CONTEXT:

Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD) encompass a range of care approaches from structured behavioral interventions to complementary medicines.

OBJECTIVES:

To assess the comparative effectiveness of nonpharmacologic treatments for ADHD among individuals 17 years of age and younger.

DATA SOURCES:

PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2009 through November 7, 2016.

STUDY SELECTION:

We included studies that compared any ADHD nonpharmacologic treatment strategy with placebo, pharmacologic, or another nonpharmacologic treatment.

DATA EXTRACTION:

Study design, patient characteristics, intervention approaches, follow-up times, and outcomes were abstracted. For comparisons with at least 3 similar studies, random-effects meta-analysis was used to generate pooled estimates.

RESULTS:

We identified 54 studies of nonpharmacologic treatments, including neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled results for omega fatty acids found no significant effects for parent rating of ADHD total symptoms (n = 411; standardized mean difference −0.32; 95% confidence interval −0.80 to 0.15; I2 = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized mean difference −0.08; 95% confidence interval −0.47 to 0.32; I2 = 0.0%; P = .56).

LIMITATIONS:

Studies often did not reflect the primary care setting and had short follow-up periods, small sample sizes, variations in outcomes, and inconsistent reporting of comparative statistical analyses.

CONCLUSIONS:

Despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.

Many options exist for treating attention-deficit/hyperactivity disorder (ADHD) beyond commonly used psychostimulant drugs.1 Nonpharmacologic approaches either alone or in combination with psychostimulants might improve ADHD symptoms and reduce the risk associated with psychostimulants by decreasing their use. Nonpharmacologic therapies encompass a broad range of approaches, from highly structured behavioral interventions to complementary medicines. Behavioral interventions include neurofeedback, cognitive training, cognitive behavioral therapy (CBT), or child or parent training. Additional approaches have focused on dietary, herbal, or omega fatty acid supplementation.

Our goal was to systematically evaluate the comparative effectiveness and safety of nonpharmacologic approaches to ADHD. This report is a subset of a systematic review sponsored by the Agency for Healthcare Research and Quality (AHRQ) to address broad issues related to the diagnosis and management of ADHD.2 In this report, we update a previous systematic review published in 20113 that was focused on the effectiveness of ADHD treatment in at-risk preschoolers, the long-term effectiveness of ADHD treatment in all ages, and the variability in ADHD prevalence, diagnosis, and treatment. In the 2011 report, dietary or complementary medicine approaches to the management of ADHD were not considered. In addition, that report only required a comparator group to assess effectiveness of therapy for preschool-aged children. The authors of the 2011 report indicated that, in general, nonpharmacologic (psychosocial and/or behavioral) interventions alone were not as effective as US Food and Drug Administration (FDA)–approved pharmacologic management of ADHD with a slight advantage to combining psychosocial or behavioral interventions with pharmacologic management. Parent behavior training as first-line treatment in preschoolers had high strength of evidence (SOE) in contrast to pharmacologic interventions.

We followed the methods for systematic reviews recommended in AHRQ’s Methods Guide for Effectiveness and Comparative Effectiveness Reviews4 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist5 using a published protocol (PROSPERO #CRD42016029134). Complete details are provided in the full AHRQ report.2 

We searched Medline, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews, limiting the search to English-language studies published from January 1, 2009 through November 7, 2016. We chose to assess evidence from 2009 forward to (1) ensure that the data represent current therapies and (2) allow this report to build on the previous systematic review published in 2011.3 Database searches were supplemented with additional searches of clinical study registries and manual search of citations from key articles. Exact search terms are provided in Supplemental Tables 1 through 15.

We included studies of individuals from birth through 17 years of age with a diagnosis of ADHD receiving a nonpharmacologic treatment of ADHD (either alone or in combination with pharmacologic treatment) that reported any of a prespecified set of intermediate, final, or adverse effect outcomes of interest (Supplemental Table 16). We required comparison of the intervention to (1) other nonpharmacologic treatments, (2) FDA-approved pharmacologic treatments, or (3) placebo, usual care, or waitlist. Studies had to include a sample size of at least 50 subjects. We set a minimum sample size to exclude pilot studies and potentially low-quality studies. In addition, a sample size of 50 subjects would improve the likelihood of detecting clinically meaningful differences. No restrictions were placed on timing of outcomes or on setting. Complete details of the inclusion and exclusion criteria for the full AHRQ review are in the Supplemental Table 16.

Pairs of investigators screened titles and abstracts independently. Citations deemed relevant by at least 1 reviewer were promoted to full-text screening, in which 2 investigators independently reviewed each article. Disagreements were resolved through discussion or by a third expert member of the team. Pairs of investigators abstracted data from included studies, with 1 researcher abstracting the data and a second overreading the article and the accompanying abstraction to check for accuracy and completeness. Disagreements were resolved by consensus or by obtaining a third investigator’s opinion.

We assessed the methodological quality, or risk of bias, for each individual study using the Cochrane Risk of Bias tool for randomized studies6 and the Newcastle-Ottawa Scale7 for observational studies. We rated each study’s quality as good (low risk of bias), fair, or poor (high risk of bias) on the basis of its adherence to well-accepted standard methods (Supplemental Table 17).4 The assessment was outcome specific such that a given study might receive a “good” quality rating for its analysis of 1 outcome but a “poor” quality rating for analysis of a different outcome. We assessed applicability using the method described in AHRQ’s Methods Guide.4,8 

When meta-analysis was feasible, we computed summary estimates of effect. We aggregated outcomes when there were at least 3 studies with the same outcome using random-effects models with the Knapp-Hartung9 correction to adjust the SEs for small (≤4) numbers of included studies. All quantitative analyses were performed in R (R Foundation for Statistical Computing, Vienna, Austria).10 

If a quantitative synthesis was not feasible, we analyzed the data qualitatively. We placed greater emphasis on the conclusions from evidence from higher quality studies with more precise estimates of effect.

We divided treatment strategies for ADHD by their comparators: FDA-approved pharmacologic versus nonpharmacologic and nonpharmacologic versus nonpharmacologic or placebo. Nonpharmacologic therapies include psychosocial interventions, behavioral interventions, school interventions, cognitive training therapies, learning training, biofeedback or neurofeedback, parent behavior training, dietary supplements (eg, omega fatty acids, vitamins, herbal supplements, probiotics), elimination diets, vision training, and chiropractic treatment. We combined studies of omega-3 and omega-6 fatty acids.

We assessed the SOE using the approach described in AHRQ’s Methods Guide.4,11 The approach requires assessment of 5 domains: study limitations, consistency, directness, precision, and reporting bias, the last of which includes publication bias, outcome reporting, and analysis reporting bias. These domains were considered qualitatively, and a summary rating of high, moderate, or low SOE was assigned for each outcome after discussion by 2 reviewers. When no evidence was available or when evidence on the outcome was too weak, sparse, or inconsistent to permit any conclusion to be drawn, a grade of “insufficient” was assigned.

Figure 1 depicts the flow of articles through the literature search and screening process for the full AHRQ systematic review.2 Of 10 764 unique citations screened, 66 articles describing 54 studies provided data relevant to the nonpharmacologic treatment.12,77 For this report, we summarize reported outcomes of changes on standardized symptom scores or progress toward patient-identified goals. Other study outcomes relating to treatment, behavior, and function were abstracted and are presented in the Supplemental Information.

FIGURE 1

Literature flow. a Three studies were relevant to >1 category of comparison.

FIGURE 1

Literature flow. a Three studies were relevant to >1 category of comparison.

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Findings for neurofeedback interventions versus nonpharmacologic or pharmacologic or placebo, usual care, or waitlist are described in Supplemental Table 18. In 4 randomized controlled trials (RCTs),19,34,55,68,69 in which a total of 353 participants were enrolled, researchers examined neurofeedback as an intervention versus a nonpharmacologic intervention (n = 3), pharmacologic intervention (n = 1), or placebo, usual care, or waitlist (n = 3).

Nonpharmacologic Versus Nonpharmacologic

In 3 studies, researchers examined neurofeedback as the primary intervention and evaluated standardized symptoms scores or progress toward patient-identified goals.34,55,68,69 All 3 studies were RCTs: 2 were of good quality34,68,69 and 1 was of fair quality.55 Follow-up times were either not reported or short-term (2 months). In 1 study, researchers found a statistically significant decrease in ADHD symptoms using a standard scale comparing neurofeedback with an attention skills control condition.34,35,75 In a second study, researchers found significant improvements in ADHD symptoms according to parent and teacher reporting for neurofeedback compared with control.68,69 Subjects in the control group also had a statistically significant increase in their average dose of stimulant therapy compared with those in the neurofeedback group, who did not have a significant change in stimulant therapy. A third study compared neurofeedback to behavioral treatment and found that the group treated with neurofeedback showed greater improvement in a continuous performance test score.55 

Nonpharmacologic Versus Pharmacologic

In 1 3-arm trial, researchers combined methylphenidate with neurofeedback25,26 enrolling 91 participants and short follow-up period of 10 weeks. This trial was judged to be of poor quality. The primary outcome measure was the Barkley Rating Scale for Parents. Findings from this study did not support any statistically significant differences between either methylphenidate alone, methylphenidate in addition to neurofeedback when compared with neurofeedback alone (P = .31).

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

In 3 RCTs, researchers compared neurofeedback to usual care or standard care enrolling a total of 251 participants. Two of the trials were judged to be of good quality19,68,69 and 1 of fair quality.55 In 2 of the studies,55,68,69 researchers found significant differences on the standardized outcome measures when comparing neurofeedback to standard pharmacologic treatment or control.

Other Findings for Neurofeedback

No significant findings for other outcomes were identified. Detailed findings on neurofeedback interventions across the included studies are presented in Supplemental Table 19.

Findings for cognitive training interventions are described in Supplemental Table 20. In 5 RCTs23,24,28,35,41,71,72,75 totaling 405 participants, researchers compared cognitive training to a nonpharmacologic intervention (n = 5) or placebo, usual care, or waitlist control (n = 1). In 1 observational study in which18 52 participants were enrolled, researchers compared cognitive training to waitlist control. Cognitive training was not compared to pharmacologic interventions and any studies.

Nonpharmacologic Versus Nonpharmacologic

In 4 RCTs, researchers evaluated cognitive training versus a nonpharmacologic intervention and evaluated standardized symptoms scores or progress toward patient identified goals. Three were good quality23,72 and the other was fair quality.71 A total of 330 participants were enrolled across these 3 trials with predominately short follow-up times (≤6 months). In a single, good-quality RCT, researchers found no significant treatment effects in improvement in Wide Range Achievement Test 4 (WRAT-4) Progress Monitoring Version scores compared with a low-level working memory training program that was identical to active intervention with respect to the types of training games used and the number of training trials per session but for which difficulty level was not adjusted according to each user’s performance parameters.23 No teacher measures revealed any significant changes. In the other study, there was improvement at 2 and 6 months on the parent rated Behavior Rating Inventory of Executive Function (BRIEF) Metacognition Index and at 2 months (but not 6 months) on the BRIEF parent-rated behavioral index.71 

Nonpharmacologic Versus Pharmacologic

No studies were identified in which the comparison of cognitive training to pharmacologic interventions was made.

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

In 1 RCT28 and 1 observational study,18 researchers compared cognitive training versus placebo or usual care. The RCT was judged to be of good quality and the observational study was judged to be of fair quality. A total of 127 participants were enrolled and follow-up times varied from 4 to 8 months. In the RCT, researchers compared Cogmed RoboMemo Program to a waitlist control group and at 8 months they report no significant differences on the ADHD rating scale (RS) Teacher or Parent total scores. In the observational study, researchers compared the Cogmed intervention with a waitlist control, and at 4 months the treatment group had significantly better scores on parent report on the ADHD Index, Conners Cognitive Problems/Inattention, Conners Hyperactivity Parent, and BRIEF Metacognition Index.18 

Other Findings for Cognitive Training

No significant findings for other outcomes assessed were identified for cognitive training versus nonpharmacologic or placebo, usual care, waitlist. In 1 study, researchers found significant behavioral differences (P < .001) on both the parent and teacher SWAN Inattention and Hyperactivity scales at 12 weeks comparing neurofeedback to methylphenidate (Supplemental Table 21).

Findings for CBT interventions are described in Supplemental Table 22. In 2 RCTs20,21,73 in which 298 participants were enrolled, researchers compared CBT to nonpharmacologic interventions (n = 1) or placebo, usual care, or waitlist control (n = 1).

Nonpharmacologic Versus Nonpharmacologic

In 1 fair-quality study,20,21 researchers evaluated 159 subjects and compared CBT with and without interventions to improve planning skills. Standard symptom scores or progress toward patient-identified goals were evaluated at 3 and 12 months. In this study, changes in the depression and anxiety scale scores were examined, and it was found that the CBT group had greater improvement in depression and anxiety scores compared with the control group at 3 months; it was found that the depression score improvements were maintained at 12 months. In addition, CBT maintained superiority in ADHD scale scores. In this study, it was also found that there was a greater improvement (P < .001) in the Child Behavior Checklist (CBCL) conduct disorder and/or oppositional defiant disorder subscale both immediately after treatment and at 12 months.

Nonpharmacologic Versus Pharmacologic

No studies were identified in which CBT interventions were compared to a pharmacologic intervention.

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

In 1 good-quality study,73 researchers compared CBT with usual care, finding significant changes (P < .001) on the ADHD RS for both adolescent and parents’ inattention and impulsivity at 12 weeks of follow-up.

Other Findings for CBT

In 1 study,20,21 researchers found significant changes in the child depression inventory (P < .001) and screen for child anxiety–related emotional disorders at 12 months when comparing CBT to solution-focused CBT. Another set of researchers73 found significant improvements in the Clinical Global Impression-Severity (CGI-S) self-report (P < .001) and CGI-S Clinician (P < .001) comparing CBT to usual care (Supplemental Table 23).

Findings for child or parent training interventions are described in Supplemental Table 24. In 9 RCTs* in which 1099 participants were enrolled, researchers compared child or parent training to nonpharmacologic interventions (n = 4), pharmacologic (n = 1), or placebo or usual care (n = 5). In 1 observational study,29 120 participants were enrolled. A range of different types of non-CBT behavioral interventions including organizational skills, social skills, attention skills, positive parenting, psychoeducational, sleep hygiene or behavioral, or parent or teacher behavioral training interventions. The interventions were mixed in terms of their strategies: some were interventions that helped parents learn how to cope with their own emotions, but most strategies were focused on how parents could manage specific behaviors from their children with ADHD.

Nonpharmacologic Versus Nonpharmacologic

In 3 good quality16,22,62 and 1 fair-quality42 RCTs representing 505 participants, researchers compared child or parent training or behavioral interventions to a nonpharmacologic intervention and evaluated standardized symptoms scores or progress toward patient-identified goals. Findings were mixed. In 1 study,16 researchers found a significant difference in the attention-deficit/hyperactivity disorder rating scale IV (ADHD RS IV) at 3 months comparing psychoeducation and general clinical counseling. Another group of researchers62 found a significant difference when comparing child life and attention skills treatment to parent group component only in the Parent Child Symptom Inventory at both 13 weeks and 7 months and Child Symptom Inventory at 13 weeks. In the third study,42 researchers found a significant difference in the CBCL Change in Attention Problems Subscale at 6 months when comparing behavioral-based social skill training for patient and parent groups to group therapy.

Nonpharmacologic Versus Pharmacologic

In 1 study,55 researchers compared standard pharmacologic treatment with behavioral treatment of children in conjunction with parent and teacher training. In this RCT, 57 participants were enrolled, and the RCT was judged to be of fair quality. At 20 weeks of follow-up, significant changes (P = .013) on the Integrated Visual and Auditory Continuous Performance Test (IVA/CPT) full-scale attention were found in this study.

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

In 4 good-quality RCTs22,32,39,59,60 and 1 fair-quality observational study29 representing 657 participants, researchers compared child or parent training interventions to placebo, usual care, or control groups. Significant findings were limited. In 1 study,39 researchers found significant changes at 6 months in the ADHD RS IV for parent report (P = .004), inattentive (P = .001), and hyperactivity and/or impulsivity (P = .04) when comparing sleep hygiene and standardized behavior strategies to usual clinical care. In another study,59 researchers found significant changes at 3 months for the ADHD combined type parent scale when comparing Barkley-based parent plus teaching behavioral interventions to waitlist. Another32 compared a psychoeducational program to a control group finding significant changes on the Conners’ Parent Rating Scale (CPRS) Inattention scale (P = .001), CPRS parent inattention/cognition scale P = .0032), and CPRS Index (P = .001) at 12 weeks.

Other Findings for Child or Parent Training

In 1 study,22 researchers compared the Strategies to Enhance Positive Parenting to a behavioral parent training program finding significant (P < .01) improvement on the acceptability of treatment with the Parent Treatment Attitude Inventory at 2.07 months. In this study, functional impairment was also significantly (P < .01) improved on the Impairment Rating Scale. In another study,39 researchers found significant (P < .001) differences in sleep disturbance on the Child Sleep Habits Questionnaire at 6 months comparing sleep hygiene practices and behavioral strategies compared with usual clinical care. In this study, significant differences were found on days late for work (P = .02) and missed days of work (P = .03) (Supplemental Table 25).

We identified 5 good-quality,14,36,43,47,50 2 fair-quality,64,77 and 1 poor-quality studies38 representing 1130 patients evaluated essential fatty acid supplementation. In 7 of these trials, researchers compared essential fatty acid supplementation with placebo. Of these, the active intervention was omega-3 alone in 4 trials,36,38,47,48,77 omega-6 alone in 1 trial,64 and a combination of omega-3 and omega-6 in 2 trials.43,44 Treatment duration ranged between 7 weeks and 6 months. The enrolled children ranged between 6 and 18 years of age and the range of included male children was 59.4% to 77.3% across the trials. In 1 of the trials,77 researchers measured outcomes of ADHD symptoms with scales that were not part of our inclusion criteria and were excluded from the meta-analysis. The remaining 7 trials measured ADHD symptoms with the Conners Scale (full or abbreviated version) or the ADHD RS.

Nonpharmacologic Versus Nonpharmacologic

Two good-quality RCTs14,50 with a total of 100 participants evaluated supplements. In 1 study,50 researchers compared eicosapentaenoic acid and docosahexaenoic acid and found no statistical differences on the CPRS ADHD Total. Researchers for the other study14 compared polyunsaturated fatty acids plus atomoxetine to atomoxetine alone found no significant differences on the CPRS-Revised Short Form at 4 months.

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

We identified 4 RCTs in which researchers compared omega fatty acid supplementation and placebo,36,38,43,47 with parent RSs as an outcome. Figure 2 summarizes these findings and the overall measure after meta-analysis. Effects were consistent and moderate heterogeneity was found across studies; however, no statistical evidence was found that omega fatty acids were superior to placebo. Three trials that were excluded from the meta-analysis for not using an outcome assessment tool that met our inclusion criteria77 or not comparing to a placebo14,50 also found no significant differences between omega-3/6 versus placebo,77 versus usual care,14 or between eicosapentaenoic acid and versus docosahexaenoic acid50 for parent ratings of ADHD total symptoms. For teacher-rated total ADHD symptoms, we identified 3 RCTs in which omega fatty acids versus placebo were examined (Fig 3).36,47,64 Effects were fairly consistent and studies were homogeneous; however, we found no statistical evidence that omega fatty acids were superior to placebo. The 2 RCTs excluded in this meta-analysis for not comparing to a placebo14 and using an outcome assessment tool that did not meet our inclusion criteria77 also found no significant difference between omega-3 and placebo or usual care for teacher ratings of ADHD total symptoms. Although adverse effects were reported in 1 trial,47 the researchers did not find any statistically significant between-group differences.

FIGURE 2

Meta-analysis of the effects on parent ratings of omega-3/6 supplementation compared with placebo. CI, confidence interval; SMD, standardized mean difference.

FIGURE 2

Meta-analysis of the effects on parent ratings of omega-3/6 supplementation compared with placebo. CI, confidence interval; SMD, standardized mean difference.

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FIGURE 3

Meta-analysis of the effects on teacher ratings of omega-3/6 supplementation compared with placebo.

FIGURE 3

Meta-analysis of the effects on teacher ratings of omega-3/6 supplementation compared with placebo.

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Other Findings for Omega Fatty Acid Supplements

In 1 study,17 researchers compared omega fatty acids to methylphenidate and found significant (P = .001) increases in functional impairment at 1 year on the Clinical Global Impression (CGI) parent and clinician scales (Supplemental Table 26).

Findings for the herbal intervention and dietary approaches can be found in Supplemental Table 27. In 7 RCTs,15,27,46,52,61,65 researchers examined herbal or dietary approaches against nonpharmacologic treatments (n = 2), pharmacologic treatments (n = 2), or placebo, usual care, or waitlist (n = 3).

Nonpharmacologic Versus Nonpharmacologic

In 1 good-quality61 and 1 fair-quality15 studies representing 152 patients, researchers evaluated herbal interventions or dietary approaches compared with other nonpharmacologic interventions. In 1 study,61 researchers compared restricted elimination diet to no elimination diet and reported significant results after 5 weeks for both the parent and teacher ADHD total scores and both Parent and Teacher Abbreviated Conners Scale. In the other study,15 researchers compared zinc supplementation once daily to zinc supplementation twice daily and reported no significant differences from 8 to 21 weeks of follow-up.

Nonpharmacologic Versus Pharmacologic

In 2 good-quality RCTs46,65 representing 122 patients, researchers compared nonpharmacologic treatments to pharmacologic treatments. Methylphenidate was the pharmacologic treatment in both studies. In 1 study,46 researchers compared ningdong granule to methylphenidate and reported no significant differences at 8 weeks. In the other study,65 researchers compared ginkgo biloba to methylphenidate and found significant differences in the ADHD Parent and Teacher RS IV at 6 weeks.

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

In 1 good-quality27 and 2 fair-quality15,52 RCTs representing 192 patients, researchers compared herbal or dietary approaches to placebo or usual care. Of the 3 RCTs, neither Memomet syrup, zinc supplementation, nor vitamin D improved ADHD symptoms compared with placebo.15,27,52 

Other Findings for Herbal or Dietary Approaches

In 1 study,66 researchers compared ginkgo biloba to placebo with both groups receiving methylphenidate. At 6 weeks, significant changes were found on the ADHD RS IV for parent and teacher inattention. In another study,65 researchers compared methylphenidate to ginkgo biloba and found significant changes in appetite (P = .0002) and sleep disturbance (P = .01) (Supplemental Table 28).

Findings for other treatment approaches to ADHD treatment can be found in Supplemental Table 29. In 3 RCTs40,53,56,76 in which 207 participants were enrolled, researchers compared other treatment approaches to placebo, usual care, or waitlist control.

Nonpharmacologic Versus Nonpharmacologic

No studies were identified in which nonpharmacologic versus nonpharmacologic interventions were compared.

Nonpharmacologic Versus Pharmacologic

No studies were identified in which nonpharmacologic versus pharmacologic interventions were compared.

Nonpharmacologic Versus Placebo, Usual Care, or Waitlist

In 3 fair-quality RCTs40,53,56,76 representing 207 patients, researchers compared other ADHD treatment approaches to placebo or usual care. Interventions varied between acupuncture,40 melatonin,53,56 and the Incredible Years Program.76 No significant findings were reported for any of these interventions across standardized symptom scores.

Other Findings for Other Treatment Approaches

In 1 study, researchers found significant behavior changes on the Vanderbilt teacher and caregiver scale at 25 weeks, comparing telemedicine to usual care plus consulting.57 In another study,58 researchers found significant changes in behavior change on the CPRS revised scale at 12 weeks, comparing homeopathy to placebo. In another study,13 researchers found significant (P = .001) behavior changes on the CPRS at 6.8 months comparing New Forest Parental Package to the waitlist control condition. Hong and Cho40 found significant (P = .012) improvements in functional impairment at 1.5 months comparing acupuncture to waitlist control. In 1 study,58 researchers found significant (P = .001) changes in functional impairment on the CGI-S Scale comparing homeopathy to placebo (Supplemental Table 30).

Supplemental Table 31 provides the adverse effects and findings from individual studies. Adverse effects were identified in 3 of the included studies examining nonpharmacologic interventions compared with pharmacologic interventions.17,46,65 In 4 studies, researchers measured and reported adverse effects in nonpharmacologic versus nonpharmacologic interventions (omega fatty acids, zinc, and compound of herbal preparation).15,45,47,48 The most commonly occurring adverse effects were gastrointestinal symptoms, sleep disturbances, and changes in appetite. None of researchers of these studies reported significant differences between study groups and the proportion of adverse effects.

Supplemental Table 32 describes the SOE findings for the changes in standardized symptom scores across each intervention. Pharmacologic interventions, neurofeedback, and other treatment approaches all were judged to have insufficient SOE to support conclusions. CBT, cognitive training, and herbal interventions or dietary approaches were all judged to have low SOE. Both omega fatty acid supplementation and child or parent training or behavior interventions were judged to have moderate SOE to support conclusions. No outcomes of interest were judged to have high SOE.

In this systematic review of studies published from 2009 through 2016, we found little new evidence to guide treatment with nonpharmacologic therapies for ADHD. Overall, there was a low SOE for the impact of nonpharmacologic treatments for ADHD across the outcome measures selected for this review. In 2011, the authors of a systematic evidence review found that parent behavior treatment could improve behavior among preschool-aged children with high risk for ADHD. However, the authors of this updated systematic review were not able to provide further guidance regarding the comparative effectiveness of nonpharmacologic approaches for children and adolescents. The behavioral interventions included in this systematic review were of limited effectiveness alone or in combination with medication therapy.

By limiting our review to studies that included at least 50 subjects, we might have eliminated studies demonstrating effectiveness. Even with setting a sample size threshold, the studies included in this review were too small to determine if there is a subgroup of children and adolescents with ADHD (eg, based on age or other characteristics) for whom these therapies might be more effective. Previous evidence reviews suggest a benefit to behavior therapy, with CBT appearing to be a promising approach.3,78 Generally, a higher proportion of adverse effects was reported with methylphenidate or combination of supplements and methylphenidate compared with supplement. The most common side effects for supplements were dyspepsia with omega fatty acids and increased appetite with ningdong granule.

The studies we included have limited generalizability because they do not reflect patients seen in the primary care setting, where most ADHD treatment occurs, and have short durations of follow-up. To better determine the effectiveness of treatment and address generalizability to primary care, there is a need for pragmatic randomized trials that, ideally, manage subjects for years.

     
  • ADHD

    attention-deficit/hyperactivity disorder

  •  
  • ADHD RS IV

    attention-deficit/hyperactivity disorder rating scale IV

  •  
  • AHRQ

    Agency for Healthcare Research and Quality

  •  
  • BRIEF

    Behavior Rating Inventory of Executive Function

  •  
  • CBCL

    Child Behavior Checklist

  •  
  • CBT

    cognitive behavioral therapy

  •  
  • CGI

    Clinical Global Impression

  •  
  • CGI-S

    Clinical Global Impression-Severity

  •  
  • CPRS

    Conners’ Parent Rating Scale

  •  
  • FDA

    Food and Drug Administration

  •  
  • IVA/CPT

    Integrated Visual and Auditory Continuous Performance Test

  •  
  • RCT

    randomized controlled trial

  •  
  • RS

    rating scale

  •  
  • SOE

    strength of evidence

  •  
  • WRAT-4

    Wide Range Achievement Test 4

Drs Bowen and McBroom conceptualized and designed the study, designed the data abstraction instruments, performed data analysis, provided methodological oversight, and reviewed and revised the manuscript; Drs Kemper and Sanders conceptualized and designed the study, provided methodological oversight, and reviewed and revised the manuscript; Dr Goode drafted the initial manuscript, participated in literature screening, data abstraction, and critical review of the manuscript; Drs Coeytaux, Maslow, Davis, Hill, Namdari, Allen Lapointe, and Befus participated in literature screening, data abstraction, and critical review of the manuscript; Ms Lallinger designed the data abstraction instruments, performed data analysis, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The authors of this manuscript are responsible for its content. Statements in the manuscript do not necessarily represent the official views of or imply endorsement by Agency for Healthcare Research and Quality (AHRQ) or US Department of Health and Human Services.

This topic was nominated by the American Academy of Pediatrics and selected by AHRQ for systematic review by an evidence-based practice center. A representative from AHRQ served as a Contracting Officer’s Technical Representative and provide technical assistance during the conduct of the full evidence report and provided comments on draft versions of the full evidence report. AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis or interpretation, or preparation, review, or approval of the manuscript for publication.

FUNDING: This report is based on research conducted by the Duke Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality, Rockville, Maryland (Contract HHSA290201500004I). Supported also in part by the National Institute of Child Health and Human Development (Hill, T32-HD07376) through the Center for Developmental Science, University of North Carolina at Chapel Hill. Funded under Contract No. HHSA290201500004I Task Order 2 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services.

*

Refs 16,22,32,39,42,55,59,60,62.

We thank Megan von Isenburg, MSLS, for help with the literature search and retrieval; Robyn E. Schmidt, BA, for assistance with project coordination; and Rebecca N. Gray, DPhil, and Liz Wing, MA, for editorial assistance.

1
Zuvekas
SH
,
Vitiello
B
.
Stimulant medication use in children: a 12-year perspective.
Am J Psychiatry
.
2012
;
169
(
2
):
160
166
[PubMed]
2
Kemper
AR
,
Maslow
GR
,
Hill
S
, et al
. Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents. Comparative Effectiveness Review No. 203. (Prepared by the Duke University Evidence-based Practice Center under Contract No. 290-2015-00004-I.) AHRQ Publication No. 18-EHC005-EF. Rockville, MD: Agency for Healthcare Research and Quality; January 2018
3
Charach
A
,
Dashti
B
,
Carson
P
, et al
. Attention deficit hyperactivity disorder: effectiveness of treatment in at-risk preschoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment. Available at: https://www.effectivehealthcare.ahrq.gov/topics/adhd/research. Accessed July 16, 2015
4
Agency for Healthcare Research and Quality
. Methods guide for effectiveness and comparative effectiveness reviews. Available at: https://www.effectivehealthcare.ahrq.gov/topics/cer-methods-guide/overview. Accessed December 13, 2017
5
Moher
D
,
Liberati
A
,
Tetzlaff
J
,
Altman
DG
;
PRISMA Group
.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
PLoS Med
.
2009
;
6
(
7
):
e1000097
[PubMed]
6
Higgins
JPT
,
Green
S
. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. London, UK: The Cochrane Collaboration;
2011
. Available at: www.cochrane-handbook.org. Accessed December 13, 2017
7
Wells
GA
,
Shea
B
,
O’Connell
D
, et al
.
The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses
.
Ottawa, Canada
:
Ottawa Hospital Research Institute
. Available at: www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed July 16, 2015
8
Atkins
D
,
Chang
SM
,
Gartlehner
G
, et al
.
Assessing applicability when comparing medical interventions: AHRQ and the Effective Health Care Program.
J Clin Epidemiol
.
2011
;
64
(
11
):
1198
1207
[PubMed]
9
Cornell
JE
,
Mulrow
CD
,
Localio
R
, et al
.
Random-effects meta-analysis of inconsistent effects: a time for change.
Ann Intern Med
.
2014
;
160
(
4
):
267
270
[PubMed]
10
Viechtbauer
W
.
Conducting meta-analyses in R with the metafor package.
J Stat Softw
.
2010
;
38
(
3
):
1
48
11
Berkman
ND
,
Lohr
KN
,
Ansari
M
, et al
.
Grading the Strength of a Body of Evidence When Assessing Health Care Interventions for the Effective Health Care Program of the Agency for Healthcare Research and Quality: An Update. Methods Guide for Comparative Effectiveness Reviews (Prepared by the RTI-UNC Evidence-based Practice Center under Contract No. 290- 2007-10056-I). AHRQ Publication No. 13(14)-EHC130-EF.
Rockville, MD
:
Agency for Healthcare Research and Quality
;
2013
12
Abikoff
H
,
Gallagher
R
,
Wells
KC
, et al
.
Remediating organizational functioning in children with ADHD: immediate and long-term effects from a randomized controlled trial.
J Consult Clin Psychol
.
2013
;
81
(
1
):
113
128
[PubMed]
13
Abikoff
HB
,
Thompson
M
,
Laver-Bradbury
C
, et al
.
Parent training for preschool ADHD: a randomized controlled trial of specialized and generic programs.
J Child Psychol Psychiatry
.
2015
;
56
(
6
):
618
631
[PubMed]
14
Anand
P
,
Sachdeva
A
.
Effect of poly unsaturated fatty acids administration on children with attention deficit hyperactivity disorder: a randomized controlled trial.
J Clin Diagn Res
.
2016
;
10
(
9
):
OC01
OC05
[PubMed]
15
Arnold
LE
,
Disilvestro
RA
,
Bozzolo
D
, et al
.
Zinc for attention-deficit/hyperactivity disorder: placebo-controlled double-blind pilot trial alone and combined with amphetamine.
J Child Adolesc Psychopharmacol
.
2011
;
21
(
1
):
1
19
[PubMed]
16
Bai
GN
,
Wang
YF
,
Yang
L
,
Niu
WY
.
Effectiveness of a focused, brief psychoeducation program for parents of ADHD children: improvement of medication adherence and symptoms.
Neuropsychiatr Dis Treat
.
2015
;
11
:
2721
2735
[PubMed]
17
Barragan
E
,
Breuer
D
,
Dopfner
M
.
Efficacy and safety of omega-3/6 fatty acids, methylphenidate, and a combined treatment in children with ADHD.
J Atten Disord
.
2017
;
21
(
5
):
433
441
[PubMed]
18
Beck
SJ
,
Hanson
CA
,
Puffenberger
SS
,
Benninger
KL
,
Benninger
WB
.
A controlled trial of working memory training for children and adolescents with ADHD.
J Clin Child Adolesc Psychol
.
2010
;
39
(
6
):
825
836
[PubMed]
19
Bink
M
,
van Nieuwenhuizen
C
,
Popma
A
,
Bongers
IL
,
van Boxtel
GJ
.
Behavioral effects of neurofeedback in adolescents with ADHD: a randomized controlled trial.
Eur Child Adolesc Psychiatry
.
2015
;
24
(
9
):
1035
1048
[PubMed]
20
Boyer
BE
,
Geurts
HM
,
Prins
PJ
,
Van der Oord
S
.
Two novel CBTs for adolescents with ADHD: the value of planning skills.
Eur Child Adolesc Psychiatry
.
2015
;
24
(
9
):
1075
1090
[PubMed]
21
Boyer
BE
,
Geurts
HM
,
Prins
PJM
,
van der Oord
S
.
One-year follow-up of two novel CBTs for adolescents with ADHD.
Eur Child Adolesc Psychiatry
.
2016
;
25
(
3
):
333
337
[PubMed]
22
Chacko
A
,
Wymbs
BT
,
Wymbs
FA
, et al
.
Enhancing traditional behavioral parent training for single mothers of children with ADHD.
J Clin Child Adolesc Psychol
.
2009
;
38
(
2
):
206
218
[PubMed]
23
Chacko
A
,
Bedard
AC
,
Marks
DJ
, et al
.
A randomized clinical trial of Cogmed working memory training in school-age children with ADHD: a replication in a diverse sample using a control condition.
J Child Psychol Psychiatry
.
2014
;
55
(
3
):
247
255
[PubMed]
24
Dovis
S
,
Van der Oord
S
,
Wiers
RW
,
Prins
PJ
.
Improving executive functioning in children with ADHD: training multiple executive functions within the context of a computer game. a randomized double-blind placebo controlled trial.
PLoS One
.
2015
;
10
(
4
):
e0121651
[PubMed]
25
Duric
NS
,
Assmus
J
,
Gundersen
D
,
Elgen
IB
.
Neurofeedback for the treatment of children and adolescents with ADHD: a randomized and controlled clinical trial using parental reports.
BMC Psychiatry
.
2012
;
12
:
107
[PubMed]
26
Duric
NS
,
Aßmus
J
,
Elgen
IB
.
Self-reported efficacy of neurofeedback treatment in a clinical randomized controlled study of ADHD children and adolescents.
Neuropsychiatr Dis Treat
.
2014
;
10
:
1645
1654
[PubMed]
27
Dutta
B
,
Barua
TK
,
Ray
J
, et al
.
A study of evaluation of safety and efficacy of memomet, a multi herbal formulation (memomet) in the treatment of behavioural disorder in children.
Int J Res Pharm Sci
.
2012
;
3
(
2
):
282
286
28
Egeland
J
,
Aarlien
AK
,
Saunes
BK
.
Few effects of far transfer of working memory training in ADHD: a randomized controlled trial.
PLoS One
.
2013
;
8
(
10
):
e75660
[PubMed]
29
Ercan
ES
,
Ardic
UA
,
Kutlu
A
,
Durak
S
.
No beneficial effects of adding parent training to methylphenidate treatment for ADHD + ODD/CD children: a 1-year prospective follow-up study.
J Atten Disord
.
2014
;
18
(
2
):
145
157
[PubMed]
30
Evans
SW
,
Langberg
JM
,
Schultz
BK
, et al
.
Evaluation of a school-based treatment program for young adolescents with ADHD.
J Consult Clin Psychol
.
2016
;
84
(
1
):
15
30
[PubMed]
31
Ferrin
M
,
Perez-Ayala
V
,
El-Abd
S
, et al
.
A randomized controlled trial evaluating the efficacy of a psychoeducation program for families of children and adolescents with ADHD in the United Kingdom: results after a 6-month follow-up [published online ahead of print February 2, 2016].
J Atten Disord
. doi:
[PubMed]
32
Ferrin
M
,
Moreno-Granados
JM
,
Salcedo-Marin
MD
,
Ruiz-Veguilla
M
,
Perez-Ayala
V
,
Taylor
E
.
Evaluation of a psychoeducation programme for parents of children and adolescents with ADHD: immediate and long-term effects using a blind randomized controlled trial.
Eur Child Adolesc Psychiatry
.
2014
;
23
(
8
):
637
647
[PubMed]
33
Geladé
K
,
Janssen
TW
,
Bink
M
,
van Mourik
R
,
Maras
A
,
Oosterlaan
J
.
Behavioral effects of neurofeedback compared to stimulants and physical activity in attention-deficit/hyperactivity disorder: a randomized controlled trial.
J Clin Psychiatry
.
2016
;
77
(
10
):
e1270
e1277
[PubMed]
34
Gevensleben
H
,
Holl
B
,
Albrecht
B
, et al
.
Is neurofeedback an efficacious treatment for ADHD? A randomised controlled clinical trial.
J Child Psychol Psychiatry
.
2009
;
50
(
7
):
780
789
[PubMed]
35
Gevensleben
H
,
Holl
B
,
Albrecht
B
, et al
.
Neurofeedback training in children with ADHD: 6-month follow-up of a randomised controlled trial.
Eur Child Adolesc Psychiatry
.
2010
;
19
(
9
):
715
724
[PubMed]
36
Gustafsson
PA
,
Birberg-Thornberg
U
,
Duchén
K
, et al
.
EPA supplementation improves teacher-rated behaviour and oppositional symptoms in children with ADHD.
Acta Paediatr
.
2010
;
99
(
10
):
1540
1549
[PubMed]
37
Hahn-Markowitz
J
,
Berger
I
,
Manor
I
,
Maeir
A
.
Efficacy of cognitive-functional (Cog-Fun) occupational therapy intervention among children with ADHD: an RCT [published online ahead of print September 16, 2016].
J Atten Disord
. doi:
[PubMed]
38
Hariri
M
,
Djazayery
A
,
Djalali
M
,
Saedisomeolia
A
,
Rahimi
A
,
Abdolahian
E
.
Effect of n-3 supplementation on hyperactivity, oxidative stress and inflammatory mediators in children with attention-deficit-hyperactivity disorder.
Malays J Nutr
.
2012
;
18
(
3
):
329
335
[PubMed]
39
Hiscock
H
,
Sciberras
E
,
Mensah
F
, et al
.
Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial.
BMJ
.
2015
;
350
:
h68
[PubMed]
40
Hong
SS
,
Cho
SH
.
Treating attention deficit hyperactivity disorder with acupuncture: a randomized controlled trial.
Eur J Integr Med
.
2016
;
8
(
3
):
150
157
41
Hovik
KT
,
Saunes
BK
,
Aarlien
AK
,
Egeland
J
.
RCT of working memory training in ADHD: long-term near-transfer effects.
PLoS One
.
2013
;
8
(
12
):
e80561
[PubMed]
42
Huang
YH
,
Chung
CY
,
Ou
HY
, et al
.
Treatment effects of combining social skill training and parent training in Taiwanese children with attention deficit hyperactivity disorder.
J Formos Med Assoc
.
2015
;
114
(
3
):
260
267
[PubMed]
43
Johnson
M
,
Ostlund
S
,
Fransson
G
,
Kadesjö
B
,
Gillberg
C
.
Omega-3/omega-6 fatty acids for attention deficit hyperactivity disorder: a randomized placebo-controlled trial in children and adolescents.
J Atten Disord
.
2009
;
12
(
5
):
394
401
[PubMed]
44
Johnson
M
,
Månsson
JE
,
Ostlund
S
, et al
.
Fatty acids in ADHD: plasma profiles in a placebo-controlled study of Omega 3/6 fatty acids in children and adolescents.
Atten Defic Hyperact Disord
.
2012
;
4
(
4
):
199
204
[PubMed]
45
Katz
M
,
Levine
AA
,
Kol-Degani
H
,
Kav-Venaki
L
.
A compound herbal preparation (CHP) in the treatment of children with ADHD: a randomized controlled trial.
J Atten Disord
.
2010
;
14
(
3
):
281
291
[PubMed]
46
Li
JJ
,
Li
ZW
,
Wang
SZ
, et al
.
Ningdong granule: a complementary and alternative therapy in the treatment of attention deficit/hyperactivity disorder.
Psychopharmacology (Berl)
.
2011
;
216
(
4
):
501
509
[PubMed]
47
Manor
I
,
Magen
A
,
Keidar
D
, et al
.
The effect of phosphatidylserine containing Omega3 fatty-acids on attention-deficit hyperactivity disorder symptoms in children: a double-blind placebo-controlled trial, followed by an open-label extension.
Eur Psychiatry
.
2012
;
27
(
5
):
335
342
[PubMed]
48
Manor
I
,
Magen
A
,
Keidar
D
, et al
.
Safety of phosphatidylserine containing omega3 fatty acids in ADHD children: a double-blind placebo-controlled trial followed by an open-label extension.
Eur Psychiatry
.
2013
;
28
(
6
):
386
391
[PubMed]
49
Mautone
JA
,
Marshall
SA
,
Sharman
J
,
Eiraldi
RB
,
Jawad
AF
,
Power
TJ
.
Development of a family-school intervention for young children with attention deficit hyperactivity disorder.
School Psych Rev
.
2012
;
41
(
4
):
447
466
[PubMed]
50
Milte
CM
,
Parletta
N
,
Buckley
JD
,
Coates
AM
,
Young
RM
,
Howe
PR
.
Eicosapentaenoic and docosahexaenoic acids, cognition, and behavior in children with attention-deficit/hyperactivity disorder: a randomized controlled trial.
Nutrition
.
2012
;
28
(
6
):
670
677
[PubMed]
51
Milte
CM
,
Parletta
N
,
Buckley
JD
,
Coates
AM
,
Young
RM
,
Howe
PR
.
Increased erythrocyte eicosapentaenoic acid and docosahexaenoic acid are associated with improved attention and behavior in children with ADHD in a randomized controlled three-way crossover trial.
J Atten Disord
.
2015
;
19
(
11
):
954
964
[PubMed]
52
Mohammadpour
N
,
Jazayeri
S
,
Tehrani-Doost
M
, et al
.
Effect of vitamin D supplementation as adjunctive therapy to methylphenidate on ADHD symptoms: a randomized, double blind, placebo-controlled trial.
Nutr Neurosci
.
2018
;
21
(
3
):
202
209
[PubMed]
53
Mohammadi
MR
,
Mostafavi
SA
,
Keshavarz
SA
, et al
.
Melatonin effects in methylphenidate treated children with attention deficit hyperactivity disorder: a randomized double blind clinical trial.
Iran J Psychiatry
.
2012
;
7
(
2
):
87
92
[PubMed]
54
Molina
BS
,
Hinshaw
SP
,
Swanson
JM
, et al;
MTA Cooperative Group
.
The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study.
J Am Acad Child Adolesc Psychiatry
.
2009
;
48
(
5
):
484
500
[PubMed]
55
Moreno-García
I
,
Delgado-Pardoa
G
,
de Reya
CC-V
,
Meneres-Sanchoa
S
,
Servera-Barceló
M
.
Neurofeedback, pharmacological treatment and behavioral therapy in hyperactivity: multilevel analysis of treatment effects on electroencephalography.
Int J Clin Health Psychol
.
2015
;
15
(
3
):
217
225
56
Mostafavi
SA
,
Mohammadi
MR
,
Hosseinzadeh
P
, et al
.
Dietary intake, growth and development of children with ADHD in a randomized clinical trial of Ritalin and Melatonin co-administration: through circadian cycle modification or appetite enhancement?
Iran J Psychiatry
.
2012
;
7
(
3
):
114
119
[PubMed]
57
Myers
K
,
Vander Stoep
A
,
Zhou
C
,
McCarty
CA
,
Katon
W
.
Effectiveness of a telehealth service delivery model for treating attention-deficit/hyperactivity disorder: a community-based randomized controlled trial.
J Am Acad Child Adolesc Psychiatry
.
2015
;
54
(
4
):
263
274
[PubMed]
58
Oberai
P
,
Gopinadhan
S
,
Varanasi
R
,
Mishra
A
,
Singh
V
,
Nayak
C
.
Homoeopathic management of attention deficit hyperactivity disorder: a randomised placebo-controlled pilot trial.
Indian J Res Homeopathy
.
2013
;
7
(
4
):
158
167
59
Ostberg
M
,
Rydell
AM
.
An efficacy study of a combined parent and teacher management training programme for children with ADHD.
Nord J Psychiatry
.
2012
;
66
(
2
):
123
130
[PubMed]
60
Papadopoulos
N
,
Sciberras
E
,
Hiscock
H
,
Mulraney
M
,
McGillivray
J
,
Rinehart
N
.
The efficacy of a brief behavioral sleep intervention in school-aged children with ADHD and comorbid autism spectrum disorder [published online ahead of print February 2, 2015].
J Atten Disord
. doi:1177/1087054714568565
[PubMed]
61
Pelsser
LM
,
Frankena
K
,
Toorman
J
, et al
.
Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial.
Lancet
.
2011
;
377
(
9764
):
494
503
[PubMed]
62
Pfiffner
LJ
,
Hinshaw
SP
,
Owens
E
, et al
.
A two-site randomized clinical trial of integrated psychosocial treatment for ADHD-inattentive type.
J Consult Clin Psychol
.
2014
;
82
(
6
):
1115
1127
[PubMed]
63
Power
TJ
,
Mautone
JA
,
Soffer
SL
, et al
.
A family-school intervention for children with ADHD: results of a randomized clinical trial.
J Consult Clin Psychol
.
2012
;
80
(
4
):
611
623
[PubMed]
64
Raz
R
,
Carasso
RL
,
Yehuda
S
.
The influence of short-chain essential fatty acids on children with attention-deficit/hyperactivity disorder: a double-blind placebo-controlled study.
J Child Adolesc Psychopharmacol
.
2009
;
19
(
2
):
167
177
[PubMed]
65
Salehi
B
,
Imani
R
,
Mohammadi
MR
, et al
.
Ginkgo biloba for attention-deficit/hyperactivity disorder in children and adolescents: a double blind, randomized controlled trial.
Prog Neuropsychopharmacol Biol Psychiatry
.
2010
;
34
(
1
):
76
80
[PubMed]
66
Shakibaei
F
,
Radmanesh
M
,
Salari
E
,
Mahaki
B
.
Ginkgo biloba in the treatment of attention-deficit/hyperactivity disorder in children and adolescents. A randomized, placebo-controlled, trial.
Complement Ther Clin Pract
.
2015
;
21
(
2
):
61
67
[PubMed]
67
Sibley
MH
,
Graziano
PA
,
Kuriyan
AB
, et al
.
Parent-teen behavior therapy + motivational interviewing for adolescents with ADHD.
J Consult Clin Psychol
.
2016
;
84
(
8
):
699
712
[PubMed]
68
Steiner
NJ
,
Frenette
EC
,
Rene
KM
,
Brennan
RT
,
Perrin
EC
.
In-school neurofeedback training for ADHD: sustained improvements from a randomized control trial.
Pediatrics
.
2014
;
133
(
3
):
483
492
[PubMed]
69
Steiner
NJ
,
Frenette
EC
,
Rene
KM
,
Brennan
RT
,
Perrin
EC
.
Neurofeedback and cognitive attention training for children with attention-deficit hyperactivity disorder in schools.
J Dev Behav Pediatr
.
2014
;
35
(
1
):
18
27
[PubMed]
70
Storebø
OJ
,
Gluud
C
,
Winkel
P
,
Simonsen
E
.
Social-skills and parental training plus standard treatment versus standard treatment for children with ADHD–the randomised SOSTRA trial.
PLoS One
.
2012
;
7
(
6
):
e37280
[PubMed]
71
van der Donk
M
,
Hiemstra-Beernink
AC
,
Tjeenk-Kalff
A
,
van der Leij
A
,
Lindauer
R
.
Cognitive training for children with ADHD: a randomized controlled trial of cogmed working memory training and ‘paying attention in class’.
Front Psychol
.
2015
;
6
:
1081
[PubMed]
72
van Dongen-Boomsma
M
,
Vollebregt
MA
,
Buitelaar
JK
,
Slaats-Willemse
D
.
Working memory training in young children with ADHD: a randomized placebo-controlled trial.
J Child Psychol Psychiatry
.
2014
;
55
(
8
):
886
896
[PubMed]
73
Vidal
R
,
Castells
J
,
Richarte
V
, et al
.
Group therapy for adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial.
J Am Acad Child Adolesc Psychiatry
.
2015
;
54
(
4
):
275
282
[PubMed]
74
Vitiello
B
,
Elliott
GR
,
Swanson
JM
, et al
.
Blood pressure and heart rate over 10 years in the multimodal treatment study of children with ADHD.
Am J Psychiatry
.
2012
;
169
(
2
):
167
177
[PubMed]
75
Wangler
S
,
Gevensleben
H
,
Albrecht
B
, et al
.
Neurofeedback in children with ADHD: specific event-related potential findings of a randomized controlled trial.
Clin Neurophysiol
.
2011
;
122
(
5
):
942
950
[PubMed]
76
Webster-Stratton
CH
,
Reid
MJ
,
Beauchaine
T
.
Combining parent and child training for young children with ADHD.
J Clin Child Adolesc Psychol
.
2011
;
40
(
2
):
191
203
[PubMed]
77
Widenhorn-Müller
K
,
Schwanda
S
,
Scholz
E
,
Spitzer
M
,
Bode
H
.
Effect of supplementation with long-chain ω-3 polyunsaturated fatty acids on behavior and cognition in children with attention deficit/hyperactivity disorder (ADHD): a randomized placebo-controlled intervention trial.
Prostaglandins Leukot Essent Fatty Acids
.
2014
;
91
(
1–2
):
49
60
[PubMed]
78
Jadad
AR
,
Boyle
M
,
Cunningham
C
,
Kim
M
,
Schachar
R
.
Treatment of attention-deficit/hyperactivity disorder.
Evid Rep Technol Assess (Summ)
.
1999
;(
11
):
i
viii, 1–341
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Davis has participated as a study clinician on a pilot trial of a nonpharmacologic intervention study sponsored by Akili and awarded to Duke; she also served as the Duke site principal investigator on a multisite trial of a nonpharmacologic intervention study sponsored by Akili and awarded to Duke; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr Davis has participated as a study clinician in industry-sponsored clinical trials awarded to Duke; pharmaceutical companies include Sunovion, Shire, Ironshore, Rhodes, and KemPharm; the other authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data