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Non-drug treatment and therapy of ADHD - overview

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Non-drug treatment and therapy of ADHD - overview

This article summarizes the non-drug treatment and therapy approaches known to us.
The (+) and (-) in the headings reflect our assessment of the benefits for ADHD.

In our experience, drug treatment is the most important and sensible form of therapy for severe and moderate forms of ADHD.
Among the thousands of sufferers we met via the forum, those who thought they had achieved sufficient symptom improvement with psychotherapy were not only clearly in the minority, but even more clearly: hardly represented at all.
in our opinion, (suitable) ADHD medications carry an efficacy label of (+++++).

  • ADHD should definitely be treated with medication - at least temporarily - especially at the beginning of therapy.
    Sufferers who have never felt what it is like to live without these distressing symptoms cannot empathize with the goal of non-drug therapy from their own perception. Edel/Vollmoeller argue in a similar way.1 In addition, dopamine is a neurotrophic factor, which means that it is required for learning processes in the brain. The dopamine deficiency typical of ADHD therefore prevents learning success and should be remedied before psychotherapeutic treatment.
  • A large meta-study of 190 studies involving 26,114 participants with ADHD found that stimulants appeared to be superior to behavioral therapy, cognitive training and non-stimulants. Stimulants in combination with behavioral therapy appeared to be the most effective.2
  • Medication has a much greater effect on ADHD symptoms than non-pharmacological treatments.3
  • Presentation of the drug treatment at Medication for ADHD - overview.

Non-pharmacological treatments are important supportive measures which, in combination with medication, can lead to relevant additional improvements.
Psychoeducation, self-help groups, sport, psychotherapy, mindfulness techniques and neurofeedback are particularly noteworthy.

1. Non-drug therapy approaches for ADHD

A review of inter- and intra-individual psychological treatments for ADHD found that psychoeducation and parent training, school interventions, reinforcement strategies and neurofeedback consistently showed small to moderate effect sizes in reducing hyperactivity/impulsivity in children. Emotional self-regulation, social skills and cognitive training, on the other hand, showed unsatisfactory results. A combination with medication brought about considerably greater improvements.4

1.1. Psychoeducation (+++)

Source5

1.1.1. Books, websites, seminars, lectures, films

Knowledge about ADHD helps those affected in several ways

  • Who am I, what about me is ADHD?
    Recognizing which symptoms stem from ADHD and that these are treatable makes it easier to identify your own personality: who you “actually” are without this ADHD. This differentiation helps to learn to accept oneself and to understand the ADHD symptoms as something that is inherent but not unchangeable. This is helpful for the often very impaired self-esteem of those affected.
  • Handling requires knowledge
    Understanding the symptoms, their causes and their effects makes it possible to deal with them in a helpful way, in particular:
    • The choice of suitable treatment methods
    • Environmental interventions (see above)
  • Understanding others
    Knowing what constitutes ADHD, how it affects perception and action, helps to understand other people. ADHD sufferers, who have known nothing but normal all their lives, just how they feel and act, can thus recognize why other people feel and act differently where they have no ADHD symptoms.
  • Knowledge facilitates renewal of the self-concept
    A sufferer who has experienced a lifetime of rejection because they are not what they should be can begin to rebuild their self-esteem, which has usually been completely destroyed by then, by understanding that most of the negative reactions were not triggered by themselves but by ADHD6
  • Limit: Avoid negative bias
    The danger of self-fulfilling prophecies should be recognized and avoided.
    Unreflected identification with ADHD symptoms can be harmful.
    You are not ADHD - you have ADHD.
    No ADHD sufferer has all the symptoms of the cluster.
  • Using the advantages of ADHD
    In some specific circumstances and aspects, ADHD sufferers have an advantage over non-affected people. This advantage can only be exploited if you know the conditions under which the advantages apply.

1.1.2. Self-help groups, forums

1.2. Endurance sports, fitness training (+++)

(Endurance) sport appears to be the best non-drug form of treatment for ADHD.789

For many sufferers, especially those with ADHD-HI-HI and ADHD-HI-C subtypes, regular intensive exercise (working out) is essential. As a rule, sport can support treatment, but is only likely to be sufficient on its own in very mild cases
In the experience of those affected, weight training, in contrast to endurance sports, is apparently much less suitable for combating ADHD symptoms in the long term

One study found that children with ADHD were 21% less likely to engage in physical activity.10 Another study found a 3.23-fold increase in excessive physical activity in children with ADHD compared to those not affected.11

1.2.1. ADHD symptoms and sport

Studies report improvements through sports training in children with ADHD:

  • Attention1213 14 , SMD = 0.8415 to 1.7916, especially through cognitively demanding physical activity.17, also through exercise therapy18
    • Memory accuracy19
    • Selective attention1920
      • By strengthening the sensorimotor basis21
    • Permanent attention20
    • Fewer omission errors19
    • Reduced interference errors19
  • Cognitive performance1422 23 , also through exercise therapy18
    • Clear24
    • Statistically significant, but the effect size is small25
  • Orientation behavior improved comparably by exercise, MPH and atomoxetine in SHR26
  • Academic performance27
  • Hyperactivity1213 14 , SMD = 0.5615
  • Impulsivity/inhibition1213 27 19 28 14 , SMD = 0.78, metastudy29, SMD = 0.56, metastudy15
  • Executive functions30
    • Through a single 30-minute sports exercise313221
    • After long-term training2133 , low to moderate34, SMD = 0.5815 to 2.1916
  • Neuroplasticity of nerve cells and synaptic connections21
  • Behavior27
    • Social problems14
    • Social disorders, SMD = 0.5915
    • Aggression14
    • Social behavior improved comparably by sport, MPH and atomoxetine in SHR26
  • Sleep quality.33, also through exercise therapy18
  • Motor skills21
  • Depression
    • Exercise improves your mood
      Even for people who find exercise unpleasant, a half-hour walk has a mood-lifting effect
    • Endurance sport has an antidepressant effect.3514
    • Exercise therapy is helpful18
  • Fear
    Endurance sport has an anxiolytic (anxiety-relieving) effect.3614 , SMD = 0.6615
  • Stress
    • Sport has a regulating effect on stress37
      • Preventive
        • Sport prevents stress.3839
      • Buffering
        acute and habitual physical activity can buffer the negative effects of stressful events on physical and mental health
        • Strengthening resources
          • If sport is included in options for action, sport itself is available as a stress-reducing instrument
          • Group sport creates social bonding
            • Reduces the stressor of social isolation, especially for mental patients40
        • Reaction reduction
          in trained people, negative stress reactions do not occur to the full extent in the first place
          • Cognitive
          • Affective
          • Behavioral
          • Biological
            • Trained men respond to psychological stressors (TSST) in comparison to untrained men41
              • Significantly lower cortisol stress response (with the same basal cortisol level)
              • Significantly lower increase in heart rate
              • Significantly greater calmness, better mood and a tendency to react less anxiously to psychological stress
      • Compensating
        negative stress reactions are reduced or balanced out by sport and exercise
        • Sport reduces cortisol
  • Social behavior with ASD18

1.2.2. Neurophysiological changes through sport

Sport is said to cause an increase in:

  • Dopamine21424344
    • Sport (like MPH) can induce the expression of tyrosine hydroxylase (TH)45 and thereby increase TH levels. TH is a precursor for dopamine. Sport can therefore support dopamine synthesis.
  • Noradrenaline4647 , in the brain regions relevant for ADHD46
  • Serotonin2146 47
  • Acetylcholine4647
  • GABA4647
  • BDNF2146 47
  • Blood flow in the brain21
  • Inflammation levels reduced through regular exercise48
  • Oxidative stress reduced through regular exercise48
  • Stress hormones reduced through regular exercise48
    (during sports competitions, the above three values are increased)
  • Telomerase activity in humans and mice increased by regular exercise48
    • Counteracts behavioral changes caused by stress-induced telomere shortening
  • Calorie consumption
    • Contrary to previous assumptions, sport does not appear to increase calorie consumption. Among the Hadza people, active hunter-gatherers in Africa, women walk an average of 8 km and men an average of 14 km a day, but do not consume any more energy than sedentary office workers in the USA.4950 51 52 Hadza are active and fit up to the age of 70 and 80 and are said to have neither diabetes nor heart disease.
    • However, high calorie consumption through exercise reduces stress systems and inflammatory reactions and thus reduces the calorie consumption that the stress reactions would have caused.51 Although acute physical stress hardly increases cerebral blood flow, there is a redistribution in brain regions involved in motor control and coordination (e.g. vestibular) and transport systems (respiration, circulation).53 This could be the nutritional-physiological equivalent of the long-standing finding that sport has a stress-regulating effect.
    • This sheds a whole new light on the common side effect of stimulants of reduced appetite. We hypothesize that this could be an adaptive response to the body’s decreased energy expenditure due to reduced stress responses. Further, we wonder whether hyperactivity as a symptom of the externalizing ADHD subtypes could possibly be a (misguided) compensatory response of the body, as inflammation is more common in the externalizing stress phenotype than in the internalizing ADHD-I subtype.

One-off training has statistically significant, but small effect size improvements in cognitive performance during, immediately after and delayed after the training session.25 In another study, working memory and inhibition were impaired immediately during exercise in ADHD sufferers compared to non-affected individuals54
The benefits of acute physical activity can gradually accumulate over time.21

A combination of sports training with cognitive tasks for children with ADHD proved to be helpful21, but not superior to sports training alone20

1.3. Psychotherapy

For information on choosing a suitable psychotherapist for ADHD, see Choosing a suitable psychotherapist for ADHD.

1.3.1. Behavioral therapy (+)

  • Cash therapy in D
  • A comprehensive study showed that treatment with medication is superior to treatment with behavioral therapy or clinical care. Multimodal treatment (combined treatment with medication and behavioral therapy or clinical care) appears to be the most promising.55
  • A comprehensive meta-study of 190 studies with 26,114 participants with ADHD also found that behavioral therapy is effective for ADHD. Stimulants were superior to behavioral therapy, cognitive training and non-stimulants. Stimulants in combination with behavioral therapy appeared to be the most effective.56
1.3.1.1. Mindfulness-based behavioral therapy (Mindfulness Based Cognitive Therapy, MBCT) (+++)
  • According to a meta-study, each of the 13 studies analyzed found improvements in ADHD symptoms through mindfulness-based interventions.57 Other studies came to similar conclusions.5859
  • A combined MBCT / MBSR therapy resulted in increased activity and connectivity of the PFC, the cingulate cortex, the insula and the hippocampus in stressed, anxious and healthy people after just 8 weeks. The improvements corresponded to what can be achieved with prolonged meditation practice. The functional activity of the amygdala decreased and the connectivity of the amygdala with the PFC was improved. In addition, the amygdala was deactivated more quickly after emotional stimuli.60 Further studies confirm these results.6162
  • An additional MBCT treatment resulted in a significantly greater improvement in symptoms 6 months after the end of therapy than conventional treatment methods alone.63
  • Mindfulness meditation reduced cortisol and inflammation levels and increased telomerase, which counteracts behavioral changes caused by stress-induced telomere shortening.64
  • Mindfulness-based treatment improved the core symptoms of attention problems and hyperactivity in ADHD.65
  • A meta-study of 32 studies found evidence for the effectiveness of mindfulness-based behavioral therapy (there: mindfulness) for ADHD.66
1.3.1.2. Cognitive behavioral therapy (o to +)
  • A meta-study of 32 studies showed positive results for cognitive behavioral therapy for ADHD in the majority of cases.66
  • A meta-study found benefits of cognitive behavioral therapy for ADHD in parent ratings, but less in the reduction of functional symptoms.13
  • According to Barkley, cognitive behavioral therapy does not work for children with ADHD.67
  • Parental treatment is much more effective for young children.
  • According to one study, patients between 7 and 6 years of age with ASD and anxiety or compulsion were 4 times more likely to respond to cognitive behavioral therapy if they had comorbid ADHD.68
  • Cognitive behavioral therapy is most suitable for self-esteem problems caused by ADHD69 and for deficits in social behavior.
  • According to a meta-study, different forms of therapy improved various symptoms in ADHD (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, from 1 high)70
    • Depression
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.52 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively slightly more effective than cognitive behavioral therapy
      • DBT
        • Ineffective in group comparison
        • Subjectively moderately effective, worse than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, even worse than DBT
    • Anxiety symptoms
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.73 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Self-worth
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective in group comparison
        • 1,404 SMD in the follow-up subjective for affected persons
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Quality of life
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective to slightly effective in group comparison
        • 0.57 SMD in follow-up subjective for affected person
      • MBSR
        • Subjectively very good in the short term
      • DBT
        • Very good in the short term compared to the group, ineffective in the long term
        • Subjectively moderately effective in the short term, weakly effective in the long term
    • Emotional dysregulation
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.64 SMD in follow-up in group comparison
        • 0.73 SMD in follow-up subjective for affected person
      • MBSR
        • Weakly effective in the short term compared to the group, not known in the long term
        • Subjectively very effective in the short term, not known in the long term

1.3.2. Dialectical Behavioral Therapy (DBT) (+)

  • Well suited for ADHD7172

  • A meta-study of 32 studies found evidence for a benefit of group-based DBT for ADHD.66

  • One study found that DBT skills training works particularly well for externalizing sufferers.73

  • A digital form of DBT proved helpful for children with ADHD74

  • According to a meta-study, different forms of therapy improved various symptoms in ADHD (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, from 1 high)70

    • Depression
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.52 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively slightly more effective than cognitive behavioral therapy
      • DBT
        • Ineffective in group comparison
        • Subjectively moderately effective, worse than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, even worse than DBT
    • Anxiety symptoms
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.73 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Self-worth
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective in group comparison
        • 1,404 SMD in the follow-up subjective for affected persons
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Quality of life
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective to slightly effective in group comparison
        • 0.57 SMD in follow-up subjective for affected person
      • MBSR
        • Subjectively very good in the short term
      • DBT
        • Very good in the short term compared to the group, ineffective in the long term
        • Subjectively moderately effective in the short term, weakly effective in the long term
    • Emotional dysregulation
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.64 SMD in follow-up in group comparison
        • 0.73 SMD in follow-up subjective for affected person
      • MBSR
        • Weakly effective in the short term compared to the group, not known in the long term
        • Subjectively very effective in the short term, not known in the long term
  • Elements of DBT:

    • Inner mindfulness
      • Improve self-awareness and learn to trust it
      • Feel safe in a situation without judging or devaluing it
      • Control, being able to participate in situations and maintain distance at the same time
      • Reconciling feelings and reason.
    • Interpersonal skills
      • Establishing and maintaining relationships
      • Balancing and integrating relationship maintenance and one’s own legitimate needs, opinions and self-esteem
    • Dealing with feelings
      • Recognize and name different feelings, understand their meaning
      • Controlling anger and resentment
      • Reduce vulnerability
      • Promote pleasant feelings
      • Letting go of emotional suffering
      • Strengthen confidence in your own feelings
    • Stress tolerance
      • Accept the fact that you are currently under stress
      • Keep your distance (take an inner step back)
      • Limit your thinking to the present and the next few minutes
      • Focus (distraction) through self-exposure to strong sensory stimuli
        • Ice cubes
        • Ball with spikes
      • Breathing exercises
      • “easy smile”
      • Mindfulness exercises
      • Learning to endure unchangeable unpleasant events and feelings (“radical acceptance”).
    • Self-esteem and self-acceptance
      • Healthy self-acceptance
      • Healthy self-confidence
      • A healthy sense of self-worth
  • Structured psychotherapy

    • Very suitable for ADHD
    • Based on Dialectical Behavioral Therapy for Borderline Personality Disorder according to Linehan75

1.3.3. Self-esteem therapy (+)

  • Very suitable for ADHD
  • Many sufferers have spent their entire lives under (inaccurate) accusations such as “their lack of drive is an expression of laziness”, or “their inability to behave in a socially appropriate manner is malice” (because the power of impulsive outbursts has been misunderstood). The fear of being further misunderstood makes it considerably more difficult to engage in a therapeutic relationship.76
  • Cognitive remediation program77
  • Note: In our opinion, rejection sensitivity is a symptom originally caused by ADHD, which responds just as well to drug treatment with stimulants as attention problems or hyperactivity/impulsivity. In our opinion, this speaks against a purely experientially mediated imprinting of self-esteem. Rejection sensitivity: offendedness and sensitivity to rejection and criticism as a specific ADHD symptom

1.3.4. EMDR-like forms of therapy (+)

  • EMDR
    EMDR is a recognized therapy option for the treatment of trauma.78 EMDR uses bilateral (alternating) activation of the two halves of the body through horizontal eye movements, alternating acoustic signals to the left/right ear or touching the left and right halves of the body. A study has shown that bilateral activation of the body leads to a reduction in activation of the PFC.79
    As EMDR-like forms of therapy such as Emoflex are said to be successful for ADHD, the results of this study could be transferable to ADHD. This is also indicated by an individual case report in which an ADHD sufferer was successfully treated with EMDR80
    Nevertheless, we must warn against assuming that EMDR is a suitable form of therapy for all ADHD sufferers. We assume that ADHD sufferers with traumatic experiences can also benefit from trauma therapy in relation to their ADHD symptoms, as trauma can be seen as a possible contributory cause of ADHD. However, it cannot be deduced from this that EMDR would be useful for all ADHD sufferers. And there are no known studies that point in this direction.
    • Structure of EMDR therapy81
      1. Treatment planning
      2. Preparation and positive stabilization
        What good things and bad things / burdens are you aware of today?
      3. Rating
        The stressful memory is assigned a current negative paraphrase (e.g.: I am defenceless) and a future positive paraphrase (e.g.: I can protect myself).
      4. Desensitization
        The stressful perception is called up and worked through with bilateral stimulation (usually 24 items of rapid right-left alternating stimulation, visual - eye movements left/right/left, auditory - acoustic signal left/right ear, sensory - body touch on left/right side of body) with free association until the physical/emotional stress is no longer perceptible. The speed is adapted to the patient’s reactions.
      5. Anchoring
        A positive new thought base is anchored and trained in place of the previous negative one. Slow bilateral movements, approx. 60 / minute.
      6. Body test
        Ensuring that negative feelings no longer occur when remembering the stressful situation.
      7. Final meeting
        among other things, indicate that after-effects may occur, e.g. in dreams.
      8. Performance review and future orientation
    • A detailed description of EMDR therapy based on example cases can be found in Schubbe.82
  • Emoflex83
    Note: Emoflex is a protected trademark. Reports on forms of therapy that are marketed with property rights should always be viewed particularly critically, as marketing interests may play a role here.
    Emoflex is an adaptation of the EMDR technique for ADHD.

Branded therapy methods

Trademark protection for therapy methods may make economic sense for the trademark owner. However, the effectiveness of EMDR (also) for ADHD is independent of whether the therapy bears a brand name or whether it “merely” uses the underlying therapeutically effective methods (which are never protectable under trademark law).

1.3.5. Hypnotherapy for ADHD

A meta-study of 32 studies found evidence of a benefit of hypnotherapy for ADHD.84 Another, less comprehensive meta-study came to no conclusion.13

1.3.6. Mentoring

In children with learning disorders and ADHD, mentoring showed improvements in self-confidence and social relationships, and prevented the development of depressive behavior.85

1.3.7. Time estimation training

A small study found that training with time estimation tasks improved the cognitive symptoms of adults with ADHD-HI. Cortical activity in areas related to attention and memory increased significantly.86

1.3.8. Systemic therapy (0/+)

  • Particularly suitable in relation to family and group problems with ADHD. Suitable in relation to family conflicts in younger children with ADHD.
    Hardly effective with regard to the causes of ADHD symptoms in those affected themselves.

1.3.9. Depth psychology (-)

  • Cash therapy in D
  • Limited to less suitable for ADHD without comorbidities
    Suitable for ADHD sufferers whose stress levels are significantly driven by formative experiences from childhood. In addition to ADHD, they usually have comorbid traumas or problems from the borderline spectrum, etc. In these cases, in-depth psychological treatment can be very useful.

1.3.10. Talk therapy (-)

  • Cash therapy in D
  • Limited suitability for ADHD
    Talk therapy can help with the management of ADHD-related problems.
    However, it is unlikely to be effective with regard to the causes of the ADHD symptoms themselves.
    Case study with Krause.87

1.3.11. Working Memory Training / Cognitive Working Memory Training (CWMT) (-)

A large-scale meta-study did not find sufficient evidence for the effectiveness of cognitive training for ADHD.88 A further study confirmed this.89

Another meta-study of 18 studies on cognitive training in schoolchildren and adolescents with ADHD found positive effects in 13 out of 18 studies. 7 out of 9 studies also found these in a follow-up examination, which indicates long-term improvements.90

Another meta-study found evidence of possible benefits of cognitive training on working memory, but predominantly no improvements in ADHD symptoms in parent or teacher ratings.13

Several small studies found evidence that working memory training could help to reduce the symptoms of ADHD.919293949596
A high training intensity (a total of 14 hours within 5 weeks) is said to increase the density of D1 dopamine receptors in the PFC,97 which leads to a significant reduction in the symptoms of attention and impulsivity.98
In ADHD, the working memory located in the dlPFC is impaired by reduced dopamine levels. The inhibitory dopamine transporters D2 to D4 are primarily affected. Neurophysiological correlates of working memory problems in ADHD

Working memory uses different areas of the brain for different content (number sequences, faces, names, goals). Training a specific working memory area (e.g. number sequences) therefore has little influence on the performance of the working memory for names.

1.3.12. Training of executive functions (-)

Studies found no benefit of executive function training for ADHD.99 According to one study, another executive function training program (EXAT) worked better for ADHD than for epilepsy.100
2 different executive, attention and motor training programs for children aged 4 to 5 were found to be equally effective.101

A meta-study on executive function training in preschool children reports no benefits for non-affected children, but mentions benefits for ADHD sufferers.102

1.3.13. Analysis ( - - )

  • Cash therapy in D
  • Not suitable for ADHD
    • So does Simchen103

1.3.14. Impulse control training (?)

A small study reports the effectiveness of impulse control training for pre-school children.104

1.4. Mindfulness techniques (+++)

Mindfulness techniques are very suitable for treating ADHD. A meta-analysis found positive results in 11 out of 12 studies in relation to the treatment of ADHD.105 A meta-analysis found improvements in inattention in adults, while too little data was available for children.106 One review found MBSR to be a useful supportive treatment method for ADHD.107

  • Stress-relieving108
  • Stress-preventing109
  • Mood-lifting110
  • Procrastination-inhibiting110111 (which is only natural, as procrastination is a symptom of stress)
  • Executive functions improved112
  • Mindfulness-based treatment improves the core symptoms of attention problems and hyperactivity in ADHD.65
  • Mindfulness training targets the autonomic nervous system
  • In one study, stress management reduced the basal DHEA level and increased the cortisol level. The change in the cortisol-DHEA ratio achieved was stress resistance-promoting.113
    It should be noted that, depending on the disorder, the cortisol/DHEA ratio may be imbalanced in one direction or the other.
    DHEA/cortisol imbalance during stress
    Psychological stress therapy should always influence the relationship in the direction of a healthy balance. In the case of drug treatment, the direction in which the balance is shifted must first be determined.
    • Internal / external
      internal: it’s up to me personally (me, my)
      external: it’s the circumstances (the others, out there)
    • Stable / variable
      stable: it is unchangeable (always, never)
      variable: I can influence it
    • Global / specific
      global: it is always and everywhere like this (everywhere, lawfulness)
      specific: the cause lies in this case itself (here, this time)Mindfulness trains a change in perception. It trains you to no longer immediately attribute the perceived event, but to let it stand on its own. This enables a less frightening and threatening perception, which can massively reduce stress as a result.
  • According to a meta-study, different forms of therapy improved various symptoms in ADHD (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, from 1 high)70
    • Depression
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.52 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively slightly more effective than cognitive behavioral therapy
      • DBT
        • Ineffective in group comparison
        • Subjectively moderately effective, worse than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, even worse than DBT
    • Anxiety symptoms
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.73 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Self-worth
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective in group comparison
        • 1.404 SMD in the follow-up subjective for affected persons
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Quality of life
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective to slightly effective in group comparison
        • 0.57 SMD in follow-up subjective for affected person
      • MBSR
        • Subjectively very good in the short term
      • DBT
        • Very good in the short term compared to the group, ineffective in the long term
        • Subjectively moderately effective in the short term, weakly effective in the long term
    • Emotional dysregulation
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.64 SMD in follow-up in group comparison
        • 0.73 SMD in follow-up subjective for affected person
      • MBSR
        • Weakly effective in the short term compared to the group, not known in the long term
        • Subjectively very effective in the short term, not known in the long term
  • Mindfulness meditation reduced ADHD symptoms (hyperactivity and inattention), but not breathing techniques, while both techniques reduced stress.114
  • Mindfulness training still showed positive effects on children with ADHD in the parent evaluation 6 months later115
  • A meta-study came to the conclusion that mindfulness techniques are a helpful supplement in the treatment of ADHD.116

How mindfulness works

Roughly speaking, the technique of mindfulness involves creating a virtual distance from perceived circumstances. In simple terms, mindfulness means separating perception and its immediate evaluation for oneself. You are trained to perceive very consciously what is happening and at the same time not to relate the events to yourself, i.e. not to take them as a reason for a reaction, but merely to observe the effect of the events on yourself with interest. This stops the automatism of the immediate impact of perceptions on one’s own state of mind.

In other words

You realize that everything is still happening in the same way, but that it no longer poses an immediate existential threat. It happens, and yet you go on living. The subjective threat of what is happening is reduced.

This technique makes sense if the automated stress regulation has previously been misdirected in such a way that events are attributed too directly to oneself.

Attribution styles

There are different attribution styles,117 how perceived circumstances are explained. Example:
A student fails an exam.
The following reaction options (i.e. attribution styles) are conceivable:

  • I’m just too stupid. (Internal - stable - global)
  • I really didn’t learn anything for this exam. (Internal - variable - specific)
  • This time I was just unlucky. (External - variable - specific)
  • They always give me the stupidest tasks. (External - stable - global)

Summarized attribution dimensions result in specific interpretations:118

  • Internal-stable: ability
  • Internal-variable: Effort
  • External-stable: task difficulty
  • External-variable: Luck/Pitch
    • Pessimistic attribution style: failures are attributed internally, globally, stably
    • Optimistic attribution style: failures are attributed externally, specifically, unstably

We assume that a global internal attribution style makes people susceptible to perceiving experiences in a threatening and fearful way.
Fearful and threatening perceptions quickly lead to cortisol stress.

1.4.1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)

  • Mindfulness training is able to sustainably reduce cortisol levels.119
  • In generalized anxiety disorder, there is an overactivation of the amygdala with ambivalent signals and a poor functional connection between the amygdala and ventrolateral PFC. MBSR reduces the overactivation of the amygdala for neutral faces more than stress management. MBSR, but not stress management, caused greater activation of the ventrolateral PFC and also improved the connection between the ventrolateral PFC and the amygdala. All changes coincided with the improvements in anxiety symptoms, indicating causal effects. The previously negative coupling of the amygdala with the activity of the ventrolateral PFC, as known in emotion reduction, changed to a positive coupling. MBSR appears to bring about substantial changes in brain regions that are relevant for emotion regulation.120
  • The functional activity of the amygdala decreased and the connectivity of the amygdala with the PFC improved. In addition, the deactivation of the amygdala after emotional stimuli was faster.60
  • Since MBSR has been proven to be very effective for ADHD, we assume that there is an analogous improvement in communication between different areas of the brain.
    Further studies show the effects of MBSR on neuronal activity.121
  • Mindfulness-based meditation technique may be superior to relaxation training in terms of long-term normalization of cortisol response.122
  • MBSR appears to be able to improve the emotional self-regulation of ADHD sufferers.123
  • MBSR may improve ADHD symptoms less through improved mindfulness skills or improved self-compassion, but through improved inhibition.124

1.4.2. Types of mindfulness techniques

  • Mindfulness-based stress reduction (MBSR) according to Kabat Zinn125
  • A combined MBCT and MBSR therapy showed the same results after 8 weeks as are known from long-term meditation practice.60
  • Stress management (possibly less effective than MBSR)120
  • Yoga
    • Yoga was moderately effective12613
    • According to several meta-studies, yoga appears to improve the core symptoms of ADHD in children.12713128
  • Meditation60
    • Zen meditation
      increased serotonin levels in the brain in the long term
    • In experienced meditators, an increase in cortical thickness in the right insula and the frontal lobes has been demonstrated.129
    • During mindfulness meditation, more gray matter was observed in areas of the brain typically used during meditation in intensive meditators (2 hours a day for more than 8 years). The areas affected are the right insula, which is involved in introspective attention (“interoceptive awareness”), the left inferior temporal gyrus and the right hippocampus.130
    • A meta-study found evidence of the effectiveness of meditation techniques in children, adolescents and adults.131 The results are said to indicate a stronger effect on inattention than on impulsivity/hyperactivity.
  • Biofeedback
  • Relaxation massages
    Massage therapy resulted in a 31% reduction in the cortisol response to stress and an increase in dopamine and serotonin of around 30%.132
    Massage therapy is said to be able to outperform the effect of methylphenidate.133
  • Shiatsu
  • Qigong
  • Tai chi chuan
    • A meta-study found a consistently positive effect of tai chi on ADHD symptoms, although the quality of the studies was rather low.13
  • Respiratory therapy
  • Progressive muscle relaxation according to Jacobson
  • Feldenkrais
  • Sound massages
  • Archery or other shooting sports (with slight positive effects on ADHD)134
  • Mindfulness apps
    also for your cell phone, which you always have with you anyway to take advantage of short breaks.135

Example of a mindfulness exercise: letting go for 100 breaths

Procedure:

  • Find a quiet place where you are undisturbed

  • Lie down / sit down comfortably

  • Close your eyes

  • Pay attention to your own breath

  • Each time you let go of your breath, count backwards from 100 to zero, one number for each time you let go of your breath.

  • Every time you let go of your breath, make sure that your belly lets go completely relaxed. And starting from the abdomen and following it, relax the whole body as you let go of the breath.
    (There are two types of breath: Active inhalers and active exhalers; the respective passive side is to let go of the breath)

  • Each time you release your breath, concentrate on feeling how your stomach relaxes

  • Recap the exercise text (below) during the exercise

  • If necessary, background noise of the sea (this also masks possible street noise); if necessary, headphones with sound recording of the spoken text, if necessary earplugs, if alone for yourself, and remember text silently

In group: Leader speaks meditation text;
Length: participants keep eyes closed as long as it works; those who stop open their eyes, wait quietly or, if necessary, read something until (most of) the others have finished; leader then ends the presentation of the meditation text

Exercise text:

You are here
Feel your body
You don’t have to do anything now
You can be with yourself
You can only feel yourself now
You don’t have to do anything else
Nobody wants anything from you
Feel your breath
Relax your belly as you let go of your breath
and the rest of the body with the stomach
Feel what it feels like when your stomach relaxes
Try to let go completely, with each release of breath
There are thoughts
Let them come
Perceive them
Do they have a color, a shape?
Look at her coming
Do not follow them
Let them go again
Watch them disappear
You are here
You feel your body
You feel yourself
If trouble comes, watch it
Make yourself aware of her wish. What does she want? Have to do something? Want to think? To look at problems? What does the wish that is there want?
Feel it
Don’t deny him, don’t follow him
Look at him, watch him
Feel the desire
How does this urge feel?
Does it have a sound, a smell?
What does it feel like outside of this desire?
You are relaxed
And let go of your belly every time you let go of your breath
And observe what you are feeling or thinking right now
Feel your body
Feel your feelings
Observe what you feel
Don’t follow the feeling, just observe it
And let it go again
When unrest comes, watch how it comes
Don’t call them here
If it is there, notice it, feel it
Do not follow her
How does it feel?
Does it have a sound, a movement?
Look at them
She may be
She has no right to determine you
Let them go again
You are here
Feel your body
You don’t have to do anything now
You can be with yourself
You can only feel yourself now
You don’t have to do anything else
Nobody wants anything from you
All thoughts that come can wait
when they are important, they come back
Now you are the most important thing
Everything else has its time later

(continue)..
..
..

The exercise aims to ensure that feelings/thoughts/inner restlessness are not denied = not suppressed.
It is easier not to follow something that is not suppressed. This naturally requires an inner position outside the pressure.
I want the feeling/thought to be there - and they don’t define me.
I am beside them, not through them.
Feelings / thoughts are there and they are not me.
They are a part of me, and only a part.
I am not these thoughts and feelings, I have them.
I have them, not they have me.

The questions about color, form and sound are aimed at viewing feelings and thoughts as something from outside, as something third, thereby separating them from oneself and not being controlled by them.

The learning steps should / could be:
Learning to perceive, to perceive and feel yourself as an alternative and separate from these thoughts and feelings. Learning to feel this “me” as an alternative.
Learning to evoke the alternative safely.
Strengthen the alternative until it is a greater option.
Let the alternative grow to such an extent that you can feel it as a basis, sense it and live it permanently at some point.

Training path:
(Introduction to transformation in daily routine)

  • First times with optimal medication
  • Increase in difficulty depending on progress with less and less / at the edge / end of medication effectiveness
  • To without medication (if possible)
  • Initially in your own ritual, in a specific, quiet place, possibly at a fixed time
  • Later less and less isolated, sometimes spontaneously
  • To the middle of the day

1.5. Neurofeedback (++)

Neurofeedback as ADHD therapy

Sources136137138

  • Good to very suitable for ADHD
  • In our opinion, this is the only form of therapy with a healing character, as the self-control mechanisms of the brain can be permanently improved
  • In our opinion, longer treatments are required than typically recommended
  • In particular, a combination of frequency band training and subsequent SCP training seems to produce very good results.
  • Neurofeedback training types
    • SMR training
      acts on relaxed attention, hyperactivity, impulsivity
    • Theta beta training
      affects concentration, tense attention
    • Alpha training
      acts on relaxation, sleep problems
    • SCP training
      Trauung of the slow cortical potentials
      acts on activation (for ADHD-I) and downregulation (for ADHD-HI)
      very strenuous, but also very helpful when carried out
  • In a small study, neurofeedback improved visual memory, acoustic short-term memory and auditory working memory, but not perceptual organization.139
  • However, neurofeedback is not a substitute for treatment with medication (especially in the first few years), but a supplement to therapy that can reduce the need for medication.
  • According to a meta-study, different forms of therapy improved various symptoms in ADHD (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, from 1 high)140
    • Depression
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.52 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively slightly more effective than cognitive behavioral therapy
      • DBT
        • Ineffective in group comparison
        • Subjectively moderately effective, worse than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, even worse than DBT
    • Anxiety symptoms
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.73 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjective for affected person
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Self-worth
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective in group comparison
        • 1,404 SMD in the follow-up subjective for affected persons
      • Neurofeedback
        • Ineffective in group comparison
        • Subjectively more effective in the long term than cognitive behavioral therapy
      • MBSR
        • Ineffective in group comparison
        • Subjectively moderately effective, ineffective in the long term
      • DBT
        • Completely ineffective
    • Quality of life
      • Cognitive behavioral therapy (medium to large effect size)
        • Ineffective to slightly effective in group comparison
        • 0.57 SMD in follow-up subjective for affected person
      • MBSR
        • Subjectively very good in the short term
      • DBT
        • Very good in the short term compared to the group, ineffective in the long term
        • Subjectively moderately effective in the short term, weakly effective in the long term
    • Emotional dysregulation
      • Cognitive behavioral therapy (medium to large effect size)
        • 0.64 SMD in follow-up in group comparison
        • 0.73 SMD in follow-up subjective for affected person
      • MBSR
        • Weakly effective in the short term compared to the group, not known in the long term
        • Subjectively very effective in the short term, not known in the long term

1.6. Environmental interventions (++)

  • Parent training

    • Parent training seems to be helpful for children with ADHD.141 This particularly applies to children with ODD142 and young children.143
  • Interventions in school/kindergarten (-)

    • A meta-study reports that classroom interventions / school interventions were found to be partly ineffective and partly effective only as long as the interventions lasted.13
  • Environmental adaptation

    • Suitable job (++)
      • Arousing enough interest to activate hyperfocus
      • Enough variety to keep your attention alert144
      • ADHD-HI: often with physical exercise
      • ADHD-I: no quick decisions
    • Suitable working environment (+)
      • According to the needs of the person concerned
        • Background noise
          • Every person needs their own specific level of arousal (excitement, stimulation).145146
        • Even if novelty seeking and curiosity behavior correlate (also genetically) with impulsivity,147 it is probably important for most ADHD-HI sufferers to reduce arousal, but for ADHD-I sufferers to increase arousal.
    • Stimulate arousal
      • Targeted (quiet) background music
        • Some people can only learn with it
      • TV running in the background
        • If noises / images are distracting: switch off
      • Motivational elements
        • This is very important, as ADHD sufferers can basically concentrate just as intensely as others. The only difference is that they cannot produce this concentration in a controlled manner, let alone control it. This is not carelessness or laziness.
        • Intrinsic motivation instead of extrinsic motivation: the central key
        • Rewards
        • Competition with others
          • Communicate goals to others (create commitment / self-commitment)
        • Don’t make those affected feel guilty
          • None: You can if you want to
          • None: You just have to try harder
            • Friedmann reports of sufferers who lost their ADHD symptoms after finding a working environment that suited their constitution: short attention spans, frequent activation, independent work organization. We also know of cases that blossomed in an environment that was just right for them. This does not mean that every affected person has to find the right environment in order to no longer have ADHD. ADHD means that the choice of which environment is suitable is extremely limited. Very few of those affected will be able to build their world in this way. In our opinion, however, one more element must be added: genuine interest. Only when this genuine personal interest kicks in will ADHD sufferers be able to resolve their attention problems. Friedmann points out that the reduced number of dopamine D2 and D3 receptors in the reward center of the brain in ADHD sufferers means that fewer things are found (rewarding), i.e. sufficiently exciting, than in non-affected people. The choice of an exciting environment therefore necessarily requires that it is something that is of (such) high interest to the respective person affected that the reward center “jumps” and the attention of the person affected is aroused. The sentence “You can do it if you want to” is absolutely correct, but not in the way it is usually misunderstood. ADHD can only be understood if one is prepared to accept that the will of the person affected is not completely freely selectable, but depends on the subject being so interesting that the shortcoming of the reduced number of D2 and D3 dopamine receptors no longer comes into play. Only with the appropriate intrinsic interest can those affected manage to “be able” to do what they want: by doing something that really interests them. This mechanism explains well why extrinsic motivation (external pressure) does not help if something is not interesting enough. External pressure can do a lot - but it does not make dopamine receptors grow. From this perspective, ADHD could also be defined as an extreme narrowing of interests.
              And yet this is not a justification that your own ADHD is not so bad, you just haven’t found what interests you.
      • Secondary employment
        • Knit
        • Draw
        • Listen to music
          • Some people have to “do” something on the side in order to be able to concentrate. This relieves inner tension. The secondary activity serves to optimize arousal. This is not a sign of disinterest or disrespect, but a means of increasing attention and concentration
  • Reduce distraction

    • Avoiding situations that are too loud, hectic, stressful and intense.
      • If you are sensitive to stress, you should avoid stress-inducing situations. This obvious-sounding fact is surprisingly often disregarded, whether due to a lack of knowledge or a guilty conscience. It’s like the temperature: you shouldn’t be cold when the thermometer says so, but when you’re cold:
      • Brightness
        • Lower the roller shutter
      • Temperature
        • Regulate according to your own needs
      • Reduce noise / voices / ..
        • Very quiet surroundings
        • Earplugs
        • Noise protection headphones
      • Own workspace148
        • No open-plan office!
        • No through room!
        • No open office!
      • Mails
        • Restrict retrieval to certain times
        • Deactivate pop-ups for incoming messages
        • Mails and other messages on cell phone only visible after active retrieval, not automatically on screen
      • Seat alignment at the workplace
        • (Closed) door in view
        • No windows in the back
        • Hide events in the room / in the window in the line of vision using curtains / transparent privacy film
        • Plenty of daylight149
        • Closed room
  • Optimize / adapt learning methods

    • Short learning sections with frequent breaks
    • E.g: Learning vocabulary;
      • Max. 10 pieces, as often as necessary until they fit securely, only then more
      • Use all senses: read quietly, read aloud, copy, etc.
      • Further vocabulary only after a break
    • Walk while learning
      uniform movement significantly optimizes receptivity in some people; movement reduces stress and increases neurotrophic factors in the brain that are necessary for neuroplasticity (formation of new synapses, learning)
    • 30 minutes of physically intensive exercise before learning (esp. ADHD-HI)
    • Suitable working methods
      • Independence
        for interesting activities, some people with ADHD-HI do better as self-employed persons than as employees, because intrinsic motivation optimizes arousal
        for less interesting activities, however, this would be rather disadvantageous because the individual’s own drive/structure is too low
      • Interesting activity
        The lack of extrinsic motivation makes it many times more important for ADHD sufferers to find a task that is really exciting for them than for those without the disorder
      • ADHD-I: structured work tasks, clear instructions, tight controls
        Example:
        One person retired at the age of 50 after a glittering career in the US Marines. He couldn’t cope in civilian life and failed. One year after leaving, he was diagnosed with ADHD.
      • A well-structured daily routine with regular alternation of activity and relaxation can support stabilization of the noradrenaline balance through self-activation (see below: take enough breaks)
  • Avoid / eliminate sources of stress

    • Even with personality disorders, a long-term study (n = 733) surprisingly found a reduction in symptoms in more than 50% of those affected within 2 years for a period of more than 12 months. In the case of borderline, this was observed in 10 % of those affected within 6 months, mostly after massively stressful current life circumstances (stressful relationship) were eliminated. Nevertheless, significant diagnostic criteria remained very constant (more so than with severe depression), but they no longer reached the required severity for a diagnosis.150
  • Promote stress reduction

    • Just one hour longer sleep reduces morning cortisol levels by 21%151152
    • For sleep disorders:
      • Shift your sleep rhythm backwards
        Postpone falling asleep and getting up
        This could be worth a try for sufferers with high stress levels immediately on waking (e.g. anxiety)
        Early awakening correlates with high cortisol levels151152
      • More about sleep problems here
  • Moving to a low-stress environment

    • People who live in poor neighborhoods are said to have a higher body weight due to stress than people who live in more affluent neighborhoods.
      • When moving house, the body weight adapts to the new environment.153
      • This could be interpreted as a consequence of a stress reaction or stress reduction, but can also be understood as an adaptation to the main environment.

1.7. Sleep problem therapy (+)

  • Sleep problems should be treated with special priority in ADHD, as they can exacerbate ADHD symptoms as a vicious circle and ADHD symptoms can cause sleep problems.
  • Sleep reduces the stress hormone cortisol. 1 hour longer sleep improves cortisol reduction by 21 %151
    All ADHD symptoms are also stress symptoms.
  • On possible measures to improve sleep and on sleeping pills specifically for ADHD:
    Sleep problems with ADHD

1.8. Nutrition and diet

Food intolerances address the stress regulation systems just as much as psychological stress or illness.
There are no specific foods that trigger ADHD. However, if there is an individual food intolerance, this can exacerbate an existing ADHD (as well as other mental disorders) because it represents an additional source of stress/strain for the body. Dietary treatment of an existing food intolerance therefore contributes to an improvement in ADHD symptoms. The mean effect size is approx. 0.25.

There is also evidence that omega-3/omega-6 fatty acids can support the treatment of ADHD. However, this does not apply to all sufferers and the effect strength is so low that it can only be recommended as an augmentation to a more effective treatment.
For more information, visit Nutrition and diet for ADHD and at ⇒ Effect size of different forms of treatment for ADHD.

1.8.1. Reasonable breakfast

One study found that 47% of students with ADHD and 33% of students without ADHD did not regularly eat a balanced breakfast. One hour after eating a balanced breakfast, both groups showed improvements in 4 cognitive areas.154

1.8.2. Drink plenty

Even if thirst is not described as a typical ADHD symptom, increased thirst and therefore increased water intake are frequently observed symptoms of stress.155 As stress aims to increase blood pressure in order to optimally prepare the body for fight or flight, increased fluid intake is an immediately useful tool.156 Fluid intake significantly reduces the stress response.157

1.9. Take enough breaks

  • Breaks are not just about recovering and letting the amount of stimuli you have been exposed to flow away:
    A clearly structured daily routine, in which activity and breaks alternate sensibly, can train the noradrenergic system and normalize the production of noradrenaline.158
  • This follows on from Scheidtmann’s suggestion that noradrenergic drugs (e.g. antidepressants) do not help with motor rehabilitation (if) they are used as long-term medication, as tricyclic antidepressants permanently stimulate the noradrenergic receptors and this leads to a loss of sensitivity of the receptor (especially with regard to learning processes).159
    This is consistent with the experience of using noradrenergically active tricyclic antidepressants for ADHD. It is often reported that there is a very good response at the beginning, but that this diminishes with continued medication.
  • Breaks can counteract the hyperactivity of ADHD.148

1.10. Therapy computer games

In recent years, the topic of computer games for therapeutic use has come into scientific focus.
In principle, ADHD symptoms can be improved by therapy computer games, e.g. attention,160

A therapeutic computer game has already been approved by the FDA for ADHD.

1.10.1. EndeavorRx

In June 2020, the FDA (US Food and Drug Administration) approved the first ever video game that can be prescribed by a doctor. It is used to treat ADHD.

180 children between the ages of 8 and 12 played EndeavorRx for 25 minutes 5 days a week for 4 weeks, 168 children played a game other than placebo. The mean change (SD) from baseline in the TOVA-API was 0.93 in the treatment group and 0.03 in the control group.161 The fact that the study was sponsored by the software manufacturer is cause for skepticism. On the other hand, Faraone, one of the authors, is a very renowned scientist in the field of ADHD and The Lancet is a very renowned scientific journal.
A preliminary study also found evidence of a positive effect.162

The manufacturer describes further:

“EndeavourRx was approved based on data from five clinical trials involving more than 600 children diagnosed with ADHD, including a prospective randomized controlled trial published in the Lancet Digital Health Journal, which showed that EndeavourRx improved objective measures of attention in children with ADHD. After four weeks of EndeavourRx treatment, one-third of the children no longer had a measurable attention deficit on at least one measure of objective attention. In addition, about half of the parents noted a clinically meaningful change in their child’s daily impairments after one month of treatment with EndeavourRx. This increased to 68% after a second month of treatment. The improvement in ADHD-HI impairment after one month of treatment with EndeavourRx was maintained for up to one month.”163

Another study, which is probably still ongoing, is investigating the effectiveness of the game over a longer application period of 2 months and the extent to which improvements persist after the end of treatment.

1.10.2. Plan-It Commander

The therapy computer game “Plan-It Commander” was/is developed by the authors of the studies mentioned below,164 so that the assessment of its effectiveness by independent studies remains to be seen. The symptoms that are said to have been improved in non-blinded studies are

  • Time management (parent assessment)165
  • Responsibility (parent assessment)165
  • Working memory (parent assessment)165
  • Planning and organizational skills (parent assessment)166 in girls overall and in boys with severe social behavior disorder and low hyperactivity.

1.11.3. RECOGNeyes

A small study found that ADHD sufferers who controlled the RECOGNeyes game with their eyes showed improvements in terms of

  • Impulsiveness
  • Response time
  • Fixation gaze control

while the control group, who controlled the game with the mouse, showed no improvement.167

1.10.4. Empowered Brain

A very small preliminary study showed that the higher their ADHD symptoms were, the better they completed the game parts of Empowered Brain.168 The software appears to be developed more from a diagnostic perspective.

1.10.5. AR-Therapist: Augmented Reality - Behavioral Therapy - Game Concept

One study describes a concept of an augmented reality game for the purpose of behavioral therapy for ADHD, including measurement of ADHD-relevant parameters.169

1.10.6. The Secret Trail of Moon

A report describes the development of this game for the treatment of ADHD.170

1.10.7. Computer therapy games for other mental disorders

Some therapy games are known for other therapeutic goals, e.g:

  • Nevermind171
    • Stress
    • Measured stress (anxiety, trauma responses) makes playing conditions more difficult
    • No “official” medical application
    • Is controlled by biofeedback
  • Elude172
    • Depression
    • Elude aims to raise awareness and provide information about depression. It is intended to be used in a clinical context as part of a psycho-education program to improve the understanding of friends and family about people suffering from depression and what they are going through.
  • Treasure hunt173174
    • Anxiety, aggression, depression
    • Created specifically for therapeutic purposes
      • Evaluated on 200 children by 41 therapists
      • Supports the therapeutic work
    • For children from 9 to 13 years
    • Goals:
      • Learn to distinguish between thoughts, feelings and behavior
      • Replace negative thought patterns with positive ones
  • Depression Quest175
    • Depression
    • In a selectable adventure, the player as a depressive tries to balance the illness, job, relationships and even treatment.
  • Actual Sunlight176
    • Depression
    • A short interactive story about love and depression.
    • Not suitable for children
  • Sym177
    • Social phobia is addressed in this game
  • Rage Control178
    • Aggression
    • Developed by the Boston Children’s Hospital
    • Uses active biofeedback
  • Boson X
    • Depression
    • Commercial, non-therapy-oriented game
    • It is disputed whether this reduces the brooding phases in people suffering from depression179180
  • Tetris
    • Trauma prevention
    • Non-therapy-oriented play
    • Use within the first 6 hours after a potentially traumatizing experience, after players were asked to recall the event, reduced risk of traumatization181
      • According to our (unverified) hypothesis, however, any mental activity and any media consumption that offers a light (!) mental activity (entertainment programs, entertainment films without dramas, light video games without social or violent components) could be suitable as trauma prophylaxis, provided they are used before the first sleep after the event. Of course, the content must not be thematically related to the event.
        According to our idea, the potentially traumatizing experiences in working and short-term memory are (at least partially) “overwritten” or “relativized” by subsequent “light” media consumption before they can be transferred to long-term memory via the hippocampus during sleep. Against this background, it could be beneficial to delay the first sleep after a potentially traumatizing event for as long as possible, to promote an abundant consumption of less significant media and, if necessary, to give medication that reduces the activity of the hippocampus.

1.11. Computer-based training programs

A meta-analysis of 31 studies with n = 2,169 subjects found improvements through digital forms of treatment with regard to182

  • Inattention (effect size ES -0.20)
  • Response time for the continuous power task (CPT) (ES -0.40)
  • impulsive hyperactivity (ES -0.07)
  • Executive function improved (ES 0.71)
  • Working memory improved (ES 0.48)

1.11.1. Computer-aided cognitive training

A computer-based cognitive training program improved focused attention and working memory in some of the test subjects (responders) better than conventional training. ADHD-I and ADHD-C benefited more than ADHD-HI.183

1.11.2. Web-based support / app-based support

A meta-study found 10 studies, 6 of which showed a positive effect of web-based support tools for young ADHD sufferers. The 4 studies that did not find a positive benefit related to apps.184

1.12. Chess training / Go training / Board games

A small study found an improvement in ADHD symptoms in connection with IQ after 11 weeks of chess training.185 The effect size was 0.85 when assessed by the parents. However, a parent-only assessment should always be treated with caution.
Another study found a comparable effect of GO, whereby inattention was improved, but not hyperactivity.186 The results of further studies could not be converted into effect sizes.187188

1.13. Transcranial magnetic stimulation / transcranial direct current stimulation (o/+)

Various studies have looked at the effect of transcranial stimulation on ADHD.189190191
Transcranial direct current stimulation was rated better than repetitive transcranial magnetic stimulation in a review.192

According to the majority opinion, there are predominantly indications of a positive effect.193194195196197198199
A meta-study found a significant positive effect in 8 (n = 133) of 13 studies (n = 308) rather in children and adolescents for inattention, impulsivity and the general symptom level, with a delayed onset of effect in relation to hyperactivity.200 A further meta-study found significant improvements in attention, inhibition, working memory and brain connectivity in 11 studies.201
Studies found improvements through transcranial stimulation in relation to:

  • fewer omission errors in ADHD sufferers, together with an improvement in P 300 amplitude202
  • Improvements in ADHD, which were further enhanced by a combination with cognitive training203
  • Hyperactivity
    • Hyperactivity improved, but not attention (individual case of an adult with ADHD)204205
    • Hyperactivity/impulsivity improved at home206
    • 1 Hz rTMS over the left dlPFC improved hyperactivity/impulsivity (and inattention) in children with ADHD207, unlike 10 Hz stimulation of the right dlPFC, which did not improve ADHD symptoms compared to sham stimulation208
  • Attention
    • 1 Hz rTMS over the left dlPFC improved inattention (and hyperactivity/impulsivity) in children with ADHD207, unlike 10 Hz stimulation of the right dlPFC, which did not improve ADHD symptoms compared to sham stimulation208
    • Attention improved without improvement in mood, anxiety or hyperactivity in adults with ADHD209
    • Attention improved, but not overall ADHD scores in children and adolescents with ADHD210
    • Improved inattention in the school context206
  • oppositional defiant behavior206
  • Risk assessment and reward discounting211
  • Working memory
    • through optimized high-resolution tACS with a frequency of 5 Hz above the left DLPFC212

Other sources speak of mixed results 213 214 215216

Several studies found evidence of increased (extracellular) dopamine levels in the striatum during or after TMS application.217218 The increase corresponded to that seen with the administration of D-amphetamine.219

1.14. Traditional Chinese Medicine (TCM)

TCM usually combines various treatment methods, just like Western “multimodal” therapy. These include herbal treatments, which can be assumed to intervene in the neurotransmitter structure in the same way as conventional medication. The risk lies in the limited knowledge of the pathways, side effects and cross-effects with conventional medication.
A meta-analysis found a surprisingly good effect of TCM in relation to ADHD (as good or better than MPH), but at the same time poor to very poor quality of the individual studies, including a risk of considerable bias, which is why TCM cannot yet be recommended as a treatment for ADHD.22013

1.15. Light therapy

A very small study with n = 29 adults found positive effects of early morning light therapy in the fall/winter months on objective and subjective ADHD symptoms, mood and a shift in the circadian rhythm.221 The advance of the circadian rhythm appeared to have the greatest influence on the improvement of ADHD symptoms. Another, even smaller study on 16 adults came to similar conclusions.222
A third placebo-controlled study, which compared the circadian rhythm with melatonin or melatonin plus light therapy, also found that light therapy (here: as an addition to treatment with melatonin) could shift the circadian rhythm forward and that this had positive effects on ADHD symptoms. Melatonin alone had a stronger effect than light therapy, light therapy improved the result of melatonin treatment.223
A review confirmed these results.224

1.16. White noise

ADHD sufferers who heard white noise during cognitive tasks performed better.
Moderate noise facilitates stimulus discrimination and cognitive performance (stochastic resonance). Computational modeling showed that ADHD requires more noise for stochastic resonance to occur in dopamine-deficient neural systems. This prediction is supported by empirical data.225226227228229

1.17. Trigeminal stimulation

Initial positive results have been found for trigeminal stimulation.230 The effect size is said to have been 0.5.231 Trigeminal stimulation is said to improve executive dysfunction (organizational problems) in children with ADHD.232
A first device for trigeminal stimulation (Monarch eTNS System) has been approved by the FDA. In a double-blind placebo study, the device significantly improved ADHD symptoms in children between the ages of 8 and 12 within 4 weeks.233

Whether neurostimulation can be reliably used as a treatment tool for ADHD and whether the improvements continue after treatment has ended remains to be seen234

1.18. Therapeutic approaches for ADHD whose effect is not proven

  • Occupational therapy
    The effectiveness of occupational therapy for ADHD is limited to the treatment of fine motor skills in preparation for school.235
    A study reports positive effects of equine-assisted occupational therapy for schoolchildren with ADHD.236
  • Hemencephalography training
    Effect not yet recognized, initial studies.189
  • Self-instructions
    Effect is disputed.237
  • listen to (classical) music to improve your mood
    • One study found that listening to Mozart for 10 minutes (Mozart piano sonata for four hands, KV 440) improved the mood of both ADHD sufferers and non-sufferers, in contrast to subjects who listened to 10 minutes of silence.238 This does not prove an ADHD-specific treatment method.
    • However, music seems to be helpful for ADHD.239
  • App-supported attention and organization training
    • One study reports on a cell phone app-supported training of attention and organization that led to relevant improvements in a third of adults with ADHD.240
    • A meta-analysis from 2019 found no further studies on the treatment of ADHD using specific apps241
  • Organizational skills training
    • In the case of SCT, training in organizational skills did not lead to any improvement in SCT symptoms from the perspective of the affected persons themselves. Only from the parents’ perspective were there improvements with an effect size of approx. 0.5.242
      Parent assessments are highly susceptible to being biased towards desired outcomes. This bias is all the stronger the greater the effort invested.
  • Homework support
    • In the case of SCT, homework support did not lead to any improvement in SCT symptoms from the point of view of those affected. Only from the parents’ perspective were there improvements with an effect size of approx. 0.5.242
      Parent assessments are highly susceptible to being biased towards desired outcomes. This bias is all the stronger the greater the effort invested.
  • Social behavior training
    • A meta-analysis found no proven effect of non-drug training methods (coaching, etc.) in terms of improving social behavior towards peers.243
    • A meta-study found weak evidence of benefits of peer-based interventions for ADHD,13 which are primarily aimed at strengthening social support among peers.
    • A further meta-analysis of 15 studies found evidence of moderate effectiveness of social skills training in children with ADHD.244
  • Transcutaneous vagus nerve stimulation
    • One report cites transcutaneous vagus nerve stimulation as a possible treatment for ADHD.245
  • Acupuncture
    • One meta-study reported a high level of effectiveness of acupuncture on hyperactivity.246 Another meta-analysis of 5 studies found no reliable evidence of an improvement in ADHD through acupuncture.247 A further meta-study intends to investigate the effect of acupuncture for the treatment of ADHD.248 A meta-analysis of 14 studies with 1185 patients found that acupuncture as an adjunct to conventional medication supported the improvement of behavioral problems, learning problems, hyperactivity-impulsivity and hyperactivity symptoms in ADHD patients and as a sole treatment improved learning problems, hyperactivity-impulsivity and hyperactivity symptoms in ADHD patients. The risk of bias in the included studies was generally concerning, so the evidence for the effectiveness of acupuncture for ADHD is currently too limited to recommend its use.249
    • The effectiveness of acupuncture is controversial. There are no conclusive medical explanatory models to date.
      However, two German double-blind studies, which conclude that so far only a placebo effect can be proven for acupuncture, show in the figures that acupuncture achieved 20% better results compared to sham acupuncture.250. 251 Other studies report an effect that goes beyond placebo.252253254255
  • Homeopathy
    • A meta-study reports benefits of additional individual homeopathic treatment for ADHD.256 An RCT also reports symptom improvements through homeopathy, but only in parent reports.257
  • Fidgets
    • One study observed significant improvements in sustained attention in pupils with ADHD who used Fidgets during lessons.258
  • Random Noise
    • Random Noise treatment uses any form of energy (e.g. light, mechanical, electrical or acoustic energy) with unpredictable intensity to stimulate the brain and sensory receptors with the aim of improving sensory, motor and cognitive functions. Random Noise treatment originally used mechanical sounds for auditory and cutaneous stimuli. Today, electrical energy is increasingly used to stimulate the brain or skin. Recent evidence shows that transcranial random noise stimulation can increase corticospinal excitability, improve cognitive/motor performance and have positive after-effects on a behavioral and psychological level.259
  • Spinal manipulation / spinal mobilization
    • A meta-analysis found no evidence of effectiveness of spinal manipulation/mobilization for ADHD260
  • Transcutaneous auricular vagus nerve stimulation (taVNS)
    • Transcutaneous auricular vagus nerve stimulation (taVNS) is a newly developed, non-invasive procedure. Stimulation of the cutaneous receptive field of the auricular branch of the vagus nerve in the outer ear is intended to activate the vagal connections to the central and peripheral nervous system.261
  • Ultrasound stimulation with low intensity
    • Low-intensity ultrasound stimulation has been shown to improve abnormal brain function in SHR. We do not have studies on clinical ADHD treatment use in humans.262
  • Quiet Eye Training263
  • Animal-assisted therapy264

1.19. Therapeutic approaches that are definitely ineffective

  • Phosphate diet (oats)
    Find out more at Nutrition and diet for ADHD
  • Certain foods / food additives certain substances as sole causal cause of ADHD
    However, food intolerances in general (individually intolerable substances) can increase stress levels to such an extent that latent mental disorders (e.g. ADHD) can appear or existing disorders can be exacerbated.
    Find out more at Nutrition and diet for ADHD

2. Multimodal therapy approach

Multimodal therapy is a combination of relevant treatment options. In the case of ADHD, a combination of medication, psychotherapy and possibly other treatment options is used. Multimodal treatment improves ADHD symptoms.265 However, this is not surprising. Only a comparison with purely psychotherapeutic and drug treatment would be relevant.

In adults with ADHD, combined treatment with medication and cognitive behavioral therapy was only superior to medication alone after the first 3 months. There was no difference after 6 and 9 months.266

3. Treatment concepts, treatment manuals, guidelines

Source: Schmidt, Petermann267

  • Group therapy manual “Psychotherapy of ADHD in adulthood” (Hesslinger et al., 2004)
    Adaptation of the Dialectical Behavioral Borderline Therapy concept to ADHD
  • “Treatment manual for ADHD in adulthood” (Lauth, Minsel, 2009)
    For individuals and groups
  • “Psychoeducation and coaching manual for ADHD in adulthood” (D’Amelio et al., 2009),
    Practical guidance on the treatment of ADHD and family groups
  • “Training for ADD in adulthood (TADSE)” (Baer & Kirsch, 2010)
  • “Cognitive behavioral therapy program for adult ADHD” (Safren et al., 2009)
    Cognitive techniques for individual therapy
  • Interdisciplinary evidence- and consensus-based (S3) guideline “ADHD in children, adolescents and adults”268

4. Subtype-specific treatment

To date, few treatment concepts are known that differentiate between the various subtypes of ADHD - ADHD-HI and ADHD-C (with hyperactivity) on the one hand and ADHD-I (without hyperactivity) on the other.

In our opinion, ADHD-HI and ADHD-C suffer from the fact that the stress system of the HPA axis is permanently overactivated and is not shut down again due to an insufficient cortisol response to acute stress or insufficient addressability of the glucocorticoid receptors, while the ADHD-I subtype suffers from an over-intense neurotransmitter and stress hormone response to acute stress, which leads to a regular shutdown of the HPA axis due to the high cortisol response, but at the same time shuts down the PFC due to the parallel excessive release of noradrenaline, thereby triggering mental blocks and an inability to make decisions.

In our opinion, mindfulness is particularly important in ADHD-HI in order to achieve therapeutic ability in the first place. The permanently elevated stress level in ADHD-HI (with hyperactivity) is so strongly increased that mindfulness (MBCT, MBSR, meditation, yoga …) is downright aversive, which correlates with an inability to recover.

5. Multi-generational treatment for ADHD

Treating the children alone overlooks the fact that the influence of ADHD-affected parents has a considerable impact on the development of the children.
Treatment and support for mothers with ADHD showed positive consequences for the children, whereby a higher intensity of treatment for mothers with ADHD (here: with DBT) only showed a temporary advantage for the children compared to less intensive treatment.269

Children of mothers with high neuroticism and low conscientiousness should benefit more from behavioral therapies than other children. In contrast, children of mothers with medium neuroticism and medium conscientiousness or low neuroticism and high conscientiousness should benefit more from a multimodal treatment of therapy and medication or from medication alone than from behavioral therapy alone.270


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