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Psychotherapy (++)

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

1. Behavioral therapy (+)

  • Treatment covered by statutory health insurance in Germany
  • 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.12
  • A large meta-analysis 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.3

1.1. Mindfulness-based behavioral therapy (Mindfulness Based Cognitive Therapy, MBCT) (+++)

  • According to a meta-analysis, each of the 13 studies analyzed found improvements in ADHD symptoms through mindfulness-based interventions.4 Other studies came to similar conclusions.56
  • 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.7 Further studies confirm these results.89
  • An additional MBCT treatment resulted in a significantly greater improvement in symptoms 6 months after the end of therapy than conventional treatment methods alone.10
  • Mindfulness meditation reduced cortisol and inflammation levels and increased telomerase, which counteracts behavioral changes caused by stress-induced telomere shortening.11
  • Mindfulness-based treatment improved the core symptoms of attention problems and hyperactivity in ADHD.12
  • A meta-analysis of 32 studies found evidence for the effectiveness of mindfulness-based behavioral therapy (there: mindfulness) for ADHD.13

1.2. Cognitive behavioral therapy (o to +)

Cognitive behavioral therapy (CBT) for the treatment of ADHD should be tailored to ADHD. Otherwise, Cognitive Behavioral Therapy can result in an unhelpful and negatively overwhelming experience for people with ADHD.14

  • A meta-analysis of 32 studies found positive results for cognitive behavioral therapy for ADHD in the majority.13
  • A meta-analysis found benefits of cognitive behavioral therapy for ADHD in parent ratings, but less in the reduction of functional symptoms.15
  • According to Barkley, cognitive behavioral therapy does not work for children with ADHD.16
  • Parental treatment is much more effective for young children.
  • Patients between the ages of 7 and 6 with ASD and anxiety or Compulsions were 4 times more likely to respond to cognitive behavioral therapy when comorbid ADHD was present, according to one study.17
  • Cognitive behavioral therapy is most suitable for self-esteem problems caused by ADHD18 and for deficits in social behavior.
  • Cognitive behavioral therapy was helpful for medicated adults with ADHD.19 The benefits were mediated by:
    • Changes in the core symptoms of ADHD
    • Changes in depressive symptoms
    • Changes in depressive symptoms and then maladaptive cognitions
    • Changes first in depressive symptoms, maladaptive cognitions and then core ADHD symptoms.
  • According to a meta-analysis, 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)20
    • Depression
      • Cognitive behavioral therapy (medium to large Effect size)
        • 0.52 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjectively 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 subjectively 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 follow-up subjectively 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
    • Quality of life
      • Cognitive behavioral therapy (medium to large Effect size)
        • Ineffective to slightly effective in group comparison
        • 0.57 SMD in follow-up subjectively 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 subjectively 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

2. Dialectical Behavioral Therapy (DBT) (+)

  • Well suited for ADHD2122

  • A meta-analysis of 32 studies found evidence of benefit from group-based DBT for ADHD.13

  • One study found that DBT skills training works particularly well for externalizing people with ADHD.23

  • A digital form of DBT proved helpful for children with ADHD24

  • According to a meta-analysis, 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)20

    • Depression
      • Cognitive behavioral therapy (medium to large Effect size)
        • 0.52 SMD in follow-up in group comparison
        • 0.74 SMD in follow-up subjectively 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 subjectively 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 follow-up subjectively 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
    • Quality of life
      • Cognitive behavioral therapy (medium to large Effect size)
        • Ineffective to slightly effective in group comparison
        • 0.57 SMD in follow-up subjectively 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 subjectively 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
      • “gentle 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 Linehan25

3. Self-esteem therapy (+)

  • Very suitable for ADHD
  • Many people with ADHD 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.26
  • Cognitive remediation program27
  • 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

4. EMDR-like forms of therapy (+)

  • EMDR
    EMDR is a recognized therapy option for the treatment of trauma.28 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.29
    As EMDR-like forms of therapy such as Emoflex30 are said to be successful in treating ADHD, the results of this study could be transferable to ADHD. This is also indicated by an individual case report in which a person with ADHD was successfully treated with EMDR31
    Nevertheless, we must caution against assuming that EMDR is a suitable form of therapy for all people with ADHD. We assume that people with ADHD who have had traumatic experiences can also benefit from trauma therapy in relation to their ADHD symptoms, as trauma can be considered a possible contributory cause of ADHD. However, it cannot be deduced from this that EMDR would be useful for all people with ADHD. And there are no known studies that point in this direction.
    • Structure of EMDR therapy32
      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 negative ones. 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.33
  • Emoflex34
    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).

5. Hypnotherapy for ADHD

A meta-analysis of 32 studies found evidence for a benefit of hypnotherapy for ADHD.35 Another, less comprehensive meta-analysis came to no conclusion.15

6. Mentoring

In children with learning disabilities and ADHD, mentoring showed improvements in self-confidence and social relationships, and prevented the development of depressive behavior.36

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.37

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 people with ADHD.
    Barely effective in addressing the causes of ADHD symptoms in the people with ADHD themselves.

9. Depth psychology (-)

  • Treatment covered by statutory health insurance in Germany
  • Limited to little suitability for ADHD without comorbidities
    Suitable for people with ADHD for whom formative experiences from childhood significantly drive the stress level. 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.

10. Talk therapy (-)

  • Treatment covered by statutory health insurance in Germany
  • Conditionally suitable for ADHD
    Talk therapy can help with the management of ADHD-related problems.
    In terms of the causes of the ADHD symptoms themselves, however, it is barely effective.
    Case study with Krause.38

11. Working Memory Training / Cognitive Working Memory Training (CWMT) (o)

A large-scale meta-analysis found insufficient evidence for the effectiveness of cognitive training for ADHD.39 A further study confirmed this.40

Another meta-analysis of 18 studies on cognitive training in schoolchildren and adolescents with ADHD found positive effects in 13 of 18 studies. 7 out of 9 studies also found these in a follow-up examination, which indicates long-term improvements.41

Another meta-analysis found evidence of possible benefits of cognitive training on working memory, but predominantly no improvements in ADHD symptomatology in parent or teacher ratings.15

Several small studies found evidence that working memory training could help to reduce the symptoms of ADHD.424344454647
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,48 which leads to a significant reduction in the symptoms of attention and impulsivity.49
One RCT found moderate improvements with executive working memory training in adults with ADHD.50

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 barely any influence on the performance of the working memory for names.

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

12. Training of executive functions (-)

Research found no benefit of executive functions training in ADHD.51 According to one study, another executive function training program (EXAT) worked better for ADHD than for epilepsy.52
2 different executive, attention and motor training programs for children aged 4 to 5 were found to be equally effective.53

A meta-analysis of executive function training in preschool children reports no benefits for non-people with ADHD, but mentions benefits for persons with ADHD.54

13. Analysis ( - )

  • Treatment covered by statutory health insurance in Germany
  • Not suitable for ADHD
    • So does Simchen55

Due to the long duration of therapy, analysis in itself would be quite suitable for ADHD therapy. However, it appears that most psychoanalysts lack the necessary basic understanding of ADHD to design a meaningful therapy. If symptoms, which in the case of ADHD are predominantly genetic, are fundamentally regarded as an expression of personal experience, we see a great danger of misguiding people with ADHD.

14. Impulse control training (?)

A small study reports the effectiveness of impulse control training for preschool children.56

15. Online group coaching (+)

The Understanding and Managing Adult ADHD Program (UMAAP) is a group-based webinar program for adults with ADHD. The six sessions include:57

  • Psychoeducation
  • Acceptance therapy
  • Commitment therapy

UMAAP showed a high participation rate and participant satisfaction. It resulted in:57

  • Quality of life: average increase 9.69
  • Self-acceptance: mean increase 0.19
  • Knowledge about ADHD: mean increase 1.55
  • Psychological flexibility: no significant increase immediately after the intervention; mean increase 0.42 after 3 months

The effects were still present after 3 months.

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