Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments

Edmund J S Sonuga-Barke, Daniel Brandeis, Samuele Cortese, David Daley, Maite Ferrin, Martin Holtmann, Jim Stevenson, Marina Danckaerts, Saskia van der Oord, Manfred Döpfner, Ralf W Dittmann, Emily Simonoff, Alessandro Zuddas, Tobias Banaschewski, Jan Buitelaar, David Coghill, Chris Hollis, Eric Konofal, Michel Lecendreux, Ian C K WongJoseph Sergeant, European ADHD Guidelines Group

    Research output: Contribution to journalArticlepeer-review

    816 Citations (Scopus)


    OBJECTIVE Nonpharmacological treatments are available for attention deficit hyperactivity disorder (ADHD), although their efficacy remains uncertain. The authors undertook meta-analyses of the efficacy of dietary (restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation) and psychological (cognitive training, neurofeedback, and behavioral interventions) ADHD treatments. METHOD Using a common systematic search and a rigorous coding and data extraction strategy across domains, the authors searched electronic databases to identify published randomized controlled trials that involved individuals who were diagnosed with ADHD (or who met a validated cutoff on a recognized rating scale) and that included an ADHD outcome. RESULTS Fifty-four of the 2,904 nonduplicate screened records were included in the analyses. Two different analyses were performed. When the outcome measure was based on ADHD assessments by raters closest to the therapeutic setting, all dietary (standardized mean differences=0.21-0.48) and psychological (standardized mean differences=0.40-0.64) treatments produced statistically significant effects. However, when the best probably blinded assessment was employed, effects remained significant for free fatty acid supplementation (standardized mean difference=0.16) and artificial food color exclusion (standardized mean difference=0.42) but were substantially attenuated to nonsignificant levels for other treatments. CONCLUSIONS Free fatty acid supplementation produced small but significant reductions in ADHD symptoms even with probably blinded assessments, although the clinical significance of these effects remains to be determined. Artificial food color exclusion produced larger effects but often in individuals selected for food sensitivities. Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms.
    Original languageEnglish
    Pages (from-to)275-89
    Number of pages15
    JournalAmerican Journal of Psychiatry
    Issue number3
    Publication statusPublished - 1 Mar 2013


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