Nonpharmacologic Treatments for

Attention-Deficit/Hyperactivity
Disorder: A Systematic Review
Adam P. Goode, DPT, PhD,​a,​b Remy R. Coeytaux, MD, PhD,​c,​d Gary R. Maslow, MD, MPH,​e,​f Naomi Davis, PhD,​e
Sherika Hill, MHA, PhD,​e Behrouz Namdari, MD,​e Nancy M. Allen LaPointe, PharmD, MHS,​g,​h
Deanna Befus, PhD, RN,​d Kathryn R. Lallinger, MSLS,​b,​i Samantha E. Bowen, PhD,​j Andrzej Kosinski, PhD,​b
Amanda J. McBroom, PhD,​b,​i Gillian D. Sanders, PhD,​b,​i Alex R. Kemper, MD, MPH, MSk

CONTEXT: Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD)

abstract
encompass a range of care approaches from structured behavioral interventions to
complementary medicines.
OBJECTIVES: To assess the comparative effectiveness of nonpharmacologic treatments for
ADHD among individuals 17 years of age and younger.
DATA SOURCES: PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for
relevant English-language studies published from January 1, 2009 through November 7,
2016.
STUDY SELECTION: We included studies that compared any ADHD nonpharmacologic treatment
strategy with placebo, pharmacologic, or another nonpharmacologic treatment.
DATA EXTRACTION: Study design, patient characteristics, intervention approaches, follow-up
times, and outcomes were abstracted. For comparisons with at least 3 similar studies,
random-effects meta-analysis was used to generate pooled estimates.
RESULTS: We identified 54 studies of nonpharmacologic treatments, including neurofeedback,
cognitive training, cognitive behavioral therapy, child or parent training, dietary omega
fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was
identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled
results for omega fatty acids found no significant effects for parent rating of ADHD total
symptoms (n = 411; standardized mean difference −0.32; 95% confidence interval −0.80
to 0.15; I2 = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized
mean difference −0.08; 95% confidence interval −0.47 to 0.32; I2 = 0.0%; P = .56).
LIMITATIONS: Studies often did not reflect the primary care setting and had short follow-up
periods, small sample sizes, variations in outcomes, and inconsistent reporting of
comparative statistical analyses.
CONCLUSIONS: Despite wide use, there are significant gaps in knowledge regarding the
effectiveness of ADHD nonpharmacologic treatments.

Departments of ePsychiatry and Behavioral Sciences, fPediatrics, and gMedicine, aDuke Orthopaedic Surgery, bDuke Clinical Research Institute, and jDuke Center for Autism and Brain
Development, School of Medicine,​Duke University, Durham, North Carolina; cDepartment of Family and Community Medicine and dCenter of Integrative Medicine, School of Medicine, Wake
Forest University, Winston-Salem, North Carolina; hPremier, Inc, Charlotte, North Carolina; iDuke Evidence-Based Practice Center, Durham, North Carolina; and kDivision of Ambulatory
Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio

To cite: Goode AP, Coeytaux RR, Maslow GR, et al. Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review. Pediatrics.
2018;141(6):e20180094

PEDIATRICS Volume 141, number 6, June 2018:e20180094 REVIEW ARTICLE

Many options exist for treating
attention-deficit/hyperactivity
disorder (ADHD) beyond commonly
used psychostimulant drugs.‍1
Nonpharmacologic approaches
either alone or in combination
with psychostimulants might
improve ADHD symptoms and
reduce the risk associated with
psychostimulants by decreasing
their use. Nonpharmacologic
therapies encompass a broad
range of approaches, from highly
structured behavioral interventions
to complementary medicines.
Behavioral interventions include
neurofeedback, cognitive training,
cognitive behavioral therapy (CBT),
or child or parent training. Additional
approaches have focused on
dietary, herbal, or omega fatty acid
supplementation.
Our goal was to systematically
evaluate the comparative
effectiveness and safety of
nonpharmacologic approaches to
ADHD. This report is a subset of a
systematic review sponsored by the
Agency for Healthcare Research and
Quality (AHRQ) to address broad
issues related to the diagnosis and
management of ADHD.‍2 In this report,
we update a previous systematic
review published in 2011‍3 that was
focused on the effectiveness of ADHD
treatment in at-risk preschoolers,
the long-term effectiveness of
ADHD treatment in all ages, and
the variability in ADHD prevalence,
diagnosis, and treatment. In the 2011
report, dietary or complementary
medicine approaches to the
management of ADHD were not
considered. In addition, that report
only required a comparator group
to assess effectiveness of therapy
for preschool-aged children. The
authors of the 2011 report indicated
that, in general, nonpharmacologic
(psychosocial and/or behavioral)
interventions alone were not as
effective as US Food and Drug
Administration (FDA)–approved
pharmacologic management of ADHD
2 GOODE et al
with a slight advantage to combining
psychosocial or behavioral
interventions with pharmacologic
management. Parent behavior
training as first-line treatment in
preschoolers had high strength
of evidence (SOE) in contrast to
pharmacologic interventions.
METHODS
We followed the methods for
systematic reviews recommended
in AHRQ’s Methods Guide for
Effectiveness and Comparative
Effectiveness Reviews‍4 and the
Preferred Reporting Items for
Systematic Reviews and Meta-
Analyses checklist‍5 using a
published protocol (PROSPERO
#CRD42016029134). Complete
details are provided in the full AHRQ
report.‍2
Data Sources and Search Strategy
We searched Medline, Embase,
PsycINFO, and the Cochrane
Database of Systematic Reviews,
limiting the search to English-
language studies published from
January 1, 2009 through November
7, 2016. We chose to assess evidence
from 2009 forward to (1) ensure
that the data represent current
therapies and (2) allow this report
to build on the previous systematic
review published in 2011.‍3 Database
searches were supplemented with
additional searches of clinical study
registries and manual search of
citations from key articles. Exact
search terms are provided in
Supplemental Tables 1 through 15.
Eligibility Criteria
We included studies of individuals
from birth through 17 years of age
with a diagnosis of ADHD receiving
a nonpharmacologic treatment of
ADHD (either alone or in combination
with pharmacologic treatment) that
reported any of a prespecified set of
intermediate, final, or adverse effect
outcomes of interest (Supplemental
Table 16). We required comparison
of the intervention to (1) other
nonpharmacologic treatments,
(2) FDA-approved pharmacologic
treatments, or (3) placebo, usual care,
or waitlist. Studies had to include a
sample size of at least 50 subjects.
We set a minimum sample size to
exclude pilot studies and potentially
low-quality studies. In addition, a
sample size of 50 subjects would
improve the likelihood of detecting
clinically meaningful differences. No
restrictions were placed on timing
of outcomes or on setting. Complete
details of the inclusion and exclusion
criteria for the full AHRQ review are
in the Supplemental Table 16.
Study Selection and Data Extraction
Pairs of investigators screened
titles and abstracts independently.
Citations deemed relevant by at
least 1 reviewer were promoted
to full-text screening, in which
2 investigators independently
reviewed each article. Disagreements
were resolved through discussion or
by a third expert member of the team.
Pairs of investigators abstracted
data from included studies, with 1
researcher abstracting the data and
a second overreading the article and
the accompanying abstraction to
check for accuracy and completeness.
Disagreements were resolved by
consensus or by obtaining a third
investigator’s opinion.
Quality and Applicability Assessment
of Individual Studies
We assessed the methodological
quality, or risk of bias, for each
individual study using the Cochrane
Risk of Bias tool for randomized
studies‍6 and the Newcastle-Ottawa
Scale‍7 for observational studies.
We rated each study’s quality as
good (low risk of bias), fair, or poor
(high risk of bias) on the basis of its
adherence to well-accepted standard
methods (Supplemental Table 17).‍4
The assessment was outcome specific
such that a given study might receive
a “good” quality rating for its analysis
of 1 outcome but a “poor” quality
rating for analysis of a different
outcome. We assessed applicability
using the method described in
AHRQ’s Methods Guide.‍4,​8

Data Synthesis
When meta-analysis was feasible,
we computed summary estimates of
effect. We aggregated outcomes when
there were at least 3 studies with the
same outcome using random-effects
models with the Knapp-Hartung‍9
correction to adjust the SEs for
small (≤4) numbers of included
studies. All quantitative analyses
were performed in R (R Foundation
for Statistical Computing, Vienna,
Austria).‍10
If a quantitative synthesis was
not feasible, we analyzed the data
qualitatively. We placed greater
emphasis on the conclusions from
evidence from higher quality studies
with more precise estimates of effect.
We divided treatment strategies
for ADHD by their comparators:
FDA-approved pharmacologic
versus nonpharmacologic and
nonpharmacologic versus
nonpharmacologic or placebo.
Nonpharmacologic therapies
include psychosocial interventions,
FIGURE 1
behavioral interventions, school Literature flow. a Three studies were relevant to >1 category of comparison.
interventions, cognitive training
therapies, learning training,
and analysis reporting bias. systematic review.‍2 Of 10 764 unique
biofeedback or neurofeedback,
These domains were considered citations screened, 66 articles
parent behavior training, dietary
qualitatively, and a summary rating describing 54 studies provided data
supplements (eg, omega fatty acids,
of high, moderate, or low SOE was relevant to the nonpharmacologic
vitamins, herbal supplements,
assigned for each outcome after treatment.‍12–‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍‍ 77
‍ For this report, we
probiotics), elimination diets, vision
discussion by 2 reviewers. When summarize reported outcomes of
training, and chiropractic treatment.
no evidence was available or when changes on standardized symptom
We combined studies of omega-3 and
evidence on the outcome was too scores or progress toward patient-
omega-6 fatty acids.
weak, sparse, or inconsistent to identified goals. Other study
SOE permit any conclusion to be drawn, a outcomes relating to treatment,
grade of “insufficient” was assigned. behavior, and function were
We assessed the SOE using the abstracted and are presented in the
approach described in AHRQ’s Supplemental Information.
Methods Guide.‍4,​11
‍ The approach RESULTS
requires assessment of 5 domains: Neurofeedback
study limitations, consistency, Result of Literature Search
directness, precision, and reporting ‍ igure 1 depicts the flow of articles
F Findings for neurofeedback
bias, the last of which includes through the literature search and interventions versus
publication bias, outcome reporting, screening process for the full AHRQ nonpharmacologic or pharmacologic

PEDIATRICS Volume 141, number 6, June 2018 3

or placebo, usual care, or waitlist
are described in Supplemental Table
18. In 4 randomized controlled
trials (RCTs),​‍19,​34,​
‍ 55,​
‍ 68,​
‍ 69 in which
a total of 353 participants were
enrolled, researchers examined
neurofeedback as an intervention
versus a nonpharmacologic
intervention (n = 3), pharmacologic
intervention (n = 1), or placebo,
usual care, or waitlist (n = 3).
Nonpharmacologic Versus
Nonpharmacologic
In 3 studies, researchers examined
neurofeedback as the primary
intervention and evaluated
standardized symptoms scores or
progress toward patient-identified
goals.‍34,​55,​
‍ 68,​
‍ 69
‍ All 3 studies were
RCTs: 2 were of good quality34,​68,​
‍ 69
‍ standardized outcome measures
55
and 1 was of fair quality.‍ Follow-up
times were either not reported or
short-term (2 months). In 1 study,
researchers found a statistically
significant decrease in ADHD
symptoms using a standard scale
comparing neurofeedback with an
attention skills control condition.‍34,​35,​75
‍ findings on neurofeedback
In a second study, researchers found
significant improvements in ADHD
symptoms according to parent and
teacher reporting for neurofeedback
compared with control.‍68,​69 ‍ Subjects
in the control group also had a
statistically significant increase
in their average dose of stimulant
therapy compared with those in the
neurofeedback group, who did not
have a significant change in stimulant
therapy. A third study compared
neurofeedback to behavioral
treatment and found that the group
treated with neurofeedback showed
greater improvement in a continuous
performance test score.‍55
Nonpharmacologic Versus
Pharmacologic
In 1 3-arm trial, researchers
combined methylphenidate with
neurofeedback‍25,​26
‍ enrolling 91
participants and short follow-up
period of 10 weeks. This trial
was judged to be of poor quality.
4 GOODE et al
The primary outcome measure
was the Barkley Rating Scale for
Parents. Findings from this study
did not support any statistically
significant differences between
either methylphenidate alone,
methylphenidate in addition to
neurofeedback when compared with
neurofeedback alone (P = .31).
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
In 3 RCTs, researchers compared
neurofeedback to usual care or
standard care enrolling a total of 251
participants. Two of the trials were
judged to be of good quality‍19,​68,​
‍ 69
‍ respect to the types of training games
and 1 of fair quality.‍55 In 2 of the
studies,​55,​68,​
‍ 69‍ researchers found
significant differences on the
when comparing neurofeedback to
standard pharmacologic treatment
or control.
Other Findings for Neurofeedback
No significant findings for other
outcomes were identified. Detailed
interventions across the
included studies are presented in
Supplemental Table 19.
Cognitive Training
Findings for cognitive training
interventions are described in
Supplemental Table 20. In 5
RCTs‍23,​24,​
‍ 28,​
‍ 35,​
‍ 41,​71,​
‍ 72,​
‍ 75
‍ totaling
405 participants, researchers
compared cognitive training to a
nonpharmacologic intervention (n = 5)
or placebo, usual care, or waitlist
control (n = 1). In 1 observational
study in which‍18 52 participants
were enrolled, researchers compared
cognitive training to waitlist control.
Cognitive training was not compared
to pharmacologic interventions and
any studies.
Nonpharmacologic Versus
Nonpharmacologic
In 4 RCTs, researchers evaluated
cognitive training versus a
nonpharmacologic intervention and
evaluated standardized symptoms
scores or progress toward patient
identified goals. Three were good
quality‍23,​72
‍ and the other was fair
quality.‍71 A total of 330 participants
were enrolled across these 3 trials
with predominately short follow-up
times (≤6 months). In a single,
good-quality RCT, researchers
found no significant treatment
effects in improvement in Wide
Range Achievement Test 4 (WRAT-4)
Progress Monitoring Version scores
compared with a low-level working
memory training program that was
identical to active intervention with
used and the number of training trials
per session but for which difficulty
level was not adjusted according to
each user’s performance parameters.‍23
No teacher measures revealed any
significant changes. In the other study,
there was improvement at 2 and 6
months on the parent rated Behavior
Rating Inventory of Executive Function
(BRIEF) Metacognition Index and at
2 months (but not 6 months) on the
BRIEF parent-rated behavioral index.71
Nonpharmacologic Versus
Pharmacologic
No studies were identified in which
the comparison of cognitive training
to pharmacologic interventions was
made.
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
In 1 RCT‍28 and 1 observational study,​‍18
researchers compared cognitive
training versus placebo or usual
care. The RCT was judged to be of
good quality and the observational
study was judged to be of fair
quality. A total of 127 participants
were enrolled and follow-up times
varied from 4 to 8 months. In the
RCT, researchers compared Cogmed
RoboMemo Program to a waitlist
control group and at 8 months they
report no significant differences
on the ADHD rating scale (RS)
Teacher or Parent total scores. In
the observational study, researchers
compared the Cogmed intervention
with a waitlist control, and at 4
months the treatment group had
significantly better scores on parent
report on the ADHD Index, Conners
Cognitive Problems/Inattention,
Conners Hyperactivity Parent, and
BRIEF Metacognition Index.‍18
Other Findings for Cognitive Training
No significant findings for other
outcomes assessed were identified
for cognitive training versus
nonpharmacologic or placebo, usual
care, waitlist. In 1 study, researchers
found significant behavioral
differences (P < .001) on both the
parent and teacher SWAN Inattention
and Hyperactivity scales at 12
weeks comparing neurofeedback
to methylphenidate (Supplemental
Table 21).
CBT
Findings for CBT interventions are
described in Supplemental Table
22. In 2 RCTs‍20,​21,​
‍ 73‍ in which 298
participants were enrolled, researchers
compared CBT to nonpharmacologic
interventions (n = 1) or placebo, usual
care, or waitlist control (n = 1).
Nonpharmacologic Versus
Nonpharmacologic
In 1 fair-quality study,​‍20,​21
‍ researchers
evaluated 159 subjects and compared
CBT with and without interventions
to improve planning skills. Standard
symptom scores or progress toward
patient-identified goals were
evaluated at 3 and 12 months. In this
study, changes in the depression
and anxiety scale scores were
examined, and it was found that the
CBT group had greater improvement
in depression and anxiety scores
compared with the control group
at 3 months; it was found that the
depression score improvements were
maintained at 12 months. In addition,
CBT maintained superiority in ADHD
scale scores. In this study, it was
also found that there was a greater
improvement (P < .001) in the Child
Behavior Checklist (CBCL) conduct
PEDIATRICS Volume 141, number 6, June 2018
disorder and/or oppositional defiant
disorder subscale both immediately
after treatment and at 12 months.
Nonpharmacologic Versus
Pharmacologic
No studies were identified in which
CBT interventions were compared to
a pharmacologic intervention.
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
In 1 good-quality study,​‍73 researchers
compared CBT with usual care,
finding significant changes (P < .001)
on the ADHD RS for both adolescent
and parents’ inattention and
impulsivity at 12 weeks of follow-up.
Other Findings for CBT
In 1 study,​‍20,​21
‍ researchers found
significant changes in the child
depression inventory (P < .001)
and screen for child anxiety–
related emotional disorders at 12
months when comparing CBT to
solution-focused CBT. Another set
of researchers‍73 found significant
improvements in the Clinical Global
Impression-Severity (CGI-S) self-
report (P < .001) and CGI-S Clinician
(P < .001) comparing CBT to usual
care (Supplemental Table 23).
Child or Parent Training
Findings for child or parent training
interventions are described in
Supplemental Table 24. In 9 RCTs*
in which 1099 participants were
enrolled, researchers compared
child or parent training to
nonpharmacologic interventions
(n = 4), pharmacologic (n = 1),
or placebo or usual care (n = 5).
In 1 observational study,​‍29 120
participants were enrolled. A
range of different types of non-CBT
behavioral interventions including
organizational skills, social skills,
attention skills, positive parenting,
psychoeducational, sleep hygiene
or behavioral, or parent or teacher
* Refs ‍16,​‍22,​‍32,​‍39,​42,​‍55,​‍59,​‍60,​‍62.
behavioral training interventions.
The interventions were mixed in
terms of their strategies: some were
interventions that helped parents
learn how to cope with their own
emotions, but most strategies were
focused on how parents could
manage specific behaviors from their
children with ADHD.
Nonpharmacologic Versus
Nonpharmacologic
In 3 good quality‍16,​22,​
‍ 62
‍ and 1
42
fair-quality‍ RCTs representing
505 participants, researchers
compared child or parent training
or behavioral interventions to a
nonpharmacologic intervention and
evaluated standardized symptoms
scores or progress toward patient-
identified goals. Findings were mixed.
In 1 study,​16 researchers found a
significant difference in the attention-
deficit/hyperactivity disorder
rating scale IV (ADHD RS IV) at 3
months comparing psychoeducation
and general clinical counseling.
Another group of researchers‍62
found a significant difference when
comparing child life and attention
skills treatment to parent group
component only in the Parent
Child Symptom Inventory at both
13 weeks and 7 months and Child
Symptom Inventory at 13 weeks.
In the third study,​‍42 researchers
found a significant difference in
the CBCL Change in Attention
Problems Subscale at 6 months when
comparing behavioral-based social
skill training for patient and parent
groups to group therapy.
Nonpharmacologic Versus
Pharmacologic
In 1 study,​‍55 researchers compared
standard pharmacologic treatment
with behavioral treatment of children
in conjunction with parent and
teacher training. In this RCT, 57
participants were enrolled, and the
RCT was judged to be of fair quality.
At 20 weeks of follow-up, significant
changes (P = .013) on the Integrated
Visual and Auditory Continuous
5
Performance Test (IVA/CPT) full-scale
attention were found in this study.
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
In 4 good-quality RCTs‍22,​32,​
‍ 39,​
‍ 59,​
‍ 60 and
1 fair-quality observational study‍29
representing 657 participants,
researchers compared child or parent
training interventions to placebo,
usual care, or control groups.
Significant findings were limited.
In 1 study,​‍39 researchers found
significant changes at 6 months in the
ADHD RS IV for parent report
(P = .004), inattentive (P = .001), and
hyperactivity and/or impulsivity
(P = .04) when comparing sleep
hygiene and standardized behavior
strategies to usual clinical care. In
another study,​‍59 researchers found
significant changes at 3 months for
the ADHD combined type parent scale
when comparing Barkley-based parent
plus teaching behavioral interventions
to waitlist. Another‍32 compared a
psychoeducational program to a
control group finding significant
changes on the Conners’ Parent
Rating Scale (CPRS) Inattention scale
(P = .001), CPRS parent inattention/
cognition scale P = .0032), and CPRS
Index (P = .001) at 12 weeks.
Other Findings for Child or Parent Training
In 1 study,​‍22
researchers compared
the Strategies to Enhance Positive
Parenting to a behavioral parent
training program finding significant
(P < .01) improvement on the
acceptability of treatment with
the Parent Treatment Attitude
Inventory at 2.07 months. In this
study, functional impairment was
also significantly (P < .01) improved
on the Impairment Rating Scale. In
another study,​‍39 researchers found
significant (P < .001) differences in
sleep disturbance on the Child Sleep
Habits Questionnaire at 6 months
comparing sleep hygiene practices
and behavioral strategies compared
with usual clinical care. In this
study, significant differences were
found on days late for work (P = .02)
6 GOODE et al
and missed days of work (P = .03)
(Supplemental Table 25).
Dietary Supplements With Omega
Fatty Acids
We identified 5 good-quality,​‍14,​36,​
‍ 43,​
‍ 47,​
‍ 50
64,​
77
2 fair-quality,​‍ ‍ and 1 poor-
quality studies‍38 representing 1130
patients evaluated essential fatty acid
supplementation. In 7 of these trials,
researchers compared essential fatty
acid supplementation with placebo.
Of these, the active intervention was
omega-3 alone in 4 trials,​‍36,​38,​47,​
‍ 48,​
‍ 77
‍ eicosapentaenoic acid and versus
64
omega-6 alone in 1 trial,​‍ and a
combination of omega-3 and omega-6
in 2 trials.43,​44
‍ Treatment duration
ranged between 7 weeks and
6 months. The enrolled children
ranged between 6 and 18 years of
age and the range of included male
children was 59.4% to 77.3% across
the trials. In 1 of the trials,​‍77
researchers measured outcomes
of ADHD symptoms with scales
that were not part of our inclusion
criteria and were excluded from the
meta-analysis. The remaining 7 trials
measured ADHD symptoms with the
Conners Scale (full or abbreviated
version) or the ADHD RS.
Nonpharmacologic Versus
Nonpharmacologic
Two good-quality RCTs‍14,​50‍ with a
total of 100 participants evaluated
supplements. In 1 study,​‍50 researchers
compared eicosapentaenoic acid and
docosahexaenoic acid and found no
statistical differences on the CPRS
ADHD Total. Researchers for the other
study‍14 compared polyunsaturated
fatty acids plus atomoxetine
to atomoxetine alone found no
significant differences on the CPRS-
Revised Short Form at 4 months.
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
We identified 4 RCTs in which
researchers compared omega
fatty acid supplementation and
placebo,​‍36,​38,​
‍ 43,​
‍ 47
‍ with parent RSs as an
outcome. Figure 2 summarizes these
findings and the overall measure after
meta-analysis. Effects were consistent
and moderate heterogeneity was
found across studies; however, no
statistical evidence was found that
omega fatty acids were superior
to placebo. Three trials that were
excluded from the meta-analysis for
not using an outcome assessment tool
that met our inclusion criteria‍77 or not
comparing to a placebo‍14,​50
‍ also found
no significant differences between
omega-3/6 versus placebo,​‍77
versus usual care,​14 or between
docosahexaenoic acid‍50 for parent
ratings of ADHD total symptoms. For
teacher-rated total ADHD symptoms,
we identified 3 RCTs in which omega
fatty acids versus placebo were
examined (‍Fig 3).‍36,​47,​
‍ 64 Effects were
fairly consistent and studies were
homogeneous; however, we found no
statistical evidence that omega fatty
acids were superior to placebo. The 2
RCTs excluded in this meta-analysis
for not comparing to a placebo‍14 and
using an outcome assessment tool that
did not meet our inclusion criteria‍77
also found no significant difference
between omega-3 and placebo or
usual care for teacher ratings of ADHD
total symptoms. Although adverse
effects were reported in 1 trial,​‍47
the researchers did not find any
statistically significant between-group
differences.
Other Findings for Omega Fatty Acid
Supplements
In 1 study,​‍17 researchers compared
omega fatty acids to methylphenidate
and found significant (P = .001)
increases in functional impairment
at 1 year on the Clinical Global
Impression (CGI) parent and clinician
scales (Supplemental Table 26).
Herbal or Dietary Approaches
Findings for the herbal intervention
and dietary approaches can be found
in Supplemental Table 27. In 7
RCTs,​‍15,​27,​
‍ 46,​
‍ 52,​
‍ 61,​65
‍ researchers
examined herbal or dietary approaches
against nonpharmacologic treatments

FIGURE 2
Meta-analysis of the effects on parent ratings of omega-3/6 supplementation compared with placebo.
CI, confidence interval; SMD, standardized mean difference.
FIGURE 3
Meta-analysis of the effects on teacher ratings of omega-3/6 supplementation compared with placebo.
(n = 2), pharmacologic treatments
(n = 2), or placebo, usual care, or
waitlist (n = 3).
Nonpharmacologic Versus
Nonpharmacologic
In 1 good-quality‍61 and 1 fair-
quality‍15 studies representing 152
patients, researchers evaluated
herbal interventions or dietary
approaches compared with other
nonpharmacologic interventions.
In 1 study,​‍61 researchers compared
restricted elimination diet to no
elimination diet and reported
significant results after 5 weeks for
both the parent and teacher ADHD total
scores and both Parent and Teacher
Abbreviated Conners Scale. In the
other study,​‍15 researchers compared
zinc supplementation once daily to
zinc supplementation twice daily and
reported no significant differences from
8 to 21 weeks of follow-up.
Nonpharmacologic Versus Pharmacologic
In 2 good-quality RCTs‍46,​65
‍ symptoms compared with
representing 122 patients,
PEDIATRICS Volume 141, number 6, June 2018
researchers compared
nonpharmacologic treatments
to pharmacologic treatments.
Methylphenidate was the
pharmacologic treatment in both
studies. In 1 study,​‍46 researchers
compared ningdong granule to
methylphenidate and reported
no significant differences at
8 weeks. In the other study,​‍65
researchers compared ginkgo biloba
to methylphenidate and found
significant differences in the ADHD
Parent and Teacher RS IV at
6 weeks.
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
In 1 good-quality‍27 and 2 fair-
quality‍15,​52
‍ RCTs representing
192 patients, researchers
compared herbal or dietary
approaches to placebo or usual care.
Of the 3 RCTs, neither Memomet
syrup, zinc supplementation,
nor vitamin D improved ADHD
placebo.‍15,​27,​52
‍ significant behavior changes on the
Other Findings for Herbal or Dietary
Approaches
In 1 study,​‍66 researchers compared
ginkgo biloba to placebo with both
groups receiving methylphenidate.
At 6 weeks, significant changes were
found on the ADHD RS IV for parent
and teacher inattention. In another
study,​‍65 researchers compared
methylphenidate to ginkgo biloba and
found significant changes in appetite
(P = .0002) and sleep disturbance
(P = .01) (Supplemental Table 28).
Other Treatment Approaches
Findings for other treatment
approaches to ADHD treatment can
be found in Supplemental Table
29. In 3 RCTs‍40,​53,​
‍ 56,​
‍ 76
‍ in which
207 participants were enrolled,
researchers compared other
treatment approaches to placebo,
usual care, or waitlist control.
Nonpharmacologic Versus
Nonpharmacologic
No studies were identified in
which nonpharmacologic versus
nonpharmacologic interventions
were compared.
Nonpharmacologic Versus Pharmacologic
No studies were identified in
which nonpharmacologic versus
pharmacologic interventions were
compared.
Nonpharmacologic Versus Placebo,
Usual Care, or Waitlist
In 3 fair-quality RCTs‍40,​53,​
‍ 56,​
‍ 76
‍
representing 207 patients,
researchers compared other ADHD
treatment approaches to placebo
or usual care. Interventions varied
between acupuncture,​40 melatonin,​‍53,​56
‍
and the Incredible Years Program.‍76
No significant findings were reported
for any of these interventions across
standardized symptom scores.
Other Findings for Other Treatment
Approaches
In 1 study, researchers found
7
Vanderbilt teacher and caregiver scale
at 25 weeks, comparing telemedicine
to usual care plus consulting.‍57 In
another study,​‍58 researchers found
significant changes in behavior change
on the CPRS revised scale at 12 weeks,
comparing homeopathy to placebo.
In another study,​‍13 researchers
found significant (P = .001) behavior
changes on the CPRS at 6.8 months
comparing New Forest Parental
Package to the waitlist control
condition. Hong and Cho‍40 found
significant (P = .012) improvements in
functional impairment at 1.5 months
comparing acupuncture to waitlist
control. In 1 study,​58 researchers
found significant (P = .001) changes
in functional impairment on the CGI-S
Scale comparing homeopathy to
placebo (Supplemental Table 30).
Adverse Effects
Supplemental Table 31 provides the
adverse effects and findings from
individual studies. Adverse effects
were identified in 3 of the included
studies examining nonpharmacologic
interventions compared with
pharmacologic interventions.‍17,​46,​
‍ 65
‍ for children and adolescents. The
In 4 studies, researchers measured
and reported adverse effects in
nonpharmacologic versus non­
pharmacologic interventions (omega
fatty acids, zinc, and compound of
herbal preparation).‍15,​45,​47,​
‍ 48‍ The
most commonly occurring adverse
effects were gastrointestinal symptoms,
sleep disturbances, and changes in
appetite. None of researchers of these
studies reported significant differences
between study groups and the
proportion of adverse effects.
SOE
Supplemental Table 32 describes
the SOE findings for the changes in
standardized symptom scores across
each intervention. Pharmacologic
interventions, neurofeedback, and
other treatment approaches all were
judged to have insufficient SOE to
support conclusions. CBT, cognitive
training, and herbal interventions or
8 GOODE et al
dietary approaches were all judged to
have low SOE. Both omega fatty acid
supplementation and child or parent
training or behavior interventions
were judged to have moderate SOE to
support conclusions. No outcomes of
interest were judged to have high SOE.
DISCUSSION
In this systematic review of studies
published from 2009 through 2016,
we found little new evidence to guide
treatment with nonpharmacologic
therapies for ADHD. Overall, there
was a low SOE for the impact of
nonpharmacologic treatments
for ADHD across the outcome
measures selected for this review.
In 2011, the authors of a systematic
evidence review found that parent
behavior treatment could improve
behavior among preschool-aged
children with high risk for ADHD.
However, the authors of this updated
systematic review were not able to
provide further guidance regarding
the comparative effectiveness of
nonpharmacologic approaches
behavioral interventions included in
this systematic review were of limited
effectiveness alone or in combination
with medication therapy.
By limiting our review to studies
that included at least 50 subjects,
we might have eliminated studies
demonstrating effectiveness. Even
with setting a sample size threshold,
the studies included in this review
were too small to determine if
there is a subgroup of children and
adolescents with ADHD (eg, based
on age or other characteristics) for
whom these therapies might be
more effective. Previous evidence
reviews suggest a benefit to behavior
therapy, with CBT appearing to be a
promising approach.‍3,​78
‍ Generally, a
higher proportion of adverse effects
was reported with methylphenidate
or combination of supplements and
methylphenidate compared with
supplement. The most common side
effects for supplements were dyspepsia
with omega fatty acids and increased
appetite with ningdong granule.
The studies we included have
limited generalizability because
they do not reflect patients seen
in the primary care setting, where
most ADHD treatment occurs,
and have short durations of
follow-up. To better determine
the effectiveness of treatment and
address generalizability to primary
care, there is a need for pragmatic
randomized trials that, ideally,
manage subjects for years.
ACKNOWLEDGMENTS
We thank Megan von Isenburg, MSLS,
for help with the literature search and
retrieval; Robyn E. Schmidt, BA, for
assistance with project coordination;
and Rebecca N. Gray, DPhil, and Liz
Wing, MA, for editorial assistance.
ABBREVIATIONS
ADHD: attention-deficit/hyperac-
tivity disorder
ADHD RS IV: attention-deficit/
hyperactivity
disorder rating
scale IV
AHRQ: Agency for Healthcare
Research and Quality
BRIEF: Behavior Rating
Inventory of Executive
Function
CBCL: Child Behavior Checklist
CBT: cognitive behavioral therapy
CGI: Clinical Global Impression
CGI-S: Clinical Global
Impression-Severity
CPRS: Conners’ Parent Rating
Scale
FDA: Food and Drug
Administration
IVA/CPT: Integrated Visual and
Auditory Continuous
Performance Test
RCT: randomized controlled trial
RS: rating scale
SOE: strength of evidence
WRAT-4: Wide Range
Achievement Test 4
Drs Bowen and McBroom conceptualized and designed the study, designed the data abstraction instruments, performed data analysis, provided methodological
oversight, and reviewed and revised the manuscript; Drs Kemper and Sanders conceptualized and designed the study, provided methodological oversight, and
reviewed and revised the manuscript; Dr Goode drafted the initial manuscript, participated in literature screening, data abstraction, and critical review of the
manuscript; Drs Coeytaux, Maslow, Davis, Hill, Namdari, Allen Lapointe, and Befus participated in literature screening, data abstraction, and critical review of
the manuscript; Ms Lallinger designed the data abstraction instruments, performed data analysis, and reviewed and revised the manuscript; and all authors
approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
The authors of this manuscript are responsible for its content. Statements in the manuscript do not necessarily represent the official views of or imply
endorsement by Agency for Healthcare Research and Quality (AHRQ) or US Department of Health and Human Services.
This topic was nominated by the American Academy of Pediatrics and selected by AHRQ for systematic review by an evidence-based practice center. A
representative from AHRQ served as a Contracting Officer’s Technical Representative and provide technical assistance during the conduct of the full evidence
report and provided comments on draft versions of the full evidence report. AHRQ did not directly participate in the literature search, determination of study
eligibility criteria, data analysis or interpretation, or preparation, review, or approval of the manuscript for publication.
DOI: https://​doi.​org/​10.​1542/​peds.​2018-​0094
Accepted for publication Mar 7, 2018
Address correspondence to Alex R. Kemper, MD, MPH, MS, Division of Ambulatory Pediatrics, Nationwide Children’s Hospital, 700 Children’s Dr, LAC5411,
Columbus, OH 43205. E-mail: alex.kemper@nationwidechildrens.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Davis has participated as a study clinician in industry-sponsored clinical trials awarded to Duke; pharmaceutical companies include
Sunovion, Shire, Ironshore, Rhodes, and KemPharm; the other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This report is based on research conducted by the Duke Evidence-based Practice Center under contract to the Agency for Healthcare Research and
Quality, Rockville, Maryland (Contract HHSA290201500004I). Supported also in part by the National Institute of Child Health and Human Development (Hill, T32-
HD07376) through the Center for Developmental Science, University of North Carolina at Chapel Hill. Funded under Contract No. HHSA290201500004I Task Order 2
from the Agency for Healthcare Research and Quality, US Department of Health and Human Services.
POTENTIAL CONFLICT OF INTEREST: Dr Davis has participated as a study clinician on a pilot trial of a nonpharmacologic intervention study sponsored by Akili
and awarded to Duke; she also served as the Duke site principal investigator on a multisite trial of a nonpharmacologic intervention study sponsored by Akili and
awarded to Duke; the other authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES
1. Zuvekas SH, Vitiello B. Stimulant
medication use in children: a 12-year
perspective. Am J Psychiatry.
2012;169(2):160–166
2. Kemper AR, Maslow GR, Hill S, et al.
Attention Deficit Hyperactivity Disorder:
Diagnosis and Treatment in Children
and Adolescents. Comparative
Effectiveness Review No. 203.
(Prepared by the Duke University
Evidence-based Practice Center under
Contract No. 290-2015-00004-I.) AHRQ
Publication No. 18-EHC005-EF. Rockville,
MD: Agency for Healthcare Research
and Quality; January 2018
3. Charach A, Dashti B, Carson P, et al.
Attention deficit hyperactivity
disorder: effectiveness of treatment
in at-risk preschoolers; long-term
effectiveness in all ages; and variability
in prevalence, diagnosis, and
treatment. Available at: https://​www.​
effectivehealthca​re.​ahrq.​gov/​topics/​
adhd/​research. Accessed July 16, 2015
4. Agency for Healthcare Research
and Quality. Methods guide for
effectiveness and comparative
effectiveness reviews. Available at:
https://​www.​effectivehealthca​re.​
ahrq.​gov/​topics/​cer-​methods-​guide/​
overview. Accessed December 13,
2017
5. Moher D, Liberati A, Tetzlaff J, Altman
DG; PRISMA Group. Preferred reporting
items for systematic reviews and
meta-analyses: the PRISMA statement.
PLoS Med. 2009;6(7):e1000097
6. Higgins JPT, Green S. Cochrane
handbook for systematic reviews of
interventions. Version 5.1.0. London,
UK: The Cochrane Collaboration; 2011.
Available at: www.​cochrane-​handbook.​
org. Accessed December 13, 2017
7. Wells GA, Shea B, O’Connell D, et al.
The Newcastle-Ottawa Scale
(NOS) for Assessing the Quality of
Nonrandomised Studies in Meta-
Analyses. Ottawa, Canada: Ottawa
Hospital Research Institute. Available
at: www.​ohri.​ca/​programs/​clinical_​
epidemiology/​oxford.​asp. Accessed
July 16, 2015
8. Atkins D, Chang SM, Gartlehner G,
et al. Assessing applicability when
comparing medical interventions:
AHRQ and the Effective Health
Care Program. J Clin Epidemiol.
2011;64(11):1198–1207
9. Cornell JE, Mulrow CD, Localio R, et al.
Random-effects meta-analysis of
inconsistent effects: a time for change.
Ann Intern Med. 2014;160(4):
267–270
10. Viechtbauer W. Conducting meta-
analyses in R with the metafor
package. J Stat Softw. 2010;38(3):
1–48
11. Berkman ND, Lohr KN, Ansari M,
et al. Grading the Strength of a
Body of Evidence When Assessing
Health Care Interventions for the
Effective Health Care Program of
the Agency for Healthcare Research
and Quality: An Update. Methods
Guide for Comparative Effectiveness
Reviews (Prepared by the RTI-UNC
Evidence-based Practice Center under
Contract No. 290- 2007-10056-I). AHRQ
Publication No. 13(14)-EHC130-EF.
Rockville, MD: Agency for Healthcare
Research and Quality; 2013

PEDIATRICS Volume 141, number 6, June 2018 9

 12. Abikoff H, Gallagher R, Wells KC, et al.
Remediating organizational functioning
in children with ADHD: immediate and
long-term effects from a randomized
controlled trial. J Consult Clin Psychol.
2013;81(1):113–128
13. Abikoff HB, Thompson M, Laver-
Bradbury C, et al. Parent training
for preschool ADHD: a randomized
controlled trial of specialized and
generic programs. J Child Psychol
Psychiatry. 2015;56(6):618–631
14. Anand P, Sachdeva A. Effect of poly
unsaturated fatty acids administration
on children with attention deficit
hyperactivity disorder: a randomized
controlled trial. J Clin Diagn Res.
2016;10(9):OC01–OC05
15. Arnold LE, Disilvestro RA, Bozzolo
D, et al. Zinc for attention-deficit/
hyperactivity disorder: placebo-
controlled double-blind pilot trial alone
and combined with amphetamine.
J Child Adolesc Psychopharmacol.
2011;21(1):1–19
16. Bai GN, Wang YF, Yang L, Niu WY.
Effectiveness of a focused, brief
psychoeducation program for parents
of ADHD children: improvement
of medication adherence and
symptoms. Neuropsychiatr Dis Treat.
2015;11:2721–2735
17. Barragan E, Breuer D, Dopfner M.
Efficacy and safety of omega-3/6 fatty
acids, methylphenidate, and a combined
treatment in children with ADHD. J Atten
Disord. 2017;21(5):433–441
18. Beck SJ, Hanson CA, Puffenberger
SS, Benninger KL, Benninger WB. A
controlled trial of working memory
training for children and adolescents
with ADHD. J Clin Child Adolesc
Psychol. 2010;39(6):825–836
19. Bink M, van Nieuwenhuizen C,
Popma A, Bongers IL, van Boxtel GJ.
Behavioral effects of neurofeedback in
adolescents with ADHD: a randomized
controlled trial. Eur Child Adolesc
Psychiatry. 2015;24(9):1035–1048
20. Boyer BE, Geurts HM, Prins PJ, Van der
Oord S. Two novel CBTs for adolescents
with ADHD: the value of planning
skills. Eur Child Adolesc Psychiatry.
2015;24(9):1075–1090
21. Boyer BE, Geurts HM, Prins PJM, van
der Oord S. One-year follow-up of
10
two novel CBTs for adolescents with
ADHD. Eur Child Adolesc Psychiatry.
2016;25(3):333–337
22. Chacko A, Wymbs BT, Wymbs FA, et al.
Enhancing traditional behavioral
parent training for single mothers
of children with ADHD. J Clin Child
Adolesc Psychol. 2009;38(2):206–218
23. Chacko A, Bedard AC, Marks DJ, et al.
A randomized clinical trial of Cogmed
working memory training in school-
age children with ADHD: a replication
in a diverse sample using a control
condition. J Child Psychol Psychiatry.
2014;55(3):247–255
24. Dovis S, Van der Oord S, Wiers
RW, Prins PJ. Improving executive
functioning in children with ADHD:
training multiple executive functions
within the context of a computer
game. a randomized double-blind
placebo controlled trial. PLoS One.
2015;10(4):e0121651
25. Duric NS, Assmus J, Gundersen D,
Elgen IB. Neurofeedback for the
treatment of children and adolescents
with ADHD: a randomized and
controlled clinical trial using parental
reports. BMC Psychiatry. 2012;12:107
26. Duric NS, Aßmus J, Elgen IB. Self-
reported efficacy of neurofeedback
treatment in a clinical randomized
controlled study of ADHD children and
adolescents. Neuropsychiatr Dis Treat.
2014;10:1645–1654
27. Dutta B, Barua TK, Ray J, et al. A study
of evaluation of safety and efficacy of
memomet, a multi herbal formulation
(memomet) in the treatment of
behavioural disorder in children.
Int J Res Pharm Sci. 2012;3(2):
282–286
28. Egeland J, Aarlien AK, Saunes
BK. Few effects of far transfer of
working memory training in ADHD: a
randomized controlled trial. PLoS One.
2013;8(10):e75660
29. Ercan ES, Ardic UA, Kutlu A, Durak S.
No beneficial effects of adding parent
training to methylphenidate treatment
for ADHD + ODD/CD children: a 1-year
prospective follow-up study. J Atten
Disord. 2014;18(2):145–157
30. Evans SW, Langberg JM, Schultz BK,
et al. Evaluation of a school-based
treatment program for young
adolescents with ADHD. J Consult Clin
Psychol. 2016;84(1):15–30
31. Ferrin M, Perez-Ayala V, El-Abd S,
et al. A randomized controlled
trial evaluating the efficacy of a
psychoeducation program for families
of children and adolescents with
ADHD in the United Kingdom: results
after a 6-month follow-up [published
online ahead of print February 2,
2016]. J Atten Disord. doi:​10.​1177/​
1087054715626509
32. Ferrin M, Moreno-Granados JM,
Salcedo-Marin MD, Ruiz-Veguilla M,
Perez-Ayala V, Taylor E. Evaluation of
a psychoeducation programme for
parents of children and adolescents
with ADHD: immediate and long-term
effects using a blind randomized
controlled trial. Eur Child Adolesc
Psychiatry. 2014;23(8):637–647
33. Geladé K, Janssen TW, Bink M, van
Mourik R, Maras A, Oosterlaan J.
Behavioral effects of neurofeedback
compared to stimulants and
physical activity in attention-deficit/
hyperactivity disorder: a randomized
controlled trial. J Clin Psychiatry.
2016;77(10):e1270–e1277
34. Gevensleben H, Holl B, Albrecht B,
et al. Is neurofeedback an efficacious
treatment for ADHD? A randomised
controlled clinical trial. J Child Psychol
Psychiatry. 2009;50(7):780–789
35. Gevensleben H, Holl B, Albrecht B, et al.
Neurofeedback training in children
with ADHD: 6-month follow-up of a
randomised controlled trial. Eur Child
Adolesc Psychiatry. 2010;19(9):715–724
36. Gustafsson PA, Birberg-Thornberg U,
Duchén K, et al. EPA supplementation
improves teacher-rated behaviour
and oppositional symptoms in
children with ADHD. Acta Paediatr.
2010;99(10):1540–1549
37. Hahn-Markowitz J, Berger I, Manor I,
Maeir A. Efficacy of cognitive-functional
(Cog-Fun) occupational therapy
intervention among children with
ADHD: an RCT [published online ahead
of print September 16, 2016]. J Atten
Disord. doi:​10.​1177/​1087054716666955
38. Hariri M, Djazayery A, Djalali M,
Saedisomeolia A, Rahimi A, Abdolahian
E. Effect of n-3 supplementation
on hyperactivity, oxidative stress
and inflammatory mediators in
GOODE et al
 children with attention-deficit-
hyperactivity disorder. Malays J Nutr.
2012;18(3):329–335
39. Hiscock H, Sciberras E, Mensah F,
et al. Impact of a behavioural sleep
intervention on symptoms and sleep
in children with attention deficit
hyperactivity disorder, and parental
mental health: randomised controlled
trial. BMJ. 2015;350:h68
40. Hong SS, Cho SH. Treating attention
deficit hyperactivity disorder
with acupuncture: a randomized
controlled trial. Eur J Integr Med.
2016;8(3):150–157
41. Hovik KT, Saunes BK, Aarlien AK,
Egeland J. RCT of working memory
training in ADHD: long-term
near-transfer effects. PLoS One.
2013;8(12):e80561
42. Huang YH, Chung CY, Ou HY, et al.
Treatment effects of combining social
skill training and parent training in
Taiwanese children with attention
deficit hyperactivity disorder. J Formos
Med Assoc. 2015;114(3):260–267
43. Johnson M, Ostlund S, Fransson
G, Kadesjö B, Gillberg C. Omega-3/
omega-6 fatty acids for attention
deficit hyperactivity disorder: a
randomized placebo-controlled trial
in children and adolescents. J Atten
Disord. 2009;12(5):394–401
44. Johnson M, Månsson JE, Ostlund S,
et al. Fatty acids in ADHD: plasma
profiles in a placebo-controlled study
of Omega 3/6 fatty acids in children
and adolescents. Atten Defic Hyperact
Disord. 2012;4(4):199–204
45. Katz M, Levine AA, Kol-Degani H,
Kav-Venaki L. A compound herbal
preparation (CHP) in the treatment
of children with ADHD: a randomized
controlled trial. J Atten Disord.
2010;14(3):281–291
46. Li JJ, Li ZW, Wang SZ, et al. Ningdong
granule: a complementary and
alternative therapy in the treatment
of attention deficit/hyperactivity
disorder. Psychopharmacology (Berl).
2011;216(4):501–509
47. Manor I, Magen A, Keidar D, et al.
The effect of phosphatidylserine
containing Omega3 fatty-acids on
attention-deficit hyperactivity disorder
symptoms in children: a double-blind
PEDIATRICS Volume 141, number 6, June 2018
placebo-controlled trial, followed by an
open-label extension. Eur Psychiatry.
2012;27(5):335–342
48. Manor I, Magen A, Keidar D, et al.
Safety of phosphatidylserine
containing omega3 fatty acids
in ADHD children: a double-blind
placebo-controlled trial followed by an
open-label extension. Eur Psychiatry.
2013;28(6):386–391
49. Mautone JA, Marshall SA, Sharman
J, Eiraldi RB, Jawad AF, Power TJ.
Development of a family-school
intervention for young children with
attention deficit hyperactivity disorder.
School Psych Rev. 2012;41(4):447–466
50. Milte CM, Parletta N, Buckley
JD, Coates AM, Young RM,
Howe PR. Eicosapentaenoic and
docosahexaenoic acids, cognition, and
behavior in children with attention-
deficit/hyperactivity disorder: a
randomized controlled trial. Nutrition.
2012;28(6):670–677
51. Milte CM, Parletta N, Buckley JD, Coates
AM, Young RM, Howe PR. Increased
erythrocyte eicosapentaenoic acid and
docosahexaenoic acid are associated
with improved attention and behavior
in children with ADHD in a randomized
controlled three-way crossover trial.
J Atten Disord. 2015;19(11):954–964
52. Mohammadpour N, Jazayeri S,
Tehrani-Doost M, et al. Effect of vitamin
D supplementation as adjunctive
therapy to methylphenidate on ADHD
symptoms: a randomized, double blind,
placebo-controlled trial. Nutr Neurosci.
2018;21(3):202–209
53. Mohammadi MR, Mostafavi SA,
Keshavarz SA, et al. Melatonin effects
in methylphenidate treated children
with attention deficit hyperactivity
disorder: a randomized double
blind clinical trial. Iran J Psychiatry.
2012;7(2):87–92
54. Molina BS, Hinshaw SP, Swanson JM,
et al; MTA Cooperative Group. The MTA
at 8 years: prospective follow-up of
children treated for combined-type
ADHD in a multisite study.
J Am Acad Child Adolesc Psychiatry.
2009;48(5):484–500
55. Moreno-García I, Delgado-Pardoa G,
de Reya CC-V, Meneres-Sanchoa S,
Servera-Barceló M. Neurofeedback,
pharmacological treatment and
behavioral therapy in hyperactivity:
multilevel analysis of treatment effects
on electroencephalography. Int J Clin
Health Psychol. 2015;15(3):217–225
56. Mostafavi SA, Mohammadi MR,
Hosseinzadeh P, et al. Dietary intake,
growth and development of children with
ADHD in a randomized clinical trial of
Ritalin and Melatonin co-administration:
through circadian cycle modification or
appetite enhancement? Iran J Psychiatry.
2012;7(3):114–119
57. Myers K, Vander Stoep A, Zhou C,
McCarty CA, Katon W. Effectiveness
of a telehealth service delivery
model for treating attention-deficit/
hyperactivity disorder: a community-
based randomized controlled trial.
J Am Acad Child Adolesc Psychiatry.
2015;54(4):263–274
58. Oberai P, Gopinadhan S, Varanasi
R, Mishra A, Singh V, Nayak C.
Homoeopathic management of
attention deficit hyperactivity disorder:
a randomised placebo-controlled
pilot trial. Indian J Res Homeopathy.
2013;7(4):158–167
59. Ostberg M, Rydell AM. An efficacy study
of a combined parent and teacher
management training programme for
children with ADHD. Nord J Psychiatry.
2012;66(2):123–130
60. Papadopoulos N, Sciberras E, Hiscock
H, Mulraney M, McGillivray J, Rinehart
N. The efficacy of a brief behavioral
sleep intervention in school-aged
children with ADHD and comorbid
autism spectrum disorder [published
online ahead of print February 2,
2015]. J Atten Disord. doi:​1177/​
1087054714568565
61. Pelsser LM, Frankena K, Toorman J,
et al. Effects of a restricted elimination
diet on the behaviour of children with
attention-deficit hyperactivity disorder
(INCA study): a randomised controlled
trial. Lancet. 2011;377(9764):494–503
62. Pfiffner LJ, Hinshaw SP, Owens E, et al.
A two-site randomized clinical trial of
integrated psychosocial treatment for
ADHD-inattentive type. J Consult Clin
Psychol. 2014;82(6):1115–1127
63. Power TJ, Mautone JA, Soffer SL,
et al. A family-school intervention
for children with ADHD: results of a
randomized clinical trial. J Consult Clin
Psychol. 2012;80(4):611–623
11
 64. Raz R, Carasso RL, Yehuda S. The
influence of short-chain essential
fatty acids on children with attention-
deficit/hyperactivity disorder: a
double-blind placebo-controlled study.
J Child Adolesc Psychopharmacol.
2009;19(2):167–177
65. Salehi B, Imani R, Mohammadi MR,
et al. Ginkgo biloba for attention-
deficit/hyperactivity disorder in
children and adolescents: a double
blind, randomized controlled trial.
Prog Neuropsychopharmacol Biol
Psychiatry. 2010;34(1):76–80
66. Shakibaei F, Radmanesh M, Salari
E, Mahaki B. Ginkgo biloba in the
treatment of attention-deficit/
hyperactivity disorder in children and
adolescents. A randomized, placebo-
controlled, trial. Complement Ther Clin
Pract. 2015;21(2):61–67
67. Sibley MH, Graziano PA, Kuriyan AB,
et al. Parent-teen behavior therapy +
motivational interviewing for
adolescents with ADHD. J Consult Clin
Psychol. 2016;84(8):699–712
68. Steiner NJ, Frenette EC, Rene KM,
Brennan RT, Perrin EC. In-school
neurofeedback training for ADHD:
sustained improvements from a
randomized control trial. Pediatrics.
2014;133(3):483–492
12
69. Steiner NJ, Frenette EC, Rene KM,
Brennan RT, Perrin EC. Neurofeedback
and cognitive attention training
for children with attention-deficit
hyperactivity disorder in schools. J Dev
Behav Pediatr. 2014;35(1):18–27
70. Storebø OJ, Gluud C, Winkel P,
Simonsen E. Social-skills and
parental training plus standard
treatment versus standard treatment
for children with ADHD–the
randomised SOSTRA trial. PLoS One.
2012;7(6):e37280
71. van der Donk M, Hiemstra-Beernink AC,
Tjeenk-Kalff A, van der Leij A, Lindauer
R. Cognitive training for children with
ADHD: a randomized controlled trial
of cogmed working memory training
and ‘paying attention in class’. Front
Psychol. 2015;6:1081
72. van Dongen-Boomsma M, Vollebregt
MA, Buitelaar JK, Slaats-Willemse D.
Working memory training in young
children with ADHD: a randomized
placebo-controlled trial. J Child
Psychol Psychiatry. 2014;55(8):886–896
73. Vidal R, Castells J, Richarte V, et al.
Group therapy for adolescents with
attention-deficit/hyperactivity disorder:
a randomized controlled trial.
J Am Acad Child Adolesc Psychiatry.
2015;54(4):275–282
74. Vitiello B, Elliott GR, Swanson JM,
et al. Blood pressure and heart rate
over 10 years in the multimodal
treatment study of children with ADHD.
Am J Psychiatry. 2012;169(2):
167–177
75. Wangler S, Gevensleben H, Albrecht
B, et al. Neurofeedback in children
with ADHD: specific event-related
potential findings of a randomized
controlled trial. Clin Neurophysiol.
2011;122(5):942–950
76. Webster-Stratton CH, Reid MJ,
Beauchaine T. Combining parent and
child training for young children with
ADHD. J Clin Child Adolesc Psychol.
2011;40(2):191–203
77. Widenhorn-Müller K, Schwanda S,
Scholz E, Spitzer M, Bode H. Effect
of supplementation with long-chain
ω-3 polyunsaturated fatty acids on
behavior and cognition in children
with attention deficit/hyperactivity
disorder (ADHD): a randomized
placebo-controlled intervention trial.
Prostaglandins Leukot Essent Fatty
Acids. 2014;91(1–2):49–60
78. Jadad AR, Boyle M, Cunningham C, Kim
M, Schachar R. Treatment of attention-
deficit/hyperactivity disorder. Evid Rep
Technol Assess (Summ). 1999;(11):
i–viii, 1–341
GOODE et al