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4. Non-Pharmacological interventions

4.1 Lifestyle Changes

Clinical Questions

1. What is the clinical effectiveness of non-pharmacological treatments for people with ADHD?
2. What are the adverse events associated with non-pharmacological treatments for people with ADHD?

Clinical Questions

Should treatments be provided individually or in groups?
Who should deliver them?


Lifestyle changes involve modifying aspects of daily life to improve health and well-being. Lifestyle changes have the potential to improve day-to-day functioning for people with ADHD. Lifestyle factors considered in this section include diet, exercise or activity levels, and sleep patterns. Studies of lifestyle interventions that met the guideline inclusion criteria explored sleep and exercise. Substance use is covered in detail in section 6.3.

Summary of evidence review

An evidence review (update of NICE 2018) was conducted to explore what principles clinicians should follow when discussing decisions to start, adjust, or discontinue pharmacological treatment for people with ADHD Whilst new evidence was found, it was not integrated because the NICE analysis was already deemed to have reached saturation of thematic data. NICE identified 69 studies and conducted a qualitative review of the views of people with a lived experience of ADHD and their families. Saturation in themes was reached after five themes were identified. Clinicians should be aware of these themes in order to improve outcomes for people with ADHD and adequately support them through the pharmacological treatment process (see below).

Sleep intervention versus waitlist/usual care

This comparison was not addressed in NICE. Two new studies (Papadopoulos et al., 2019; Sciberras, Mulraney, et al., 2020) were identified in this evidence review using data from the same RCT testing the efficacy of a brief (2–3 sessions) behavioural sleep intervention in children with ADHD, compared with usual clinical care. These studies have been described narratively here following feedback from public consultation.

Sciberras et al., 2020 examined the 12-month outcomes of this intervention relative to usual care and found benefits up to 12 months later in parent-reported child sleep difficulties, ADHD total symptoms, ADHD inattentive symptoms, ADHD hyperactivity/impulsivity symptoms, quality of life, daily functioning, total behavioural difficulties and emotional difficulties. However, there were no benefits in parent-reported child conduct difficulties, parent mental health or any teacher-reported outcomes.

Papadopoulos et al., 2019 examined the outcomes for children with co-occurring ADHD and ASD from the original trial and found some significant benefits in terms of parent-reported sleep but not in other aspects of child or parent functioning. A translational RCT by Hiscock et al., (2019) found that sleep interventions delivered by paediatricians or psychologists in their clinical practice led to improvements in child sleep but not in other domains of functioning.


Overall, few RCTs have examined the efficacy of exercise interventions to help to improve health and wellbeing in people with ADHD. No evidence was identified that evaluated the effectiveness of exercise interventions for ADHD in children under the age of 5 years or in adults. NICE identified very limited evidence in children and adolescents (ages 5–18 years) and the updated search identified an additional two randomised controlled trials (RCTs) of low to very low certainty and with very small sample sizes.

Exercise versus waitlist/usual care
No new evidence was found. NICE previously identified one low-quality study of moderate intensity physical activity (Ahmed & Mohamed, 2011) which found a benefit for inattention symptoms and academic performance as rated by teachers, but no benefit for behaviour or broader functioning by teacher report.

Exercise (exergaming) versus waitlist
New evidence was identified for a new comparison consisting of one new RCT with moderate risk of bias comparing cognitively and physically demanding exergaming to a waitlist (Benzing & Schmidt, 2017). There was a statistically significant benefit of exergaming over waitlist for global ADHD index scores as rated parents, and no statistically significant differences for ADHD symptoms (total, inattention and hyperactive-impulsive) by parent report.

Relaxation versus usual care

There were no clinically important benefits for ADHD total symptoms (parent-rated; 1 study very low quality; teacher rated; 1 study very low quality).

Evidence-to-recommendation statement

Overall, very few studies have examined the potential benefits of lifestyle changes for people with ADHD. No studies meeting the guideline criteria were identified for adults and children under 5 years. The NICE 2018 guideline recommended the following about lifestyle: ‘Healthcare professionals should stress the value of a balanced diet, good nutrition and regular exercise for children, adolescents and adults with ADHD’. This updated review continues to support this recommendation but suggests that it is important to include sleep when considering lifestyle changes.

The few studies identified were small and of low to very low quality, with moderate to high risk of bias. Given the lack of evidence, no specific evidence-based recommendations about these lifestyle interventions were made, but several clinical practice points have been suggested to guide practice.

Next 4.2 Cognitive-behavioural intervention approaches