Optimal Management of ADHD - Episode 6

Non-Pharmacological Therapy in ADHD

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Andrew J. Cutler, MD, discusses the benefits of cognitive behavior therapy (CBT), exercise, and family therapy for the management of ADHD.

Andrew J. Cutler, MD: There are various nonpharmacological treatments that have been documented to have efficacy in the treatment and management of ADHD [attention-deficit/hyperactivity disorder]. Cognitive behavioral therapy [CBT] is 1 of the most extensively studied and has some of the best evidence for efficacy. Cognitive behavioral therapy—a lot of the work has been done on this at Massachusetts General Hospital at Harvard Medical School—includes various manuals and videos to help with training and to help with the administration of CBT. I’ve even seen some CBT programs online that allow someone to participate in individually.

Basically, this involves psychoeducation and training in concrete skills such as organization and planning. There is an emphasis on practice and maintenance of strategies. CBT can be delivered either with or without medication. It has been shown to be effective in either situation. There are certainly many patients for whom medication is contraindicated or who you’re treating with medicine and there are still residual symptoms and impairments.

CBT has been best studied in adults. CBT has been shown to improve not only self-ratings of the symptoms of the illness but also clinician-administered ratings, not only for the core symptoms of ADHD but also for associated anxiety and depression. As we mentioned, these are common comorbidities associated with ADHD. CBT has the best evidence for use, but there’s also evidence for other modalities including group therapy, mindfulness and relaxation, and coaching. 

There is another nonpharmacological intervention that has an extensive and growing database with very convincing evidence for efficacy, and that’s exercise. Exercise has been shown to improve not only the core symptoms of ADHD but also executive function, which can often be a problem. That includes organization and planning. Also, there is good evidence that this can improve depression, anxiety, and a sense of well-being. This has been demonstrated not only in adults but also in children. This is a modality that I recommend for all patients with ADHD. 

Biologically, we think exercise increases blood flow to various parts of the brain, so it makes the blood flow and probably makes the function of various parts of the brain more efficient. It also increases levels of dopamine and norepinephrine in the brain. That’s interesting because we know there are abnormalities of dopamine and norepinephrine neurotransmission and we know there are effective approved medications to treat ADHD, increasing norepinephrine and dopamine. We also believe exercise can improve neuroplasticity, which means neurogenesis, growth factors, synaptogenesis, the connections between nerve cells, and things like that.

We also have evidence that exercise can improve functioning in certain key areas of the brain that are related to ADHD, including the prefrontal cortex, the basal ganglia, or striatum, the cerebellum, as well as the amygdalae. Exercise is a very low-tech, very easy-to-implement strategy that I recommend for all patients. It doesn’t have to be high-intensity, serious weight lifting. It can be any form of exercise, including walking, dancing, martial arts, sports, and other training. There are various forms of exercise.

Family therapy is another nonpharmacological intervention that has a very good database and is highly recommended as part of the multimodal treatment plan for patients with ADHD and their families. Family therapy is delivered by a therapist, typically as 8 or more sessions, and can be done with 1 family or with groups of parents without the children. Family therapy entails education and structure, working on various problematic behaviors, and teaching coping skills to help decrease the stress involved with having a family member with ADHD. The idea is to build and strengthen positive relationships and to emphasize positive ways of interacting. This can help with arguing, blame, and negative attitudes that are so common in families with ADHD. Also, it provides a safe environment to discuss various problematic and stressful behaviors. It offers practical solutions and a behavior modification plan and focuses not only on positive attitudes but on positive methods of communication and positive ways to reinforce certain behaviors.

The communication can be emphasized as parent to parent, because there’s often very real stress in the parental relationship, and also parent to child. The evidence base, as I mentioned, is very good and certainly can be part of the multimodal treatment plan for ADHD.

Transcript Edited for Clarity