Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments
Publication: American Journal of Psychiatry
Abstract
Objective
Nonpharmacological treatments are available for attention deficit hyperactivity disorder (ADHD), although their efficacy remains uncertain. The authors undertook meta-analyses of the efficacy of dietary (restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation) and psychological (cognitive training, neurofeedback, and behavioral interventions) ADHD treatments.
Method
Using a common systematic search and a rigorous coding and data extraction strategy across domains, the authors searched electronic databases to identify published randomized controlled trials that involved individuals who were diagnosed with ADHD (or who met a validated cutoff on a recognized rating scale) and that included an ADHD outcome.
Results
Fifty-four of the 2,904 nonduplicate screened records were included in the analyses. Two different analyses were performed. When the outcome measure was based on ADHD assessments by raters closest to the therapeutic setting, all dietary (standardized mean differences=0.21–0.48) and psychological (standardized mean differences=0.40–0.64) treatments produced statistically significant effects. However, when the best probably blinded assessment was employed, effects remained significant for free fatty acid supplementation (standardized mean difference=0.16) and artificial food color exclusion (standardized mean difference=0.42) but were substantially attenuated to nonsignificant levels for other treatments.
Conclusions
Free fatty acid supplementation produced small but significant reductions in ADHD symptoms even with probably blinded assessments, although the clinical significance of these effects remains to be determined. Artificial food color exclusion produced larger effects but often in individuals selected for food sensitivities. Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms.
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History
Received: 30 July 2012
Revision received: 19 September 2012
Accepted: 28 September 2012
Published online: 1 March 2013
Published in print: March 2013
Authors
Funding Information
Dr. Sonuga-Barke has been involved in the development, implementation, and trialing of the New Forest Parenting Programme for preschool children with ADHD and has received royalties from sales of a New Forest Parent Training self-help manual; he has served as a speaker, adviser, or consultant for AstraZeneca, Flynn Pharma, Shire, and UCB Pharma, has received conference support from Shire, and has received research support from Janssen-Cilag, Shire, and Qbtech. Dr. Cortese has received financial support to attend medical meetings from Eli Lilly and Shire, has been co-investigator in studies sponsored by GlaxoSmithKline, Eli Lilly, and Genopharm, and has served as a consultant for Shire. Dr. Daley has served as a speaker or adviser for or received funding or travel support from Eli Lilly, Janssen-Cilag, UCB, and Shire. Dr. Holtmann has served as an adviser, consultant, or speaker or received conference attendance support from AstraZeneca, Bristol-Myers Squibb, Janssen-Cilag, Lilly, Medice, Neuroconn, Novartis, and Shire. Dr. Danckaerts has received research funding or educational grants from or served as a speaker or adviser for Janssen-Cilag, Lilly, Novartis, Medice, and Shire; she has also been involved in the development and dissemination of an ADHD toolkit for primary school teachers, distributed to all primary schools in Belgium by the Ministry of Education. Dr. Döpfner has received research support from or served as an adviser or speaker for Janssen-Cilag, Medice, Vifor, Shire, Lilly, and Novartis; he has been involved in the development, evaluation, and dissemination of the German behavioral interventions for children with ADHD; he has received royalties for treatment manuals (Beltz, Hogrefe Publisher) and has served as a as a consultant, supervisor, lecturer for the German Kassenärztliche Bundesvereinigung for the evaluation of behavior therapy; he is conducting a trial on the effects of omega-3 and omega-6 fatty acids supported by Vifor Pharma and several trials on the effects of behavioral interventions for children with ADHD supported by the German Research Foundation, the German Ministry of Education and Research, Shire, and Lilly. Dr. Dittmann is a former employee of Lilly Deutschland and now holds the Eli Lilly Endowed Chair of Pediatric Psychopharmacology at the Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Germany; he also holds shares of Eli Lilly & Co. stock; he has received research grants from the European Union, NIMH, the German Research Association, the Ministry of Research/Education (BMBF), and the Federal Institute for Drugs and Medical Devices (BfArM), as well as from Ferring, Janssen, Lilly, and Shire; he has received travel support and speaking honoraria from Lilly and Shire. Dr. Zuddas has received research grants or served as speaker, adviser, or consultant for AstraZeneca, Bristol-Myers Squibb/Otsuka, Lilly, Lundbeck, Schering-Plough, Shire, and Vifor. Dr. Banaschewski as served as adviser or consultant for Bristol Myers-Squibb, Develco Pharma, Lilly, Medice, Novartis, Shire, and Vifor Pharma; he has received conference attendance support and conference support or speakers honoraria from Janssen McNeil, Lilly, Medice, Novartis, and Shire and has been involved in clinical trials conducted by Lilly and Shire. Dr. Buitelaar is involved in clinical trials examining the efficacy of elimination diets, EEG-neurofeedback, and working memory training in ADHD that are funded by the BrainGain grant, NOW, Netherlands; he has planned studies on the metabolism of free fatty acids and biomarkers in ADHD that will be supported by Vifor; he has served as consultant, adviser, or speaker for Bristol-Myers Squibb, Janssen Cilag BV, Eli Lilly, Novartis, Schering-Plough, Servier, Shire, and UCB. Dr. Coghill has received research funding from Janssen-Cilag, Lilly, Shire, Vifor, the U.K. National Health Service, the U.K. National Institute for Health Research, and the European Union FP7 program and has served as a consultant, adviser, or speaker for Flynn, Janssen-Cilag, Lilly, Medice, Novartis, Otsuka, Pfizer, Schering-Plough, Shire, and Vifor. Dr. Lecendreux has served as a consultant for Bioprojet, Shire, and UCB Pharma and has received research support from Shire and UCB and honoraria from UCB and Shire. Dr. Wong has received research grants from or served as speaker or adviser for Janssen-Cilag, Eli Lilly, and Shire. Dr. Sergeant has received research funding from Lilly and has served as speaker or adviser for Janssen-Cilag, Lilly, Novartis, and Shire. The other authors report no financial relationships with commercial interests.
Supplementary Material
Support for meetings and analyses was received from Brain Products GMBH, Janssen-Cilag, Lilly, Medice, Shire, and Vifor. (No honoraria were received, and funders made no input into the review and meta-analysis process or the writing of the paper.)Metrics & Citations
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