Non-drug treatment and therapy of ADHD - overview

This article compiles the non-drug treatment and therapeutic approaches that we are aware of.
The + and - in parentheses reflect our assessment of benefit in ADHD.

• 1. Therapy approaches
  • 1.1 Recognized therapeutic approaches for ADHD
    • 1.1.1. Medication (++++)
    • 1.1.2. Endurance sports, fitness training (+++)
    • 1.1.3. Psychotherapy
      • 1.1.3.1. Behavioral therapy (+)
        • 1.1.3.1.1. Mindfulness Based Cognitive Therapy (MBCT) (+++)
        • 1.1.3.1.2. Cognitive behavioral therapy (o to +)
      • 1.1.3.2. Dialectical Behavioral Therapy (DBT) (+)
      • 1.1.3.3. Self-esteem therapy (+)
      • 1.1.3.4. EMDR-like therapies (+)
      • 1.1.3.5. Hypnotherapy for ADHD
      • 1.1.3.6. Mentoring
      • 1.1.3.7. Time estimation training
      • 1.1.3.8. Systemic therapy (0/+)
      • 1.1.3.9. Depth psychology (-)
      • 1.1.3.10. Talk therapy (-)
      • 1.1.3.11. Working Memory Training / Cognitive Working Memory Training (CWMT) (-)
      • 1.1.3.12. Training of executive functions (-)
      • 1.1.3.13. Analysis ( - - )
      • 1.1.3.14. Impulse control training (?)
    • 1.1.4. Mindfulness techniques (+++)
      • 1.1.4.1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)
      • 1.1.4.2. Types of mindfulness techniques
    • 1.1.5. Neurofeedback (++)
    • 1.1.5. Self-help groups (++)
    • 1.1.6. Environment interventions (++)
    • 1.1.7. Psychoeducation (++)
    • 1.1.8. Sleep problem therapy (+)
    • 1.1.9. Diet and nutrition
      • 1.1.9.1. Reasonable breakfast
      • 1.1.9.2. Drink plenty
    • 1.1.10. Take enough breaks
    • 1.1.11. Therapy Computer Games
      • 1.1.11.1. EndeavorRx
      • 1.1.11.2. Plan-It Commander
      • 1.1.11.3. RECOGNeyes
      • 1.1.11.4. Empowered Brain
      • 1.1.11.5. AR-Therapist: Augmented Reality - Behavioral Therapy - Game Concept
      • 1.1.11.6. The Secret Trail of Moon
      • 1.1.11.7. Computer therapy games for other mental disorders
    • 1.1.12. Computer based training programs
      • 1.1.12.1. Computer assisted congnitive training
      • 1.1.12.2. Web-based support / App-based support
    • 1.1.13. Chess training / Go training / Board games
    • 1.1.14. Transcranial magnetic stimulation / Transcranial direct current stimulation (o/+)
    • 1.1.15. Traditional Chinese Medicine (TCM)
    • 1.1.16. Light therapy
    • 1.1.17. White noise
    • 1.1.18. Trigeminal Stimulation
  • 1.2. Therapeutic approaches for ADHD whose effect is not proven
  • 1.3. Therapeutic approaches that are proven ineffective
• 2. Multimodal therapy approach
• 3. Treatment concepts, treatment manuals, guidelines
• 4. Subtype-specific treatment
• 5. Multi-generational treatment for ADHD

1. Therapy approaches¶

1.1 Recognized therapeutic approaches for ADHD¶

1.1.1. Medication (++++)¶

• ADHD should definitely be treated with medication, especially at the beginning of therapy.
  Sufferers who have never felt what it is like to live without these distressing symptoms cannot relate to the goal of non-drug therapy from their own perception. Edel/Vollmoeller argue in a comparable way.¹
• A large metastudy of 190 studies involving 26,114 participants with ADHD found that stimulants appeared to be superior to behavior therapy, cognitive training, and non-stimulants. Stimulants in combination with behavioral therapy appeared to be most effective.²
• Illustration of drug treatment at ⇒ Medications for ADHD - Overview.

1.1.2. Endurance sports, fitness training (+++)¶

(Endurance) sports seem to be the best non-drug treatment for ADHD.³⁴⁵
Several metastudies found that exercise can help improve attention and hyperactivity/impulsivity symptoms in ADHD and is a useful treatment adjunct.⁶⁷ Also improved were executive functions and sleep quality.⁸ The magnitude of improvement was small to moderate⁹

For many sufferers, especially of the ADHD-HI and ADHD-HI-C subtypes, regular intense exercise (working out) is essential.

• Calorie consumption
  • Contrary to previous assumptions, exercise 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 daily, but use no more energy each day than sedentary office workers in the U.S.^{1011 12 13} Hadza are active and fit into their 70s and 80s and are said to have neither diabetes nor heart disease.
  • However, high caloric expenditure from exercise shuts down stress systems and inflammatory responses, reducing the caloric expenditure that would have caused the stress responses.¹² Acute physical stress hardly increases cerebral blood flow, but there is a redistribution to brain regions involved in motor control and coordination (e.g., vestibular) and transport systems (respiratory, circulatory).¹⁴ This could be the nutritional equivalent of the long-standing finding that exercise has a stress-regulating effect.
  • This sheds a whole new light on the common side effect of stimulants of decreased appetite. We hypothesize that this may be an adaptive response to the decreased energy expenditure of the body due to the decreased stress responses. Further, we wonder whether hyperactivity as a symptom of the externalizing ADHD subtypes might be a (misdirected) compensatory response of the body, since inflammation is more common in the externalizing stress phenotype than in the internalizing ADHD-I subtype.
• Stress
  • Sport has a regulating effect on stress¹⁵
    • Preventive
      • Sport is stress preventive.¹⁶¹⁷
    • Buffering
      acute as well as habitual physical activity can buffer negative effects of stressful events on physical and mental health
      • Resource Strengthening
        • When sport is included in options for action, sport itself is available as a stress-reducing tool
        • Group sports bring about social bonding
          • Reduces stressor of social isolation, especially in mental patients¹⁸
      • Response Reduction
        in trained people negative stress reactions do not even occur to their full extent
        • Cognitive
        • Affective
        • Behavioural
        • Biological
          • Trained men show on psychological stressors (TSST) compared to untrained men¹⁹
            • Significantly lower cortisol stress response (with the same basal cortisol level)
            • Significantly lower heart rate increase
            • Significantly higher calmness, better mood, and tended to have lower anxiety responses to mental stress exposure
    • Compensating
      negative stress reactions that have occurred are reduced or balanced out again through sport and exercise
      • Sport reduces cortisol
• Depression
  • Exercise improves mood
    Even for people who find exercise unpleasant, a half-hour walk has a mood-lifting effect
  • Endurance sports have an antidepressant effect.²⁰²¹
• Fear
  Endurance exercise has anxiolytic (anxiety-reducing) effects.²²²¹
• Exercise increases dopamine²³ and norepinephrine in brain regions relevant to ADHD²⁴
  • Exercise (like MPH) can induce tyrosine hydroxylase (TH) expression²⁵ and increase TH levels. TH is a precursor for dopamine. Thus, sport can support dopamine synthesis.
  • As a rule, exercise can support treatment, but is likely to be sufficient on its own only in very mild cases
• Regular physical exercise²⁶
  • Reduces the levels of inflammation
  • Reduces oxidative stress
  • Reduces stress hormones
    (during sports competitions the above three values are increased)
  • Increases telomerase activity in humans and mice, counteracting behavioral changes caused by stress-induced telomere shortening.
• Cognitive performance
  • Endurance exercise significantly improved cognitive performance in ADHD²⁷²⁸²⁹
  • One-time training has statistically significant, but small in effect size, improvements in cognitive performance during, immediately after, and time-delayed after the training session.³⁰
• A metastudy of eight randomized trials found improvements with areoben sports in children with ADHD in terms of³¹
  • Attention (SMD = 0.84)
  • Anxiety (SMD = 0.66)
  • Social disorders (SMD = 0.59)
  • Executive function (SMD = 0.58)
  • Hyperactivity (SMD = 0.56)
  • Impulsivity (SMD = 0.56)
• One (very small) study found significant improvement in ADHD symptoms overall with exercise training.³²
• A metastudy found a small but not statistically significant improvement in attention and hyperactivity/impulsivity with physical training in ADHD.²¹ Nevertheless, there was a significant improvement in cognitive problems (“thought problems”), social problems and aggressive behavior, and problems overall in ADHD.
• One study found a 21% decreased propensity to exercise in children with ADHD.³³ Another study found a 3.23-fold increase in excessive exercise in children with ADHD compared to non-affected individuals.³⁴
• According to 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 reports improvements with sports training in children with ADHD regarding³⁵
  • Memory accuracy
  • Selective attention
  • Inhibition
  • Lower omission errors
  • Reduced interference errors
• One study reported improvements with swimming training in 9-12 year old children with ADHD in terms of:³⁶
  • Behavior
  • Academic achievement
  • Inhibition
• One study reported that a single bout of aerobic exercise (30 minutes of cycling) improved inhibition ability, particularly in ADHD sufferers with poor impulse inhibition, but otherwise did not improve behavior.³⁷
• One metastudy reported improvements in executive function (organizational ability) with a single 30-minute exercise session.³⁸³⁹
• Sport should cause an increase of²⁴⁴⁰
  • Norepinephrine
  • Serotonin
  • Acetylcholine
  • GABA
  • BDNF
• One study reported comparable improvements in orientation behavior and social behavior in SHR (a rat breeding line showing ADHD symptoms) with exercise training, MPH, and atomoxetine.⁴¹
• The benefits of exercise can accumulate over time. Exercise improves executive function over the long term. Aerobic exercise seems to lead to an increase in neurotransmitters such as serotonin, dopamine, BDNF and cerebral blood flow.⁴²
• A metastudy found a significant and marked (SMD = 0.78) improvement in inhibition with exercise in children with ADHD. 60 minutes of open training 2 x / week showed the best effect on improving inhibition.⁴³

Immediately during exercise, working memory and inhibition were worsened in ADHD sufferers compared to non-affected individuals.⁴⁴ Thus, it seems that it is not the sporting activity per se that triggers the improvement, but a subsequent process triggered by the sport.

1.1.3. Psychotherapy¶

For choosing an appropriate psychotherapist for ADHD, see ⇒ Choosing an Appropriate Psychotherapist for ADHD Choosing an appropriate psychotherapist for ADHD.

1.1.3.1. Behavioral therapy (+)¶

• Cassation therapy in D
• A comprehensive review showed that medication treatment is superior to treatment with behavioral therapy or clinical care. Multimodal treatment (combined treatment with medication and behavioral therapy or clinical care) seems most promising.⁴⁵
• A large metastudy of 190 studies involving 26,114 participants with ADHD similarly found behavioral therapy to be effective for ADHD. Stimulants were superior to behavioral therapy, cognitive training, and non-stimulants. Stimulants in combination with behavioral therapy appearedeb to be most effective.²

1.1.3.1.1. Mindfulness Based Cognitive Therapy (MBCT) (+++)¶

• According to a meta-study, each of the 13 studies analyzed found improvements in ADHD symptomatology with mindfulness-based interventions.⁴⁶ Other studies found comparable results.⁴⁷⁴⁸
• Combined MBCT / MBSR therapy produced increased activity and connectivity of the PFC, cingulate cortex, insula, and hippocampus in stressed, anxious, and healthy individuals after only 8 weeks. The improvements were consistent with 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, deactivation of the amygdala occurred more rapidly after emotional stimuli.⁴⁹ Further studies confirmed these results.⁵⁰⁵¹
• Additional MBCT treatment produced significantly greater symptom improvement than conventional treatment alone 6 months after cessation of therapy.⁵²
• Mindfulness meditation decreased cortisol and inflammation levels and increased telomerase, which counteracts behavioral changes due to stress-induced telomere shortening.⁵³
• Mindfulness-based treatment improved core symptoms of attention problems and hyperactivity in ADHD.⁵⁴
• A meta-study of 32 studies found evidence for effectiveness of mindfulness-based behavior therapy (there: mindfulness) for ADHD.⁵⁵

1.1.3.1.2. Cognitive behavioral therapy (o to +)¶

• A metastudy of 32 studies found positive results for cognitive behavioral therapy for ADHD in the majority.⁵⁵
• A metastudy found benefits of cognitive behavioral therapy for ADHD in parenting assessments but less so in reducing functional symptoms.⁷
• According to Barkley, cognitive behavioral therapy does not work for children with ADHD.⁵⁶
• In young children, treatment of the parents is much more effective.
• Patients between 7 and 6 years of age with ASD and anxiety or compulsivity were 4 times more likely to respond to cognitive behavioral therapy when comorbid ADHD was present, according to one study.⁵⁷
• Cognitive behavioral therapy is most likely to be appropriate with regard to self-esteem problems caused by ADHD⁵⁸ and with deficits in social behavior.
• Different forms of therapy improved different symptoms in ADHD according to a meta-study (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, above 1 high)⁵⁹
  • Depression
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.52 SMD at 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 (moderate to greater effect size)
      • 0.73 SMD at 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
      • Totally ineffective
  • Self-worth
    • Cognitive behavioral therapy (moderate to greater effect size)
      • Ineffective in group comparison
      • 1,404 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
      • Totally ineffective
  • Quality of life
    • Cognitive behavioral therapy (moderate to greater 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
      • In group comparison very good in the short term, ineffective in the long term
      • Subjectively moderately effective in the short term, weakly effective in the long term
  • Emotional dysregulation
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.64 SMD at follow-up in group comparison
      • 0.73 SMD in follow-up subjective for affected person
    • MBSR
      • In group comparison weakly effective in the short term, not known in the long term
      • Subjectively very effective in the short term, not known in the long term

1.1.3.2. Dialectical Behavioral Therapy (DBT) (+)¶

• Well suited for ADHD⁶⁰⁶¹

• A metastudy of 32 studies found evidence of benefit from group-based DBT for ADHD.⁵⁵

• One study found that DBT skills training worked particularly well for externalizing sufferers.⁶²

• Different forms of therapy improved different symptoms in ADHD according to a meta-study (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, above 1 high)⁵⁹

  • Depression
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.52 SMD at 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 (moderate to greater effect size)
      • 0.73 SMD at 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
      • Totally ineffective
  • Self-worth
    • Cognitive behavioral therapy (moderate to greater effect size)
      • Ineffective in group comparison
      • 1,404 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
      • Totally ineffective
  • Quality of life
    • Cognitive behavioral therapy (moderate to greater 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
      • In group comparison very good in the short term, ineffective in the long term
      • Subjectively moderately effective in the short term, weakly effective in the long term
  • Emotional dysregulation
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.64 SMD at follow-up in group comparison
      • 0.73 SMD in follow-up subjective for affected person
    • MBSR
      • In group comparison weakly effective in the short term, not known in the long term
      • Subjectively very effective in the short term, not known in the long term

• Elements of a DBT:

  • Inner mindfulness
    • Improve self-awareness and learn to trust it
    • Feel safe in situation without judging or devaluing it
    • Control, being able to participate in situations while maintaining distance
    • Reconcile feelings and mind.
  • Interpersonal skills
    • Establish and maintain relationships
    • Balancing and integrating relationship maintenance with own legitimate needs, opinions, and self-respect
  • Dealing with feelings
    • Recognize different feelings, name them, grasp their meaning
    • Controlling anger and resentment
    • Reduce vulnerability
    • Promote pleasant feelings
    • Release emotional suffering
    • Strengthen trust in your own feelings
  • Stress tolerance
    • Accept the fact of being under stress at the moment
    • Taking a step back (inwardly taking a step back)
    • Limit thinking to the now and the next minutes
    • Focus (distraction) through self-exposure to strong sensory stimuli
      • Ice cube
      • Ball with spikes
    • Breathing exercises
    • “easy smile”
    • Mindfulness exercises
    • Learning to endure unchangeable unpleasant events and feelings (“radical acceptance”).
  • Self-worth or self-acceptance
    • Healthy self-acceptance
    • Healthy self-confidence
    • Healthy sense of self-worth

• Structured psychotherapy

  • Very suitable for ADHD
  • Based on Dialectical Behavioral Therapy of Borderline Personality Disorder according to Linehan⁶³

1.1.3.3. Self-esteem therapy (+)¶

• Very suitable for ADHD
• Many sufferers spent their entire lives under (inaccurate) accusations such as “their lack of drive was an expression of laziness,” or “their inability to behave in a socially appropriate manner was malice” (because the power of impulsive breakthroughs was misunderstood). The fear of being further misunderstood makes it much more difficult to engage in a therapeutic relationship.⁶⁴
• Cognitive remediation program⁶⁵
• Note: Rejection Sensitivity is, in our opinion, an original ADHD-related symptom that responds to drug treatment with stimulants just as well as attention problems or hyperactivity/impulsivity. In our opinion, this argues against self-esteem imprinting mediated purely by experience. ⇒ Rejection sensitivity: sickliness and sensitivity to rejection and criticism as a specific ADHD symptom

1.1.3.4. EMDR-like therapies (+)¶

• EMDR
  In the therapy of trauma, EMDR is a recognized therapeutic option.⁶⁶ EMDR uses bilateral (alternating) activation of the two halves of the body through horizontal eye movements, alternating auditory signals to the left/right ear, or touch on the left and right sides of the body. A study proves that bilateral activation of the body leads to a decrease in activation of the PFC.⁶⁷
  Since EMDR-like therapies such as Emoflex have been reported to produce good results in ADHD, these results from the aforementioned study may be transferable to ADHD.
  • Structure of an EMDR therapy⁶⁸
    1. Treatment planning
    2. Preparation and positive stabilization
       What good things are aware of today, what bad things / burdens?
    3. Evaluation
       The stressful memory is assigned a present negative paraphrase (e.g., I am defenseless) and a future positive paraphrase (e.g., I can protect myself).
    4. Desensitization
       The stressful perception is called up and worked through under the accompaniment of 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/mental stress is no longer perceptible. The speed is adapted to the patient’s reactions.
    5. Anchoring
       Instead of the negative previous ones, a positive new thought base is anchored and trained. Slow bilateral movements, about 60 / minute.
    6. Body test
       Ensuring that negative sensations no longer occur when the stressful situation is remembered.
    7. Final meeting
       among other things, indicate that aftereffects can occur, e.g. in dreams.
    8. Success control and future orientation
  • For a detailed account of EMDR therapy using example cases, see Schubbe.⁶⁹
• Emoflex⁷⁰
  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.

1.1.3.5. Hypnotherapy for ADHD¶

One meta-study of 32 studies found evidence of benefit from hypnotherapy for ADHD.⁷¹ Another, less comprehensive meta-study came to no conclusion.⁷

1.1.3.6. Mentoring¶

For children with learning disabilities and ADHD, mentoring showed improvements in self-confidence and social relationships, and prevented the development of depressive behavior.⁷²

1.1.3.7. Time estimation training¶

A small study found that training with time estimation tasks improved cognitive symptoms in adults with ADHD-HI. Cortical activity in areas related to attention and memory increased significantly.⁷³

1.1.3.8. Systemic therapy (0/+)¶

• Especially suitable in relation to family and group problems in ADHD. Suitable in relation to family conflicts in ADHD affected younger children.
  With regard to the causes of ADHD symptoms in the affected persons themselves hardly effective.

1.1.3.9. Depth psychology (-)¶

• Cassation therapy in D
• Conditionally to poorly suitable for ADHD without comorbidities
  Suitable for ADHD sufferers in whom formative experiences from childhood clearly drive the stress level. In addition to ADHD, these patients usually have comorbid traumas or problems from the borderline spectrum, etc. In these cases, a depth psychological reappraisal can be very useful.

1.1.3.10. Talk therapy (-)¶

• Cassation therapy in D
• Conditionally suitable for ADHD
  Talk therapy can help manage ADHD sequelae.
  In contrast, it is unlikely to be effective with respect to the causes of ADHD symptoms themselves.
  Case study at Krause.⁷⁴

1.1.3.11. Working Memory Training / Cognitive Working Memory Training (CWMT) (-)¶

A large-scale meta-study found insufficient evidence of effectiveness of cognitive training for ADHD.⁷⁵ Another study confirmed this.⁷⁶

Another meta-study of 18 studies of cognitive training in school-age children and adolescents with ADHD found positive effects in 13 of 18 studies. 7 of 9 studies also found these at follow-up, suggesting long-term improvements.⁷⁷

Another meta-study found evidence of possible benefits of cognitive training on working memory, but predominantly no improvements in ADHD symptomatology in parent or teacher ratings.⁷

Several small studies found evidence that working memory training could help reduce ADHD symptoms.^7879808182
High intensity training (a total of 14 hours over 5 weeks) was reported to increase the density of D1 dopamine receptors in the PFC,⁸³ leading to a significant reduction in symptoms of attention and impulsivity.⁸⁴
In ADHD, working memory residing 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 brain areas for different content (number sequences, faces, names, goals). Training a specific working memory area (e.g., number sequences) therefore has little effect on working memory performance for names.

1.1.3.12. Training of executive functions (-)¶

Research found no benefit of executive function training in ADHD.⁸⁵ Another executive function training (EXAT) worked better for ADHD than for epilepsy, according to one study.⁸⁶
2 different executive, attentional, and motor trainings in children 4 to 5 years of age were found to be equally effective.⁸⁷

A meta-study of executive function training in preschool children reports no benefits for unaffected individuals, but mentions benefits for ADHD sufferers.⁸⁸

1.1.3.13. Analysis ( - - )¶

• Cassation therapy in D
• Not suitable for ADHD
  • So also Simchen⁸⁹

1.1.3.14. Impulse control training (?)¶

A small study reports an effectiveness of impulse control training with advance children.⁹⁰

1.1.4. Mindfulness techniques (+++)¶

Mindfulness techniques are very good for treating ADHD. A meta-analysis found positive results in 11 of 12 studies in relation to the treatment of ADHD.⁹¹ One meta-analysis found improvements in inattention in adults, while there was still too little data for children.⁹² One review found MBSR to be a useful supportive treatment for ADHD.⁹³

• Stress relieving⁹⁴
• Stress-preventing⁹⁵
• Mood enhancing⁹⁶
• Procrastination-inhibiting⁹⁶⁹⁷ (which is only natural, since procrastination is a symptom of stress)
• Mindfulness-based treatment improves the core symptoms of attention problems and hyperactivity in ADHD.⁵⁴
• Mindfulness training targets the vegetative nervous system
• Stress management decreased basal DHEA levels and increased cortisol levels in one study. The change in the cortisol-DHEA ratio achieved was stress resistance-promoting.⁹⁸
  It should be noted that depending on the disturbance pattern, the cortisol/DHEA ratio may be imbalanced in either direction.
  ⇒ DHEA/cortisol imbalance in stress
  Psychological stress therapy should always influence the ratio in the direction of the healthy balance. In the case of drug treatment, it must first be determined in which direction the balance is shifted.
  • Internal / external
    internal: it’s up to me personally (me, my)
    external: it’s because of 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, regularity)
    specific: the cause lies in this case itself (here, this time)Mindfulness trains a change of perception. It is trained that the perceived event is no longer immediately attributed, but that it is left to stand on its own. This enables a less frightening and threatening perception, which can massively reduce stress.
• Different forms of therapy improved different symptoms in ADHD according to a meta-study (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, above 1 high)⁵⁹
  • Depression
    • Cognitive behavioral therapy (moderate to greater 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 (moderate to greater effect size)
      • 0.73 SMD at 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
      • Totally ineffective
  • Self-worth
    • Cognitive behavioral therapy (moderate to greater effect size)
      • Ineffective in group comparison
      • 1,404 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
      • Totally ineffective
  • Quality of life
    • Cognitive behavioral therapy (moderate to greater 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
      • In group comparison very good in the short term, ineffective in the long term
      • Subjectively moderately effective in the short term, weakly effective in the long term
  • Emotional dysregulation
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.64 SMD in follow-up in group comparison
      • 0.73 SMD in follow-up subjective for affected person
    • MBSR
      • In group comparison weakly effective in the short term, 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 breathing techniques did not, while both techniques reduced stress.⁹⁹
• Mindfulness training still showed positive effects on children with ADHD in parent assessment 6 months later¹⁰⁰
• A meta-study concluded that mindfulness techniques are a helpful adjunct in the treatment of ADHD.¹⁰¹

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

• Mindfulness training is able to sustainably reduce cortisol levels.¹⁰⁴
• In generalized anxiety disorder, there is overactivation of the amygdala in response to ambivalent signals and a deficient functional connection between the amygdala and ventrolateral PFC. MBSR reduces amygdala overactivation 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 ventrolateral PFC and amygdala. All changes coincided with improvements in anxiety symptoms, suggesting causal effects. The previously negative coupling of the amygdala with ventrolateral PFC activity, as known in emotion reduction, changed to a positive coupling. MBSR appears to produce substantial changes in brain regions relevant to emotion regulation.¹⁰⁵
• The functional activity of the amygdala decreased and the connectivity of the amygdala with the PFC is improved. In addition, deactivation of the amygdala occurred more rapidly after emotional stimuli.⁴⁹
• Since MBSR has been shown to be very effective for ADHD, we assume that there is an analogous improvement in communication between different brain areas.
  Further research demonstrates effects of MBSR on neural activity.¹⁰⁶
• Mindfulness-based meditation technique may be superior to relaxation training in terms of long-term normalization of cortisol response.¹⁰⁷
• MBSR appears to be able to improve emotional self-regulation in ADHD sufferers.¹⁰⁸
• MBSR may improve ADHD symptoms not so much through improved mindfulness skills or improved self-compassion, but through improved inhibition.¹⁰⁹

1.1.4.2. Types of mindfulness techniques¶

• Mindfulness-based stress reduction (MBSR) according to Kabat Zinn¹¹⁰
• A combined MBCT and MBSR therapy showed the same results after 8 weeks as known from long-lasting meditation practice.⁴⁹
• Stress management (possibly less effective than MBSR)¹⁰⁵
• Yoga
  • Yoga showed to be moderately effective¹¹¹⁷
  • Yoga appears to improve core ADHD symptoms in children, according to several metastudies.^1127113
• Meditation⁴⁹
  • Zen Meditation
    increased the level of serotonin in the brain in the long term
  • Experienced meditators have been shown to have an increase in cortical thickness in the right insula and frontal lobes.¹¹⁴
  • In mindfulness meditation, more gray matter was observed in brain areas typically used in meditation in intensive meditators (2 hours daily for more than 8 years). The right insula, which is involved in introspective attention (“interoceptive awareness”), the left inferior temporal gyrus and the right hippocampus are affected.¹¹⁵
  • A meta-study found evidence of effectiveness of meditation techniques in children, adolescents, and adults.¹¹⁶ The results are said to indicate a stronger effect on inattention than on impulsivity/hyperactivity.
• Biofeedback
• Relaxation massages
  Massage therapy produced a 31% reduction in the cortisol response to stress and an increase in dopamine and serotonin of about 30%.¹¹⁷
  Massage therapy is said to be able to surpass the effect of methylphenidate.¹¹⁸
• Shiatsu
• Qigong
• Tai chi chuan
  • One meta-study found consistently positive effects of Tai chi on ADHD symptoms, although the quality of the studies was rather low.⁷
• Respiratory therapy
• Progressive muscle relaxation according to Jacobson
• Feldenkrais
• Sound massages
• Archery or other shooting sports (with mild positive effects on ADHD)¹¹⁹
• Mindfulness Apps
  also for the cell phone, which you always have with you anyway to take advantage of small breaks.¹²⁰

1.1.5. Neurofeedback (++)¶

⇒ Neurofeedback as ADHD therapy

Sources^121122123

• Good to very good for ADHD
• In our opinion, 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 followed by SCP training seems to produce very good results.
• Neurofeedback training types
  • SMR Training
    acts on relaxed attention, hyperactivity, impulsivity
  • Theta Beta Training
    acts on concentration, tense attention
  • Alpha Training
    acts on relaxation, sleep problems
  • SCP Training
    Slow cortical potentials marriage
    acts on activation (in ADHD-I) and down-regulation (in ADHD-HI)
    very exhausting, but also very helpful when carried out
• Neurofeedback improved visual memory, auditory short-term memory, and auditory working memory in a small study, but not perceptual organization.¹²⁴
• However, neurofeedback is not a substitute for treatment with medication (especially in the early years), but an adjunct to therapy that can reduce the need for medication.
• Different forms of therapy improved different symptoms in ADHD according to a meta-study (SMD: standard mean difference; higher is better: up to 0.5 low to medium, up to 1 medium to high, above 1 high)¹²⁵
  • Depression
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.52 SMD at 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 (moderate to greater effect size)
      • 0.73 SMD at 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
      • Totally ineffective
  • Self-worth
    • Cognitive behavioral therapy (moderate to greater effect size)
      • Ineffective in group comparison
      • 1,404 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
      • Totally ineffective
  • Quality of life
    • Cognitive behavioral therapy (moderate to greater 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
      • In group comparison very good in the short term, ineffective in the long term
      • Subjectively moderately effective in the short term, weakly effective in the long term
  • Emotional dysregulation
    • Cognitive behavioral therapy (moderate to greater effect size)
      • 0.64 SMD at follow-up in group comparison
      • 0.73 SMD in follow-up subjective for affected person
    • MBSR
      • In group comparison weakly effective in the short term, not known in the long term
      • Subjectively very effective in the short term, not known in the long term

1.1.5. Self-help groups (++)¶

• If necessary, (professionally) guided/supervised
• Knowledge about ADHD reduces suffering
• Improve management of symptom/stress triggers
• Improving the use of stress avoidance techniques
• Improving the use of stress reduction techniques
• Valuable experience of not being alone
• Self-help groups can be found here, among other places:
  • <http://www.adhs-deutschland.de/Home/Unser-Angebot/Selbsthilfegruppen/Bundesweites-Netz-von-Selbsthilfegruppen.aspx&amp;gt
  • http://www.zentrales-adhs-netz.de/fuer-betroffene/selbsthilfe.html
  • <https://www.mehr-vom-tag.de/rat-service-hilfe/adhs-selbsthilfegruppen/&amp;gt

1.1.6. Environment interventions (++)¶

• Parent Training

  • Parent training seems to be helpful for children with ADHD.¹²⁶ This probably concerns especially children with ODD¹²⁷ and young children.¹²⁸

• Interventions in school/kindergarten (-)

  • One meta-study reported that classroom interventions/school interventions were found to be partly ineffective and partly effective only as long as the interventions lasted.⁷

• Environment adaptation

  • Suitable job (++)
    • Arousing enough interest to activate hyperfocus
    • Enough variety to keep attention awake¹²⁹
    • ADHD-HI: often with physical activity
    • ADHD-I: no quick decisions
  • Suitable working environment (+)
    • According to the needs of the person concerned
      • Background noise
        • Each person needs his or her specific level of arousal (excitement, stimulation).¹³⁰¹³¹
      • Even though Novelty Seeking and Curiosity Behavior correlate (also genetically) with Impulsivity,¹³² it is likely to be important for most ADHD-HI sufferers to reduce Arousal, whereas for ADHD-I sufferers to increase Arousal.
  • Stimulate arousal
    • Targeted (soft) background music
      • Some people can only learn with it
    • TV running in the background
      • If sounds / images are distracting: switch off
    • Motivational elements
      • Very important, because ADHD sufferers can basically concentrate just as intensively as others. It’s just that they can’t evoke this concentration in a controlled manner and certainly can’t control it. This is not negligence or laziness.
      • Intrinsic motivation instead of extrinsic motivation: the central key
      • Rewards
      • Competition with others
        • Communicate goals to others (create commitment / self-commitment)
      • Do not make those affected feel guilty
        • None: You can if you want
        • None: You just have to try harder
          • Friedmann reports of sufferers who lost their ADHD symptoms after finding a work environment that suited their constitution: short attention spans, frequent activation, independent work organization. We also know of cases who flourished in the environment that was just right for them. This does not mean that only each affected person has to find his or her suitable environment and then no longer have ADHD. ADHD means that the choice of which environment is suitable is extremely limited. Very few people with ADHD will be able to build their world in this way. In our opinion, however, another element must be added: genuine interest. Only when this genuine interest of one’s own kicks in are ADHD sufferers able to remedy their attention problems. Friedmann points out that the reduced number of dopamine D2 and D3 receptors in the brain’s reward center in ADHD sufferers results in fewer things being found (be)rewarding, i.e., sufficiently exciting, than in non-affected individuals. The choice of an exciting environment therefore necessarily requires that it is something that is of (such) high interest to the respective affected person that the reward center “kicks in” and the attention of the affected person is aroused. The sentence “You can if you want to” is quite correct, but not in the way it is usually misunderstood. ADHD can only be understood if one is willing to accept that the will of the affected person is not completely free to choose, but depends on the occupational topic being so interesting that the deficiency of the reduced number of D2 and D3 dopamine receptors no longer comes into play. Only with the appropriate intrinsic interest can sufferers manage to “be able” to do what they want: by doing something that really 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 point of view, ADHD could also be defined as an extreme narrowing of interest.
            And yet this is also no justification that one’s own ADHD is not so bad, one has just not found what one is interested in.
    • Sideline
      • Knitting
      • Draw
      • Listen to music
        • Some people need to “do” something on the side in order to concentrate. This diverts the inner tension. The side activity serves to optimize the arousal. This is not a sign of disinterest or disrespect, but a means to increase attention and concentration

• Reduce distraction

  • Avoidance of too loud, hectic, stressful, intense situations.
    • Anyone who is sensitive to stress should avoid situations that trigger stress. This fact, which sounds self-evident, is surprisingly often disregarded, whether due to a lack of knowledge of the correlations or a guilty conscience. It is like the temperature: you should not freeze when the thermometer says so, but when you are cold:
    • Brightness
      • Lower roller shutter
    • Temperature
      • Regulate according to own needs
    • Reduce noise / voices / ..
      • Very quiet environment
      • Earplugs
      • Noise protection headphones
    • Own working space¹³³
      • No open plan office!
      • No passage room!
      • No open office!
    • Mails
      • Restrict retrieval to specific times
      • Disable pop-ups for incoming messages
      • Mails and other messages on the cell phone only visible after active retrieval, not automatically on screen
    • Workplace seating orientation
      • (closed) door in view
      • No windows in the back
      • Hide events in the room / in the window in the direction of view with curtains / transparent privacy film
      • Much daylight¹³⁴
      • Closed room

• Optimize / adapt learning methods

  • Short learning sections with frequent breaks
  • E.g.: Learning vocabulary;
    • Max. 10 pieces, so often, until they sit quite securely, only then further
    • Using all senses: reading quietly, reading aloud, copying, etc.
    • More vocabulary only after break
  • Walk while learning
    uniform movement significantly optimizes receptivity in some people; movement reduces stress and increases neurotrophic factors in the brain, which are necessary for neuroplasticity (formation of new synapses, learning)
  • 30 minutes of intensive physical exercise before learning (esp. ADHD-HI)
  • Appropriate working methods
    • Self-employment
      for interesting activities some affected persons (esp. ADHD-HI) cope better as self-employed than as employees, because intrinsic motivation optimizes arousal
      in the case of less interesting activities, however, this would be rather disadvantageous, because self-drive / self-structure is too low
    • Interesting activity
      The lack of extrinsic motivability makes it many times more important for ADHD sufferers than for non-affected people to find a task that is truly exciting for them
    • ADHD-I: structured work tasks, clear announcements, tight controls
      Example:
      One individual retired at age 50 after an illustrious career in the U.S. Marines. In civilian life, he couldn’t cope and failed. A year after leaving, he received his ADHD diagnosis.
    • Well-structured daily routine with regular alternation of activity and relaxation can support stabilization of norepinephrine balance through self-activation (see below: take enough breaks)

• Avoid / eliminate sources of stress

  • Even in personality disorders, a long-term study (n = 733) surprisingly found a decrease in symptoms within 2 years for a period of more than 12 months in more than 50% of those affected. In borderline, this was observed in 10% of sufferers within 6 months, mostly after massively stressful current life circumstances (stressful relationship) were removed. Nevertheless, significant diagnostic criteria remained very constant (stronger than in major depression), but they no longer reached the required severity for a diagnosis.¹³⁵

• Promote stress reduction

  • Just one hour of extended sleep reduces morning cortisol levels by 21¹³⁶¹³⁷
  • For sleep disorders:
    • Shift sleep rhythm backwards
      Move falling asleep and getting up to the end of the day
      This might be worth a try for sufferers with high stress levels immediately upon waking (e.g. anxiety)
      Early awakening correlates with high cortisol levels¹³⁶¹³⁷
    • More about sleep problems here

• Move to low stress environment

  • People living in poor neighborhoods are reported to have higher stress-related body weights than people living in more affluent neighborhoods.
    • When moving, the body weight adjusts to that of the new environment.¹³⁸
    • This could be interpreted as a result of a stress response or stress reduction, but can also be understood as an adaptation to the main environment.

1.1.7. Psychoeducation (++)¶

Source¹³⁹

• self-help groups (if necessary, professionally led/supervised)
• Books, seminars, lectures

• Coping Techniques
• Addiction therapies
  • Recognize addiction issue
    • Nicotine, caffeine, alcohol, drugs, sex, sports, internet, work, high-risk behavior, ..
  • Recognize short-term / long-term consequences
• Food diet
  more details at ⇒ Nutrition and diet for ADHD

1.1.8. Sleep problem therapy (+)¶

• Sleep problems should be treated with special priority in ADHD, as they can act as a vicious cycle to increase ADHD symptoms and ADHD symptoms can cause sleep problems.
• Sleep reduces the stress hormone cortisol. 1 hour longer sleep improves cortisol reduction by 21¹³⁶
  All ADHD symptoms are also stress symptoms.
• On the possible measures to improve sleep as well as sleep medications specifically for ADHD:
  ⇒ Sleep problems with ADHD

1.1.9. Diet and nutrition¶

Food intolerances address the stress regulatory systems as does psychological stress or disease.
There are no specific foods that trigger ADHD. However, if an individual food intolerance exists, it can exacerbate an existing ADHD (as well as other mental disorders) because it represents an additional source of stress/strain for the organism. Dietary treatment of an existing food intolerance therefore contributes to an improvement of an ADHD symptomatology. The mean effect size is approx. 0.25.

In addition, there are indications that omega-3/omega-6 fatty acids can support a treatment of ADHD. However, this does not affect all sufferers and the effect strength is so low that this can only be recommended as an augmentation (supplement) to a treatment with a strong effect.
See ⇒ for more details Nutrition and diet for ADHD as well as at ⇒ Effect size of different forms of treatment for ADHD.

1.1.9.1. Reasonable breakfast¶

One study found that 47% of students with ADHD and 33% of students without ADHD regularly did not eat a balanced breakfast. One hour after eating a balanced breakfast, both groups showed improvements in 4 cognitive domains.¹⁴¹

1.1.9.2. Drink plenty¶

Although thirst is not described as a typical ADHD symptom, increased thirst and therefore increased water intake are commonly observed symptoms of stress.¹⁴² Since 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.¹⁴³ Fluid intake significantly reduces the stress response.¹⁴⁴

1.1.10. Take enough breaks¶

• Breaks are not just for recovering and letting the amount of stimuli you’ve been exposed to drain away:
  A clearly structured daily routine, in which activity and breaks are sensibly alternated, can train the noradrenergic system and normalize the production of noradrenaline again.¹⁴⁵
• This follows on from Scheidtmann’s suggestion that noradrenergic drugs (e.g., antidepressants) do not help in motor rehabilitation (if) they are used as permanent medication, since tricyclic antidepressants permanently stimulate noradrenergic receptors and this leads to the sensitivity of the receptor (especially with regard to learning processes) being lost as a result.¹⁴⁶
  This is consistent with experience with the use of noradrenergic tricyclic antidepressants in ADHD. Here, it is often reported that initially there is a very good response, which, however, decreases with continued medication.
• Breaks can counteract the hyperactivity of ADHD.¹³³

1.1.11. Therapy Computer Games¶

In recent years, the topic of computer games for the purpose of therapeutic use has come into scientific focus.
Basically, ADHD symptoms should be able to be improved by therapy computer games, e.g. attention,¹⁴⁷

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

1.1.11.1. EndeavorRx¶

The FDA (U.S. Food and Drug Administration) approved the first ever doctor-prescribable video game in June 2020. It is used to treat ADHD.

180 children between 8 and 12 years of age played EndeavorRx for 25 minutes each 5 days/week for 4 weeks, and 168 children played a game other than placebo. The mean change (SD) from baseline on the TOVA-API was 0.93 in the treatment group and 0.03 in the control group.¹⁴⁸ It is skeptical that the study was sponsored by the software manufacturer. 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.¹⁴⁹

The manufacturer further describes:

“EndeavourRx was granted clearance 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 that showed EndeavourRx improved objective measures of attention in children with ADHD. After four weeks of EndeavourRx treatment, one-third of children no longer had a measurable attention deficit on at least one measure of objective attention. In addition, after one month of treatment with EndeavourRx, about half of the parents noted a clinically significant change in their child’s daily impairments. This increased to 68% after a second month of treatment. The improvement in ADHD-HI impairments after one month of treatment with EndeavourRx was maintained up to one month.”¹⁵⁰

Another study, probably still ongoing, is investigating the efficacy of the game at a longer application duration of 2 months and to what extent improvements persist after the end of treatment.

1.1.11.2. Plan-It Commander¶

The therapy computer game “Plan-It Commander” was / is developed by the authors of the studies mentioned below themselves,¹⁵¹ so that the assessment of its effectiveness by independent studies is to be awaited. The symptoms that are said to have been improved by it in non-blinded studies are as follows

• Time management (parent evaluation)¹⁵²
• Accountability (parent evaluation)¹⁵²
• Working memory (parent assessment)¹⁵²
• Planning and Organizational Skills (Parent Assessment)¹⁵³ in girls overall and in boys with severe social behavior disorder and low hyperactivity.

1.1.11.3. RECOGNeyes¶

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

• Impulsivity
• Response time
• Fixation eye control

while the control group, who controlled the game with the mouse, showed no improvements.¹⁵⁴

1.1.11.4. Empowered Brain¶

A very small preliminary study showed that the higher their ADHD symptoms, the better autism spectrum disorder sufferers completed the game portions of Empowered Brain.¹⁵⁵ The software seems to be developed more from a diagnostic perspective.

1.1.11.5. AR-Therapist: Augmented Reality - Behavioral Therapy - Game Concept¶

A study describes a concept of an augmented reality game for the purpose of behavioral therapy in ADHD including measurement of ADHD-relevant parameters.¹⁵⁶

1.1.11.6. The Secret Trail of Moon¶

A report describes the development of this game for ADHD treatment.¹⁵⁷

1.1.11.7. Computer therapy games for other mental disorders¶

For other therapy goals, some therapy games are known, e.g.:

• Nevermind¹⁵⁸
  • Stress
  • Measured stress (anxiety, trauma responses) complicates playing conditions
  • No “official” medical application
  • Is also controlled by biofeedback
• Elude¹⁵⁹
  • 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 to improve friends’ and relatives’ understanding of people suffering from depression, of what the sufferers are going through.
• Treasure hunt¹⁶⁰¹⁶¹
  • 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
  • Objectives:
    • Learning to distinguish between thoughts, feelings and behavior
    • Replace negative thought patterns with positive ones
• Depression Quest¹⁶²
  • Depression
  • In a selectable adventure, the player as a depressive tries to balance the illness, job, relationships and even treatment.
• Actual Sunlight¹⁶³
  • Depression
  • A short interactive story about love and depression.
  • Not suitable for children
• Sym¹⁶⁴
  • Social phobia is addressed in this game
• Rage Control¹⁶⁵
  • Aggression
  • Developed by Boston Children’s Hospital
  • Uses active biofeedback
• Boson X
  • Depression
  • Commercial, not therapy oriented game
  • It is disputed whether this reduces the brooding phases in depression sufferers¹⁶⁶¹⁶⁷
• Tetris
  • Trauma Prevention
  • Non-therapy game
  • Use within the first 6 hours after a potentially traumatizing experience, after players were asked to recall the event, reduced risk of traumatization¹⁶⁸
    • However, according to our (unverified) hypothesis, any mental occupation and media consumption that provides a light (!) mental occupation (entertainment programs, entertainment movies without dramas, light video games without social or violent components) could be suitable as trauma prophylaxis, provided that they are used before the first sleep after the event. Of course, the content must not be thematically tangential to the event.
      According to our conception, subsequent “light” media consumption (at least partially) “overwrites” or “relativizes” the potentially traumatizing experiences in working and short-term memory before they can be transferred to long-term memory via the hippocampus during sleep. With this in mind, it may be beneficial to delay the first sleep after a potentially traumatizing event as long as possible, to encourage abundant low-significance media consumption, and, if necessary, to give medication that reduces hippocampal activity.

1.1.12. Computer based training programs¶

1.1.12.1. Computer assisted congnitive training¶

A computer-based cognitive training program improved focused attention and working memory better than conventional training in a proportion of subjects (responders). ADHD-I and ADHD-C were more likely to benefit than ADHD-HI.¹⁶⁹

1.1.12.2. 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 found no positive benefit each involved apps.¹⁷⁰

1.1.13. Chess training / Go training / Board games¶

A small study found an improvement in ADHD symptomatology related to IQ with 11 weeks of chess training.¹⁷¹ The effect size was 0.85 with parent assessment. Parent-only assessment should always be treated with caution.
Another study found a comparable effect of GO, improving inattention but not hyperactivity.¹⁷² The results of other studies could not be converted into effect sizes.¹⁷³¹⁷⁴

1.1.14. Transcranial magnetic stimulation / Transcranial direct current stimulation (o/+)¶

Several studies address the effect of transcranial stimulation in ADHD.^175176177
Transcranial direct current stimulation was better evaluated than repetitive transcranial magnetic stimulation in one review.¹⁷⁸

The majority view is that evidence of positive effects predominates,^{179180181182183184}
One 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 overall symptom level, with a concomitant delayed onset of effect with respect to hyperactivity.¹⁸⁵. Another metastudy found significant improvements in attention, inhibition, working memory, and brain connectivity in 11 studies.¹⁸⁶

Other sources speak of mixed results ^{187 188 189190}

One study reported an improvement in omission errors in ADHD sufferers with transcranial stimulation that was accompanied by an improvement in P 300 amplitude.¹⁹¹ In a placebo-controlled double-blind study, subjects received either anodal transcranial direct current stimulation (tDCS) over the left dorsolateral prefrontal cortex (dlPFC) or transcranial random noise stimulation (tRNS) while undergoing cognitive training. The improvements in ADHD from transcranial magnetic stimulation were enhanced when combined with cognitive training.¹⁹²
Two reports of a single case in an adult with ADHD indicated improvement in hyperactivity but not attention.¹⁹³¹⁹⁴ In contrast, a small placebo-controlled study in adults with ADHD found improvement in attention with no improvement in mood, anxiety, or hyperactivity.¹⁹⁵
Two studies of children with ADHD found improvements of:¹⁹⁶

• Inattention in the school context
• Hyperactivity/impulsivity at home
• oppositional defiant behavior

One study found increased dopamine levels in the striatum during TMS application. The increase was similar to that seen with administration of D-amphetamine,¹⁹⁷ Repeated TMS of the left dlPFC increased extracellular dopamine in the left dorsal caudate nucleus, compared with repeated TMS of the left occipital cortex. Unchanged was dopamine in the putamen, nucleus accumbens, or right caudate¹⁹⁸

1.1.15. Traditional Chinese Medicine (TCM)¶

TCM usually combines various treatment methods, as does Western “multimodal” therapy. Among them are herbal treatments, which can be assumed to interfere with the neurotransmitter structure in the same way as conventional medication. The risk is less knowledge of the pathways, side effects, and cross effects with conventional medication.
A meta-analysis found a surprisingly good effect of TCM with regard to ADHD (equally good or better than MPH), but at the same time poor to very poor quality of the individual studies, including a risk of significant bias, which is why TCM cannot yet be recommended as a treatment for ADHD.¹⁹⁹⁷

1.1.16. Light therapy¶

A very small study with n = 29 adults found positive effects of early morning light therapy in autumn/winter months on objective and subjective ADHD symptoms, mood and an advance of the circadian rhythm.²⁰⁰ The advance of the circadian rhythm seemed to have the greatest influence on the improvement of ADHD symptoms. Another, even smaller study on 16 adults came to comparable results.²⁰¹
A third placebo-controlled study comparing cordian rhythm with melatonin or melatonin plus light therapy also found that light therapy (here: as an adjunct to treatment with melatonin) could shift the circadian rhythm forward and that this had positive effects on ADHD symptomatology. Melatonin alone had a stronger effect than light therapy, light therapy improved the outcome of melatonin treatment.²⁰²
A review confirmed these findings.²⁰³

1.1.17. 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 more noise is required in ADHD for stochastic resonance to occur in dopamine-deficient neural systems. This prediction was supported by empirical data, he said.^204205206207

1.1.18. Trigeminal Stimulation¶

The first positive results have been obtained for trigeminal stimulation.²⁰⁸ The effect size is said to be 0.5.²⁰⁹ Trigeminal stimulation is said to improve executive dysfunction (organizational problems) in particular in children with ADHD.²¹⁰
A first-of-its-kind trigeminal stimulation device (Monarch eTNS System) was approved by the FDA. In a double-blind placebo study, the device significantly improved ADHD symptoms within 4 weeks in children aged 8 to 12 years.²¹¹

Whether neurostimulation can be reliably used as a treatment tool for ADHD and whether the improvements persist after the end of treatment remains to be observed²¹²

1.2. Therapeutic approaches for ADHD whose effect is not proven¶

• Occupational Therapy
  The effectiveness of occupational therapy for ADHD is limited to school-preparatory treatment of fine motor skills, he said.²¹³
  A study reports positive effects of equine-assisted occupational therapy in school-aged children with ADHD.²¹⁴
• Hemoencephalography Training
  Effect not yet recognized, initial studies.¹⁷⁵
• Self-instructions
  Effect in dispute.²¹⁵
• listening to (classical) music to improve the mood
  • One study found that listening to Mozart for 10 minutes (Mozart piano sonata for four hands, KV 440) improved mood in both ADHD sufferers and non-affected subjects, in contrast to subjects who completed 10 minutes of silence.²¹⁶ This does not prove an ADHD-specific treatment method.
• App-supported attention and organization training
  • One study reported a cell phone app-based training of attention and organization led to relevant improvements in one-third of adults with ADHD.²¹⁷
  • A 2019 meta-analysis found no other research on ADHD treatment using specific apps²¹⁸
• Organizational skills training
  • In SCT, training in organizational skills did not result in any improvement of SCT symptoms from the perspective of the affected persons themselves. Only from the perspective of the parents did improvements occur, with an effect size of approximately 0.5.²¹⁹
    Parent assessments are highly susceptible to being biased toward desired outcomes. This bias is stronger the greater the effort invested.
• Homework support
  • In SCT, homework support did not result in any improvement of SCT symptoms from the perspective of the affected persons themselves. Only from the perspective of the parents did improvements occur, with an effect size of approximately 0.5.²¹⁹
    Parent assessments are highly susceptible to being biased toward desired outcomes. This bias is stronger the greater the effort invested.
• Social Behavior Training
  • A meta-analysis found no confirmed effect of non-drug training methods (coaching and others) in improving social behavior toward peers.²²⁰
  • One meta-study found weak evidence of benefits from peer-based interventions for ADHD,⁷ which are primarily aimed at strengthening social support among peers.
  • Another meta-analysis of 15 studies found evidence of moderate effectiveness of social skills training in children with ADHD.²²¹
• Transcutaneous vagus nerve stimulation
  • One report cites transcutaneous vagus nerve stimulation as a possible treatment for ADHD.²²²
• Acupuncture
  • One metastudy reports a high efficacy of acupuncture on hyperactivity.²²³ Another metastudy also intends to investigate the effect of acupuncture for the treatment of ADHD.²²⁴
  • How effectiveness of acupuncture is controversial. So far, no conclusive medical explanatory models exist.
    However, two German double-blinded studies, which conclude that only a placebo effect can be demonstrated for Acupucture so far, show in the figures that Acupucture achieved 20% better results compared to sham acupuncture.²²⁵. ²²⁶ Other studies reported an effect beyond placebo.^227228229230
• Homeopathy
  • A metastudy reports benefits of additional individual homeopathy treatment for ADHD.²³¹
• Fidgets
  • One study observed significant improvement in sustained attention in students with ADHD who used Fidgets during class.²³²
• Random Noise
  • Random Noise treatment uses any form of energy (e.g., light, mechanical, electrical, or acoustic) with unpredictable intensity to stimulate the brain and sensory receptors, aiming to improve sensory, motor, and cognitive functions. Random Noise treatment originally used mechanical sounds for auditory and cutaneous stimuli. Today, electrical energies are increasingly used to affect 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 at behavioral and psychological levels.²³³
• Spinal manipulation / spinal mobilization
  • A meta-analysis found no evidence of efficacy of spinal manipulation/mobilization for ADHD²³⁴

1.3. Therapeutic approaches that are proven ineffective¶

• Phosphate diet (oats)
  See 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 incompatible substances in each case) can increase the stress level in such a way that latent mental disorders (e.g. also ADHD) can appear or existing disorders are intensified.
  See 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, if necessary, other treatment options is used. Multimodal treatment improves ADHD symptoms.²³⁵ This is not surprising. Only a comparison with purely psychotherapeutic and drug treatment would be relevant.

3. Treatment concepts, treatment manuals, guidelines¶

Source: Schmidt, Petermann²³⁶

• 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 ADHD in Adulthood” (D’Amelio et al., 2009),
  Practical guidance on the treatment of ADHD and family groups
• “Training for ADHD in Adulthood (TADSE)” (Baer &amp; Kirsch, 2010)
• “Therapy Program Cognitive Behavioral Therapy of Adult ADHD” (Safren et al.,2009)
  Cognitive techniques for individual therapy
• Interdisciplinary evidence- and consensus-based (S3) guideline “ADHD in children, adolescents, and adults”²³⁷

4. Subtype-specific treatment¶

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

In our view, ADHD-HI and ADHD-C suffer from the HPA axis stress system being permanently over-activated and not shutting down again due to too low a cortisol response to acute stress or poor addressability of glucocorticoid receptors, whereas 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 norepinephrine release, thus triggering thought blocks and decision-making incapacity.

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

5. Multi-generational treatment for ADHD¶

Treating children alone overlooks the fact that the influence of ADHD-affected parents has a significant impact on children’s development.
Treatment and support of ADHD-affected mothers showed positive consequences for the children, although higher intensity treatment of ADHD-affected mothers (here: with DBT) showed a benefit for the children only for a limited time compared to less intensive treatment.²³⁸

Children of mothers with high neuroticism and low conscientiousness should benefit more from behavioral therapies than other children. In contrast, children of mothers with moderate neuroticism and moderate conscientiousness or low neuroticism and high conscientiousness are expected to benefit more from a multimodal treatment consisting of therapy and medication or medication alone than from behavioral therapy alone.²³⁹