There are several guidelines for treating children with ADHD:

1. Always start with psychoeducation.
2. Offer behavioural parent and/or teacher training.
3. Offer medication in severe cases or when the previous interventions were not effective.

Behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. This is especially the case in studies where the outcomes are blinded. However, parenting practices and conduct problems improve after behavioural interventions and this is often the main reason for referral, meaning that behavioural interventions serve their goal. Improving parents’ behaviour towards their children may improve child behaviour and improve the quality of the parent-child relationship.

Children who receive behavioural consultation are less likely to receive medication later that year. If they do receive medication, the dosages are lower compared to children who did not receive behavioural consultation. Using ­a low-intensity behavioural intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.

There are several reasons why it is important to reduce the need for medication:

• Parents prefer non-pharmacological interventions.
• Medication does not lead to improvement on all domains (i.e. it does not normalize functioning).
• Medication does not improve outcomes on the long-term.
• The long-term compliance is low.
• The long-term safety of medication is unclear.
• There are frequent side-effects of medication.

Adding medication secondary to initial behavioural treatment leads to better outcomes on primary outcomes than the other way around. Parents who began treatment with behavioural parent training had better attendance than those assigned to receive training after medication. The cost of starting with a low-intensity behavioural intervention is also lower. It is thus important to start with behavioural intervention.

Behaviour modification is teaches skills to parents, teachers and children to overcome some of the key functional impairments associated with ADHD. Effective treatments need to focus on peer relationships (1), parenting (2) and academic functioning (3). Combining recreational activities with educational activities increases children’s attendance.

Behavioural parent/teacher training is a mediation therapy. This means that the therapist trains the parent or teacher and this person then uses their newly learned skills on the child. This is done because interventions directly involving the child often have little effect due to self-regulation problems of children with ADHD. Using both parents may increase the consistency of the implementation of strategies and shared understanding of ADHD which may lead to better outcomes. However, the evidence for this is limited.

Barriers to parent training include situational factors (1), psychological factors (2), lack of awareness of programmes (3), unavailability of programmes (4) and issues with poor interagency collaboration (5). There are several moderators of treatment effect:

• Mild to moderate parental psychopathology may reduce treatment effectiveness.
• Parents at risk for ADHD may have more difficulty maintaining gains.
• High levels of ADHD in mothers reduces the effect.
• The presence of a conduct disorder in the child reduces the impact of the intervention.
• The presence of an anxiety disorder makes the intervention more effective.

Behavioural interventions can be used irrespective of the severity of the symptoms and while comorbidity may alter the effects, the effects will not be iatrogenic. Early intervention does not lead to better outcomes though it may reduce the impact of ADHD for a longer period of time.

It is not entirely clear what the active components of behavioural interventions are, meaning that the components should not be used in isolation. While the effect of behavioural interventions do not differ across treatment setting and delivery structure, drop-out (1), preferences (2) and cost (3) should be considered. Nonetheless, behavioural interventions often show limited generalizability.

Antecedent-based interventions focus on events before the problematic behaviour arises. This can be a lack of rules (1), expectations (2), structure (3) or support (4). Alternatively, an environmental stimulus (e.g. reinforcement) may trigger the behaviour.

Improving rules, expectations, structure or support can be done by giving clear instructions by:

• Providing the child with visual support.
• Repeat the instructions when necessary.
• Divide the task in smaller components.

There need to be clear rules for undesired behaviour. Alternatively, other stimuli may need to be removed or minimalized by adjusting the position of the child in class (e.g. close to the teacher) or take the children apart.

It may be useful for children with ADHD to visualize the time frame of an activity. Antecedent-based interventions can focus on setting events, which refer to events that intensify problems or increase the probability of problematic behaviours (e.g. being hungry).

Consequent-based interventions focus on the consequence of behaviour. This requires to take into account the function of behaviour. There are several major functions:

1. Escape or avoid a stimulus.
2. Gain attention.
3. Obtain activity or object.
4. Change sensory input (e.g. receive more sensory input or decrease stimulation)

The core of consequent interventions is to reward desired behaviour and ignore or punish undesired behaviour (e.g. time-out). Ignoring refers to not reinforcing behaviour that was previously reinforced (i.e. extinction). This works but can also lead to a lot of frustration in the child. Shaping refers to learning new behaviour through selective reinforcement of behaviour that approaches the desired behaviour (i.e. zone of proximal development).

Children with ADHD have a higher sensitivity to punishment. This may explain the lack of persistence in children with ADHD for tasks that are annoying, frustrating or aversive. This means that punishment may be less effective in children with ADHD as they focus on avoiding punishment rather than increasing desirable behaviour.

It is not entirely clear which elements of behavioural interventions are effective. A meta-analysis demonstrated that there is a medium-sized effect on all parenting outcomes of behavioural interventions. Different techniques have different outcomes:

• Techniques that manipulate antecedents (e.g. anticipate for misbehaviour) had a positive effect on parenting competence (1), parenting stress (2) and parental mental health (3).
• Techniques that focus on providing positive consequences (e.g. offering a social reward) had a positive effect on negative parenting.

The higher the dosage of psychoeducation in a treatment, the lower the effect of the intervention on positive parenting and parent-child relationship. This may be because interventions that focus more on psychoeducation have less time to focus on behavioural skills. Behavioural parent training should thus deliver antecedent techniques and positive consequent techniques at a high dosage.

A microtrial refers to a small, randomized study which is designed to assess causal effects of each randomized intervention component. It isolates a specific treatment component. This allows to find out which component of a treatment is effective.

For younger children, consequent-based techniques are more effective than antecedent-based techniques. For older children, antecedent-based techniques are more effective than consequent-based techniques. This may be because the classroom for older children is less structured and teachers already have higher expectations. The beneficial effects of antecedent-based techniques increases when the number of students per class decreased. The effectiveness of consequent-based techniques does not depend on class size.

Children with ADHD and executive function problems may benefit more from antecedent problems. Children with ADHD and a differential reinforcement sensitivity may benefit more from consequent techniques. However, whether this is truly the case is not clear yet.

Treatments can be personalized by targeting behaviours selected by parents and/or teachers. This can make use of ecological momentary assessment, which refers to repeated assessment of the participant’s behaviour in real-time and its natural environment (e.g. ask the teacher to report target behaviour at a random point in time for half a minute). This minimizes bias and maximizes ecological validity.

The summer can be used to teach parents skills while working intensively with children during the day. This helps the skills generalize. It is important to maintain treatment over the summer as treatment gains may otherwise be lost. The Summer Treatment Programme (STP) is a summer treatment for children with ADHD which aims to improve children’s peer relationships (1), interactions with adults (2) and self-efficacy (3) while training their parents in behavioural management. Children are placed in a group and these groups stay together to make sure that children receive intensive experience in group functioning (1), making friends (2) and interacting appropriately with adults (3). The treatment consists of several components:

1. Point system
   Children earn points for appropriate behaviour (i.e. behaviour targeted for development) and lose points for inappropriate behaviour (e.g. teasing).
2. Social reinforcement and appropriate commands
   Children receive praise and public recognition for appropriate behaviour to allow modelling of social behaviour.
3. Daily report cards and parent involvement
   Children receive daily report cards which include individualized target behaviours across all settings. Parents are supposed to provide rewards for reaching goals.
4. Time-out
   This includes disciplining (e.g. privilege loss) for certain behaviours.
5. Medication assessment
   Children receive elaborate assessment to assess the usefulness of medication.

The intervention includes skill building in several ways:

1. Sports skills training
   The involvement in sports may enhance self-efficacy which may promote behavioural change.
2. Peer intervention
   There are daily, short group sessions which include instruction (1), modelling (2), role playing (3) and review (4) to enhance cohesive peer relationships. Positive behaviours are rewarded.
3. Academic setting
   Children engage in a variety of structured academic activities and complete assignments to facilitate transfer of skills to the regular settings.

STR produces large, clinically meaningful changes in child behaviour and there is an incremental contribution of individual treatment components (e.g. time-out). The drop-out rate is extremely low and the effect of medication is maximized at a very low dose when STP is in place.

Cognitive training is a treatment which aims to train executive functioning in children with ADHD. However, the evidence-base for this is limited. There is little transfer of executive function improvement to daily life (e.g. only improvements on aspect of the training itself). There is no or a minimal effect on academic tasks (1), behaviour (2) and cognitive tasks (3). Next, there are significant placebo effects. One example of cognitive training is EndeavorRX, which is a videogame-delivered cognitive training. The lack of evidence for cognitive training may be due to methodological issues as most treatments target a different neurocognitive function.

To make treatment decisions, it is essential that somebody knows what it means for a treatment to be evidence-based and know what it means for a treatment to receive FDA clearance. It is essential that the differences are understood, as FDA clearance does not mean that a treatment is evidence-based.

Dietary interventions believe that artificial food colours (1), sugar (2), omega-3 fatty acids (3) and a supplement of micronutrients influence ADHD or ADHD symptoms. The intervention aim to change one’s diet regarding these foods. Elimination diet focuses on eliminating almost everything from one’s diet and slowly adding foods to the diet to find out which foods contribute to ADHD. However, dietary interventions have a limited evidence-base.

Neurofeedback is a treatment which aims at regulating brain activity of a child by giving real-time feedback about brain activity. A meta-analysis found that there are significant effects on ADHD symptoms rated by the least blinded assessors (e.g. self-report; parent-report). When blinded measures are included, the results are not significant. This means that the evidence-base of neurofeedback is limited.

Organization skills training involves direct instruction, practice and coaching in use of new or replacement behaviours designed to address ADHD symptoms and associated impairments. Participant are taught to organize materials and time and to practice with performance feedback. The amount of practice and performance feedback, and the degree to which the content of training matches real-world behaviour and domains of impairment determine efficacy of the treatment.

Mindfulness should not be considered as a first-line intervention for ADHD. There are positive effect sizes but this may be due to significant methodological limitations. It may be beneficial in the treatment of ADHD but it requires more research.