = 218), followed longitudinally for 4 years, from early adolescence until approximately age 17 (M = 16.80, standard deviation = 1.65). Methods: Electronic surveys administered between 2012 and 2019 queried parent and youth reports of medication initiation, persistence, diversion, and misuse, as well as reasons for desistence. Nonpharmacological treatment utilization (including complementary and alternative treatments) was also measured. Results: Results indicated that: (1) the majority of the sample sought treatment for ADHD in their community, (2) rates of psychosocial treatment utilization were higher than medication utilization, (3) approximately half of the medicated sample discontinued community-administered ADHD medication during the follow-up period, most frequently citing tolerability issues and concerns that they were "tired of taking" medication, and (4) medication misuse consisted of youth diversion and parent utilization of teen medication, but both were reported at low rates. Race/ethnicity did not predict treatment utilization patterns, but lower family adversity and psychiatric comorbidity predicted persistence of medication use over time. Conclusions: ADHD treatment engagement efforts for Latinx and/or Black adolescents might link treatment to goals valued by the youth, address concerns related to medication tolerability, and promote secure monitoring of medication. Nonpharmacological treatments for ADHD may be more palatable to Latinx and Black youth with ADHD, and efforts to engage youth with ADHD in treatment should consider offering medication and psychosocial treatment options.

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.

Safety and efficacy of antioxidant therapy in children and adolescents with attention deficit hyperactivity disorder: A systematic review and network meta-analysis

OBJECTIVE

To systematically evaluate the safety and efficacy of antioxidant therapy in children and adolescents with attention deficit hyperactivity disorder (ADHD).

METHODS

Randomized controlled trials and prospective studies on antioxidant therapy in children and adolescents with ADHD were searched in PubMed, Embase, and Cochrane Library from the inception of databases to November 12, 2022. Two investigators independently screened the literature, extracted data, and evaluated the quality of the included studies. Network meta-analysis (PROSPERO registration number CRD 42023382824) was carried out by using R Studio 4.2.1.

RESULTS

48 studies involving 12 antioxidant drugs (resveratrol, pycnogenol, omega-3, omega-6, quercetin, phosphatidylserine, almond, vitamin D, zinc, folic acid, ginkgo biloba, Acetyl-L-carnitine) were finally included, with 3,650 patients. Network meta-analysis showed that omega-6 (0.18), vitamin D (0.19), and quercetin (0.24) were the top three safest drugs according to SUCRA. The omega-3 (SUCRA 0.35), pycnogenol (SUCRA 0.36), and vitamin D (SUCRA 0.27) were the most effective in improving attention, hyperactivity, and total score of Conners' parent rating scale (CPRS), respectively. In terms of improving attention, hyperactivity, and total score of Conners' teacher rating scale (CTRS), pycnogenol (SUCRA 0.32), phosphatidylserine+omega-3 (SUCRA 0.26), and zinc (SUCRA 0.34) were the most effective, respectively. In terms of improving attention, hyperactivity and total score of ADHD Rating Scale-Parent, the optimal agents were phosphatidylserine (SUCRA 0.39), resveratrol+MPH (SUCRA 0.24), and phosphatidylserine (SUCRA 0.34), respectively. In terms of improving attention, hyperactivity and total score of ADHD Rating Scale-Teacher, pycnogenol (SUCRA 0.32), vitamin D (SUCRA 0.31) and vitamin D (SUCRA 0.18) were the optimal agents, respectively. The response rate of omega-3+6 was the highest in CGI (SUCRA 0.95) and CPT (SUCRA 0.42).

CONCLUSION

The rankings of safety and efficacy of the 12 antioxidants vary. Due to the low methodological quality of the included studies, the probability ranking cannot fully explain the clinical efficacy, and the results need to be interpreted with caution. More high-quality studies are still needed to verify our findings.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

The Effects of Mindfulness for Youth (MYmind) versus Group Cognitive Behavioral Therapy in Improving Attention and Reducing Behavioral Problems among Children with Attention-Deficit Hyperactivity Disorder and Their Parents: A Randomized Controlled Trial

INTRODUCTION

There is a lack of studies evaluating mindfulness-based interventions for children with attention-deficit hyperactivity disorder (ADHD) compared with an evidence-based control. This randomized controlled trial (RCT) evaluated the effects of mindfulness for youth (MYmind) in improving children's attention, behavior, and parent-related outcomes versus cognitive behavioral therapy (CBT).

METHODS

A total of 138 families of children with ADHD aged 8-12 years were recruited from the community with 69 randomized to MYmind and 69 to CBT. Participants were assessed at baseline, immediately after intervention, at 3 months and 6 months. The primary outcome was the attention score of the Sky Search subtest of the Test of Everyday Attention for Children (TEA-Ch). Secondary outcomes were child behavior and parent-related assessments. Linear mixed models were used to assess the efficacy of MYmind compared with CBT.

RESULTS

Both MYmind and CBT significantly improved children's attention score at 6 months (MYmind: β = 1.48, p = 0.013, Cohen's d = 0.32; CBT: β = 1.46, p = 0.008, d = 0.27). There were significant within-group improvements in most secondary outcomes. No significant difference was shown for both primary or secondary outcomes between the two arms at any time point.

CONCLUSIONS

Both MYmind and CBT appeared to improve children's attention and behavior outcomes, although no difference was found between these two interventions. This is the largest RCT so far comparing MYmind and CBT although there was loss of follow-up assessments during the pandemic. Further RCTs adopting a non-inferiority design are needed to validate the results.