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Evidence-Based Practice Paper:
Attention Deficit-Hyperactive Disorder
Zackary A. Shaikh
MCC503-T303 Statistics and Quantitative Re (2235-1)
Dr. Barry Trunk
June 3, 2023
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Introduction
Attention-deficit/hyperactivity disorder (ADHD) is one of the most well-known mental
disorders, so much so that people will often attribute something like fidgeting or attention issues
to ADHD without seriously considering what it means to have ADHD. ADHD commonly affects
children, and over the years there has been a consistent increase in the diagnosis among children
(CDC, 2022). It was once thought that it might only occur in children, but there is evidence now
that ADHD can persist from childhood to adulthood (Pary et al., 2011). Because of this, adult
ADHD has gone largely undiagnosed and therefore understudied (Turgay et al., 2012). Adult
ADHD, in order to be diagnosed, has to be shown through symptoms occurring from childhood
and adolescence. According to the CDC (2022), a study between 2016-2019 showed that an
estimated 6 million children between ages 3-17 have been diagnosed with ADHD, a majority
being white, non-Hispanic or black, non-Hispanic males.
ADHD is typically divided into two categories: inattention and hyperactivity. They both
have their own criteria of diagnosis according to the DSM-5, and both have nine possible
symptoms that the patient must meet. For children age 0-16, six or more of the symptoms must
be present for at least six months and be disruptive to the normal lifestyle. For children 17+, only
five must be present for at least six months and disruptive to the normal lifestyle (CDC, 2022).
The criteria for inattentive ADHD is the following: Often fails to give close attention to
details or makes careless mistakes, often has trouble focusing their attention on activities or
tasks, often does not seem to listen even when spoken to directly, often does not follow through
on instructions and fails to finish schoolwork or duties, often has trouble organizing tasks and
activities, often avoids or dislikes tasks that require mental effort over a long period of time,
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often loses things necessary for tasks and activities, is often distracted easily, and/or is often
forgetful in daily activities (DSM-5).
The criteria for hyperactivity/impulsivity is the following: Often fidgets with hands or
feet, often leaves their seat when remaining seated is expected, often runs about or climbs in
inappropriate situations, often unable to play or take part in leisure activities quietly, is often
continuously moving about, talks excessively, blurts out a response before the question can be
completed, has trouble waiting their turn, and/or often interrupts others or activities (DSM-5).
Empirically Supported Treatment Strategies
The addition of comorbidities to ADHD makes ADHD itself a challenge to treat. One
study in 2022 of 428 ADHD-diagnosed participants in the United Arab Emirates showed that
77% of those participants had a comorbidity (Jorgia et al., 2022). Comorbidities include sleep
disorders, mood disorders, anxiety disorders, autism, and learning disorders. Many of the
treatments discussed in this paper will seek to decrease the symptoms of ADHD which could
also concur with decreased symptoms of another disorder. However, there are verifiable,
empirically-supported treatments specifically used to treat patients with ADHD. This paper will
exclude medication as a sole treatment because while it is typically the first thought for treatment
(Mattingly et al., 2017), there are treatment options in which a practitioner may find beneficial
within their own practice in addition to medication (Young, 2010).
Treatment 1
The first treatment of interest for patients with ADHD is behavioral therapy. The goal of
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behavioral therapy is to objectively identify potential harmful or unhealthy behaviors and replace
them with healthier and helpful behaviors (Johnson, 2021). The most common types of
behavioral therapy are Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy
(DBT). In the case of ADHD, CBT is the preferred method of treatment. This type of therapy
helps the client change the way they see challenges and the way they see their own behavior,
challenges them to change that behavior, then follows up with continued healthier behaviors
(Johnson).
CBT has been shown to be useful with ADHD in kids (Knopf, 2021) and useful in
college students (Anastopoulos et al., 2020) by reducing the symptoms of anxiety and stress.
Even if comorbidities exist, CBT might be a helpful treatment considering many disorders have
overlapping symptoms. In later sections, both studies with kids and studies with adults will be
further examined to analyze efficacy of the treatment in different contexts.
Two studies will be examined side-by-side in this paper, one study in children and one
study in adults. This is included because there are limitations in both that will further highlight
the need for continued studies in the field of ADHD for both children and adults.
Treatment 2
Another treatment option for ADHD is yoga or meditation of some sort. This treatment
modality is considered low-risk because, unlike medications, it does not directly cause sleep
issues, appetite loss, or mood problems (Chou & Huang, 2017). The theory that Chou and Huang
(2017) tested with yoga was that yoga teaches techniques like breath control, posture, and
cognitive control, therefore aiding in reducing symptoms such as being easily distracted or
fidgeting. Gunaseelan et al. (2021) discussed this theory using a case study about a South Asian
male whose parents refused medication but consented to yoga. After the yoga intervention was
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implemented, the reported ADHD symptoms were decreased, suggesting that yoga could
potentially be a standalone treatment for ADHD (Gunaseelan et al., 2021).
Treatment 3
ADHD can also be effectively treated by diet, even though the exact mechanisms behind
the “why” is still unknown. It is estimated that 60% of children experience reduced symptoms
with a “few-foods diet” (Hontelez, 2021). A few-foods diet is one that limits the diet to the few
foods known to cause the least number of issues, such as meat, rice, pears, etc. There is also a
diet called the Feingold diet that restricts food additives, dyes, etc. that are thought to make
ADHD symptoms worse. A study by McCann et al. (2007) tested this diet to see if this was, in
fact, an effective treatment against ADHD. McCann et al. (2007) concludes that increased
artificial colors or sodium benzoate preservative increases hyperactivity in the general
population. Another study by Baaki et al. (2021) resulted in a theory that a fixed diet could
reduce obesity and could be effective in also improving ADHD symptoms.
Reliability and Validity of Past Research
Treatment 1
The study conducted by Sprich et al. (2016) concluded results that were consistent with
other similar studies, making it more likely to be both valuable and reliable. The factors that
limited reliability was: small sample size, the consistent use of stable doses of medications (as
opposed to doses that changed during the study), comorbid conduct disorder was ruled out as a
possibly participation criteria, no validation of self-reported usage of medication (therefore
reliance upon truthful reporting), and no follow-up at any period after the study.
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With the consent of all participants, all sessions were audio taped. Five percent of the
tapes were then reviewed by a second therapist and rated for fidelity to protocol. The average
general session fidelity rating was 97.5%.
The study on adults with and without medication was performed in a similar manner to
the one by Sprich et al. The sessions for CBT were recorded and listened to by other
therapists/investigators (Weiss et al., 2012). Internal validity and reliability were assured by
using a double-blind method: the therapist using CBT was unaware if their patient was receiving
a stimulant medication, and the participants were unaware if their medication was a stimulant or
placebo. External validity was increased due to examination of the demographics between
control and intervention group, and the demographics were determined to be virtually
homogenous.
Treatment 2
In the 8-week yoga intervention study in children with ADHD, the sample size was small
(Chou & Huang, 2017). This means an increase in threat to external validity. There were no
significant differences between the two groups in terms of BMI, age, IQ, or fitness, suggesting
the groups were homogenous and assuming good internal validity. The findings of this study
were consistent with other studies that have been done before and since this study was
conducted, therefore the researchers concluded the results were valid and reliable.
Treatment 3
The study conducted by Hontelez et al. (2012) was only blind to the researchers who
were evaluating the data after it was collected, suggesting room for threats to internal reliability
and validity. Self-reports also increase those threats.
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Evaluation of Research Designs of Studies for Treatment Strategies
Treatment 1
Sprich et al. (2016) utilized a cross-over RCT (randomized controlled trial). This means
two interventions were assessed, and the participants in the groups are randomized as to which
intervention they receive and when, and they used stratified randomization to assign participants
to groups. One group of participants started CBT immediately, the other group waited until the 4month mark to receive CBT. An Independent Evaluator was used to rate the status of the
participants at baseline, 4 months, and 8 months, and this IE was blind to treatment method
(CBT vs. Wait List).
Weiss et al. (2012) utilized a double-blind RCT, with five sites reporting, and a placebocontrolled parallel group. The participants were assigned to groups using random sampling, and
participants randomly assigned to one of the five different sites. The first session of CBT was
spent educating the patient on ADHD and how it affects people. Then, 7 sessions were provided
every other week which allowed the patient to focus on a particular issue. Lastly, there were two
follow-up mini sessions at weeks 15 and 20. Participants were evaluated after each session.
Treatment 2
Our first study focuses on yoga spent eight weeks testing the effects of yoga on sustained
attention and discrimination function in children with ADHD (Chou & Huang, 2017). This study
used convenience sampling via flyers posted in random locations, referrals by schools, and
orientations. The inclusion criteria was a diagnosis of ADHD and age 8-12 years old. Those with
comorbid conduct disorders, a history of brain damage, and usage of sedatives were excluded.
Students were then assigned to either the intervention group or control group by their school
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district. The students were invited to the laboratory on two different days. The first day, 3 tests
were given: Visual Pursuit Test, Determination Test, and Physical Fitness Test. Then, the
intervention group was given eight weeks of yoga exercise. Then, the students were evaluated
using the same 3 tests.
Treatment 3
The Few-Foods Diet (FFD) was studied by Hontelez et al. (2021). 138 children were
screened for participation, and 100 of them were accepted. This screening was considered t0.
Then, the participants had to go through a series of tests for task performance, brain scans,
behavior scores, etc. Between t0-t1 was considered baseline, and at t1 the participants were
evaluated again. The FFD was implemented for 32-33 days. During the first two weeks, the FFD
was expanded to include more foods than the stringent FFD. If, after two weeks, participants
showed no improvement, they were directed to be on the most stringent FFD. At the end of the 5
weeks, t2, the participants were examined again using all of the tests.
Evaluation of Statistical Methods in Studies for Treatment Strategies
Treatment 1
To begin their study, Sprich et al. (2016) confirmed ADHD diagnosis and psychiatric
comorbidities by the Kiddie-Schedule for Affective Disorders and Schizophrenia-Epidemiologic
Version. 56.4% of participants had a comorbidity. The exclusion criteria for the study was a
comorbid condition that would interfere with participation (none met this criteria), active
suicidality, conduct disorder, active substance abuse, mental retardation, pervasive
developmental disorder, organic mental disorder, or a history of CBT for ADHD. After the
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participants were confirmed, they were then rated using IE Rated Clinical Global Impression
Scale to measure overall severity of ADHD symptoms.
Furthermore, Sprich et al. (2016) summarized their data by mean ± Standard Deviation. A
longitudinal general linear mixed effects model (SAS, v. 9.2) was used, with the variance
components error correlation structure among the repeated measures, which were 0, 4, and 8
months. Treatment efficacy was determined by the change in longitudinal mean between the
CBT and Wait List conditions at each measure. The final analysis was repeated over 100
multiply imputed data sets in order to take into account missing data. The difference in responses
after CBT versus after Wait List was calculated using the raw data and a chi square test. During
the study, Cohen’s d = 0.78 to detect statistical significance, with 80% power at a two-tailed p =
0.05 significance level using the ADHD Current Symptoms Scale.
Weiss et al. (2012) determined their participants based on the ADHD-RS-Inv, a DSM-IV
symptom checklist that is validated for assessing children. Other information was assessed on the
Conners’ Adults ADHD Rating Scales. Patient functioning, which was self-reported, was
recorded using the Sheehan Disability Scale. Weiss et al. used a two-way repeated measures
ANOVA to test if there is a difference between the groups at different times. Sample size was 48,
alpha was 0.5, and effect size was 1.1, so Weiss et al. concluded that they had greater than a 90%
chance of finding discrepancies if there were any.
Treatment 2
To ensure homogeneity for both groups in the Chou & Huang study (2017), independent
t-tests or chi-square tests were used. The Visual Pursuit Test and Determination Test were
examined using 2X2 mixed design ANOVAs, then Bonferroni-Holm adjustments were made to
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control for increased Type 1 error due to the small sample size. Effect sizes were calculated using
Cohen’s d and partial eta-square. Significance level of .05 was used for all statistical analyses.
Treatment 3
To determine eligibility, Hontelez et al. (2012) accepted those who were diagnosed with
ADHD by a trained pediatrician, and were given an abbreviated IQ test. Behavior scores were
measured using the ARS, and those measurements were taking at t0, t1, and t2 using a paired ttest. An fMRI scan was used on the participants to record brain activity. Task performance during
the interventions were measured by the GoRT, the SSRT, and the GoRT variability. To test task
performance, a Flanker test was administered. All results were tested for normality using the
Shapiro-Wilk test; if normality was assumed to have been violated, then non-parametric tests
were used (Wilcoxon signed rank test or Kruskal-Wallis test). The percent change between t1 and
t2 was analyzed using ANOCOVA.
Effective Treatment Strategies
Treatment 1
The conclusions of the studies presented here were similar: CBT is effective in the
treatment of ADHD symptoms (Sprich et al., 2016; Weiss et al., 2012). Studies have shown that
medication has developed in such a way that makes it more feasible for people, especially
children, to take medication even when behavioral therapy is not effective (Mattingly et al.,
2017). Other studies have shown that behavioral therapy in addition to the medication makes for
a better treatment option (Sprich et al., 2016). Sprich et al. claims that their findings support CBT
as an alternative or complement to medication. Weiss et al. (2012) found that time had a
significant impact on ADHD symptoms in both the control group and intervention group,
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showing that there was no significant difference between treatment and non-treatment in respect
to time. Ultimately, it would be statistically valid to say that CBT aids in reducing ADHD
symptoms with and without stimulants.
Treatment 2
The studies presented in this paper were consistent with others that suggests yoga
exercise alleviates anxiety, impulsivity, and social disruptions (Chou & Huang, 2017). Because
of studies like these, yoga has now been considered a front-line therapy for ADHD patients
between 3-5 years old (Gunaseelan et al., 2021). Another study quoted by Gunaseelan et al.
concluded that yoga can be effective even in the absence of medication. Yoga is considered a
low-risk treatment option given that medications can often have unwanted side-effects or may be
ineffective at times.
Treatment 3
There is a consensus that our microbiome affects mental health (Aetna, 2023). Research
shows that those who consume 28% or more of their calories from ultra-processed foods (like
fast foods) have a higher risk of dementia (Haase, 2022). So, it should be no surprised that food
also has a link to how our brain dictates our behavior. As shown in this paper, food can have an
effect on ADHD by the role it plays in brain activity.
Ineffective Treatment Strategies
As it has been made clear, treating ADHD is pretty complex. Regardless, there are many
interventions out there that think they can contribute to the smorgasbord of treatments. Some of
those include certain vitamins, EEG Biofeedback, and kinesiology (Goldstein & Ingersoll). We
must also keep in mind that effective treatments themselves can become ineffective if they are
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not adhered to as they should be (Krewson, 2022). This could mean stimulants can become
ineffective if they are not taken properly or the correct dose is not prescribed. Yoga, FFD, and
CBT can be ineffective if the patient is unwilling (or the symptoms of the patient interfere with
the ability to) consistently receive the intervention. Regardless, research continues and hopefully
the amount of ineffective versus effective treatments will become more obvious and practical.
Recommendations for Future Research
One of the things that is common among all of the studies presented in this paper is that
they use small sample sizes. Most of the studies admit to needing larger sample sizes. This will
help generalize the studies’ findings to the general population. There is also little research on
ADHD in adults, and in the context of the presented empirically-proven treatments, there is little
known about the effects of mindfulness-based therapy in adults (Bachmann et al., 2016) while
we have studies on mindfulness-based therapy in children (Evans et al., 2018). Further studies on
ADHD can also incorporate comorbidities, as there are plenty who exclude them and studies that
include them would be considered more novel. Lastly, it could be said that research lacks
comparing the connection between individual interventions and interventions that include the
parent structure or family structure. There are many studies out there that include the parents of
children with ADHD as part of the intervention (Rios-Davis et al., 2023), and there are some that
focus on the individual child outside of the realm of the family (Sprich et al., 2016). There could
be more research done on the effects of the two and how to combine family-oriented therapy
with patient-oriented therapy to get the best results for those with ADHD.
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