The benefits of a combination approach
First of all, let’s have a look at what is considered the most effective approach. A landmark study was carried out several years ago, by the MTA Cooperative Group in the US with 579 children aged 7 to 9.9 years who were assigned a course of treatment for 14 months. The study showed that medical treatment alone as well as the combination of medical treatment and behavioural treatment was significantly superior to intensive behavioural treatment alone and to routine community care in reducing core ADHD symptoms. In related areas of functioning that are not deemed core symptoms of ADHD (anxiety symptoms, academic performance, parent-child relations and social skills), combination treatment was consistently superior to routine community care, whereas medication alone or behavioural treatment alone were not; supporting the use of combining drug and non-drug treatments.
To optimize the combination approach and to offer an intervention in patients not suitable or not responding to medical treatment, alternative non-drug treatments are often considered. In general, the alternatives can be classified as behavioural, neurocognitive or dietary interventions. Commonly used are cognitive behavioural therapy, memory training, neurofeedback, fatty acid supplementation and dietary restrictions. The question, however, is which of these alternative non-drug interventions have a documented effect on ADHD related symptoms- hyperactivity, inattention and impulsivity. To answer this question, a comprehensive review by the European ADHD Guidelines Group of non-drug interventions was recently performed2. They found small but statistically significant effects for free fatty acid supplements (Omega 3 and Omega 6 oils) on the core symptoms of ADHD - a finding supported by a review article from the US3. Also, excluding artificial food colorants was found to be effective, most often in individuals with food sensitivities. For behavioural interventions and cognitive training, the non-blinded studies showed significant effects but fell short of statistical significance when only blinded studies were included in the analysis. These findings indicate that subjectivity can impact the evaluation of treatment effects which is of special importance for psychological and behavioural interventions since they are complicated to blind.
The QbTest is designed to help clinicians to diagnose, treat and monitor ADHD in patients. By objectively measuring the core symptoms of ADHD, a more unbiased view of the patients struggles can be provided. Several studies have been performed with the QbTest that show clear effects of different pharmacological treatments4,5,6. There is, however, much more to be learned about the effects of alternative interventions on ADHD. QbTest was recently used within a randomised placebo-controlled study examining the potential benefits of a cannabinoid medication on objective markers and subjective symptoms of ADHD7. Also, excluding artificial food colorants was found to be effective, most often in individuals with food sensitivities. For behavioural interventions and cognitive tand we have initiated studies that will use QbTest to objectively examine the effect of memory training, neurofeedback and dietary supplementation but also more novel approaches like transcranial direct current stimulation. Our ambition is to contribute to the increasing knowledge about the effect of these interventions and will publish any new findings at this website.
One very important finding of the MTA study was that careful monitoring and titration can double response rates (25% to 56%). This is the approach advocated by the National Institute for Health and Care Excellence (NICE) Guidance (2009)8. Nevertheless, the systematic follow up of ADHD treatment is challenging, as it is labour intensive and relies on subjective measures. We believe that, whatever the treatment, it should always be followed up. Furthermore, it is very important to take objective measurements at baseline and at each treatment change, this will help to bring about the most benefit for each patient.
1 MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry. 1999, 56(12): 1073-86. [RETURN]
2 Sonuga-Barke E. J. et. al. (2013). European ADHD Guidelines Group: Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. American Journal of Psychiatry, 170, 275–289. [RETURN]
3 Bloch M. H. et al. (2014). Nutritional supplements for the treatment of ADHD. Child and Adolescent Psychiatric Clinics of North America, 23, 883–97. [RETURN]
4 Wehmeier, P. M. et al. (2012). Does atomoxetine improve executive function, inhibitory control, and hyperactivity? Results from a placebo-controlled trial using quantitative measurement technology. Journal of Clinical Psychopharmacology, 32, 653-660. [RETURN]
5 Ramtvedt, B.E. et al. (2013). Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. Journal of Child and Adolescent Psychopharmacology, 23, 1-8. [RETURN]
6 Bijlenga, D. et al. (2014). Objective QbTest and subjective evaluation of stimulant treatment in adult attention deficit-hyperactivity disorder. European Psychiatry, Online 2014, 26 August. [RETURN]
7 Cooper, R.E., et al. (2017) Cannabinoids in attention-deficit/hyperactivity disorder: a randomised-controlled trial. European Neuropsychopharmacology, 27(8): 795-808. doi: 10.1016/j.euroneuro.2017.05.005. [RETURN]