ADHD treatment: Guidelines and Effect sizes of different therapies

ADHD is very treatable¹² and may be the most treatable psychiatric problem of all.³⁴ The Effect sizes of stimulants are the highest ever found for psychiatric medications⁵
While amphetamines show an Effect size of 0.8-1.5 (NNT = 1.6) for ADHD in adults, internal medications for hypertension or antidepressants show an NNT of 10.⁶
The response rate of stimulants in ADHD is also remarkable. While only every second person with an anxiety disorder responds to treatment with the first choice of medication⁷, 70% (to MPH) to 80% (to amphetamine medication) do so with ADHD.

Stimulants for ADHD have a special position in the world of psychotropic drugs.

Effect size of medications / treatments is measured in SMD.
0.2: purely statistically perceptible.
0.5: Beginning of perceptibility on individual patients (from here clinical use = use in treatment)
0.8: good effect, clearly perceptible on individual patients.

There are very few drugs or forms of treatment in all of medicine that have an Effect size of 0.8 or more.
Antidepressants have an overall average of 0.3, psychotherapy for depression 0.6, sports 0.8.

ADHD stimulants, on the other hand, have impressive Effect sizes:
1.0 for methylphenidate
1.5 for lisdexamfetamine (Vyvanse)
and are effective from the first day (even if it takes a lot of fine-tuning to get the dose just right).

Non-stimulants have a weaker effect:
0.8 Atomoxetine
0.6 Guanfacine
and take weeks to work properly.

The Effect size of stimulants thus exceeds the typical experience of doctors. In contrast to depression, medication is much more effective here than psychotherapy (which has a lower effect of around 0.5 on ADHD than on depression), for which it takes several years, if it works at all (see below), while stimulants are much less effective than psychotherapy

only need to be dosed
unlike AD, do not take weeks to see if they help
do not share the risk of the sometimes very severe side effects of AD.

It is understandable that doctors who have not studied stimulants in detail do not expect this particular effect.
At the same time, this high Effect size is also the reason why experienced ADHD doctors primarily work with medication, while less experienced doctors, alternative practitioners and psychotherapists (the latter two of whom are not allowed to prescribe medication) are cut off from this unusual experience and therefore do not refer to the special features of stimulants, but to general medical and psychological experience.

In addition, ADHD medication increases dopamine levels, which are reduced in ADHD, dopamine is a neurotrophic factor required for brain plasticity (i.e. the ability to learn) and therefore ADHD medication often first establishes the ability to undergo therapy. In our experience, psychotherapies for ADHD usually only work after medication has been taken for a while.

Today’s drug and psychological treatment methods for ADHD make it possible to largely or completely eliminate the symptoms. However, a cure would also require the symptoms to disappear permanently without ongoing further treatment (including coping strategies).
Long-term behavioral therapy can achieve a comparable effect to medication - but only after years. However, incorrectly applied psychotherapy can cause just as much damage as unsuitable medication.

Unfortunately, there are therapists who are not familiar with all the symptoms of ADHD. Some therapists only know the diagnostic DSM symptoms of ADHD or do not understand that DSM and ICD only name those symptoms that are particularly well differentiated from other disorders and that other symptoms originally caused by ADHD can also occur. We call this entirety of symptoms the treatment-relevant symptoms in order to distinguish the subset of diagnostic symptoms from them.
If this leads to the person with ADHD attributing these symptoms to personal responsibility rather than as a consequence of ADHD, the person with ADHD may come out of therapy with more feelings of guilt and inadequacy than they went in with. Unfortunately, we know of many such cases, both in outpatient and inpatient treatment.

In addition, 25% of people with ADHD-HI (with hyperactivity) showed a worsening of symptoms after social skills training.⁸

Nevertheless, there are methods that can permanently alleviate ADHD symptoms.

ADHD - symptom treatment vs cure

Some evidence suggests that a cure for ADHD may be possible in some areas. In some cases, neurofeedback appears to be able to permanently reduce or, in the best case (albeit rarely), even eliminate the symptoms. There are also cautious indications that very early medication with methylphenidate as well as long-term medication could have measurable healing effects ⁹¹⁰
Mindfulness-based forms of treatment consistently show improvements in ADHD symptoms. If ADHD is completely incurable, the question arises as to why ADHD decreases in 20 to 50% of people with ADHD by adulthood, at least to such an extent that ADHD is no longer diagnosed. There are several possible explanations for this, either alone or together:

Lack of knowledge about the changing symptoms in adulthood, so that adult ADHD, which manifests differently, is no longer recognized
Coping strategies are developed more effectively so that the symptoms are better masked
Change in life circumstances; in particular, discontinuation of school organized mainly by extrinsic motivation and replacement by training or studies in a field chosen by the individual (more intrinsic motivation).
Actual remitting (subsiding) of the symptoms, e.g. due to post-maturation of affected brain regions
Real recovery

This question, which has not yet been conclusively answered, allows us to retain a little bit of hope.
It is certain that long-term psychotherapy and neurofeedback can have a curative effect and significantly reduce the severity of symptoms, and that drug treatment can generally largely eliminate the symptoms and enable a stress-free life, without any stressful side effects.

Systematic treatment of ADHD not only significantly improves the quality of life of people with ADHD, but also halves the risk of developing alcohol, nicotine or drug addiction compared to untreated people with ADHD.¹¹ The risk of developing psychiatric comorbidities (depression, anxiety disorders, Compulsions, etc.) is reduced to less than half.¹¹
While untreated children with ADHD show massive impairments in executive functions, treated children with ADHD were found to have executive functions close to those of unaffected children.¹²

Some people reject treatment of ADHD with medication on principle. This appears to be more a question of attitude than a question of fact. One study reports that the following factors in particular influence parents’ decisions as to whether children with ADHD receive medication:¹³

The extent to which ADHD is perceived as a stigma
The basic attitude towards medication for ADHD
Knowledge about ADHD.

Treatment: Guide and Effect size