A common question many adults with ADHD ask is “Should I need to take medication for the rest of my life? To put it succinctly – No, Not Always. But the real solution involves an understanding of the impact of ADHD on the grown-up mind and of a few approaches that can be deployed to treat ADHD that are well supported by clinic evidence.
I am a psychiatrist working with adults in NYC, who have varying forms of ADHD presentations. Some do well taking only medications. Still others need to use a mix of the two. And a significant number manage their symptoms without any drugs.
In this post I have attempted to make sense of what the evidence states – and what I have observed to be effective in practice.
Why Adults Often Seek ADHD Treatment Without Medication
Adults seeking medical attention for ADHD don’t have to be difficult, or even guilty of denial. They have good and valid motives:
- The negative effects of stimulants such as decreased appetite, increased heart rate, sleep disturbances.”
- An history of substance use which can make their use of stimulants more complex
- Pregnancy or breastfeeding
- Personal opinion on behavioural or holistic approach
- Professional or job licensure which limits schedule II substances
The main thing is, wherever it comes from, the objective is the same: minimize disability, maximize functioning and create a viable mechanism to support daily living.
What the Research Says About Non-Medication ADHD Treatment
One thing is clear in the clinical literature: There is no more immediate intervention for the symptoms of ADHD than a drug. The effect sizes of stimulants, e.g., amphetamines and methylphenidate, are not typically similar to the effect on their own of behavioral treatments.
However, this is not all that can be fixed with medicine. It isn’t a skills-based course. It doesn’t change the way you think. The most successful results in the long term are achieved with structured behavioral approaches – plus medication for many adults, or behavioral approaches alone for those who do not or cannot take medications.
Best ADHD Treatment for Adults Without Medication
1. Cognitive Behavioral Therapy (CBT)
The most extensively studied non-medication treatment for adults is ADHD CBT. Adhd-cbt is not the same as CBT for depression or anxiety, and aims to help with:
- Skill building in executive functioning – planning, time management, beginning tasks.
- Avoidance and procrastination patterns – discovering the emotions that lie beneath.
- Cognitive restructuring – challenging the “I’m lazy” or “I’ll never get it together” thoughts that may develop throughout a lifetime with untreated ADHD.
CBT was effective both in children and in adults – according to the Safren cohort (Massachusetts General Hospital) ADHD symptoms and functional impairment were significantly reduced. It continues to be the first-line behavioral intervention for patients who are not on medication.
What to look for: A therapist who has specialized training in ADHD-focused CBT (therapy that focuses on ADHD instead of just therapy). Ask directly. It matters.
2. ADHD Coaching
Coaching for Adults with ADHD is not a clinical service but rather a useful service missed by many talk therapy sessions. Coaches train in the real time of:
- Daily activities and Schedule
- Accountability systems
- Goal-setting and follow-through
- Issues in the workplace and in relationships
Coaching is not therapy. No underlying emotional dysregulation or co-morbidities such as anxiety and depression are treated. For milder presentations in adults, however, and in addition to therapy it can be very effective in functioning in daily life.
3. Mindfulness-Based Interventions
The use of mindfulness training in the treatment research for ADHD has become quite prevalent. The key feature: intentional and intentional practice of sustained attention.
According to a 2017 meta analysis conducted by authors in the Journal of Child Psychology and Psychiatry, the use of mindfulness-based therapies resulted in moderate effects on emotional regulation and symptoms of ADHD. In adults, the emotional dysregulation component (frustration, rejection sensitivity, impulsivity) is the greatest area of value for mindfulness.
Both Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR) can be applied, and they’re both gaining popularity in NYC.
4. Neurofeedback
Neurofeedback (EEG biofeedback) helps the brain change its activity so that it is closer to patterns that are associated with focused attention. The patient gets instant information about his/her brain activity and learns (after lots of sessions) how to regulate himself.
The study is encouraging, but is disputed. There are some controlled trials, which demonstrate significant improvements in attention and impulse control. Others exhibit effects that are more resistant to the effects of the active placebo. My clinical perspective: I believe neurofeedback can be valuable for adults that have tried other treatments first and do not wish to use any medication or for those with a strong preference for non-medication interventions.
5. Lifestyle Modifications That Move the Needle
I feel the areas that need to be overvalued in adult ADHD are where I see the most undervalued interventions:
Exercise This is no frivolous extras! Acute increases in these neurotransmitters occur during aerobic exercises: dopamine and norepinephrine, which are targeted by adult ADHD medications. In the 2019 study published in Medicine & Science in Sports & Exercise, 20 minutes of moderate cardio activity in adults with ADHD prior to cognitive tasks led to a significant improvement in attention and inhibitory (or execution) control. Intensity is least as significant as consistency.
There is a strong connection between sleep ADHD and sleep disorders. A delayed sleep onset or restlessness in sleeping patterns and chronic sleep deprivation are all significant in dramatically exacerbating ADHD symptoms. I see sleep hygiene assessment prior to realignment of any treatment plan adjustments. Restoration of sleep can be like adding drugs – without the drugs.
Nutrition Facts and figures on specific diet changes are not as clear as the online communities for ADHD would have it. But the logic supporting avoiding blood sugar crashes (consistent, protein-heavy meals), the moderate evidence supporting them, and the biology behind their presence for the food categories of limiting ultra-processed food and getting more good fats (omega-3) are proven fairly.
Outside the Box ADHD Adults are not lazy! They are under-structured. Environmental scaffolding addresses deficits in executive functions in ways that nothing internal can duplicate: body doubling, time blocking, physical checklists, calendar system with hard alerts etc.
When Medication Is Still Worth Considering
Medication is an option but avoiding it is also OK. When you don’t want to think about it when you are drunk, not working or ruining relationships that’s another story.
Medications, such as stimulants and non-stimulants, are the quickest working treatments for adults with ADHD. Once non-medication methods have not worked to improve in the real world, after a proper effort (roughly 3-6 months of diligent application), then medication should be given another serious consideration.
The aim is to get it to work. Not “pure” in terms of the methodology of their treatment.
How a NYC Psychiatrist Approaches Non-Medication ADHD Plans
Where a non-medical treatment plan is suggested for an adult with ADHD I will take the following approach:
- Full assessment (excluding disorders that can mimic or worsen ADHD including anxiety, depression, sleep disorders and trauma)
- Attention Deficit/Hyperactivity Disorder (ADHD) and a CBT therapist with ADHD specialty
- Creating the groundwork by assessing and intervening in sleep.The bases of sleep assessment and sleep intervention.
- Specific exercise prescription – not negotiable – scheduled
- Understand programme structures – working hours and deadlines, setting up the work area.
- Continual review to monitor progress and adapt plan as necessary
This is NOT a “passive” process. Very active in developing and maintaining their system, those adults who come out fairly successful without drugs. It’s a real need and one that needs to be known from the start.
Frequently Asked Questions (FAQ)
Q. Can adults with ADHD function well without medication?
Yes. There are several treatments that can assist adults with their ADHD, such as adult ADHD therapy, routine, regular exercise and coaching. The main thing is to be as honest in their estimation of the amount of impairment and then apply the strategies that are effective for them with their presentation.
Q. What is the best ADHD treatment for adults who don’t want medication?
Current evidence suggests that cognitive behavioral therapy (CBT) is the better treatment choice for ADHD, as well as optimizing sleep patterns, external structure systems and aerobic exercises. ADHD coaching can offer practical day-to-day assistance which can’t be given by therapy.
Q. Is ADHD therapy effective without medication?
Yes, especially if you are an adult who has mild to moderate ADHD or you just aren’t good with organization, time management skills or procrastination. Medication treatment may be required, in addition to specialist treatment to help alleviate hyperactivity or inattention.
Q. How long does it take to see results from non-medication ADHD treatment?
Behavioural treatment of adult ADHD can take 2-4 months and any improvements in function are likely to not be seen for several months after the patient has practiced these techniques, before starting adult stimulant treatment which can respond within hours.
Q. What’s the difference between ADHD coaching and ADHD therapy?
Cognitive behavioral therapy (CBT) is one of the therapies for ADHD based on the nature of thoughts and emotional control and clinical symptoms. Emphasis of coaching is on real world skill development, accountability and function. They have different applications and complement each other.
Q. Can exercise really replace ADHD medication?
There is a real effect on the neurochemicals from exercise, some of which are similar to what a drug does for an adult who suffers from ADHD. It will not cure moderate to severe ADHD or replace medication, but it is an important tool and one that can measurably decrease ADHD symptoms and is vital to any serious treatment program that does not involve medication.
Q. Can ADHD in adults be managed through diet and nutrition alone?
The effects of diet are likely to be relatively modest in helping manage the treatment needs of adult ADHD; however, it does have a role to play. Protein-rich foods help to regulate dopamine, N-3 fatty acids help to regulate communication between neurons, and avoiding too much sugar-rich ultra-processed foods helps prevent blood sugar from spiking and crashing, freeing up the room for attention and happiness. Nutrition is not a substitute for adult ADHD treatment and/or medication, but rather a negative risk factor for all other treatments used.
Q. How is ADHD cognitive behavioral therapy different from regular CBT?
The traditional CBT focuses on unhelpful thinking styles. So, doesn’t ADHD cognitive-behavioral therapy do that too except that it has a primary focus on executive dysfunction, which I just described as planning, initiating, prioritizing and following through. The “Skills, Procrastination and Organizing” sessions are practical and skills-based, as opposed to traditional CBT sessions, and focus on Time Management Systems, Procrastination Cycles and Organizing Tools. Unless a therapist has a specific ADHD training, they will miss these targets entirely that are practical and functional.