2024 ADHD Review: “Interventions”

Nature Reviews Disease Primers published a 2024 review on ADHD. B/c only the abstract is publically available, here are points of possible interest.

Medication: “Pharmacotherapy is considered the first-line treatment for ADHD (after implementation
of environmental modifications).” And yet environmental modifications are so often overlooked!! Even the article says little about them, though it says, “In some patients, assessment of neurocognitive functions may detect cognitive strengths and weaknesses…helpful for planning educational or
vocational strategies.” I’d add that these strategies could include environmental modifications.

FDA-approved medications for ADHD are stimulants (methylphenidate and amphetamine
formulations) and non-stimulants. “Clinical guidelines recommend stimulants as the first-choice medication for ADHD owing to their high efficacy.”

“Some patients have an excellent response to non-stimulant monotherapy, whereas others are optimally treated with combinations of stimulants and non-stimulants, or combinations of longer-acting and shorter-acting stimulants.”

“No clinical or biological predictors of response are available for ADHD. Finding the optimal medication relies on educated trial-and-error. Identifying the optimal dose of stimulants may require several
weeks, with weekly titration.”

Most common adverse side effects are “appetite reduction, delayed sleep onset (stimulants) and other sleep issues (non-stimulants), although patients can also experience” better sleep due to decreased evening hyperactivity.

With ADHD, “There are no guidelines as to how” a medication “should be continued and how or when it should be stopped.”

Psychosocial (Adolescents & Children): “Behavioural therapy and cognitive–behavioural therapy (CBT)” are primary here. “These therapies are typically multicomponent, engage parents and modify behaviours based on social learning principles and cognitive–behavioural strategies (organization skills, problem solving, metacognitive strategies and social skills).” These therapies seek to temper the effect of ADHD …by modifying environmental factors (for example, parenting and educational context) and psychological factors (for example, psychological beliefs and coping mechanisms)

“Compared with medication, behavioural therapy puts higher demands on parents, patients and clinicians. Moreover, behavioural therapy takes longer to show initial efficacy than pharmacological therapy, because many weeks of therapy are needed. Behavioural therapy is well-liked by patients and consistently shows maintenance effects for months and sometimes years,” especially for adolescents.

Psychosocial (Adults): CBT (individual or group)…”as well as skills training have the greatest
evidence for efficacy.” “CBT aims to change dysfunctional thoughts and behaviours. Skills training addresses problem solving, distraction delay techniques, time management, behavioural control instructions, emotion regulation, mindfulness and social communication.”

Randomized controlled trials “show that combined treatment with medication and CBT is superior to medication alone for ADHD symptoms. CBT alone also improves anxiety, depression, self-esteem and emotional regulation.” In adults, “behavioural therapies can have long-lasting effects.”

Nutrition & Exercise: “ADHD is associated with unhealthy diets…high intake of ultra-processed foods with high proportions of refined sugar and saturated fat, and nutritional deficiencies, such as of vitamins B2 and B6 and polyunsaturated fatty acids. Importantly, however, these findings are observational rather than causal, because ADHD symptoms and the genetic risk of ADHD may influence dietary choices.”

“Significant although small to moderate reductions…ADHD symptoms based on properly blinded and controlled RCTs have been reported for ω3 fatty acid supplements, broad-spectrum micronutrient supplements, and exclusion of food colour additives and preservatives.”

“Complex interventions with healthy diets, a Mediterranean diet and the Dietary Approach to Stop Hypertension offer promise but await rigorous testing. Similarly, physical exercise may briefly relieve ADHD symptoms but has limited efficacy.”

Neurotherapy: “Trigeminal nerve stimulation (TNS) is an FDA-approved treatment for ADHD” based on an RCT with 62 child participants. A medium effect size was found “after 4 weeks of nightly TNS applications.”