This expert review collected no new data. The authors summarized published reviews and trials on ADHD treatment in children, adolescents and adults, and added their own opinion. The paper does not say how studies were chosen.
Stimulant medicines were judged the most effective treatment, at least in the short term. Non-stimulant medicines, such as atomoxetine, guanfacine and clonidine, worked less well and suit special situations. Roughly a third of patients did not respond well to stimulants or could not tolerate them.
Psychosocial support was seen as most useful for very young children, mild ADHD, or as an add-on to medicine. Counting only raters who probably did not know the treatment, the evidence did not support behavioral therapy, cognitive training or neurofeedback for core symptoms. Neurofeedback's effect fell by half and lost reliability under those raters. Behavioral therapy still improved positive parenting and conduct problems in children. Fatty acid supplements had effects too small to matter.
Long-term studies of 6 years or more reported that about 50% of child-onset cases still had impairing symptoms. The authors note their summary table ignores evidence strength, and its non-drug estimates come from raters who knew the treatment. One network analysis they relied on had low to very low study quality.
The authors suggest matching treatment to severity, with medicine and non-drug care combined for severe cases, though whether that beats stimulants alone is still debated.
Talk to a clinician about your own situation.
The numbers Stats and what the terms mean
The statistics behind the plain-language claims above.
- One included study (cited in Caye, 2018): how well methylphenidate worked compared with placebo, ++++ (40 trials).
- One included study (cited in Caye, 2018): how well amphetamine derivatives worked compared with placebo, ++++ (9).
- One included study (cited in Caye, 2018): how well atomoxetine worked compared with placebo, +++ (27).
- One included study (cited in Caye, 2018): how well guanfacine worked compared with placebo, +++ (10).
- One included study (cited in Caye, 2018): how well clonidine worked compared with placebo, +++ (4).
- One included study (cited in Caye, 2018): how well behavioral therapies worked compared with placebo, +++ (15).
- One included study (cited in Caye, 2018): how well cognitive training worked compared with placebo, +/- (2).
- One included study (cited in Caye, 2018): how well neurofeedback worked compared with placebo, ++/- (4).
- One included study (cited in Caye, 2018): how well poly-unsaturated fatty acids worked compared with placebo, ++/- (3). What the terms mean:
- + to ++++ A size band for the benefit over placebo, converted to Cohen's d: + is up to 0.2, ++ is 0.2 to 0.5, +++ is 0.5 to 0.8 and ++++ is more than 0.8. The number in brackets is how many trials fed the rating.
- /- The result was not statistically significant, so it could be down to chance.
- d Roughly, 0.2 is small, 0.5 is moderate and 0.8 is large. A minus sign shows the direction of the change, not its size.
Source: Caye A, Swanson J, Coghill D, et al.. Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Molecular Psychiatry (2018). doi:10.1038/s41380-018-0116-3