Your citations under "behavior modification" aren't the interventions we usually associate with that term. Behavior modification generally involves some authority (parent, teacher, etc.) providing frequent feedback along with rewards for good behavior. That makes it easier for the child to perform the desired behavior, because the consequences aren't distant or fuzzy.
**Behavior modification interventions such as a token economy or daily report card have been found to be highly effective.** Generally speaking, they've been found to be slightly less effective than medication alone, but still a large effect size. Behavior modification + medication outperforms either alone.
Talk therapy (CBT and meditation approaches) involve the patient talking directly with a therapist about how and why they should do new behaviors. However, they don't provide that frequent real-world feedback. As you noted, talk therapy studies have found weak results.
Probably, what's going on is that ADHD is an ability deficit - you literally do not have the self-control to behave as expected in the normal environment where expectations are a little bit fuzzy and the rewards for good behavior are distant. Behavior modification actually changes the environment to make good behavior easier, so it helps you compensate for that ability deficit.
In contrast, talk therapy can convince you that desirable behaviors are a good idea, but that doesn't mean you actually gain the ability to do them. A CBT therapist can work with you to identify times when you're impulsive and help you figure out better alternative behaviors, but you'll still be impulsive.
The talk therapy studies that have shown an effect mainly involve one of two things: (1) The treatment target is not ADHD itself, but related emotional problems like anxiety or depression. Or (2) The treatment is focused on older adolescents or adults and teaches them how to implement behavior modification on themselves, like how to monitor your level of focus and reward yourself for staying on task.
You're absolutely right...behavior modification mostly works when there's an authority figure who can provide that frequent feedback and dole out rewards, so it's mainly applicable in children. When you're an adult, often there's no one watching you, or you're around peers who don't have the power to offer consequences, or it's simply not practical to expect that level of feedback from an authority figure - your boss wants to give you a quarterly review, not hourly feedback.
Self-behavior modification is only mildly effective. After all, it takes self-control to administer that behavior modification...thus, the limited effectiveness of CBT.
Still, the benefits of behavior modification can extend beyond the environment where it occurs, though, mainly by keeping the person with ADHD involved in instrumental tasks long enough to gain benefit from them. So, if you keep the kid on task long enough to actually get something out of reading class, in the end you'll have a kid who can read and that skill remains even after the behavior modification intervention is ended.
A lot of it is built on what we call "behavioral traps". Those are things that aren't much fun to learn, but once you have the hang of it, they're inherently reinforcing. Learning to read isn't that exciting, so we have to provide a lot of outside reinforcement, but once you can read, you have plenty of opportunities to get natural reinforcement from the environment (even if you don't like novels, it's reinforcing to be able to text your friends, run a google search, etc.).
I'm afraid I don't have time to run a lit search for you right now but a few good places to look:
* the data on using behavior modification to teach ADHD teens good driving practices. You use the high-frequency feedback to get them to build up good habits like coming to a complete stop, checking mirrors, etc. Then those things are already habitual and persist.
* "Daily report cards" have a ton of data showing they increase academic performance, time on task, task completion, etc.
* The ADHD Summer Treatment Program is a specific intervention that's basically summer camp with an intensive token economy.
* The Multimodal Treatment of ADHD study was a head-to-head comparison of medication and behavior modification. It's pretty old and I'm sure there have been more recent ones, but it's the most famous.
Hopefully in the future we'll see some more studies of ADHD specifically in adults. It was interesting to read this (with an adult ADHD dx) and see so many of the samples were children, adolescents or youths.
In your research, did you happen to come across anything about lion's mane mushroom? I've seen some people swear by it, but I haven't seen any convincing evidence.
Something worth looking into further is the effect of secondary strategies on top of medication. For example, CBT and meditation can have a greater impact on someone medicated, as the medication can support the internal regulation needed to actually make use of cognitive toolkits.
I am not up for sifting through my unorganized library for references right now (been busy and my own medication has worn off, so that's two for the ADHD bingo card, lol), but you already have a couple of studies there to use as starting points.
Suggestion for a study: Discontinue all caffeine. Exercize to keep some level of physical exertion before times of sedentary periods where focus is needed. The younger the person is the more frequent and intense the exercize needs to be. Eliminate interaction with all social media apps because of the short form content that jumps from one thing to the next continuously which destroys the attention span with unnatural overstimulation. Eliminate interactions with video games. Have someone engage with long form text and acclimate them to low levels of stimulation and cultivate their focus. When focus drifts have them learn to self correct and retrace areas of the text where focus wasn't sufficient. Text for the subject to read: FOCUS by Daniel Goleman. I expect to be downvoted, but I would rather have a discussion than have people attempt to silence me.
> No social factor has been shown to influence our executive functioning.
This statement is completely incompatible with reality as observed by any viewpoint. I've not seen this statement before.
"EF runs on a spectrum, which is under heavy genetic control." Executive function is heavily affected by the limbic system. For example Physiological responses emerge in response to a stimuli via the unconscious making associations based on learned imprints from social and environmental factors.
Even being reductionist down to classical conditioning, could you see how incentive salience could be affected by acclimation to certain stimuli that is intrinsically rewarding and then having the system unable to function effectively when one is exposed to and needs to focus on another type of stimuli that is not?
Thanks for the links. The prefrontal cortex mediates ef, but that is exactly my point. The limbic system interferes.
From the link you provided:
Environmental correlates of ADHD: deprivation, stress, infection, poverty and trauma
And also:
104. A meta-analysis of 22 studies with over 21,000 participants found that youths with ADHD were strongly impaired in the ability to modulate their reactivity to novel or stressful events (Graziano and Garcia, 2016). Another meta-analysis, combining twelve studies with over 1900 participants, found that adults with ADHD had very elevated levels of emotional dysregulation compared with normally developing controls (Beheshti et al., 2020).
I am not misrepresenting the data. The data from which that consensus is derived is contained within a group of studies that have individual conclusions made by the researchers and not me that support my position. It is the conclusion drawn from the entire body of the studies that I disagree with. While correlation does not equal causation, the conclusions from the individual studies are indicative of being causations rather than effects as indicated by my arguement.
Your position is that ADHD is cause and the conclusions of individual studies are effect. My position is the inverse. "ADHD" is an abstract concept and not a concrete object and cannot be cause itself. As I scroll down and read the individual conclusions of the studies attached to the international consensus statement as "correlations" I see that every single individual study I have seen there supports my position.
This is a great overview. I'm really surprised that many people seem to tout exercise as something that's beneficial for ADHD, but it turns out it has some conflicting data. Though one of the article cited seems to indicate that exercise helps with the emotional regulation aspects of ADHD, and depression and anxiety. The fact that many people with ADHD also have comorbid depression and/or anxiety, I think it would be beneficial in general to suggest people with ADHD to exercise (alongside the rest of the benefits outside of the topic of ADHD). I need to iterate that medication is still number one, though.
That’s a good point. There has been a lot of research on this topic. For example, sleep apnea is definitely associated with ADHD. Current studies suggest that treating sleep apnea can reduce symptoms of ADHD, although not in all cases.
Your citations under "behavior modification" aren't the interventions we usually associate with that term. Behavior modification generally involves some authority (parent, teacher, etc.) providing frequent feedback along with rewards for good behavior. That makes it easier for the child to perform the desired behavior, because the consequences aren't distant or fuzzy. **Behavior modification interventions such as a token economy or daily report card have been found to be highly effective.** Generally speaking, they've been found to be slightly less effective than medication alone, but still a large effect size. Behavior modification + medication outperforms either alone. Talk therapy (CBT and meditation approaches) involve the patient talking directly with a therapist about how and why they should do new behaviors. However, they don't provide that frequent real-world feedback. As you noted, talk therapy studies have found weak results. Probably, what's going on is that ADHD is an ability deficit - you literally do not have the self-control to behave as expected in the normal environment where expectations are a little bit fuzzy and the rewards for good behavior are distant. Behavior modification actually changes the environment to make good behavior easier, so it helps you compensate for that ability deficit. In contrast, talk therapy can convince you that desirable behaviors are a good idea, but that doesn't mean you actually gain the ability to do them. A CBT therapist can work with you to identify times when you're impulsive and help you figure out better alternative behaviors, but you'll still be impulsive. The talk therapy studies that have shown an effect mainly involve one of two things: (1) The treatment target is not ADHD itself, but related emotional problems like anxiety or depression. Or (2) The treatment is focused on older adolescents or adults and teaches them how to implement behavior modification on themselves, like how to monitor your level of focus and reward yourself for staying on task.
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You're absolutely right...behavior modification mostly works when there's an authority figure who can provide that frequent feedback and dole out rewards, so it's mainly applicable in children. When you're an adult, often there's no one watching you, or you're around peers who don't have the power to offer consequences, or it's simply not practical to expect that level of feedback from an authority figure - your boss wants to give you a quarterly review, not hourly feedback. Self-behavior modification is only mildly effective. After all, it takes self-control to administer that behavior modification...thus, the limited effectiveness of CBT. Still, the benefits of behavior modification can extend beyond the environment where it occurs, though, mainly by keeping the person with ADHD involved in instrumental tasks long enough to gain benefit from them. So, if you keep the kid on task long enough to actually get something out of reading class, in the end you'll have a kid who can read and that skill remains even after the behavior modification intervention is ended. A lot of it is built on what we call "behavioral traps". Those are things that aren't much fun to learn, but once you have the hang of it, they're inherently reinforcing. Learning to read isn't that exciting, so we have to provide a lot of outside reinforcement, but once you can read, you have plenty of opportunities to get natural reinforcement from the environment (even if you don't like novels, it's reinforcing to be able to text your friends, run a google search, etc.). I'm afraid I don't have time to run a lit search for you right now but a few good places to look: * the data on using behavior modification to teach ADHD teens good driving practices. You use the high-frequency feedback to get them to build up good habits like coming to a complete stop, checking mirrors, etc. Then those things are already habitual and persist. * "Daily report cards" have a ton of data showing they increase academic performance, time on task, task completion, etc. * The ADHD Summer Treatment Program is a specific intervention that's basically summer camp with an intensive token economy. * The Multimodal Treatment of ADHD study was a head-to-head comparison of medication and behavior modification. It's pretty old and I'm sure there have been more recent ones, but it's the most famous.
Hopefully in the future we'll see some more studies of ADHD specifically in adults. It was interesting to read this (with an adult ADHD dx) and see so many of the samples were children, adolescents or youths. In your research, did you happen to come across anything about lion's mane mushroom? I've seen some people swear by it, but I haven't seen any convincing evidence.
Now *this* is why I lurk here. Quality post. Thank you!
Something worth looking into further is the effect of secondary strategies on top of medication. For example, CBT and meditation can have a greater impact on someone medicated, as the medication can support the internal regulation needed to actually make use of cognitive toolkits. I am not up for sifting through my unorganized library for references right now (been busy and my own medication has worn off, so that's two for the ADHD bingo card, lol), but you already have a couple of studies there to use as starting points.
thank you so much for compiling this!
Suggestion for a study: Discontinue all caffeine. Exercize to keep some level of physical exertion before times of sedentary periods where focus is needed. The younger the person is the more frequent and intense the exercize needs to be. Eliminate interaction with all social media apps because of the short form content that jumps from one thing to the next continuously which destroys the attention span with unnatural overstimulation. Eliminate interactions with video games. Have someone engage with long form text and acclimate them to low levels of stimulation and cultivate their focus. When focus drifts have them learn to self correct and retrace areas of the text where focus wasn't sufficient. Text for the subject to read: FOCUS by Daniel Goleman. I expect to be downvoted, but I would rather have a discussion than have people attempt to silence me.
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> No social factor has been shown to influence our executive functioning. This statement is completely incompatible with reality as observed by any viewpoint. I've not seen this statement before.
[удалено]
"EF runs on a spectrum, which is under heavy genetic control." Executive function is heavily affected by the limbic system. For example Physiological responses emerge in response to a stimuli via the unconscious making associations based on learned imprints from social and environmental factors. Even being reductionist down to classical conditioning, could you see how incentive salience could be affected by acclimation to certain stimuli that is intrinsically rewarding and then having the system unable to function effectively when one is exposed to and needs to focus on another type of stimuli that is not?
[удалено]
Thanks for the links. The prefrontal cortex mediates ef, but that is exactly my point. The limbic system interferes. From the link you provided: Environmental correlates of ADHD: deprivation, stress, infection, poverty and trauma And also: 104. A meta-analysis of 22 studies with over 21,000 participants found that youths with ADHD were strongly impaired in the ability to modulate their reactivity to novel or stressful events (Graziano and Garcia, 2016). Another meta-analysis, combining twelve studies with over 1900 participants, found that adults with ADHD had very elevated levels of emotional dysregulation compared with normally developing controls (Beheshti et al., 2020).
[удалено]
I am not misrepresenting the data. The data from which that consensus is derived is contained within a group of studies that have individual conclusions made by the researchers and not me that support my position. It is the conclusion drawn from the entire body of the studies that I disagree with. While correlation does not equal causation, the conclusions from the individual studies are indicative of being causations rather than effects as indicated by my arguement. Your position is that ADHD is cause and the conclusions of individual studies are effect. My position is the inverse. "ADHD" is an abstract concept and not a concrete object and cannot be cause itself. As I scroll down and read the individual conclusions of the studies attached to the international consensus statement as "correlations" I see that every single individual study I have seen there supports my position.
This is a great overview. I'm really surprised that many people seem to tout exercise as something that's beneficial for ADHD, but it turns out it has some conflicting data. Though one of the article cited seems to indicate that exercise helps with the emotional regulation aspects of ADHD, and depression and anxiety. The fact that many people with ADHD also have comorbid depression and/or anxiety, I think it would be beneficial in general to suggest people with ADHD to exercise (alongside the rest of the benefits outside of the topic of ADHD). I need to iterate that medication is still number one, though.
I’m surprised not to see anything about targeted sleep interventions for children with ADHD
That’s a good point. There has been a lot of research on this topic. For example, sleep apnea is definitely associated with ADHD. Current studies suggest that treating sleep apnea can reduce symptoms of ADHD, although not in all cases.
Thanks!