Attention-deficit/hyperactivity disorder is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with the person’s normal development and functioning (American Psychiatric Association, 2014). It is currently a diagnosis with an increase in the presence of cases compared to a few decades ago. Its evaluation is exclusively clinical, No There are biological markers that allow it to be diagnosed from brain scans, blood or genetic tests. Given this exclusive clinical assessment and the way in which the same diagnostic criteria are written in manuals such as the DSM-5, it is one of the most controversial labels today, going to extremes where they consider it to be an invented disorder, to those who Any indication of activity that exceeds what is “normal” in a child, they seek a diagnosis. It is a worrying trend of overdiagnosis, exceeding even psychiatrists and psychologists.
It is common for teachers to refer children with behavioral problems from school, under suspicion of possible ADHD or autism (ASD), without taking into account the contextual variables that maintain these behavioral problems. In the case of those who already have a diagnosis of ADHD, medication is common as the first line of treatment, without having previously gone through psychological approaches.
Despite the observations made in the previous paragraphs, from here on the existence of ADHD as a diagnostic entity will not be questioned. There is a historical record of children with similar characteristics in this disorder for at least two and a half centuries; Therefore, it does not seem to be an invention of pharmaceutical companies, beyond the fact that they take advantage of the opportunity to install medication as their main approach. In any case, this mess between real and fictitious entities, business by some sectors and overmedicalization highlights the need to study the available therapeutic offer, in order to offer those who carry this diagnostic label the most effective treatments.
Taking this context into account, a group of researchers () published last year a bibliographic review of the effectiveness of psychological treatments in children, adolescents and adults with ADHD and which we will review in this article.
Therapeutics in ADHD
Currently, the treatment of ADHD is usually interdisciplinary. It includes various professionals in the field of mental health, including psychologists, educational psychologists, doctors, special teachers, etc. This speaks of complex approaches, not restricted to a single area of the subject’s life. In fact, the difficulties present in ADHD manifest themselves at home, at school or in recreational settings. Not only to sustain attention on school tasks, but to carry out diverse social interactions, maintain threads of conversations and/or activities, focus on specific situations, etc.
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In order to provide guidelines that help in the daily lives of these people, we have published articles aimed at both the educational field (and) and aimed at families (and); understanding that no approach can be effective in ADHD if it does not consider the participation and adaptation of all the people and areas where those who suffer from it work.
Regarding the line of approach, whether exclusively psychological, pharmacological or a combination of both, for the moment there is no full consensus. Although in recent years various institutions recommend psychological therapy as the first option, especially , in practice this is not always fulfilled. In this you can read, for example, how 20% of US doctors recommend pharmacological therapy as the first option, contrary to suggestions from international institutions. There are also joint recommendations, that is, combining the psychological approach with the pharmacological approach, especially for the most serious cases (Catalá-López et al., 2017, Krull, 2017).
Let us now return to the meta-analysis on which this article is based.
Method
Regarding the psychological approaches analyzed by the team of researchers, they took into account those that make a correct diagnosis of ADHD, an adequate functional assessment of the problem behaviors and also the therapeutic objectives. This for a very simple reason, not working on a clear diagnosis and not operationalizing those target behaviors as well as the therapeutic objectives means that the effectiveness of the analyzed therapy cannot be clearly established, possibly taking as effective forms of intervention that are not effective in general. reality.
The review was carried out taking into account the databases Pubmed/Medline, Psycinfo, CSIC Bases (ISOC and IME summaries) and Web of Knowledge. They excluded pharmacological, physical exercise and dietary treatments, as they were not the purpose of the review. The search was conducted in Spanish and English and addressed the following treatments: behavioral therapy, cognitive behavioral therapy, cognitive therapy, neurofeedback, cognitive training and mindfulness.
Results
The results of the review are discussed below, separating each of the approaches studied.
Behavior therapy (CT): Uses the knowledge of behavior analysis to develop, increase and decrease objective behaviors, based on various strategies, establishing norms, token economies and behavioral contracts, among others. All of these strategies, which are not exhaustive, must be used in turn by performing . At school, interventions focus on the development of various academic, organizational, classroom behavior, and relationships with peers and elders. In family settings, they seek to complete tasks, follow routines and rules of coexistence, develop healthy habits, improve interpersonal relationships, etc.
Most clinical practice guidelines recommend behavioral therapy as the first line of treatment for ADHD at preschool age and also at school age, in those cases where the symptoms are not severe or there is no serious functional impairment. In more serious cases, they recommend a combined approach (behavioral therapy + drugs). The observation is made that with respect to isolated medication, studies indicate that its effects are significantly lower than those cases where stimulant medication is combined with behavioral therapy.
Regarding adolescents, a 2016 review that included 2,668 participants showed evidence of effectiveness for psychosocial treatments (behavioral intervention strategies, cognitive behavioral and skills training for parents, teachers and children) improving behavioral, emotional aspects and interpersonal functioning. , in addition to academic and organizational skills.
What stands out about CT is the emphasis it places on training the skills necessary not only for those diagnosed, but also for teachers, parents, and all those who deal with them.
Cognitive behavioral therapy (CBT): The authors of the review mention within their tools self-instructions, response inhibition or self-control and the development of more organized and reflective ways of thinking. A 2016 review assesses the influence of psychosocial treatments (including CBT) on outcomes such as task completion, organizational skills, parent-reported symptoms, and coexisting psychopathology.
A 2014 guide notes that CBT when it integrates psychoeducation, planning and organizational skills, training in academic skills, cognitive therapy, and communication and emotional management strategies; It achieves improvements in schedule compliance, school absenteeism decreases, improvements appear at a behavioral level documented by parents and in the classroom documented by teachers, and it is even associated with a decrease in stimulant medication.
CBT for adults, on the other hand, shows comparable effect sizes to what behavior therapy shows for children for the same types of problems, according to Knouse, Teller & Brooks (2017).
Neurofeedback (NF): The authors describe NF as a treatment that provides feedback on electroencephalographic signals in real time and aims to acquire self-control over certain patterns of brain activity, and then apply these skills in daily life situations.
Division 53 of the American Psychological Association considers NF a promising treatment, although compared with no treatment, not against established approaches. At the same time, it highlights the methodological deficiencies of the research that studied NF. Other reviews find similar difficulties in the research, among which the absence of follow-up and generalization of the results stands out and that the effects of the treatments disappear or decrease when the research is blind.
The authors of the review on which this article is based consider Neurofeedback a promising approach, which at the moment cannot be recommended as a treatment for ADHD due to the absence of methodologically well-designed studies.
Cognitive training (CE): This is a type of approach that seeks to train participants in various cognitive domains where they present difficulties, through computer tools and activities where the levels of difficulty gradually increase.
Division 53 of the American Psychological Association considers it a treatment with unproven evidence. There are other systematic reviews where improvements are observed in patients treated with this type of training, but these effects decrease when the evaluation is blind.
Studying working memory through computer programs, some research shows promising results, while others do not, presenting methodological difficulties in both cases. On the other hand, other reviews have shown that working memory training produces moderate results in the short term, but that it fails to generalize.
In general terms, there is not enough scientific evidence to recommend cognitive training to address ADHD, given the absence of significant results, the lack of generalization and the methodological flaws present in the research.
Mindfulness (MF): Mindfulness is a formal practice of increasing awareness, focusing attention on the present moment and observing without making judgments. This would theoretically have a beneficial effect on the ability to focus…