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This article summarizes the non-drug treatment and therapy approaches known to us.
The (+) and (-) in the headings reflect our assessment of the benefits for ADHD.
In our experience, drug treatment is the most important and sensible form of therapy for severe and moderate forms of ADHD.
Among the thousands of people with ADHD that we got to know via the forum, those who thought that they had achieved sufficient symptom improvement with psychotherapy were not only clearly in the minority, but even more clearly: barely represented.
in our opinion, (suitable) ADHD medications deem effective (or suitable) are given an efficacy label of (+++++).
ADHD should definitely be treated with medication - at least temporarily - especially at the beginning of therapy.
People with ADHD who have never felt what it is like to live without these distressing symptoms cannot understand the goal of non-drug therapy from their own perception. Edel/Vollmoeller argue in a similar way.1 In addition, dopamine is a neurotrophic factor, which means that it is required for learning processes in the brain. The dopamine deficiency typical of ADHD therefore prevents learning success and should be remedied before psychotherapeutic treatment.
A large meta-analysis of 190 studies involving 26,114 participants with ADHD found that stimulants appeared to be superior to behavioral therapy, cognitive training, and non-stimulants. Stimulants in combination with behavioral therapy appeared to be the most effective.2
Medications show a much greater Effect size on ADHD symptoms than non-pharmacological treatments.3
Non-pharmacological treatments are important supportive measures which, in combination with medication, can lead to relevant additional improvements.
Psychoeducation, self-help groups, sports, psychotherapy, mindfulness techniques and neurofeedback are particularly noteworthy.
A review of inter- and intra-individual psychological treatments for ADHD found that psychoeducation and parent training, school-based interventions, reinforcement strategies and neurofeedback consistently showed small to moderate Effect sizes in reducing hyperactivity/impulsivity in children. Emotional self-regulation, social skills and cognitive training, on the other hand, showed unsatisfactory results. A combination with medication brought about considerably greater improvements.4
Knowledge about people with ADHD helps them in several ways
Who am I, what about me is ADHD?
Recognizing which symptoms stem from ADHD and that these are treatable makes it easier to identify your own personality: who you “actually” are without this ADHD. This differentiation helps to learn to accept oneself and to understand ADHD symptoms as something that is inherent but not unchangeable. This is helpful for the often very impaired self-esteem of people with ADHD.
Handling requires knowledge
Understanding the symptoms, their causes and their effects makes it possible to deal with them in a helpful way, in particular:
The choice of suitable treatment methods
Environmental interventions (see above)
Understanding others
Knowing what constitutes ADHD, how it affects perception and action, helps to understand other people. People with ADHD, who have never known anything else as normal all their lives, can recognize why other people feel and act differently where they do not have ADHD symptoms.
Knowledge facilitates renewal of the self-concept
A person with ADHD who has experienced a lifetime of rejection because they are not what they should be can begin to rebuild their self-esteem, which has usually been completely destroyed by then, by understanding that most of the negative reactions were not triggered by themselves but by ADHD6
Limit: Avoid negative bias
The danger of self-fulfilling prophecies should be recognized and avoided.
Unreflective identification with ADHD symptoms can be harmful.
You are not ADHD - you have ADHD.
No person with ADHD has all the symptoms of the cluster.
Using the advantages of ADHD
In some specific circumstances and aspects, people with ADHD have an advantage over people without ADHD. This advantage can only be exploited if you know the conditions under which the advantages apply.
In the adhs-forum.adxs.org there are virtual self-help groups and new virtual self-help groups (also on special topics) can be set up via the ADxS’ own video server.
The largest German-language forum on the subject of ADHD can be found at adhs-forum.adxs.org(more than 6,000 members, more than 70,000 unique visitors/month; as of 11/2023)
(Endurance) sports appear to be the best non-drug form of treatment for ADHD.8910
For many people with ADHD, especially those with ADHD-HI and ADHD-HI-C, regular intensive sports (burning off excess energy) is essential. As a rule, sports can support ADHD treatment, but are only likely to be sufficient on their own in very mild cases
In the experience of people with ADHD, weight training, in contrast to endurance sports, is apparently much less suitable for combating ADHD symptoms in the long term.
One study found a 21% reduction in the tendency to exercise in children with ADHD.11 Another study found a 3.23-fold increase in excessive physical activity in children with ADHD compared to those not affected.12
Sports (as well as MPH) can induce the expression of tyrosine hydroxylase (TH)47 and thereby increase TH levels. TH is a precursor for dopamine. Sports can thus support dopamine synthesis.
Noradrenaline4849 , in the brain regions relevant for ADHD48
Inflammation levels reduced through regular exercise50
Oxidative stress reduced through regular exercise50
Stress hormones reduced through regular exercise50
(during sports competitions, the above three values are increased)
Telomerase activity in humans and mice increased by regular exercise50
Counteracts behavioral changes caused by stress-induced telomere shortening
Calorie consumption
Contrary to previous assumptions, sports do not appear to increase calorie consumption. Among the Hadza people, active hunter-gatherers in Africa, women walk an average of 8 km and men an average of 14 km a day, but do not consume any more energy than sedentary office workers in the USA.51525354 Hadza are active and fit up to the age of 70 and 80 and are said to have neither diabetes nor heart disease.
However, high calorie consumption through exercise reduces stress systems and inflammatory reactions and thus reduces the calorie consumption that the stress reactions would have caused.53Acute physical stress barely increases cerebral blood flow, but there is a redistribution in brain regions involved in motor control and coordination (e.g. vestibular) and transport systems (respiration, circulation).55 This could be the nutritional-physiological equivalent of the long-standing finding that sports have a stress-regulating effect.
This sheds a whole new light on the common side effect of stimulants of reduced appetite. We hypothesize that this could be an adaptive response to the body’s decreased energy expenditure due to reduced stress responses. Further, we wonder whether hyperactivity as a symptom of the externalizing ADHD subtypes could possibly be a (misguided) compensatory response of the body, as inflammation is more common in the externalizing stress phenotype than in the internalizing ADHD-I subtype.
One-off training has statistically significant but small Effect size improvements in cognitive performance during, immediately after and delayed after the training session.26 In another study, working memory and inhibition were impaired immediately during exercise in people with ADHD compared to those without ADHD56
The benefits of acute physical activity can gradually accumulate over time.22
A combination of sports training with cognitive tasks for children with ADHD proved to be helpful22, but not superior to sports training alone21
Treatment covered by statutory health insurance in D
A comprehensive study showed that treatment with medication is superior to treatment with behavioral therapy or clinical care. Multimodal treatment (combined treatment with medication and behavioral therapy or clinical care) appears to be the most promising.5758
1.3.1.1. 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.59 Other studies came to similar conclusions.6061
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.62 Further studies confirm these results.6364
An additional MBCT treatment resulted in a significantly greater improvement in symptoms 6 months after the end of therapy than conventional treatment methods alone.65
Mindfulness meditation reduced cortisol and inflammation levels and increased telomerase, which counteracts behavioral changes caused by stress-induced telomere shortening.66
Mindfulness-based treatment improved the core symptoms of attention problems and hyperactivity in ADHD.67
A meta-analysis of 32 studies found evidence for the effectiveness of mindfulness-based behavioral therapy (there: mindfulness) for ADHD.68
A meta-analysis of 32 studies found positive results for cognitive behavioral therapy for ADHD in the majority.68
A meta-analysis found benefits of cognitive behavioral therapy for ADHD in parent ratings, but less in the reduction of functional symptoms.14
According to Barkley, cognitive behavioral therapy does not work for children with ADHD.69
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.70
Cognitive behavioral therapy is most suitable for self-esteem problems caused by ADHD71 and for deficits in social behavior.
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)72
Depression
Cognitive behavioral therapy (medium to larger 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
A meta-analysis of 32 studies found evidence of benefit from group-based DBT for ADHD.68
One study found that DBT skills training works particularly well for externalizing people with ADHD.75
A digital form of DBT proved helpful for children with ADHD76
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)72
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
Distance yourself (take a step back internally)
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 Linehan77
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.78
EMDR
EMDR is a recognized therapy option for the treatment of trauma.80 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.81
As EMDR-like forms of therapy such as Emoflex are said to be successful in treating ADHD, the results of the above-mentioned 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 EMDR82
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.
Preparation and positive stabilization
What good things and bad things / burdens are you aware of today?
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).
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.
Anchoring
A positive new thought base is anchored and trained in place of the negative ones. Slow bilateral movements, approx. 60 / minute.
Body test
Ensuring that negative feelings no longer occur when remembering the stressful situation.
Final meeting
among other things, indicate that after-effects may occur, e.g. in dreams.
Performance review and future orientation
A detailed description of EMDR therapy based on example cases can be found in Schubbe.84
Emoflex85
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” applies the underlying therapeutically effective methods (which are never protectable under trademark law).
A meta-analysis of 32 studies found evidence for a benefit of hypnotherapy for ADHD.86 Another, less comprehensive meta-analysis came to no conclusion.14
In children with learning disabilities and ADHD, mentoring showed improvements in self-confidence and social relationships, and prevented the development of depressive behavior.87
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.88
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.
Treatment covered by statutory health insurance in D
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.
Treatment covered by statutory health insurance in D
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.89
1.3.11. Working Memory Training / Cognitive Working Memory Training (CWMT) (-)¶
A large-scale meta-analysis found insufficient evidence for the effectiveness of cognitive training for ADHD.90 A further study confirmed this.91
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.92
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.14
Several small studies found evidence that working memory training could help to reduce the symptoms of ADHD.939495969798
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,99 which leads to a significant reduction in the symptoms of attention and impulsivity.100
In ADHD, the working memory located in the dlPFC is impaired by reduced dopamine levels. The inhibitory dopamine transporters D2 to D4 are primarily affected. ⇒ Neurophysiological correlates of working memory problems in ADHD
Working memory uses different areas of the brain for different content (number sequences, faces, names, goals). Training a specific working memory area (e.g. number sequences) therefore has barely any influence on the performance of the working memory for names.
Research found no benefit of executive functions training in ADHD.101 According to one study, another executive function training program (EXAT) worked better for ADHD than for epilepsy.102
2 different executive, attention and motor training programs for children aged 4 to 5 were found to be equally effective.103
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.104
Mindfulness techniques are very well suited for the treatment of ADHD. A meta-analysis found positive results in 11 out of 12 studies in relation to the treatment of ADHD.107 A meta-analysis found improvements in inattention in adults, while too little data was available for children.108 One review found MBSR to be a useful supportive treatment method for ADHD.109
Mindfulness-based treatment improves the core symptoms of attention problems and hyperactivity in ADHD.67
Mindfulness training targets the autonomic nervous system
In one study, stress management reduced the basal DHEA level and increased the cortisol level. The change in the cortisol-DHEA ratio achieved was stress resistance-promoting.115
It should be noted that, depending on the disorder, the cortisol/DHEA ratio may be imbalanced in one direction or the other. ⇒ DHEA/cortisol imbalance during stress
Psychological stress therapy should always influence the relationship in the direction of a healthy balance. In the case of drug treatment, the direction in which the balance is shifted must first be determined.
Internal / external
internal: it’s up to me personally (me, my)
external: it’s the circumstances (the others, out there)
Stable / variable
stable: it is unchangeable (always, never)
variable: I can influence it
Global / specific
global: it is always and everywhere like this (everywhere, lawfulness)
specific: the cause lies in this case itself (here, this time)Mindfulness trains a change in perception. It trains you to no longer immediately attribute the perceived event, but to let it stand on its own. This enables a less frightening and threatening perception, which can massively reduce stress as a consequence.
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)72
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 larger 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 larger 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
Mindfulness meditation reduced ADHD symptoms (hyperactivity and inattention), but breathing techniques did not, while both techniques reduced stress.116
Mindfulness training still showed positive effects on children with ADHD in the parent evaluation 6 months later117
A meta-analysis came to the conclusion that mindfulness techniques are a helpful supplement in the treatment of ADHD.118
How mindfulness works
Roughly speaking, the technique of mindfulness involves creating a virtual distance from perceived circumstances. In simple terms, mindfulness means separating perception and its immediate evaluation for oneself. You are trained to perceive very consciously what is happening and at the same time not to relate the events to yourself, i.e. not to take them as a reason for a reaction, but merely to observe the effect of the events on yourself with interest. This stops the automatism of the immediate impact of perceptions on one’s own state of mind.
In other words
You realize that everything is still happening in the same way, but that it no longer poses an immediate existential threat. It happens, and yet you go on living. The subjective threat of what is happening is reduced.
This technique makes sense if the automated stress regulation has previously been misdirected in such a way that events are attributed too directly to oneself.
Attribution styles
There are different attribution styles,119 how perceived circumstances are explained. Example:
A student fails an exam.
The following reaction options (i.e. attribution styles) are conceivable:
I’m just too stupid. (Internal - stable - global)
I really didn’t learn anything for this exam. (Internal - variable - specific)
This time I was just unlucky. (External - variable - specific)
They always give me the stupidest tasks. (External - stable - global)
Summarized attribution dimensions result in specific interpretations:120
Internal-stable: ability
Internal-variable: Effort
External-stable: task difficulty
External-variable: Luck/Pitch
Pessimistic attribution style: failures are attributed internally, globally, stably
Optimistic attribution style: failures are attributed externally, specifically, unstably
We assume that a global internal attribution style makes people susceptible to perceiving experiences in a threatening and fearful way.
Fearful and threatening perceptions quickly lead to cortisolergic stress.
1.4.1. Neurophysiological mechanisms of action of mindfulness techniques (here: MBSR)¶
Mindfulness training is able to sustainably reduce cortisol levels.121
In generalized anxiety disorder, there is an overactivation of the amygdala with ambivalent signals and a poor functional connection between the amygdala and ventrolateral PFC. MBSR reduces the overactivation of the amygdala for neutral faces more than stress management. MBSR, but not stress management, caused greater activation of the ventrolateral PFC and also improved the connection between the ventrolateral PFC and the amygdala. All changes coincided with the improvements in anxiety symptoms, indicating causal effects. The previously negative coupling of the amygdala with the activity of the ventrolateral PFC, as known in emotion reduction, changed to a positive coupling. MBSR appears to bring about substantial changes in brain regions that are relevant for emotion regulation.122
The functional activity of the amygdala decreased and the connectivity of the amygdala with the PFC improved. In addition, the deactivation of the amygdala after emotional stimuli was faster.62
Since MBSR has been shown to be very effective for ADHD, we assume that there is an analogous improvement in communication between different areas of the brain.
Further studies show the effects of MBSR on neuronal activity.123
Mindfulness-based meditation technique may be superior to relaxation training in terms of long-term normalization of cortisol response.124
MBSR appears to be able to improve the emotional self-regulation of people with ADHD.125
MBSR may improve ADHD symptoms not so much through improved mindfulness skills or improved self-compassion, but through improved inhibition.126
Zen meditation
increased serotonin levels in the brain in the long term
In experienced meditators, an increase in cortical thickness in the right insula and the frontal lobes has been demonstrated.131
During mindfulness meditation, more gray matter was observed in areas of the brain typically used during meditation in intensive meditators (2 hours a day for more than 8 years). People with ADHD are the right insula, which is involved in introspective attention (“interoceptive awareness”), the left inferior temporal gyrus and the right hippocampus.132
A meta-analysis found evidence of the effectiveness of meditation techniques in children, adolescents and adults.133 The results are said to indicate a stronger effect on inattention than on impulsivity/hyperactivity.
Biofeedback
Relaxation massages
Massage therapy resulted in a 31% reduction in the cortisol response to stress and an increase in dopamine and serotonin of around 30%.134
Massage therapy is said to be able to outperform the effect of methylphenidate.135
Shiatsu
Qigong
Tai chi chuan
A meta-analysis found a consistently positive effect of tai chi on ADHD symptoms, although the quality of the studies was rather low.14
Respiratory therapy
Progressive muscle relaxation according to Jacobson
Feldenkrais
Sound massages
Archery or other shooting sports (with slight positive effects on ADHD)136
Mindfulness apps
also for your cell phone, which you always have with you anyway to take advantage of short breaks.137
Example of a mindfulness exercise: letting go for 100 breaths
Procedure:
Find a quiet place where you are undisturbed
Lie down / sit down comfortably
Close your eyes
Pay attention to your own breath
Each time you let go of your breath, count backwards from 100 to zero, one number for each time you let go of your breath.
Every time you let go of your breath, make sure that your belly lets go completely relaxed. And starting from the belly, Consequences, the whole body relaxes with the release of the breath.
(There are two types of breath: Active inhalers and active exhalers; the respective passive side is to let go of the breath)
Each time you release your breath, concentrate on feeling how your stomach relaxes
Recap the exercise text (below) during the exercise
If necessary, background noise of the sea (this also masks possible street noise); if necessary, headphones with sound recording of the spoken text, if necessary earplugs, if alone for yourself, and remember text silently
In group: Leader speaks meditation text;
Length: participants keep eyes closed as long as it works; those who stop open their eyes, wait quietly or, if necessary, read something until (most of) the others have finished; leader then ends the presentation of the meditation text
Exercise text:
You are here
Feel your body
You don’t have to do anything now
You can be with yourself
You can only feel yourself now
You don’t have to do anything else
Nobody wants anything from you
Feel your breath
Relax your belly as you let go of your breath
and the rest of the body with the stomach
Feel what it feels like when your stomach relaxes
Try to let go completely, with each release of breath
There are thoughts
Let them come
Perceive them
Do they have a color, a shape?
Look at her coming
Do not follow them
Let them go again
Watch them disappear
You are here
You feel your body
You feel yourself
If trouble comes, watch it
Make yourself aware of her wish. What does she want? Have to do something? Want to think? To look at problems? What does the wish that is there want?
Feel it
Don’t deny him, don’t follow him
Look at him, watch him
Feel the desire
How does this urge feel?
Does it have a sound, a smell?
What does it feel like outside of this desire?
You are relaxed
And let go of your belly every time you let go of your breath
And observe what you are feeling or thinking right now
Feel your body
Feel your feelings
Observe what you feel
Do not Consequences the feeling, just observe it
And let it go again
When unrest comes, watch how it comes
Don’t call them here
If it is there, notice it, feel it
Do not follow her
How does it feel?
Does it have a sound, a movement?
Look at them
She may be
She has no right to determine you
Let them go again
You are here
Feel your body
You don’t have to do anything now
You can be with yourself
You can only feel yourself now
You don’t have to do anything else
Nobody wants anything from you
All thoughts that come can wait
when they are important, they come back
Now you are the most important thing
Everything else has its time later
(continue)..
..
..
The exercise aims to ensure that feelings/thoughts/inner restlessness are not denied = not suppressed.
It is easier not to follow something that is not suppressed. This naturally requires an inner position outside the pressure.
I want the feeling/thought to be there - and they don’t define me.
I am beside them, not through them.
Feelings / thoughts are there and they are not me.
They are a part of me, and only a part.
I am not these thoughts and feelings, I have them.
I have them, not they have me.
The questions about color, form and sound are aimed at viewing feelings and thoughts as something from outside, as something third, thereby separating them from oneself and not being controlled by them.
The learning steps should / could be:
Learning to perceive, to perceive and feel yourself as an alternative and separate from these thoughts and feelings. Learning to feel this “me” as an alternative.
Learning to evoke the alternative safely.
Strengthen the alternative until it is a greater option.
Let the alternative grow to such an extent that you can feel it as a basis, sense it and live it permanently at some point.
Training path:
(Introduction to transformation in daily routine)
First times with optimal medication
Increase in difficulty depending on progress with less and less / at the edge / end of medication effectiveness
To without medication (if possible)
Initially in your own ritual, in a specific, quiet place, possibly at a fixed time
Later less and less isolated, sometimes spontaneously
In our opinion, this is the only form of therapy with a healing effect, as the brain’s self-regulation mechanisms can be permanently improved. Nevertheless, its effectiveness is very limited.
In our opinion, longer treatments are required than typically recommended
In particular, a combination of frequency band training and subsequent SCP training seems to produce good results.
Neurofeedback training types
SMR training
acts on relaxed attention, hyperactivity, impulsivity
Theta beta training
affects concentration, tense attention
Alpha training
acts on relaxation, sleep problems
SCP training
Trauung of the slow cortical potentials
acts on activation (for ADHD-I) and downregulation (for ADHD-HI)
very strenuous, but also very helpful when carried out
In a small study, neurofeedback improved visual memory, acoustic short-term memory and auditory working memory, but not perceptual organization.141
However, neurofeedback is not a substitute for treatment with medication (especially in the first few years), but a supplement to therapy that can reduce the need for medication.
According to a meta-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)142
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
Parent training seems to be helpful for children with ADHD.143 This particularly applies to children with ODD144 and young children.145
Interventions in school/kindergarten (-)
One meta-analysis reported that classroom interventions/school interventions were found to be partly ineffective and partly effective only as long as the interventions lasted.14
Every person needs their own specific level of arousal (excitement, stimulation).147148
Even if novelty seeking and curiosity behavior correlate (also genetically) with impulsivity,149 it is probably important for most people with ADHD-HI to reduce arousal, but for people with ADHD-I to increase arousal.
Stimulate arousal
Targeted (quiet) background music
Some people can only learn with it
TV running in the background
If noises / images are distracting: switch off
Motivational elements
Very important, as people with ADHD can basically concentrate just as intensely as others. The only difference is that they cannot produce this concentration in a controlled manner, let alone control it. This is not carelessness or laziness.
Intrinsic motivation instead of extrinsic motivation: the central key
Rewards
Competition with others
Communicate goals to others (create commitment / self-commitment)
Don’t make people with ADHD feel guilty
None: You can if you want to
None: You just have to try harder
Friedmann reports of people with ADHD who lost their ADHD symptoms after finding a working environment that suited their constitution: short attention spans, frequent activation, independent work organization. We also know of cases that blossomed in an environment that was just right for them. This does not mean that only every person with ADHD has to find the right environment in order to no longer have ADHD. ADHD means that the choice of which environment is suitable is extremely limited. Very few people with ADHD will be able to build their world in this way. In our opinion, however, one more element must be added: genuine interest. Only when this genuine interest of their own kicks in will people with ADHD be able to resolve their attention problems. Friedmann points out that the reduced number of dopamine D2 and D3 receptors in the reward center of the brain in people with ADHD means that fewer things are found (rewarding), i.e. sufficiently exciting, than in people without ADHD. The choice of an exciting environment therefore necessarily requires that it is something that is of (such) high interest to the person with ADHD that the reward center “jumps” and the attention of the person with ADHD is aroused. The sentence “You can do it if you want to” is absolutely correct, but not in the way it is usually misunderstood. ADHD can only be understood if one is prepared to accept that the will of the person with ADHD is not completely free to choose, but depends on the subject being so interesting that the shortcoming of the reduced number of D2 and D3 dopamine receptors no longer comes into play. Only with the appropriate intrinsic interest can people with ADHD 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 perspective, ADHD could also be defined as an extreme narrowing of interests. And yet this is not a justification that your ADHD is not that bad, you just haven’t found what interests you.
Secondary employment
Knit
Draw
Listen to music
Some people have to “do” something on the side in order to be able to concentrate. This relieves inner tension. The secondary activity serves to optimize arousal. This is not a sign of disinterest or disrespect, but a means of increasing attention and concentration
Reduce distraction
Avoiding situations that are too loud, hectic, stressful and intense.
If you are sensitive to stress, you should avoid stress-inducing situations. This obvious-sounding fact is surprisingly often disregarded, whether due to a lack of knowledge or a guilty conscience. It’s like the temperature: you shouldn’t be cold when the thermometer says so, but when you’re cold:
Max. 10 pieces, as often as necessary until they fit securely, only then more
Use all senses: read quietly, read aloud, copy, etc.
Further vocabulary only after a break
Walk while learning
uniform movement significantly optimizes receptivity in some people; movement reduces stress and increases neurotrophic factors in the brain that are necessary for neuroplasticity (formation of new synapses, learning)
30 minutes of physically intensive exercise before learning (esp. ADHD-HI)
Suitable working methods
Independence
for interesting activities, some people with ADHD-HI do better as self-employed persons than as employees, because intrinsic motivation optimizes arousal
for less interesting activities, however, this would be rather disadvantageous because the individual’s own drive/structure is too low
Interesting activity
The lack of extrinsic motivation makes it many times more important for persons with ADHD to find a task that is really exciting for them than for people without ADHD
ADHD-I: structured work tasks, clear instructions, tight controls
Example:
One person with ADHD retired at the age of 50 after a glittering career in the US Marines. He couldn’t cope in civilian life and failed. A year after leaving, he was diagnosed with ADHD.
A well-structured daily routine with regular alternation of activity and relaxation can support stabilization of the noradrenaline balance through self-activation (see below: take enough breaks)
Avoid / eliminate sources of stress
Even in the case of personality disorders, a long-term study (n = 733) surprisingly found a reduction in symptoms within 2 years for a period of more than 12 months in more than 50% of people with ADHD. In the case of borderline, this was observed in 10% of people with ADHD within 6 months, usually after massively stressful current life circumstances (stressful relationship) were eliminated. Nevertheless, significant diagnostic criteria remained very constant (more so than with severe depression), but they no longer reached the required severity for a diagnosis.152
Promote stress reduction
Just one hour longer sleep reduces morning cortisol levels by 21%153154
For sleep disorders:
Shift your sleep rhythm backwards
Postpone falling asleep and getting up
This could be worth a try for people with ADHD with high stress levels immediately on waking (e.g. anxiety)
Early awakening correlates with high cortisol levels153154
People who live in poor neighborhoods are said to have a higher body weight due to stress than people who live in more affluent neighborhoods.
When moving house, the body weight adapts to the new environment.155
This could be interpreted as a consequence of a stress response or stress reduction, but can also be understood as an adaptation to the main environment.
Sleep problems should be treated with special priority in ADHD, as they can exacerbate ADHD symptoms as a vicious cycle and ADHD symptoms can cause sleep problems.
Sleep reduces the stress hormone cortisol. 1 hour longer sleep improves cortisol reduction by 21 %153
All ADHD symptoms are also stress symptoms.
On possible measures to improve sleep and on sleeping pills specifically for ADHD: ⇒ Sleep problems with ADHD
Food intolerances address the stress regulation systems just as much as psychological stress or illness.
There are no specific foods that trigger ADHD. However, if there is an individual food intolerance, this can exacerbate an existing ADHD (as well as other mental disorders) because it represents an additional source of stress/strain for the organism. Dietary treatment of an existing food intolerance therefore contributes to an improvement in ADHD symptoms. The average Effect size is approx. 0.25.
There is also evidence that omega-3/omega-6 fatty acids can support the treatment of ADHD. However, this does not apply to all persons with ADHD and the Effect size is so small that this can only be recommended as an augmentation (supplement) to a treatment with a strong effect.
For more information, visit ⇒ Nutrition and diet for ADHD and at ⇒ Effect size of different forms of treatment for ADHD.
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 areas.156
Even though thirst is not described as a typical ADHD symptom, increased thirst and therefore increased water intake are frequently observed symptoms of stress.157 As stress aims to increase blood pressure in order to optimally prepare the body for fight or flight, increased fluid intake is an immediately useful tool.158 Fluid intake significantly reduces the stress response.159
Breaks are not just about recovering and letting the amount of stimuli you have been exposed to flow away:
A clearly structured daily routine, in which activity and breaks alternate sensibly, can train the noradrenergic system and normalize the production of noradrenaline.160
This follows on from Scheidtmann’s suggestion that noradrenergic drugs (e.g. antidepressants) do not help with motor rehabilitation if they are used as long-term medication, as tricyclic antidepressants permanently stimulate the noradrenergic receptors and this leads to a loss of receptor sensitivity (especially with regard to learning processes).161
This is consistent with the experience of using noradrenergic tricyclic antidepressants for ADHD. It is often reported that there is a very good response at the beginning, but that this diminishes with continued medication.
Taking breaks can counteract the hyperactivity of ADHD.150
In recent years, the topic of computer games for therapeutic use has come into scientific focus.
In principle, ADHD symptoms should be able to be improved by therapy computer games, e.g. attention,162
A therapeutic computer game has already been approved by the FDA for ADHD.
In June 2020, the FDA (US Food and Drug Administration) approved the first ever video game that can be prescribed by a doctor. It is used to treat ADHD.
180 children between the ages of 8 and 12 played EndeavorRx for 25 minutes 5 days a week for 4 weeks, 168 children played a game other than placebo. The mean change (SD) from baseline in the TOVA-API was 0.93 in the treatment group and 0.03 in the control group.163 The fact that the study was sponsored by the software manufacturer is cause for skepticism. On the other hand, Faraone, one of the authors, is a very renowned scientist in the field of ADHD and The Lancet is a very renowned scientific journal.
A preliminary study also found evidence of a positive effect.164
The manufacturer describes further:
“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, which showed that EndeavourRx improved objective measures of attention in children with ADHD. After four weeks of EndeavourRx treatment, one-third of the children no longer had a measurable attention deficit on at least one measure of objective attention. In addition, about half of the parents noted a clinically meaningful change in their child’s daily impairments after one month of treatment with EndeavourRx. This increased to 68% after a second month of treatment. The improvement in ADHD-HI impairment after one month of treatment with EndeavourRx was maintained for up to one month.”165
Another study, which is probably still ongoing, is investigating the effectiveness of the game over a longer application period of 2 months and the extent to which improvements persist after the end of treatment.
The therapy computer game “Plan-It Commander” was/is developed by the authors of the studies mentioned below,166 so that the assessment of its effectiveness by independent studies remains to be seen. The symptoms that are said to have been improved in non-blinded studies are
A very small preliminary study showed that the higher their ADHD symptoms were, the better people with ADHD completed the game parts of Empowered Brain.170 The software appears to be developed more from a diagnostic perspective.
1.10.5. AR-Therapist: Augmented Reality - Behavioral Therapy - Game Concept¶
One study describes a concept of an augmented reality game for the purpose of behavioral therapy for ADHD, including measurement of ADHD-relevant parameters.171
Elude aims to raise awareness and provide information about depression. It is intended to be used in a clinical context as part of psycho-education to improve the understanding of friends and relatives about people suffering from depression, about what people with ADHD are going through.
Whether this reduces the brooding phases in people with ADHD is disputed181182
Tetris
Trauma prevention
Non-therapy-oriented play
Use within the first 6 hours after a potentially traumatizing experience, after players were asked to recall the event, reduced risk of traumatization183
According to our (unverified) hypothesis, however, any mental activity and any media consumption that offers a light (!) mental activity (entertainment programs, entertainment films without dramas, light video games without social or violent components) could be suitable as trauma prophylaxis, provided they are used before the first sleep after the event. Of course, the content must not be thematically related to the event.
According to our idea, the potentially traumatizing experiences in working and short-term memory are (at least partially) “overwritten” or “relativized” by subsequent “light” media consumption before they can be transferred to long-term memory via the hippocampus during sleep. Against this background, it could be beneficial to delay the first sleep after a potentially traumatizing event for as long as possible, to promote an abundant consumption of less significant media and, if necessary, to give medication that reduces the activity of the hippocampus.
A computer-based cognitive training program improved focused attention and working memory in some of the test subjects (responders) better than conventional training. ADHD-I and ADHD-C benefited more than ADHD-HI.185
A meta-analysis found 10 studies, 6 of which showed a positive effect of web-based support tools for young people with ADHD. The 4 studies that did not find a positive benefit related to apps.186
A small study found an improvement in ADHD symptoms related to IQ after 11 weeks of chess training.187 Effect size was 0.85 when assessed by the parents. However, a parent-only assessment should always be treated with caution.
Another study found a comparable effect of GO, whereby inattention was improved, but not hyperactivity.188 The results of further studies could not be converted into Effect sizes.189190
1.13. Transcranial magnetic stimulation / transcranial direct current stimulation (o/+)¶
Various studies have looked at the effect of transcranial stimulation on ADHD.191192193
Transcranial direct current stimulation was rated better than repetitive transcranial magnetic stimulation in a review.194
According to the majority opinion, there are predominantly indications of a positive effect.195196197198199200201
A meta-analysis found a significant positive effect in 8 (n = 133) of 13 studies (n = 308) rather in children and adolescents for inattention, impulsivity and general symptom levels, with a delayed onset of effect for hyperactivity.202 Another meta-analysis found significant improvements in attention, inhibition, working memory and brain connectivity in 11 studies.203
Studies found improvements through transcranial stimulation in relation to:
fewer omission errors in people with ADHD, along with an improvement in P 300 amplitude204
Improvements in ADHD, which were further enhanced by a combination with cognitive training205
Hyperactivity
Hyperactivity improved, but not attention (individual case of an adult with ADHD)206207
1 Hz rTMS over the left dlPFC improved hyperactivity/impulsivity (and inattention) in children with ADHD209, unlike 10 Hz stimulation of the right dlPFC, which did not improve ADHD symptoms compared to sham stimulation210
Attention
1 Hz rTMS over the left dlPFC improved inattention (and hyperactivity/impulsivity) in children with ADHD209, unlike 10 Hz stimulation of the right dlPFC, which did not improve ADHD symptoms compared to sham stimulation210
Attention improved without improvement in mood, anxiety or hyperactivity in adults with ADHD211
Attention improved, but not overall ADHD scores in children and adolescents with ADHD212
through optimized high-resolution tACS with a frequency of 5 Hz above the left DLPFC214
Other sources report mixed results.215216217218 One study found no improvement with transcranial direct current treatment over the left dorsolateral PFC.219
Several studies found evidence of increased (extracellular) dopamine levels in the striatum during or after TMS application.220221 The increase corresponded to that seen with the administration of D-amphetamine.222
TCM usually combines various treatment methods, just like Western “multimodal” therapy. These include herbal treatments, which can be assumed to intervene in the neurotransmitter structure in the same way as conventional medication. The risk lies in the limited knowledge of the pathways, side effects and cross-effects with conventional medication.
A meta-analysis found a surprisingly good effect of TCM on ADHD (as good or better than MPH), but at the same time poor to very poor quality of the individual studies, including a risk of considerable bias, which is why TCM cannot yet be recommended as a treatment for ADHD.22314
A very small study with n = 29 adults found positive effects of early morning light therapy in the fall/winter months on objective and subjective ADHD symptoms, mood and a shift in the circadian rhythm.224 The shift in the circadian rhythm appeared to have the greatest influence on the improvement of ADHD symptoms. Another, even smaller study on 16 adults came to similar conclusions.225
A third placebo-controlled study comparing the circadian rhythm with melatonin or melatonin plus light therapy also found that light therapy (here: as an addition to treatment with melatonin) could shift the circadian rhythm forward and that this had positive effects on ADHD symptoms. Melatonin alone had a stronger effect than light therapy, light therapy improved the result of melatonin treatment.226
A review confirmed these results.227
People with ADHD 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 is supported by empirical data.228229230231232
A meta-analysis found stable results showing a slight improvement in ADHD with white or pink noise.233
Initial positive results have been found for trigeminal stimulation.234 The Effect size is said to have been 0.5.235 Trigeminal stimulation is said to improve executive dysfunction (organizational problems) in children with ADHD.236
A first device for trigeminal stimulation (Monarch eTNS System) has been approved by the FDA. In a double-blind placebo study, the device significantly improved ADHD symptoms in children between 8 and 12 years of age within 4 weeks.237
However, it remains to be seen whether neurostimulation can be reliably used as a treatment tool for ADHD and whether the improvements continue after treatment has ended.238
Breathing techniques outside of the mindfulness approach (see above) are not suitable for treating ADHD symptoms in general.
However, certain breathing techniques are suitable for some individual symptoms associated with ADHD, which is why we would like to mention them here.
The sympathetic nervous system dominates during inhalation and the parasympathetic nervous system dominates during exhalation. A different emphasis on inhaling or exhaling can therefore have an effect on the distribution of dominance between the sympathetic and parasympathetic nervous system.
Breathing techniques (in more specific forms) can be helpful in relation to239
Sleep problems
Anxiety and panic states
Depression
increased blood pressure
reduced blood pressure
Sensation of cold
1.19. Therapeutic approaches for ADHD whose effect is not proven¶
Occupational therapy
The effectiveness of occupational therapy for ADHD is limited to the treatment of fine motor skills in preparation for school.240
A study reports positive effects of equine-assisted occupational therapy for schoolchildren with ADHD.241
Hemencephalography training
Effect not yet recognized, initial studies.191
One study found that listening to Mozart for 10 minutes (Mozart piano sonata for four hands, KV 440) improved the mood of people with ADHD as well as people without ADHD, in contrast to subjects who listened to 10 minutes of silence.243 This does not prove an ADHD-specific treatment method.
One study reports that cell phone app-based training in attention and organization led to relevant improvements in a third of adults with ADHD.245
A meta-analysis from 2019 found no further studies on the treatment of ADHD using specific apps246
Organizational skills training
In the case of SCT, training in organizational skills did not improve SCT symptoms from the perspective of the people with ADHD themselves. Only from the parents’ perspective were there improvements with an Effect size of approx. 0.5.247
Parent assessments are highly susceptible to being biased towards desired outcomes. This bias is all the stronger the greater the effort invested.
Homework support
In the case of SCT, homework support did not improve SCT symptoms from the perspective of the people with ADHD themselves. Only from the parents’ perspective were there improvements with an Effect size of approx. 0.5.247
Parent assessments are highly susceptible to being biased towards desired outcomes. This bias is all the stronger the greater the effort invested.
Social behavior training
A meta-analysis found no proven effect of non-drug training methods (coaching, etc.) in terms of improving social behavior towards peers.248
A meta-analysis found weak evidence of benefits of peer-based interventions for ADHD,14 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.249
Transcutaneous vagus nerve stimulation
One report cites transcutaneous vagus nerve stimulation as a possible treatment for ADHD.250
Acupuncture
One meta-analysis reported a high efficacy of acupuncture on hyperactivity.251 Another meta-analysis of 5 studies found no robust evidence for an improvement in ADHD through acupuncture.252 Another meta-analysis intends to investigate the effect of acupuncture for the treatment of ADHD.253 A meta-analysis of 14 studies with 1185 patients found that acupuncture as an adjunct to conventional medication supported the improvement of behavioral problems, learning problems, hyperactivity-impulsivity and hyperactivity symptoms in ADHD patients and as a stand-alone treatment improved learning problems, hyperactivity-impulsivity and hyperactivity symptoms in ADHD patients. The risk of bias in the included studies was generally concerning, so the evidence for the effectiveness of acupuncture for ADHD is currently too limited to recommend its use.254
The effectiveness of acupuncture is controversial. There are no conclusive medical explanatory models to date.
However, two German double-blind studies, which conclude that so far only a placebo effect can be proven for acupuncture, show in the figures that acupuncture achieved 20% better results compared to sham acupuncture.255. 256 Other studies report an effect that goes beyond placebo.257258259260
Homeopathy
A meta-analysis reports benefits of additional individual homeopathic treatment for ADHD.261 An RCT also reports symptom improvements through homeopathy, but only in parent reports.262
Fidgets
One study observed significant improvement in sustained attention in students with ADHD who used Fidgets during class.263
Random Noise
Random Noise treatment uses any form of energy (e.g. light, mechanical, electrical or acoustic energy) with unpredictable intensity to stimulate the brain and sensory receptors with the aim of improving sensory, motor and cognitive functions. Random Noise treatment originally used mechanical sounds for auditory and cutaneous stimuli. Today, electrical energy is increasingly used to stimulate the brain or skin. Recent evidence shows that transcranial random noise stimulation can increase corticospinal excitability, improve cognitive/motor performance and have positive after-effects on a behavioral and psychological level.264
Spinal manipulation / spinal mobilization
A meta-analysis found no evidence of effectiveness of spinal manipulation/mobilization for ADHD265
Transcutaneous auricular vagus nerve stimulation (taVNS) is a newly developed, non-invasive procedure. Stimulation of the cutaneous receptive field of the auricular branch of the vagus nerve in the outer ear is intended to activate the vagal connections to the central and peripheral nervous system.266
Ultrasound stimulation with low intensity
Low intensity ultrasound stimulation has been shown to improve abnormal brain function in SHR. We do not have studies on clinical ADHD treatment use in humans.267
Certain foods / food additives certain substances as sole causal cause of ADHD
However, food intolerances in general (individually intolerable substances) can increase the stress level to such an extent that latent mental disorders (e.g. ADHD) can appear or existing disorders can be exacerbated.
Find out more at ⇒ Nutrition and diet for ADHD
Multimodal therapy is a combination of relevant treatment options. A combination of medication, psychotherapy and possibly other treatment options is used to treat ADHD. Multimodal treatment improves ADHD symptoms.270 However, this is not surprising. Only a comparison with purely psychotherapeutic and drug treatment would be relevant.
In adults with ADHD, combined treatment with medication and cognitive behavioral therapy was only superior to medication alone after the first 3 months. There was no difference after 6 and 9 months.271
Group therapy manual “Psychotherapy of ADHD in adults” (Hesslinger et al., 2004)
Adaptation of the Dialectical Behavioral Borderline Therapy concept to ADHD
“Treatment manual for ADHD in adulthood” (Lauth, Minsel, 2009)
For individuals and groups
“Psychoeducation and coaching manual for ADHD in adults” (D’Amelio et al., 2009),
Practical guidance on the treatment of ADHD and family groups
“Training for ADD in adulthood (TADSE)” (Baer & Kirsch, 2010)
“Cognitive behavioral therapy program for adult ADHD” (Safren et al., 2009)
Cognitive techniques for individual therapy
Interdisciplinary evidence- and consensus-based (S3) guideline “ADHD in children, adolescents and adults”273
To date, few treatment concepts are known that differentiate between the various subtypes of ADHD - ADHD-HI and ADHD-C (with hyperactivity) on the one hand and ADHD-I (without hyperactivity) on the other.
In our opinion, ADHD-HI and ADHD-C suffer from the fact that the stress system of the HPA axis is permanently overactivated and is not shut down again due to an insufficient cortisol response to acute stress or insufficient addressability of the glucocorticoid receptors, while the ADHD-I subtype suffers from an over-intense neurotransmitter and stress hormone response to acute stress, which leads to a regular shutdown of the HPA axis due to the high cortisol response, but at the same time shuts down the PFC due to the parallel excessive release of noradrenaline, thereby triggering mental blocks and an inability to make decisions.
In our opinion, mindfulness is particularly important in ADHD-HI in order to achieve therapeutic ability in the first place. The permanently elevated stress level in ADHD-HI (with hyperactivity) is so strongly increased that mindfulness (MBCT, MBSR, meditation, yoga …) is downright aversive, which correlates with an inability to recover.
Treating the children alone overlooks the fact that the influence of people with ADHD has a significant impact on the development of the children.
Treatment and support for mothers with ADHD showed positive Consequences for the children, whereby a higher intensity of treatment for mothers with ADHD (here: with DBT) only showed a temporary advantage for the children compared to less intensive treatment.274
Children of mothers with high neuroticism and low conscientiousness should benefit more from behavioral therapies than other children. In contrast, children of mothers with medium neuroticism and medium conscientiousness or low neuroticism and high conscientiousness should benefit more from a multimodal treatment of therapy and medication or from medication alone than from behavioral therapy alone.275
