Non-drug treatment of ADHD - Overview

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
• Presentation of the medication treatment at ⇒ Medication for ADHD - Overview.

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.

• 1. Non-drug therapy approaches for ADHD
  • 1.1. Effective therapeutic approaches for ADHD (see individual articles)
    • 1.1.1. Psychoeducation (+++)
    • 1.1.2. Endurance sports, fitness training (+++)
    • 1.1.3. Psychotherapy (++)
      • 1.1.3.1. Choosing a suitable psychotherapist for ADHD
    • 1.1.4. Mindfulness techniques (+++)
    • 1.1.5. Breathing techniques
    • 1.1.6. Environmental interventions (++)
    • 1.1.7. Everyday strategies for people with ADHD
    • 1.1.8. Take enough breaks
    • 1.1.9. Nutrition and diet for ADHD
    • 1.1.10. Sleep problems with ADHD - treatment
    • 1.1.11. Binaural music for ADHD and sleep problems
    • 1.1.12. Neurofeedback as ADHD therapy
    • 1.1.13. Transcranial magnetic stimulation / transcranial direct current stimulation (o/+)
    • 1.1.14. Trigeminal stimulation
    • 1.1.15. Therapy computer games
    • 1.1.16. Computer-based training programs
    • 1.1.17. Chess training / Go training / Board games
    • 1.1.18. Traditional Chinese Medicine (TCM)
    • 1.1.19. Light therapy
    • 1.1.20. White noise
    • 1.1.21. ADHD for teachers
  • 1.2. Therapeutic approaches for ADHD whose effect is not proven
    • 1.2.1. Occupational therapy
    • 1.2.2. Hemencephalography training
    • 1.2.3. Self-instructions
    • 1.2.4. Listen to (classical) music to improve your mood
    • 1.2.5. App-supported attention and organization training
    • 1.2.6. Organizational skills training
    • 1.2.7. Homework support
    • 1.2.8. Social behavior training
    • 1.2.9. Transcutaneous auricular vagus nerve stimulation (taVNS)
    • 1.2.10. Acupuncture (?)
    • 1.2.11. Homeopathy
    • 1.2.12. Fidgets
    • 1.2.13. Random Noise
    • 1.2.14. Spinal manipulation / spinal mobilization
    • 1.2.15. Ultrasound stimulation with low intensity
    • 1.2.16. Quiet Eye Training
    • 1.2.17. Animal-assisted therapy
    • 1.2.18. Parent management training
    • 1.2.19. Attention process training
  • 1.3. Therapeutic approaches that are definitely ineffective
    • 1.3.1. Phosphate diet (oats)
    • 1.3.2. Certain Foods / food additives as sole causal cause of ADHD
• 2. Multimodal therapy approach
• 3. Subtype-specific treatment
• 4. Multi-generational treatment for ADHD

1. Non-drug therapy approaches for ADHD¶

1.1. Effective therapeutic approaches for ADHD (see individual articles)¶

For the effective forms of therapy, see the linked individual articles.

1.1.1. Psychoeducation (+++)¶

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

1.1.3. Psychotherapy (++)¶

1.1.3.1. Choosing a suitable psychotherapist for ADHD¶

1.1.4. Mindfulness techniques (+++)¶

1.1.5. Breathing techniques¶

1.1.6. Environmental interventions (++)¶

1.1.7. Everyday strategies for people with ADHD¶

1.1.8. Take enough breaks¶

1.1.9. Nutrition and diet for ADHD¶

1.1.10. Sleep problems with ADHD - treatment¶

1.1.11. Binaural music for ADHD and sleep problems¶

1.1.12. Neurofeedback as ADHD therapy¶

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

1.1.14. Trigeminal stimulation¶

1.1.15. Therapy computer games¶

1.1.16. Computer-based training programs¶

1.1.17. Chess training / Go training / Board games¶

1.1.18. Traditional Chinese Medicine (TCM)¶

1.1.19. Light therapy¶

1.1.20. White noise¶

1.1.21. ADHD for teachers¶

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

1.2.1. Occupational therapy¶

The effectiveness of occupational therapy for ADHD is limited to the treatment of fine motor skills in preparation for school.⁴
A study reports positive effects of equine-assisted occupational therapy for schoolchildren with ADHD.⁵

1.2.2. Hemencephalography training¶

Effect not yet recognized, initial studies.⁶

1.2.3. Self-instructions¶

Effect is disputed.⁷

1.2.4. Listen to (classical) music to improve your mood¶

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.⁸ This does not prove an ADHD-specific treatment method.
However, music seems to be helpful for ADHD.⁹

1.2.5. App-supported attention and organization training¶

One study reports that cell phone app-based training in attention and organization led to relevant improvements in a third of adults with ADHD.¹⁰
A meta-analysis from 2019 found no further studies on the treatment of ADHD using specific apps¹¹

1.2.6. Organizational skills training¶

In SCT, training in organizational skills did not lead to any improvement in 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. 0.5.¹²
Parent assessments are highly susceptible to being biased towards desired outcomes. The greater the effort invested, the stronger this bias is.

1.2.7. Homework support¶

In the case of SCT, homework support did not lead to any improvement in 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. 0.5.¹²
Parent assessments are highly susceptible to being biased towards desired outcomes. This bias is all the stronger the greater the effort invested.

1.2.8. 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.¹³
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.¹⁵

1.2.9. Transcutaneous auricular vagus nerve stimulation (taVNS)¶

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.¹⁶
One report cites transcutaneous vagus nerve stimulation as a possible treatment for ADHD.¹⁷
So far, there are not even any individual studies that show a benefit in ADHD, let alone a reliable overall picture. taVNS is therefore only relevant as a research topic in relation to ADHD
One study found no effect of taVNS on locus coreuleus noradrenergic-controlled) sustained attention, but attenuation of cortisol reduction over time by active taVNS and interindividual effects of taVNS on alpha-amylase and salivary cortisol levels as indirect markers of locus coreuleus-noradrenaline.¹⁸
Similarly, taVNS did not show a general improvement in performance on reversal tasks, but worsened performance on distractor stimuli. taVNS did not lead to an increase in tonic pupil and alpha-amylase. The drop in cortisol was flattened by taVNS. taVNS lowered the respiratory rate but had no effect on cardiac vagus activity.¹⁹

In rats, a two-week VNS intervention significantly increased extracellular noradrenaline levels in PFC and hippocampus and enhanced tonic activation of postsynaptic α2A in pyramidal neurons²⁰
In mice, taVNS significantly increased c-Fos protein expression in the NST and locus coeruleus nuclei and reduced the heroin-induced anxiety response.²¹

The treatment approach should be considered against the background of the possible connection between the gut-brain axis and ADHD. In our understanding, however, if the cause of the ADHD is present, treatment with probiotics and dietary changes should be considered first. More on this under Gut-brain axis and ADHD

1.2.10. Acupuncture (?)¶

The effectiveness of acupuncture is controversial. To date, there are no conclusive medical explanatory models.

• Positive results

  • A meta-analysis reports a high effectiveness of acupuncture on hyperactivity²⁵
  • A meta-analysis of k = 14 studies with n = 1,185 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 sole 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.²⁶
  • Some studies report an effect that goes beyond placebo.^27282930

• Unclear results
  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 ³¹³²

• No improvements

  • Another meta-analysis of 5 studies found no robust evidence that acupuncture improves ADHD.³³

Another meta-analysis intends to investigate the effect of acupuncture for the treatment of ADHD³⁴

1.2.11. Homeopathy¶

A meta-analysis that had reported benefits of additional individual homeopathic treatment for ADHD was retracted due to erroneous interpretation in favor of homeopathy ³⁵³⁶
One RCT reported symptom improvements with homeopathy, but only in parental reports.³⁷ Parent reports are systematically biased and are generally more positive than teacher reports or physician evaluations.

1.2.12. Fidgets¶

One study observed significant improvement in sustained attention in students with ADHD who used Fidgets during class.³⁸

1.2.13. 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.³⁹

1.2.14. Spinal manipulation / spinal mobilization¶

A meta-analysis found no evidence of efficacy of spinal manipulation/mobilization for ADHD.⁴⁰

1.2.15. 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.⁴¹

1.2.16. Quiet Eye Training¶

Source⁴²

1.2.17. Animal-assisted therapy¶

Animal-assisted therapy is said to be helpful for ADHD.⁴³
A study reports positive effects of equine-assisted occupational therapy for schoolchildren with ADHD.⁵

A meta-analysis of k = 17 RCTs found an effectiveness of animal-assisted treatment compared to non-animal-assisted treatment groups in children with ADHD:⁴⁴

• 0.77 Motor skills
• 0.69 Learning and cognitive problems
• 0.42 Attention
• 0.46 Self-esteem

The pooled effect of animal-assisted treatment on the severity of ADHD symptoms did not differ significantly from the effect of conventional treatments in the control group.
As an ADHD treatment strategy that complements gold-standard approaches such as medication or multimodal interventions, animal-assisted therapy does not appear to be more effective in improving most of the core ADHD outcomes in children.⁴⁴

Animal-assisted treatment had no significant positive effects on⁴⁴

• social interaction
• social skills
• problematic behavior
• emotional problems, including depression and anxiety

1.2.18. Parent management training¶

Parent management training and attention process training were compared in three groups of children with ADHD of n = 15 each, all of whom were treated with methylphenidate.
Educational methods (parent management training) plus MPH proved to be more effective than MPH alone, but less effective than attention process training plus MPH.⁴⁵

1.2.19. Attention process training¶

Parent management training and attention process training were compared in three groups of children with ADHD of n = 15 each, all of whom were treated with methylphenidate.
Educational methods (parent management training) plus MPH proved to be more effective than MPH alone, but less effective than attention process training plus MPH.⁴⁵

1.3. Therapeutic approaches that are definitely ineffective¶

1.3.1. Phosphate diet (oats)¶

Find out more at ⇒ Nutrition and diet for ADHD

1.3.2. Certain Foods / food additives as sole causal cause of ADHD¶

There is no reliable evidence that certain foods or additives are responsible for ADHD.
However, food intolerances in general (in each case individual Incompatible substances) can lead to corresponding symptoms in the respective people with ADHD or increase the stress level in such a way that latent mental disorders (e.g. also ADHD) can appear or existing disorders can be exacerbated.
Find out more at ⇒ Nutrition and diet for ADHD

2. Multimodal therapy approach¶

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.⁴⁶ 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.⁴⁷

3. Subtype-specific treatment¶

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.

4. Multi-generational treatment for ADHD¶

Treating the children alone overlooks the fact that the influence of parents 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.⁴⁸

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.⁴⁹