by drnieman on June 27, 2018

in Monthly

Many options other than the use of pharmaceutical products exist for the treatment of attention-deficit/hyperactivity disorder (ADHD). The most common medications used in the treatment are by far psychostimulants.

Alternative medications to psychostimulants are the so-called non-stimulant products—a class of medications which is becoming increasingly popular, most likely because side effects impacting appetite and sleep are far less common.

But what can families expect when they elect to avoid medication all together and opt instead for nonpharmacological approaches such as neurofeedback, cognitive training, cognitive behavioral therapy (CBT), child or parent training, dietary or herbal remedies or fatty acid supplementation?

In the June 2018 edition of Pediatrics, research conducted by the Duke Evidence-based Practice Center looked at this specific question by doing a very comprehensive systematic review of 54 studies of nonpharmacologic treatments.

These studies were all published between January 1, 2009 and November 7, 2016 and sourced from comprehensive data bases including PubMed, Embase, PsycINFO and the Cochrane Database of Systematic Reviews for relevant English-language studies.

Cognitive bias is a term used by social psychologists which essentially discuss why humans pick and choose the narrative they believe in the most. (One of the best books I have ever read on this important behavioral pattern is Mistakes Were Made (but not by me), written by Carol Tavris and Elliot Aronson)

Both doctors and the public fall prey to cognitive biases and as the above book so convincing shows they are quick to deny that.

The strength of evidence (SOE) is what makes the Duke study one of the milestone studies ever undertaken. The authors were very meticulous to dig deep in terms of how all the papers published between 2009 and 2016 met high standards—or not.

Here are some of the main highlights and take-home messages:
• When a preschooler is diagnosed with ADHD, parent behavior training as first-line treatment had a high SEO in contrast to pharmacological intervention. (Academically that makes sense, but in real life many pediatricians struggle to find the appropriate parent behavior training programs for parents who often cannot afford it or attend all the classes)
• Neurofeedback generally provided very good results when compared to pharmacological treatment, placebo or other nonpharmacological interventions.
• CBT was particularly useful in patients who also had anxiety and depression in addition to ADHD. It was found that depression score improvements were maintained for as long as 12 months. Out of 54 studies, surprisingly there was not a single study in which CBT interventions were compared to pharmacologic interventions—CBT was used in combination with medications. Compared to placebo, CBT worked very well.
• Child or parent training included teaching organizational skills, social skills, positive parenting, sleep hygiene and teacher behavioral training. The outcomes varied widely, but generally showed positive results. (Once again, this training is not always freely available and are often found in non-primary care settings as opposed to the “real world” where doctors and families find themselves in communities without the luxury of academic settings)
• Dietary supplementation with Omega Fatty Acids—including both omega-3 and omega-6 fatty acids—did not seem to consistently deliver desired outcomes. The same was true for herbal supplements and zinc supplementation. However, when ginkgo biloba was used, and compared to placebo, there were some advantages. When ginkgo was combined with methylphenidate one study showed that appetite suppression and sleep disturbances caused by medication were reduced.
• No significant improvements in outcomes were found when patients with ADHD were also given acupuncture treatment.

As much as we would like to be given a bottom-line conclusion and one that would settle things once and for ever, it was simply not possible to draw final conclusions. The authors admit that all 54 studies, although very useful, often were incomplete because they did not reflect a primary care setting, had too short follow-up periods, sample sizes that were too small and there were too many inconsistent reporting of statistical analyses.
Even when the Duke study was useful, it still struck out. It will no doubt be used by academic developmental pediatricians to argue against the isolated use of nonpharmacological interventions.

The final sentence in the Duke publication said it all as far as I am concerned: “The studies we have 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. There is a need for pragmatic randomized trials that ideally manage subjects for years”

I for one am curious to find such a trial– specifically for patients who followed a strict vegan diet or pescatarian diet from a young age. It just makes sense that consuming real food will be beneficial to the developing brain.

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