Running head: NON-PHARMACOLOGICAL TREATMENT

Non-Pharmacological Treatment Approach to
Attention Deficit Hyperactivity Disorder
Adam T. Carter
Arizona State University

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Abstract
Attention Deficit Hyperactivity Disorder (ADHD) impacts as many as 1 in 10 children. ADHD
can affect academic performance, social interactions, relationships, and self-esteem.
Pharmacological interventions with the use of stimulant medication is the first line of treatment.
Children who do not respond to medication trials and suffer adverse side effects need alternative
treatment options to manage symptoms. New and immerging treatment options being studied to
determine efficacy for symptom management is cognitive behavior therapy, social skills training,
exercise and neuro feedback. They represent alternative options for non-pharmacological
treatment. Evidence supports the use of these treatment options alone, or in conjunction with
medication management. The evidence has led to an evidence base practice project conducted in
a psychiatric outpatient clinic using Play Attention technology and quantitative behavior testing
to determine the effectiveness of neurofeedback in treating children and adolescents with
ADHD.

Keywords: attention deficit hyperactivity disorder, nonpharmacological, pharmacological,
children

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Non-Pharmacological Treatment Approach to Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder (ADHD) is a medical diagnosis that affects
both children and adults. The American Psychiatric Association (2013) notes that ADHD
impacts 5-10% of children across all cultures. Children affected by ADHD suffer from reduced
academic performance, social rejection, decreased self-esteem, depression, and anxiety which
can lead to additional comorbidities across the lifespan (Sadock, Sadock & Ruiz 2015). Sadock
et al. (2015) also notes that pharmacological treatment is considered the first line of treatment for
ADHD. In the clinical setting, evidence has shown pharmacological treatment to be most
effective; however, additional non-pharmacological options exist for treating symptoms (Shaw et
al., 2012). Internal evidence has shown that often parent and children refuse pharmacological
treatment for ADHD and then are not always presented with clear alternate treatments. There
exists a gap between pharmacological treatment and non-pharmacological treatment options and
the child and parents understanding of what treatment is available. When parents are not in
agreement with giving their children medication despite its effectiveness, there needs to be
additional non-pharmacological interventions and resources available for children and parents to
consider.
Children with ADHD, and their families are impacted by not being properly educated
regarding pharmacological and non-pharmacological interventions. This lack of understanding of
treatment options impacts the child’s success in school, at home, and in the community, as well
as with relationships in these settings. Children with untreated or undertreated ADHD can
experience increased frustration, anxiety and depression at home and at school. ADHD tends to
impact the child most significantly in the school and home settings as they are not able to focus
or complete necessary tasks due to impulsivity, inattention or a combination of both (American

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Psychiatric Association, 2013). In a review of non-pharmacological interventions in school
settings by Richardson et al. (2015), it was suggested that ADHD psychoeducation and
relationship-building skills are potential implications for interventions and could provide
beneficial outcomes for patients with ADHD.
Problem Statement
Serrano-Troncoso, Guidi, and Alda-Diez (2013) state that ADHD is the most prevalent
psychiatric disorder in children and adolescents. As many as 1 in 10 children are diagnosed with
this disease, and it has a great impact on the psychological development of the patients it affects.
Initially ADHD was thought to be simply a behavior problem. There remains a stigma attached
to ADHD in our communities, school systems, and with parents and family members. Many
believe that children simply have behavior problems or need additional discipline. Unfortunately,
trying to discipline ADHD out of a child can worsen the patient’s symptoms and additionally
cause increased comorbidities (Sadock et al., 2015). ADHD cannot be “disciplined” out of
children. ADHD is a medical diagnosis that can be treated effectively. Stakeholders, those
impacted by the disease, such as the child and parents need to understand the disease and what
options are available for treatment, including non-pharmacological interventions. Although
stimulants are considered first line treatment, Shaw et al. (2012) identified that a combination of
pharmacological and non-pharmacological treatment for patients with ADHD helps reduce the
long term negative impact of untreated ADHD in as many as 72% of the outcomes reported. The
diagnosis of ADHD continues to gain better understanding as a medical diagnosis. As such, it
requires appropriate treatment. The use of non-pharmacological treatment options can be
beneficial for patients who decline or have adverse reactions to pharmacological treatment
options.

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Purpose and Rationale
The purpose of this paper is to identify and discuss non-pharmacological treatment
options for children diagnosed with ADHD. Providers and patients have many different
approaches to treating ADHD. This paper will identify various approaches to treatment including
the benefits of nonpharmacological treatment compared with pharmacological treatment alone. It
will include the benefits of educating patients and families about both pharmacological
interventions and provide them with non-pharmacological interventions that can be readily
accessible through group or individual settings. Educating patients concerning various modalities
of treatment will provide the patient with a better understanding of medication management as
well as skills training and therapy that could maximize the benefits of treatment.
Serrano-Troncoso et al (2013) identified several limitations with medication treatment for
ADHD and stated that non-pharmacological treatments are considered a necessary component of
treatment. Serrano-Troncoso et al. (2013) go on to identify the efficacy of alternative treatments
including behavior therapy, parent training, cognitive therapy and social skills training.
Medications are not the only option in treating ADHD. When medications don’t work children
and parents need to understand alternative options exist that can be utilized to treat and manage
symptom.
Background/Significance
It is observed at various clinical sites that many parents and children do not want to
initiate pharmacological interventions to treat diagnosed ADHD. For those that do initiate
pharmacological treatment, there are some that experience adverse side effects that make taking
the medication problematic. Failure to initiate pharmacological interventions or discontinued use
of medications due to side effects should not limit a child’s ability to manage symptoms.

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The role of pharmacological and non-pharmacological treatment of ADHD is to reduce
symptoms and improve functional outcomes (Arnold, Hodgkins, Caci, Kahle, & Young 2015).
Untreated ADHD typically presents with many comorbidities including anxiety and depression.
Depressed mood and anxiety are often treated unnecessarily as these symptoms would be
reduced or non-existent if the patient was properly treated for ADHD. Hauck, Lau, Wing, and
Kurdyak (2017) presented a study conducted in a primary care setting, identifying that patients
with ADHD were 12 times as likely to also be prescribed an antipsychotic medication and four
times as likely to be prescribed an antidepressant. The primary care setting is not ideal for
managing psychiatric health problems. Many primary care providers do not have sufficient
understanding of the disease process. They utilize additional medications when nonpharmacological interventions may be more appropriate to treat the ADHD and help reduce or
resolve comorbidities.
Schoenfelder and Sasser (2016) note that despite family concerns and lack of long term
medication adherence, stimulant medications continue to be the first line for treatment for
ADHD. Schoenfelder and Sasser (2016) also identify the growing evidence of implementing
psychosocial treatment alone or in conjunction with pharmacological treatment. Behavior parent
training, behavior classroom management and behavior peer interventions are being utilized to
help children and adolescents with ADHD work on improving functional outcomes. These nonpharmacological interventions address staying on task, being compliant with instructions,
increasing academic performance and working on social and family interactions and
relationships (Schoenfelder &Sasser, 2016). Practitioners play a critical role in educating patients
and parents about these treatment options and encourage family motivation and engagement in
the treatment of the patient.

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De Crescenzo, Cortese, Adamo, and Janiri (2017) conducted a meta review of 40 articles
identifying pharmacological and non-pharmacological treatment of ADHD. They determined
that pharmacological treatment is significantly more efficacious than placebo despite being less
accepted or tolerated. They went on to state that more research and empirical support is needed
to determine if non-pharmacological treatments are supported. Fabiano, Schatz, Aloe, Chacko,
and Chronis-Tuscano (2015) preformed a meta-analysis and determined that the use of nonpharmacological interventions and psychosocial treatments for ADHD are efficacious and
consistent with many literature reviews that strongly endorse non-pharmacological treatment for
youth with ADHD.
Neurofeedback is a non-pharmacological treatment that has mixed results in terms of
efficacy. Neurofeedback is a tool used to display real-time brain activity and is used to teach
individuals to self-regulate brain function. Gelade et al. (2016) compared the efficacy of
neurofeedback treatment for ADHD in comparison to stimulant medication and physical activity.
They determined based on the Strengths and Weakness of ADHD and Normal behavior (SWAN)
hyperactive/impulsive scales that behaviors improved simply with intention to treat, per parental
reports. SWAN inattention scales identified more improvement in patients who were receiving
stimulant medication treatment over neurofeedback. This was true with parental reports and
school reports. Interestingly, in another study Duric, Abmus, and Elgen (2014) identified
significant improvement in attention, hyperactivity and school performance of children and
adolescents in a randomized control trial based on a self-report of symptoms. This suggested that
patients felt neurofeedback was helpful and offers a promising alternative to treatment in those
who do not respond to pharmacological interventions or suffer from adverse side effects.

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In addition to neurofeedback as a non-pharmacological treatment option, there is a belief
that physical exercise can be efficacious for treatment of ADHD in children. Berwid and
Halperin (2012) identify that non-pharmacological treatment options for ADHD have been
expanding and indicate that intense aerobic exercise enhances brain structure and function which
can be beneficial for children with ADHD. There is not sufficient evidence to recommend this as
widespread treatment. Additional studies do need to be conducted.
A major area for concern with children and adolescents with ADHD is school
performance and homework completion. Sitting down and completing homework can present
significant problems for the child. The use of stimulant medication can be helpful but
alternatives need to be available. In a study by Merrill et al. (2017), they identified that
behavioral treatment that were homework focused resulted in clear benefits for homework
completion. Accuracy and long acting stimulant medication resulted in nonsignificant effects on
homework performance. Soderlund, Bjork, and Gustafsson (2016) added that auditory noise
treatment (white noise) resulted in task performance improvement when compared to stimulant
medications alone, adding to the conclusion that non-pharmacological interventions are a
potential alternative treatment for cognitive ADHD symptoms.
The treatment of ADHD symptoms is complex. There are no perfect treatments that work
the same for everyone. While pharmacological treatment utilizing stimulant medications is the
recognized first line treatment, Serrano-Troncoso et al (2013) state there are clear indications that
a combination of non-pharmacological and pharmacological treatment is recommended to treat
ADHD symptoms, and additional studies must be completed.

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This inquiry has led to the clinically significant PICOT question, “In children with
ADHD, how does non-pharmacological interventions compared to usual care, affect attention,
impulsivity and hyperactivity over a 3-month period?”
Search Strategies
To answer this clinical question, an exhaustive literature search was conducted. The
search of three databases including PsychInfo, PubMed, and CINAHL were utilized. Key words
used in this search included ADHD (and) non-pharmacological (and) pharmacological (and)
treatment (and) children. Search criteria was limited to include peer reviewed journal articles
that were written in English and published between 2012 to 2017. The abstracts were reviewed
and articles that addressed only pharmacological treatment for ADHD were excluded. Studies
identifying non-pharmacological interventions included neurofeedback, psychological treatment,
exercise, behavior parent training, skills training and cognitive behavioral therapy.
The initial search in PubMed was performed with the same search criteria and a yield of
46 articles resulted (Appendix A). Changing the search criteria to include only the title and not
the abstract condensed the yield to 15 articles. Of those 15, two articles were selected which
included one meta-analysis and one systematic literature review. PsychInfo yielded 342 results
(Appendix B). After adding additional search criteria, a final yield of 66 articles resulted. Upon
reviewing the abstracts and excluding various articles based on exclusion criteria, five final
articles were chosen from this database, including three randomized control trials, one metaanalysis, and one systematic literature review. The initial search in CINAHL yielded 109 articles
(Appendix C). With addition of search criteria, a final yield of 11 studies resulted. Upon further
review, three were chosen, including one randomized control trial and two meta-analysis.

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Critical Appraisal and Synthesis of Evidence
Ten studies were selected for this review (Appendix D). The studies included four
randomized control trials, four meta-analysis, and two systematic literature reviews. The level of
evidence in these studies included four level I studies, four level II studies and two level V studies.
Although these studies reviewed a variety of different non-pharmacological treatment options for
ADHD, all studies demonstrated moderate homogeneity. Similar designs were implemented to
provide strong validity and limit bias. Self-report, parental report, teacher report and testing for
academic performance were utilized to capture outcome measurements. The primary outcome
measurements included increased attention, increased academic performance, increased social
functioning and decreased hyperactivity (Appendix E). Seven studies implemented a form of CBT,
four studies implemented psychosocial therapy, three identified social skills training and
neurofeedback and two identified exercise. Six of the studies included a control group utilizing
pharmacological interventions to compare measurement outcomes between the control group and
the test group. This allowed for added validity regarding outcome measures for
nonpharmacological interventions as pharmacological treatment is the first line therapy for treating
children with ADHD.
Data analysis was well presented in the randomized control trial studies. The metaanalysis and systematic literature reviews provided an overarching significance of the evidence
as related to outcome measures but there were limited specifics as to what testing methods were
utilized. The benefit of utilizing meta-analysis and literature reviews is that they examine a large
number of studies and provide unbiased high levels of evidence. Two studies identified using the
Chi-square, Analysis of variance and paired t-tests. Additional studies utilized surveys and
questionnaires providing qualitative data that indicated effective treatment. These surveys and

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questionnaires demonstrate strong validity but without additional information regarding study
demographics and way these surveys and questionnaires were administer it is difficult to
determine reliability.
All studies included a population of children and adolescents ranging from ages 5-18
years old. One study did include adults age 18 and older. It is not clear in the meta-analysis or
systematic literature reviews as to the more specific demographics of the population studied.
Gender, race, socioeconomic status, and additional demographic information would need to be
obtained from the individual studies. This information will impact the heterogeneity, reliability
and validity of the studies. As noted, this information can be obtained through the individual
RCT’s that were reviewed in the meta-analysis and literature reviews but it was difficult to
identify specific test scores in the studies selected.
Conclusion from Evidence
The major findings of the body of evidence reviewed indicates that nonpharmacological
treatment plays a significant role in treating children with ADHD. Pharmacological interventions
are more frequently studied and continue to be first line treatment. Data indicates that a
combination of medication and non-pharmacological interventions or non-pharmacological
interventions alone increase children’s ability to manage ADHD Symptoms. Increased attention,
increased academic performance, increased self-esteem, increased cognitive functioning,
increased social interactions and decreased antisocial behavior and hyperactivity are indicated
when implementing non-pharmacological interventions. CBT, exercise, neurofeedback,
psychosocial therapy and social skills training all indicated improvement in outcome measures
identified (Appendix E). ADHD symptoms can be debilitating for children. Untreated or
undertreated ADHD can have a significant negative impact on a child’s social, academic and

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family interactions. Non-pharmacological interventions are an effective alternative to
medication. Additional research is needed to provide more clinical evidence for initiating nonpharmacological treatment options into clinical practice.
Contribution of Theory and EBP Model to Guide Implementation of Evidence
The theoretical framework varied from study to study, but the health promotions model
(HPM) was the underlying framework for the majority of the studies. HPM was proposed by
Nola Pender in 1982 and revised in 1996. HPM defines health as a positive dynamic state and
not just an absence of disease. Through the HPM, patients reach a desired behavioral outcome
that results in improved health, enhanced functional ability and increased quality of life in all
stages of development (Butts & Rich, 2015). The application of the HPM in working with
children with ADHD focuses on helping them reach a desired outcome of improved attention,
focus, self-esteem and social interaction. The theory will guide the project by looking to improve
quality of life for children with ADHD. The use of non-pharmacological treatment focuses on
creating a positive dynamic state and symptom management in a variety of settings.
The implementation of this evidence into clinical practice will utilize the Rosswurm and
Larrabee (1999) model for evidence based practice change (Appendix F). This model is selected
as it outlines the steps needed to implement practice change. Treatment for children with ADHD
has primarily focused on pharmacological treatment. Implementing practice change to
incorporate non-pharmacological interventions will require provider buy-in and must be
supported by evidence based practice in the clinical setting. This model is composed of six steps
including 1) Assess the need for change in practice; 2) Locate the best evidence; 3) Critically
analyze the evidence; 4) Design practice change; 5) Implement and evaluate change in practice;
and 6) Integrate and maintain change in practice (MeInyk & Fineout-Overholt, 2011). As

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previously identified, treatment for ADHD can include multiple modalities. There is a need for
practice change to incorporate more treatment options, including non-pharmacological treatment.
Evidence supports that non-pharmacological treatment is effective in reducing ADHD
symptoms. Evaluating and analyzing the evidence will lead to design and implementation of
practice change. Engagement with this model will allow the clinical team to work together to
promote change.
Purpose Statement
The purpose of this study is to determine the efficacy of neurofeedback training for
treating children with ADHD. Many patients and their families are in search of nonpharmacological interventions to treat ADHD and avoid initiating medications. Providing
additional studies to determine the efficacy of neurofeedback in treating ADHD can equip
providers with additional, non-pharmacological treatment options for combating the symptoms
of ADHD, including: activity, attention and impulsivity.
Project Methods / Applying Evidence to Practice
An evidence base practice project, incorporating neurofeedback training; was conducted
over a 20-week period in an outpatient psychiatric clinic in Gilbert, AZ. The project was
reviewed and approved by the Arizona State University Institutional Review Board. Key
stakeholders include the practice, psychiatrists, nurse practitioners, therapists, social workers,
and the patients and families involved in the study. Instruments for this project include
Quantitative Behavioral testing (Qb)and Play Attention neurofeedback treatment. Qb testing is a
15-minute test used to identify ADHD symptoms of inattention, impulsivity and activity; and
provides objective data points to be used along with clinical evaluation to assist in diagnosing
ADHD. Qb testing has proven reliability and validity, consistently measuring and recording

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scores for attention, impulsivity and activity as previously mentioned. Play Attention is a
neurofeedback software developed to help re-train the brain and improve/decrease ADHD
symptoms.
Participants voluntarily enrolled in Play Attention treatment groups as part of the
standard of care at the identified clinic. Treatment consists of 40 sessions, 2 sessions per week
over a 20-week period. These sessions are one hour in duration and the participants are in
groups not to exceed 6 participants. A baseline Qb test, a mid-point test, and a final Qb test were
intended to be completed to track quantitative data points and mean scores in relation to
attention, impulsivity and activity. Data analysis was conducted to identify statistical and/or
clinical significance of pre and mid-point Qb scores.
Project Results/Outcomes
Thirteen participants (N = 13), nine males and four females all with an ADHD diagnosis,
between the ages of 6 and 13 were involved in the project. These participants all completed at
least 20 neurofeedback sessions as well as pre and mid-point Qb testing. Due to the small sample
size, a Wilcoxon signed ranks test was utilized to compare the sample mean scores of the pre and
mid-point test values for activity, attention and impulsivity. Wilcoxon signed ranks test indicated
that midpoint test ranks were statistically significantly lower than pre-test ranks. Activity prescore (M = 1.82, SD = 1.12), midpoint score (M = 1.14, SD = 1.01) Z = -3.06, p = .002. Attention
pre-score (M = 2.47, SD = 1.27), midpoint score (M = 1.25, SD = 0.93) Z = -2.97, p = .003.
Impulsivity pre-score (M = 1.55, SD = 1.18), midpoint score (M = .36, SD = 1.05) Z = -3.18, p =
.001. A mean Qb score ≥ 1.5 indicates clinically significant symptoms for ADHD. For all three
categories, the mean Qb scores decreased from a clinically significant score (≥ 1.5) to a score
indicating an absence of clinically significant ADHD symptoms (< 1.5). The p-values also

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indicate statistical significance with all values ≤ .003. The effect size for the variables of activity,
attention and impulsivity = 1.10, 1.27, and 1.43 respectively; indicating that Play Attention
treatment has a large impact on all three dependent variables (activity, attention, and
impulsivity).
Impact of the Project
Neurofeedback as a non-pharmacological treatment option for ADHD shows clinical
promise based on the reduction of midpoint mean Qb scores. Unfortunately, Play Attention
neurofeedback treatment groups are not currently offered at the clinical site. Completion of all
40 sessions of Play Attention treatment and posttest Qb scores were not obtained because the
Play Attention treatment group was discontinued. It was not anticipated that the Play Attention
treatment group would be discontinued, however due to multiple complications with staff
turnover, schedule conflicts, and decreased client participation the administrative staff
discontinued the program.
The findings from this project warrant a discussion with the program director to discuss
reorganizing and resuming Play Attention treatment groups. Neurofeedback provides an
alternative treatment option for parents who do not want to medicate their children or for those
children who have experienced unwanted side effects from pharmacological treatment. Providers
can utilize the clinically significant data to determine non-pharmacological treatment options for
their patients. The data can also be used to advocate for further studies to be conducted to
determine if neurofeedback can be an evidenced based non-pharmacological treatment option for
ADHD.

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Conclusion
Pharmacological treatment remains first line treatment for children diagnosed with
ADHD. Children who struggle with ADHD and do not respond to medications need additional
treatment options. Neurofeedback provides an alternative non-pharmacological treatment option
that may help change the way children with ADHD are treated in the future. This pilot study
provided clinically and statistically significant data regarding the efficacy of Play Attention and
the use of neurofeedback to help re-train the brain and reduce ADHD symptoms. Additional
studies are needed to determine long term efficacy of non-pharmacological treatment options and
Play Attention studies need to be included in this process. If proven to be effective, Play
Attention can be introduced at additional outpatient clinics and be implemented as a treatment
option for children with ADHD who have previously failed medication trials or who are looking
for an alternative to pharmacological interventions.

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References
American Psychiatric Association (2013). The diagnostic and statistical manual of mental
disorders 5). Washington, D.C.: American Psychiatric Association
Arnold, L. E., Hodgkins, P., Caci, H., Kahle, J., & Young, S. (2015). Effect of treatment
modality on long-term outcomes in attention-deficit/hyperactivity disorder: A systematic
review. PloS One, 10(2), e0116407. doi:10.1371/journal.pone.0116407 [doi]
Berwid, O. G., & Halperin, J. M. (2012). Emerging support for a role of exercise in attentiondeficit/hyperactivity disorder intervention planning. Current Psychiatry Reports, 14(5), 543551. doi:10.1007/s11920-012-0297-4 [doi]
Butts, J.B., & Rich, K.L. (2015). Philosophies and theories for advanced nursing practice., MA:
Jones & Bartlett Learning
De Crescenzo, F., Cortese, S., Adamo, N., & Janiri, L. (2017). Pharmacological and nonpharmacological treatment of adults with ADHD: A meta-review. Evidence-Based Mental
Health, 20(1), 4-11. doi:10.1136/eb-2016-102415 [doi]
Duric, N. S., Assmus, J., & Elgen, I. B. (2014). Self-reported efficacy of neurofeedback
treatment in a clinical randomized controlled study of ADHD children and
adolescents. Neuropsychiatric Disease and Treatment, 10, 1645-1654.
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Fabiano, G. A., Schatz, N. K., Aloe, A. M., Chacko, A., & Chronis-Tuscano, A. (2015). A
systematic review of meta-analyses of psychosocial treatment for attentiondeficit/hyperactivity disorder. Clinical Child and Family Psychology Review, 18(1), 77-97.
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Gelade, K., Janssen, T. W., Bink, M., van Mourik, R., Maras, A., & Oosterlaan, J. (2016).
Behavioral effects of neurofeedback compared to stimulants and physical activity in
attention-deficit/hyperactivity disorder: A randomized controlled trial. The Journal of
Clinical Psychiatry, 77(10), e1270-e1277. doi:10.4088/JCP.15m10149 [doi]
Hauck, T. S., Lau, C., Wing, L. L., Kurdyak, P., & Tu, K. (2017). ADHD treatment in primary
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. Pelham, W. E. (2017). Improving homework performance among children with ADHD: A
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Sadock, B. & Sadock, V. & Ruiz, P. (2015). Kaplan and Sadock's synopsis of psychiatry:
Behavioral sciences/clinical psychiatry. Philadelphia, PA: Lippincott, Williams &
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Schoenfelder, E. N., & Sasser, T. (2016). Skills versus pills: Psychosocial treatments for ADHD
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Serrano-Troncoso, E., Guidi, M., & Alda-Diez, J. A. (2013). Is psychological treatment
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Shaw, M., Hodgkins, P., Caci, H., Young, S., Kahle, J., Woods, A. G., & Arnold, L. E. (2012). A
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NON-PHARMACOLOGICAL TREATMENT APPROACH
Appendix A
Search Strategy 1
PubMed

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NON-PHARMACOLOGICAL TREATMENT APPROACH
Appendix B
Search Strategy 2
PsycINFO

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NON-PHARMACOLOGICAL TREATMENT APPROACH
Appendix C
Search Strategy 3
CINAHL

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ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS

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Appendix D
Evaluation Table

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Arnold, L. E.
(2015)

Health
Promotion
Model

Design: MA

N-51 studies
looking at PT,
NPT, and Com
for ADHD

Effect of treatment
modality on longterm outcomes in
attentiondeficit/hyperactivity
disorder: A
systematic review.
Country: USA
Funding: Shire
Development LLC
Bias: none reported

Method:
systematic
search of 12
literature
databases to
identify peerreviewed,
primary studies
that reported
long-term
outcomes of
individuals with
ADHD.

Inclusion
criteria: English
language
publications
dated between
Jan. 1980 and
Dec 2011
Exclusion
criteria: MA,
CS, and LR
were excluded

Major
Variables
Definitions
IV1-NPT
IV2-PT
IV3- Com
DV1-A
DV2-AB
DV3driving
DV4NMDU
DV5-O
DV6- Occ
DV7services
used
DV8-SE
DV9-SF

Measurements

Data
Analysis

Findings

Data extraction
from 51
identified
studies.

Qualitative
Content
Analysis

Highest
improved
outcomes in
Com =83%
increase in
positive
symptom
outcomes
NPT= 65%
increase in
positive
symptom
outcomes
PT=56%
increase in
positive
symptom
outcomes

Survey
questionnaire to
identify
improvement or
no benefit in
treatment

Multiple
tools used
based on
the various
studies.
Post-hoc
analysis,
chi-square,
ANOVA
To
determine
if improved
outcomes
for DV1-9

Decision for Use in
Practice/Application to
Practice
Level V
Strengths: All studies used
were peer reviewed. Each
study was broken down to
review treatment outcomes
on the same 9 DV for
consistency of outcomes
based on treatment.
Weaknesses: different study
demographics and
population types, different
follow up intervals, different
treatment types, publication
bias
Conclusion: NPT, PT, and
Com all demonstrated
improved symptom
outcomes. Com was most
effective for significant
improvement in symptoms
in both short term and long
term follow up.

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS

24

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Berwid, O. G.
(2012)

Health
Promotion
Model

Design:
Multiple RCT
and CS to look
at the impact of
E on CF for
children with
ADHD

Multiple RCT
with N=64
healthy 5 and 6
year old N=171
sedentary 7-11
year old, N=40
school age
children with
ADHD, N-17
children grades
K-3

Emerging support
for a role of exercise
in attentiondeficit/hyperactivity
disorder
intervention
planning.
Country: USA
Funding: Grants
from the National
Institute of Mental
Health
Bias: none reported

Method:
Investigate the
impact of a set
exercise
program
compared to a
control group to
determine if CF
and A improve.

Major
Variables
Definitions
IV- E
DV- CF

Measurements

Data
Analysis

Findings

Spatial Span
Spatial working
memory

CANTAB
scores
showed
improved
CF and
Parent
rating
scales
indicated a
decrease in
inattention
and
disruptive
behaviors

CAS scores did
not show
significant
differences
from the control
group. Those
receiving
intense E
showed
improved
parental ratings
on cognitive
problems and
inattention.
Evidence
showed a
correlation
between E and
improved
behavioral
symptoms and
CF of school
age children
with ADHD

CAS
CANTAB
Connor’s Parent
Rating Scale
WoodstockJohnson Test of
Achievement

Decision for Use in
Practice/Application to
Practice
Level II
Strengths: Multiple RCT
were incorporated into this
study. Participants were all
school age children, both
male and female
Weaknesses: small sample
size, unblind status of the
researchers and raters of
behavior, lack of designed
control conditions, lack of
actual statistical evidence
(test scores, parental rating
scores) available to the
reader
Conclusion: There needs to
be more research and data to
evaluate the impact of E on
children with ADHD.
Larger controlled double
blind studies and longer
follow up times are needed
to determine the efficacy of
E as it relates to symptom
management of ADHD.
These studies identified do
correlate positive effects for
E on ADHD symptoms but
the data is not significant
enough to make E a

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS

25

Citation

Conceptual
Framework

Design/Method

Sample/Setting

De Crescenzo, F.
(2017)

Systems
Theory, Health
Promotion
Model

Design: MA,
LR

N=635 initial
studies, N=40
final studies
used in this MA
to determine
efficacy for PT
and NPT for
AHDD

Pharmacological
and nonpharmacological
treatment of adults
with ADHD: A
meta-review.
Country: England
Funding: Not
identified
Bias: none reported

Method:
database search
from 1 January
2010 to 31 May
2016 for
systematic
reviews on the
pharmacologica
l and nonpharmacologica
l treatment of
adults with
ADHD

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Duric, N. S. (2014)

Structural
Functional
Theory. Health
Promotion
Model

Design: RCT

N=91
Children and
adolescents
with ADHD

Self-reported
efficacy of
neurofeedback

Method:
children under
the age of 18

Major
Variables
Definitions
IV1-NPT
IV2-PT
DV- SM

Major
Variables
Definitions
IV1-MPH
IV2-MPH
and NF
IV3- NF

Measurements

Data
Analysis

Findings

Data extraction
from 40
identified
studies
ADHD
Symptoms
checklist

Qualitative
Content
Analysis
Medication
analysis
comparing
PT and
NPT to
placebo.

PT was more
effective than
placebo with a
standard mean
difference
(SMD) 0.45,
95% CI 0.37 to
0.52
NPT was not
shown to be
clinically
significant.
CBT did show
some
improvement in
ADHD
symptoms.

Measurements

Data
Analysis

Findings

Self-report
evaluation

General
linear
model

80% of
participants
completed the
study. All
treatment

treatment option at this
time.
Decision for Use in
Practice/Application to
Practice
Level I
Strengths: Multiple RCT
selected, Multiple authors
used in selection process.
No language restrictions,
only studies completed in
the last 10 years were
eligible for review. Only
peer reviewed articles were
included.
Weaknesses: RCT focused
on PT and included adult
trials. NPT was not
thourouly researched or
included in this MA
Conclusion: PT is more
efficacious than placebo,
additional data is needed to
include NPT as a clinical
option for treating ADHD
Decision for Use in
Practice/Application to
Practice
Level II
Strengths: Randomized
design, use of ICD-10
diagnostics with a multi-

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS
treatment in a
clinical randomized
controlled study of
ADHD children and
adolescents.
Country: New
Zealand
Funding: Grant
money from the
Department of
Research, Helse
Fonna Hospital,
Norway

26

participated in a
30-session
program of
intense NF
treatment.
Three groups
were randomly
selected. The
CG was given
MPH, the next
group was
given MPH and
NF, and the
third was
treated with NF
alone.

less than 18
years of age.

DV1-H
DV2-Att
DV3-AP

30 sessions of
intense NF
treatment

Analysis of
Variance
Paired ttest

groups resulted
in significant
improvements
regarding A and
H (p<0.001)
Only the NF
group resulted
in significant
improvements
in school
performance
(p=0.042)

Bias: none reported

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Fabiano, G. A.
(2015)

Integrated
Conceptual
model

Design: SLR

N=12, MA

Method:
Synthesized
outcomes
across MA of
NPT for
ADHD.

This included a
review of all
MA of
psychosocial
interventions
for children and
adolescents
with ADHD to
be as inclusive
as possible.

A systematic review
of meta-analyses of
psychosocial
treatment for
attentiondeficit/hyperactivity
disorder.
Country: USA

Major
Variables
Definitions
IV-NPT
DV1-AP
DV2-SF
DV3-A, H

Measurements

Data
Analysis

Findings

Data extraction
of 12 MA

Variability
across
outcomes
is apparent,
Many
categories
of outcome
measures
yield
significant
as well as
nonsignificant
estimates

Due to effect
size, little
overlap in
studies,
diversity of
inclusion and
exclusion
criteria and
types of PST it
was difficult to
complete a
quality
literature

Parent and
teacher ratings
AP
Observation of
behaviors

domain diagnostic
assessment and acceptable
follow up rate.
Weaknesses: No wellestablished NF protocol for
duration of treatment of
number of sessions.
Conclusion:
MPH, MPH and NF, and
NF groups all resulted in
improved SM of A and H.
The NF group was the only
group to show significant
improvement in school
performance. NF is an
effective NPT in treating
ADHD in children
Decision for Use in
Practice/Application to
Practice
Level V
Strengths: Thorough review
of the literature, multiple
authors determining
inclusion criteria for this
SLR
Weaknesses: Little overlap
in studies, diversity of
inclusion and exclusion
criteria, methodological
differences.

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS

27

Funding: Eunice K.
Shriver National
Institute for Child
Health and Human
Development

of effect
size

review of the
selected MA.

Conclusion: Using any one
of the meta-analyses
reviewed to make policy
decisions or determine the
efficacy of psychosocial
treatments for ADHD
appears unwise. There is a
strong need for a
comprehensive metaanalysis across all studies
in the psychosocial
treatment literature,
reporting separate effect
sizes for different
psychosocial treatment
approaches, so that the field
can continue to move
toward more evidenceinformed practice in the
treatment for ADHD.

Data
Analysis

Findings

Decision for Use in
Practice/Application to
Practice

Bias: none reported

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Major
Variables
Definitions

Measurements

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS
Gelade, K. (2016)
Behavioral effects
of neurofeedback
compared to
stimulants and
physical activity in
attentiondeficit/hyperactivity
disorder: A
randomized
controlled trial.

Health
Promotion
Model

County: USA
Funding: Not
identified
Bias: None reported

Citation

Conceptual
Framework

Design: RCT
Method: A
multicenter 3way parallelgroup study
with balanced
randomization
was conducted.
Children with
ADHD, ages 7–
13 years, were
randomly
allocated to
receive
neurofeedback
(n = 39),
methylphenidat
e (n = 36), or
physical
activity (n= 37)
over a period of
10–12 weeks.

Design/Method

28
N=39, NF
N=36, MPH
N=37, E
The study
reviewed results
of Parent and
teacher ratings
on the SDQ and
SWAN

IV1-NF
IV2-MPH
IV3-E
DV1-A
DV2-H

SDQ
SWAN
Parental and
teacher reports

Doubleblind
pseudorandomized
placebo
controlled
cross
titration
procedure.

Improved
parental reports
and scores on
the SDQ and
SWAN
regardless of
treatment
method,
including MPH,
NF, and E
Teachers
reported a
decrease in all
ADHD
measures of
children taking
MPH but not a
decrease in all
measures with
children
engaged in NF
and E.

Sample/Setting

Major
Variables
Definitions

Measurements

Data
Analysis

Findings

Level II
Strengths: Random
assignment to one of three
groups, sufficient duration
for observation of
symptoms
Weaknesses: Limited
sample size, not aware if
participants were male,
female or a combination.
Conclusion: The current
study found that optimally
titrated methylphenidate is
superior to neurofeedback
and physical activity in
decreasing ADHD
symptoms in children with
ADHD.

Decision for Use in
Practice/Application to
Practice

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS
Merrill, B. M.
(2017)

Pender’s Health
Promotion
Model

Improving
homework
performance among
children with
ADHD: A
randomized clinical
trial.
Country: USA
Funding: Not
identified

Design: RCT
Method:
Children were
placed in a
behavioral
treatment group
or a waitlist
group and also
participate
concurrently in
a psychostimulant
crossover trial

Bias: None reported

29
N=75
children with
ADHD ages 512
Exclusion
criteria: IQ <80,
previous
diagnosis of
ASD,
intolerability to
stimulant
medication, or
currently
receiving
psychotropic
medications for
a diagnosis
other than
ADHD

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Schoenfelder, E. N.
(2016)

Pender’s Health
Promotion
Model
Behavioral
Parent
Teaching,
Behavioral
Classroom

Design:
Evidence based
review of the
effectiveness of
Psychosocial
treatments to
improve
functional

Not identified
as a sample,
rather
presenting EBP
on the increased
functionality of
children with
ADHD based

Skills versus pills:
Psychosocial
treatments for
ADHD in childhood
and adolescence.

IV1-BT
IV2-WL
DV1homework
completion
DV2homework
accuracy

Major
Variables
Definitions
IV-PST
DV-SM

Objective
measures
Parental reports
Homework
completion and
accuracy

GLMM
Behavioral
parental
treatment
plan and
Digital
report card

Children who
had BT and a
digital report
card did on
average 2 letter
grades better
and completed
homework with
increase
accuracy. Those
placed on the
WL or given PT
showed no
improvement in
homework
completion or
accuracy.

Measurements

Data
Analysis

Findings

Behavior Parent
Training

Multimodal
treatment
studies

Behavior Parent
Training,
Behavioral
Classroom
Management,
Behavioral Peer
Interactions,
and

Behavioral
Classroom
Management

Level II
Strengths: Random
assignment to test group or
WL, Low attrition rate.
Weaknesses: sample size
included 71% males and
83% Hispanics. Limited
diversity in sample size.
Strength and type of
medication was limited.
Study was conducted in a
controlled environment and
not in a traditional school
setting.
Conclusion: the current
study indicated that children
with ADHD benefitted more
from a behavioral treatment
plan and digital report cards
than from PT with MPH. No
improvement was noticed
with PT as opposed to NPT.
Decision for Use in
Practice/Application to
Practice
Level I
Strengths: Several peer
reviewed articles referenced
in this opinion paper with
EBP to support claims

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS
Country: USA
Funding: Not
reported

Management
and Behavioral
Peer
Interventions

problems
associated with
ADHD

30
on behavioral
training and
treatment.

Organized
Skills Training

Method: EBP
review of the
benefits of
psychosocial
treatment and
parent/adult
training and
involvement.

Bias: None
identified

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Serrano-Troncoso,
E. (2013)
Is psychological
treatment
efficacious for
attention deficit
hyperactivity
disorder (ADHD)?
review of nonpharmacological
treatments in
children and
adolescents with
ADHD.

Health
Promotion
Model, Clinical
Practice
Guidelines

Design: MA

N=609 articles
with search
criteria
including
ADHD, parent
training, CBT,
SST, school
based
interventions,
academic
interventions,
and multimodal
treatment.
Languages
included
English,
Spanish, and
French. These

Country: Spain

Behavioral Peer
Interactions

Method: MA of
literature
published
between 1995
and 2010 on
nonpharmacologica
l treatment of
ADHD

Major
Variables
Definitions
IV-NPT
DV1-SF
DV2-A
DV3-AP

Measurements

Data extraction
and literature
review

Data
Analysis

Qualitative
Content
Analysis
Review of
EBP
articles
addressing
NPT for
children
with
ADHD. A
final
number of
12 (N=12)
were
analyzed.

Organized
Skills Training
do have studies
and evidence to
support they are
beneficial NPT
for children
with ADHD

Weaknesses: This is more of
an opinion article and does
not conduct any research to
support its claim that PST
for ADHD is effective
treatment
Conclusion: PST for ADHD
are effective evidence-based
approaches to improve
functional problems
associated with ADHD

Findings

Decision for Use in
Practice/Application to
Practice
Level I

Data reviewed
indicates
beneficial
affects of NPT
for children
with ADHD.
Decreased
symptoms of A
and H as well as
increase CF,
AP, SF are
indicated.
Literature is
still limited and
additional
studies need to
be conducted.

Strengths: Multiple search
databases were utilized to
search for literature. Levels
of evidence were
determined by the Scottish
Intercollegiate Guidelines
Network and were
determined by clinical
guideline practices.
Weaknesses: Limited
research articles available
addressing NPT for ADHD
Conclusion: This current
review indicated that there

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS
Funding: Shire
Development, LLC

31
articles
included SLR,
MA, and CCT.

Bias: None
identified

Citation

Conceptual
Framework

Design/Method

Sample/Setting

Shaw, M. (2012)

Multi-modal
Treatment
Study

Design: SLR

Sample: initial
yield of 5467
studies that
were manually
reviewed and
yielded 351
studies for
inclusion in this
analysis.

A systematic review
and analysis of
long-term outcomes
in attention deficit
hyperactivity
disorder: Effects of
treatment and nontreatment.
Country: England
Funding: Shire
Development, LLC.
Bias: Only using
English studies,
search criteria
exclusions,

Method:
An exhaustive
database search
was performed
to examine
outcomes of
participants
with untreated
ADHD and
participants
with treated
ADHD. Studies
were published
between 1980
and 2010.

Outcome
measures
included
NMDU, AP,
AB, SF, Occ,
SE, driving,
services used,
and O.

Major
Variables
Definitions
IV1-NPT
IV2-PT
IV3- Com
DV1-A
DV2-AB
DV3driving
DV4NMDU
DV5-O
DV6- Occ
DV7services
used
DV8-SE
DV9-SF

Measurements

DSM-IV
ADHD
diagnostic
criteria.
Data extraction
and 351 studies
were included
and categorized
into 9 major
categories or
symptoms of
ADHD
including AP,
AB, driving,
NMDU, O,
Occ, service
use, selfesteem, and SF

These
included
RCT
looking at
the efficacy
of NPT
including
BT,
parental
training,
CBT, and
SST.
Data
Analysis
Qualitative
Content
Analysis

is clear scientific evidence
of the efficacy of NPT for
ADHD

Findings

Outcomes of
ADHD were
identified by
age, treated vs
untreated
ADHD and by
region
including North
America as 1
region and the
rest of the
world as
another region.
Those treated
for ADHD had
better long term
outcomes than
those not
treated.

Decision for Use in
Practice/Application to
Practice
Level I
Strengths: 12 databases
were included in this search
for literature. Studies were
peer reviewed, primary
studies with long term
outcomes for ADHD
symptom management.
Weaknesses: Only English
language papers were
searched. Relevant studies
may have been omitted.
Conclusion: Without proper
treatment, those with
ADHD often experience
poor long term outcomes.
Treatment may improve
long term outcomes but not

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS
researcher bias,
changes over time

32
to the degree of healthy
controls.

in diagnostic criteria

Key: A-attention, AB- antisocial behavior, ADHD- attention deficit hyperactivity disorder, ANOVA-analysis of variance, AP-academic performance, ASD-autism spectrum
disorder, BT-behavioral treatment, CANTAB-cambridge neuropsychological test battery CAS-cognitive assessment system, CBT-cognitive behavioral therapy, CCT-clinical
control trial, CF-cognitive function, CG-control group, CI- Confidence interval, Com-combination treatment (pharmacological and non-pharmacological), CS-case studies, DVdependent variable, E-Exercise, EBP-evidence based practice, GLMM-Generalized linear mixed model, H-hyperactivity, IV-independent variable, LR- literature reviews, MAmeta-analysis, MPH-methylphenidate, N- number of participants, NF-neurofeedback, NMDU- non-medical drug use, NPT- non-pharmacological treatment, O-obesity, Occoccupation, PST-psychosocial treatment, PT-pharmacological treatment, RCT-randomized control trial, SDQ- strengths and difficulties questionnaire SE-self-esteem, SF-social
functioning, SLR-systematic literature review, SM-symptom management, SMD- standard mean difference, SST-social skills training, SWAN-strengths and weaknesses of ADHD
symptoms and normal behavior, WL-waitlist

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS

33

Appendix E

Major Findings Interventions

Basic Information

Shaw

Serrano Troncoso

Schoenfelder

Merrill

Gelade

Fabiano

Daric

Arnold

Berwid

STUDIES

DeCrescenzo

Synthesis Table

2015

2012

2017

2014

2015

2016

2017

2016

2013

2012

I
MA
Ø

II
RCT
Ø

I
MA
Ø

II
RCT
Ø

V
SLR
Ø

II
RCT
Ø

II
RCT
Ø

I
MA
Ø

I
MA
Ø

V
SLR
OELS

# of
participants
/studies

51

64,
171,
17

40

91

12

112

75

Ø

609

351

CBT
Ex
NF
PST
PT
SST

X

X

X

X

X

AB
AP
ATT
CF
HYP
SE
SF

↓
↑
↑
↑
↓
↑
↑

Year
LOE
Design
Bias

X

X

X

X
X

X
X
X
X

X
X
↓
↑
↑
↑
↓
↑

X

X
X

↑

↑
↑

↑
↑

↓

↓

↓

↓
↑
↑
↑
↓

↑

↑

↑

X
X
↑ w/CBT

↓
↑
↑
↑
↓
↑
↑

↑
↑
↑
↓
↑

X
X
X
X
↓
↑
↑
↑
↓
↑
↑

Key: AB- antisocial behavior, AP-academic performance, ATT-attention, CBT-cognitive behavioral therapy, CF-cognitive function, ,
Ex-Exercise, HYP-hyperactivity, MA-meta-analysis, NF-neurofeedback, PST-psychosocial treatment, PT-pharmacological treatment,
RCT-randomized control trial, SE-self-esteem, SF-social functioning, SLR-systematic literature review, SST-social skills training,

ADHD AND NON-PHARMACOLOGICAL INTERVENTIONS

Appendix F
Rosswurm and Larrabee Model

34