This article is aimed to compare the efficacy and acceptability of exercise intervention with other nonpharmacological therapies in improving attention in ADHD patients and then rank those therapies.
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder commonly seen in the early childhood, with a global incidence rate of about 1.4–3.0% among children, and most of them are males. Its main symptoms include attention deficit, hyperactivity, impulsivity, and a mixture of the three disorders [
The traditional treatment of ADHD mostly uses pharmacological intervention to improve attention and alleviate hyperactive impulse and other explicit behavior by regulating the transmission of signal factors between synapses [
Based on the characteristics of hyperactive impulsion of patients, modern scholars have integrated sport intervention therapy into traditional treatment methods and achieved the expected effect. Studies demonstrate that [
The published and unpublished randomized controlled trials (RCTs) from PubMed, Cochrane Library, Psycinfo, and Web of Science were systematically searched. The searching items included “Attention Deficit Hyperactivity Disorder,” “Non-Pharmacotherapy,” “Cognitive Behavior Therapy,” “Physical Activity,” “Cognitive Training,” and “Mindfulness,” Working Memory Training,” “Neurofeedback,” “Biofeedback,” “Psychoeducation,” “School-based Treatment,” “Dietary,” “Multivitamin,” “Mineral,” and “Polyunsaturated Fatty Acid.” The searching content was limited to English literature, and the searching time span was from January 2011 to January 2021. For articles that are registered but not yet published, or where the relevant data is not fully presented in the results, the researchers contacted the author by e-mail or searched the journal's website for unpublished data to supplement the incomplete report in the original paper or to provide data for unpublished research.
Non-RCT studies, systematic reviews, animal studies, and studies with a sample size of less than 10 people were excluded. Eventually, 14 kinds of nonpharmacological therapy were included: cognitive behavioral therapy (CBT), working memory training (WMT), computer training (CT), meditation (MAP), meditation and cognitive training (MC), vitamin and mineral (VM) supplements, vitamin (VI), mineral (MI), polyunsaturated fatty acids (PUFAs), neural feedback training (NF), school-based training (SB), biofeedback training (BF), psychological education (PE), and sport intervention (SPT).
Four researchers (WLY, XSY, WC, and CJH) independently screened the qualified literature and collected the main outcomes and supplementary materials which support the original reports and could be used for this analysis, and four researchers (CZY, SJ, YD, and XHS) extracted relevant information using predetermined data extraction tables and assessed the risk of bias. Any differences shall be resolved by consensus and arbitration by the corresponding author (XSC).
In this study, the score changes of inattention of the subjects before and after the experiment were extracted as the efficacy evaluation index. The scores were derived from results measured by a variety of standardized psychological scales, such as The Barkley ADHD Current Symptoms Scale, ADHD Rating Scale, “Conners Adult ADHD Rating Scale Self-Report,” and “Swanson, Nolan, and Pelham (SNAP-IV) DSM-IV ADHD Rating Scale.” For the results of different surveyors in the same scale, priority is given to the results reported by observers, followed by those reported by teachers and finally by parents [
Under the random-effects model, a series of paired meta-analyses were performed for all directly compared studies, with relative risk (RR) used for dicaromatic outcomes and normalized mean difference (SMD) used for continuous outcomes, with a 95% confidence interval.
Homogeneity test:
First, Stata16 was used to map the network evidence for each therapy and to test for homogeneity. Secondly, based on the Bayesian framework, WinBugs1.4.3 was used for network analysis, and all relative treatment effects were compared and evaluated by combining direct and indirect comparative evidence. The average effect estimate (SMD or RR) and its 95% confidence interval (CI) for each comparison were calculated using the Markov chain Monte Carlo (MCMC) method, with both Markov chains running simultaneously [
Because fixed-effect models are based on the assumption that all studies come from the same population, they deviate from reality. In order to better fit the model, the random-effects model was used for analysis in this study. The model is iterated 100,000 times, and the first 5000 times are used for annealing to eliminate the influence of the initial value. The degree of convergence is judged according to the model iteration diagram. The iterative steps of the algorithm are as follows: A candidate state The acceptance probability is calculated. A number The three steps mentioned above are repeated Each moment of the posterior distribution is calculated according to the posterior samples, and the corresponding statistical inference is made.
After dividing the evidence of a specific comparison into direct evidence and indirect evidence by the node-splitting method, the inconsistency of the model was calculated [
A total of 2952 studies were retrieved, including 2118 from the Cochrane Library, 465 from Web of Science, 174 from Psycinfo, and 195 from PubMed. 2,715 either repeated studies or inconsistent research topics were excluded from systematic reviews. After reading the full text, 153 studies with inconsistent outcome indicators and nonrandomized controlled trials were excluded, and 86 studies were included, six of which were CBT vs. NF; one study was CBT vs. PE; seven studies were CBT vs. control; nine studies were WMT vs. control; one study was CT vs. NF; six studies were CT vs. control; eight studies were MAP vs. control; two studies were MAP vs. control; two studies were MC vs. control; three studies were VM vs. control; five studies were MI vs. control; nine studies were PUFA vs. control; three studies were NF vs. BF; two studies were NF vs. SPT; eleven studies were NF vs. control; two studies were SB vs. control; four studies were PE vs. control; and two studies were SPT vs. control. See Figure
Flowchart of study selection.
General characteristics of the literature: 86 RCTS were included, involving 14 kinds of nonpharmacological treatments, and they are cognitive behavioral therapy (CBT), working memory training (WMT), computer training (CT), meditation (MAP), meditation and cognitive (MC), vitamin and mineral (VM), vitamin (VI), mineral (MI), polyunsaturated fatty acid (PUFA), neural feedback (NF), biofeedback (BF), school-based training (SB), psychological education (PE), and sport intervention therapy (SPT). A total of 4998 participants were included, with 2538 in the experimental group and 2460 in the control group. Forty-three studies reported CAARS scores; three studies reported BCS scores; ten studies reported SNAP scores; three studies reported IPDDAI scores; two studies reported DBDRS-P scores; sixteen studies reported ASRS scores; two studies reported DISYPs scores; CBCL scores were reported in four studies; SWAN score was reported in three studies; three studies reported FBB-HKS scores; one study reported DSM-IV scores; and two studies reported a CSI-4 score. The Jadad score is above average, which means the quality of included studies in this analysis is above average (Jadad score ≥ 4), and only six studies were below average in quality (Jadad score < 4) (See Table
Characteristics of included studies.
Author, year | Design | Sample size | Age | Jadad score | Tool | |||
---|---|---|---|---|---|---|---|---|
Expl | Ctrol | Expl | Ctrol | Exp | Ctrol | |||
Naomi, 2014 | CBT | Ctrol | 34 | 36 | 8.9 ± 1 | 8.4 ± 1.1 | 4 | CAARS |
Young, 2016 | PUFA | PE | 11 | 14 | 7 | SNAP | ||
Safren, 2010 | CBT | Ctrol | 43 | 43 | 42.3 ± 10 | 44 ± 12.2 | 6 | CAARS-S |
Young, 2016 | PUFA | Ctrol | 11 | 11 | 7 | SNAP | ||
Arthur, 2015 | CBT | Ctrol | 43 | 43 | 20.3 | 6 | CAARS-S | |
Toshiko, 2015 | PUFA | Ctrol | 38 | 38 | 13.7 ± 1.1 | 3 | CAARS | |
LaCount, 2015 | CBT | Ctrol | 17 | 17 | 4 | BCS | ||
Crippa, 2017 | PUFA | Ctrol | 25 | 23 | 11.1 ± 1.9 | 10.9 ± 1.4 | 6 | ASRS |
Leanne, 2015 | CBT | Ctrol | 10 | 9 | 4.9 ± 1.1 | 5.2 ± 1.4 | 4 | SNAP-IV |
Tzang, 2016 | PUFA | Ctrol | 58 | 58 | 9.3 ± 2.7 | 9 ± 2.2 | 6 | SNAP |
Fleming, 2015 | CBT | Ctrol | 19 | 16 | 21.2 ± 1.7 | 21.5 ± 1.1 | 6 | BCS |
Cornu, 2017 | PUFA | Ctrol | 80 | 82 | 7 ± 3 | 6.9 ± 2.9 | 6 | ASRS |
Wang, 2016 | CBT | Ctrol | 10 | 12 | 26 ± 4.5 | 24.8 ± 4 | 7 | CAARS-S |
Muller, 2014 | PUFA | Ctrol | 55 | 55 | 6 | DISYPs | ||
Zahra, 2014 | WMT | Ctrol | 12 | 12 | 5 | SNAP | ||
Dienke, 2015 | PUFA | Ctrol | 19 | 18 | 10.3 ± 2.0 | 6 | CBCL | |
Anna, 2015 | WMT | Ctrol | 13 | 13 | 5.29 ± 0.4 | 5.3 ± 0.4 | 7 | IPDDAI |
Crippa, 2019 | PUFA | Ctrol | 25 | 25 | 11.1 ± 1.9 | 10.9 ± 1.4 | 6 | ASRS |
Wei, 2017 | WMT | Ctrol | 11 | 9 | 10.3 ± 3.5 | 10.3 ± 2.9 | 5 | SNAP-IV |
Celestino, 2019 | PUFA | Ctrol | 46 | 49 | 6 | CAARS | ||
Martine, 2014 | WMT | Ctrol | 27 | 24 | 6.5 ± 0.6 | 6.6 ± 0.7 | 6 | CAARS-S |
Pelsser, 2011 | PUFA | Ctrol | 50 | 50 | 6.8 ± 1.3 | 7 ± 1.3 | 6 | ASRS |
Jens, 2013 | WMT | Ctrol | 38 | 37 | 2 | CAARS-S | ||
Moreno, 2019 | NF | CBT | 21 | 19 | 9.21 ± 1.9 | 8.1 ± 1.3 | 7 | ASRS |
Agnese, 2018 | WMT | Ctrol | 40 | 40 | 6 | IPDDAI | ||
Minder, 2018A | NF | CBT | 29 | 23 | 11.4 ± 1.7 | 10.8 ± 1.8 | 6 | CAARS |
Beck, 2013 | WMT | Ctrol | 26 | 26 | 6 | CAARS-S | ||
Minder, 2018B | NF | CBT | 25 | 25 | 10.6 ± 2.3 | 10.4 ± 2.0 | 6 | CAARS |
Sandie, 2018 | WMT | Ctrol | 22 | 13 | 6 | CAARS-S | ||
Michael, 2017A | NF | CBT | 38 | 41 | 40 ± 11.2 | 38 ± 11.3 | 4 | CAARS |
Naomi, 2011 | CT | Ctrol | 13 | 15 | 12.4 ± 0.9 | 6 | CAARS-S | |
Michael, 2017B | NF | CBT | 39 | 41 | 35.7 ± 11 | 38 ± 11.3 | 4 | CAARS |
Aida, 2018 | CT | Ctrol | 35 | 35 | 9.8 ± 2.0 | 10.1 ± 1.5 | 6 | CAARS-S |
Maurizio, 2014 | NF | BF | 13 | 12 | 10.6 ± 1.3 | 10 ± 1.2 | 7 | CAARS |
Leanne, 2013 | CT | Ctrol | 51 | 51 | 9.1 ± 1.2 | 9.5 ± 1.5 | 6 | SNAP-IV |
Ali, 2011 | NF | BF | 18 | 17 | 9.6 ± 2.2 | 9.1 ± 1.6 | 6 | CAARS |
Oord, 2012 | CT | Ctrol | 21 | 22 | 10 ± 1.0 | 9.6 ± 1.4 | 6 | DBDRS-P |
Strehl, 2017 | NF | BF | 76 | 74 | 8.6 ± 0.9 | 8.6 ± 0.9 | 4 | ASRS |
Choon, 2019 | CT | Ctrol | 85 | 87 | 8.7 ± 1.4 | 8.6 ± 1.7 | 6 | CAARS-S |
Gelade, 2018 | NF | SPT | 39 | 37 | 10 ± 1.9 | 9.8 ± 2.0 | 6 | SWAN |
Bachmann, 2018 | MAP | PE | 21 | 19 | 40 ± 10.6 | 40 ± 13.8 | 7 | CAARS-S |
Gelade, 2016 | NF | SPT | 39 | 37 | 9.8 ± 1.9 | 9.6 ± 1.8 | 6 | SWAN |
Dovis, 2015 | MAP | PE | 41 | 40 | 10.3 ± 1.3 | 10.5 ± 1.3 | 6 | CAARS-S |
Chien, 2016 | SPT | Ctrol | 16 | 16 | 10.7 ± 1 | 10 ± 1.2 | 7 | CBCL |
John, 2017 | MAP | Ctrol | 11 | 11 | 40.6 ± 6.8 | 36.2 ± 6.9 | 2 | CAARS-S |
Claudia, 2012 | SPT | Ctrol | 10 | 11 | 9.1 ± 1.1 | 6 | CBCL | |
Huguet, 2017 | MAP | Ctrol | 5 | 5 | 9.2 ± 1.3 | 7 | CAARS-S | |
Naomi, 2014 | NF | Ctrol | 34 | 36 | 8.4 ± 1.1 | 8.9 ± 1 | 5 | CAARS |
Poppy, 2013 | MAP | Ctrol | 32 | 29 | 39.5 ± 9.5 | 33.9 ± 9.8 | 2 | CAARS-S |
Naomi, 2011 | NF | Ctrol | 13 | 15 | 12.4 ± 0.9 | 6 | CAARS-S | |
Jillian, 2013 | MAP | Ctrol | 20 | 20 | 15.5 ± 1.6 | 3 | CAARS-S | |
Holger, 2010 | NF | Ctrol | 59 | 35 | 9.1 ± 1.3 | 9.5 ± 1.1 | 7 | FBB-HKS |
Herman, 2017 | MAP | Ctrol | 50 | 50 | 6.3 ± 0.9 | 5.92 ± 0.7 | 6 | ASRS |
M.M, 2010 | NF | Ctrol | 8 | 6 | 10.4 ± 2.3 | 10 ± 1.7 | 7 | DSM-IV |
Lotte, 2018 | MAP | Ctrol | 60 | 60 | 39.7 ± 1 | 39 ± 10.1 | 6 | CAARS |
Meise l, 2013 | NF | Ctrol | 14 | 13 | 9.53 ± 1.8 | 6 | ASRS | |
Edel, 2014 | MAP | Ctrol | 39 | 52 | 33.8 ± 10 | 36.7 ± 10 | 7 | CAARS |
Bink, 2016 | NF | Ctrol | 59 | 31 | 15.9 ± 3.3 | 16.2 ± 3 | 6 | ASRS |
Gu, 2018 | MC | Ctrol | 30 | 26 | 4 | CAARS | ||
Shereena, 2018 | NF | Ctrol | 24 | 19 | 8.7 ± 1.8 | 9.7 ± 2.4 | 6 | ASRS |
Hepark, 2019 | MC | Ctrol | 55 | 48 | 36.5 ± 10 | 35.2 ± 9 | 6 | CAARS-S |
Albrecht, 2017 | NF | Ctrol | 24 | 24 | 11.3 ± 2.8 | 11.5 ± 3 | 6 | FBB-HKS |
Kathryn, 2019 | VM | Ctrol | 47 | 46 | 9.3 ± 1.1 | 9.9 ± 1.8 | 6 | ASRS |
ManHee, 2015 | NF | Ctrol | 8 | 8 | 5 | CAARS | ||
Julia, 2018 | VM | Ctrol | 47 | 46 | 10.1 ± 1.6 | 9.4 ± 1.5 | 6 | ASRS |
Alegria, 2017 | NF | Ctrol | 18 | 13 | 14.1 ± 1.5 | 13.6 ± 2 | 7 | CAARS |
Julia, 2017 | VM | Ctrol | 42 | 38 | 34 ± 12.7 | 6 | CAARS | |
Harris, 2019 | NF | Ctrol | 11 | 11 | 7 | CAARS | ||
Hatem, 2018 | VI | Ctrol | 20 | 20 | 9.3 ± 2.6 | 8.8 ± 3.72 | 6 | CAARS |
Joshua, 2012 | SB | Ctrol | 23 | 24 | 3 | ASRS | ||
Nadia, 2019 | VI | Ctrol | 51 | 51 | 9.8 ± 2.4 | 8.6 ± 2.0 | 6 | CAARS |
Looyeh, 2012 | SB | Ctrol | 7 | 7 | 5 | CSI-4 | ||
Eugene, 2011 | MI | Ctrol | 8 | 24 | 8.9 ± 2.3 | 10.2 ± 2.7 | 7 | SNAP |
Young, 2016 | PE | Ctrol | 14 | 11 | 7 | SNAP | ||
Fereshteh, 2015 | MI | Ctrol | 33 | 33 | 7.8 ± 1.2 | 8.4 ± 1.4 | 6 | ASRS |
Alexandra, 2015 | PE | Ctrol | 107 | 109 | 35 ± 11 | 35 ± 10 | 6 | CAARS-S |
Vidal, 2013 | PE | CBT | 17 | 15 | 39.4 ± 9.3 | 39.5 ± 6 | 4 | CAARS-S |
Bai, 2015 | PE | Ctrol | 44 | 45 | 9.3 ± 2.8 | 9.6 ± 2.9 | 7 | ASRS |
Maite, 2013 | PE | Ctrol | 44 | 37 | 11.3 ± 3.0 | 9.9 ± 3.0 | 6 | CAARS |
Naomi, 2014 | CBT | NF | 34 | 34 | 8.4 ± 1.1 | 4 | CAARS | |
Naomi, 2011 | CT | NF | 13 | 13 | 12.4 ± 0.9 | 6 | CAARS-S |
Note: CBT = cognitive behavioral therapy; WMT = working memory training; CT = computer training; MAP = meditation; MC = meditation and cognition; VM = vitamin and mineral; VI = vitamin; Mi = mineral; PUFA = polyunsaturated fatty acid; NF = neurofeedback; BF = biofeedback; SB = school-based training; PE = psychological education; SPT = sport intervention therapy; ctrol = control group; CAARS-S = Conners’ Adult ADHD Rating Scale Self-Report; BCS = Barkley ADHD Current Symptoms Scale; SNAP = Swanson, Nolan, Pelham; IPDDAI = rating scale “identificazione precoce del disturbo da deficit di attenzione iperattivita; DBDRS-P = Disruptive Behavior Disorders Rating Scale; ASRS = adult ADHD Self-Report Scale; DISYPs = FBB ADHS parent-rated and teacher-rated programmes; CBCL = Child Behavior Checklist; SWAN = Strengths and Weaknesses in ADHD and Normal Behaviors; FBB-HKS = Fremdbeurteilungsbogen fur Hyperkinetische Storungen; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders; CSI-4 = Children Symptom Inventory.
Homogeneity test results indicate that cognitive behavioral therapy SMD = −0.77 (−1.00, −0.54), working memory training SMD = −0.49 (−0.71, −0.27), computer training SMD = −0.94 (−1.87, −0.01), meditation SMD = −0.66 (−0.85, −0.47), meditation and cognitive training SMD = −0.99 (−1.33, −0.66), vitamin and mineral SMD = −1.78 (−2.13, −1.44), vitamin SMD = −0.86 (−1.17, −0.55), mineral SMD = −0.52 (−0.88, −0.16), polyunsaturated fatty acid SMD = −0.42 (−0.58, −0.26), neural feedback SMD = −0.26 (−0.46, −0.05), school-based practice SMD = −0.60 (−1.11, −0.08), the psychological education SMD = −0.39 (−0.60, −0.19), the sport intervention SMD = −1.04 (−1.68, −0.39), the efficacy was significantly better than that of the control group, and the computer training is superior to the neural feedback therapy SMD = −0.94 (−1.87, −0.01). The efficacy of other comparative studies was not statistically significant. The homogeneity test results showed that 11 groups of comparative studies had high homogeneity, while the degree of heterogeneity among the other comparative studies was medium to high (Table
Homogeneity test.
Study | SMD | 95% CI | % weight | HI | |||||
---|---|---|---|---|---|---|---|---|---|
CBT-NF | 0.12 | 0.34 | 0.10 | 7.46 | 24.65 | 0.00 | 0.80 | 1.08 | 0.28 |
CBT-ctrol | 0.77 | 1.00 | 0.54 | 6.76 | 7.88 | 0.25 | 0.24 | 6.57 | 0.00 |
CBT-PE | 0.16 | 0.62 | 0.94 | 0.59 | 0.00 | 0.00 | 0.00 | 0.40 | 0.69 |
WMT-ctrol | 0.49 | 0.71 | 0.27 | 7.61 | 110.31 | 0.00 | 0.93 | 4.43 | 0.00 |
CT-NF | 0.94 | 1.87 | 0.01 | 0.41 | 0.00 | 0.00 | 0.00 | 1.98 | 0.05 |
CT-ctrol | 0.53 | 0.72 | 0.34 | 9.96 | 26.99 | 0.00 | 0.82 | 5.47 | 0.00 |
MAP-PE | 0.06 | 0.43 | 0.30 | 2.67 | 0.15 | 0.70 | 0.00 | 0.34 | 0.73 |
MAP-ctrol | 0.66 | 0.85 | 0.47 | 10.19 | 16.39 | 0.02 | 0.57 | 6.91 | 0.00 |
MC-ctrol | 0.99 | 1.33 | 0.66 | 3.21 | 2.23 | 0.14 | 0.55 | 5.83 | 0.00 |
VM-ctrol | 1.78 | 2.13 | 1.44 | 3.03 | 11.44 | 0.00 | 0.83 | 10.16 | 0.00 |
VI-ctrol | 0.86 | 1.17 | 0.55 | 3.82 | 10.15 | 0.00 | 0.90 | 5.51 | 0.00 |
MI-ctrol | 0.52 | 0.88 | 0.16 | 2.79 | 29.28 | 0.00 | 0.86 | 2.83 | 0.01 |
PUFA-PE | 0.37 | 1.15 | 0.41 | 0.59 | 0.00 | 0.00 | 0.00 | 0.92 | 0.36 |
PUFA-ctrol | 0.42 | 0.58 | 0.26 | 14.19 | 61.88 | 0.00 | 0.87 | 5.14 | 0.00 |
NF-BF | 0.16 | 0.45 | 0.12 | 4.46 | 2.48 | 0.29 | 0.19 | 1.13 | 0.26 |
NF-SPT | 0.00 | 0.33 | 0.33 | 3.23 | 0.02 | 0.87 | 0.00 | 0.00 | 1.00 |
NF-ctrol | 0.26 | 0.46 | 0.05 | 8.20 | 18.62 | 0.05 | 0.46 | 2.39 | 0.02 |
SB-ctrol | 0.60 | 1.11 | 0.08 | 1.35 | 0.28 | 0.60 | 0.00 | 2.26 | 0.02 |
PE-ctrol | 0.39 | 0.60 | 0.19 | 8.62 | 49.72 | 0.00 | 0.94 | 3.76 | 0.00 |
SPT-ctrol | 1.04 | 1.68 | 0.39 | 0.86 | 13.23 | 0.00 | 0.92 | 3.16 | 0.00 |
CBT, cognitive behavioral therapy; WMT, working memory training; CT, computer training; MAP, meditation; MC, meditation and cognition; VM, vitamin and mineral; VI, vitamin; MI, mineral; PUFA, polyunsaturated fatty acid; NF, neurofeedback therapy; BF, biofeedback therapy; SB, school-based exercise; PE, psychological education; SPT, sport intervention; ctrol, control group.
As can be seen from Figure
Network plot of meta-analysis.
The loop inconsistency test was used to explore the level of inconsistency among the internal comparison studies of each closed loop. As shown in Figure
Loop inconsistency test.
As can be seen from Figure
Local inconsistency test.
Direct | Indirect | Difference | Tau | |||||
---|---|---|---|---|---|---|---|---|
Coef | SE | Coef | SE | Coef | SE | |||
CBT-NF | 0.01 | 0.32 | 0.52 | 0.40 | 0.54 | 0.51 | 0.30 | 0.73 |
CBT-PE | 0.15 | 0.84 | 0.00 | 0.41 | 0.16 | 0.94 | 0.87 | 0.74 |
CBT-ctrol | 0.84 | 0.31 | 0.34 | 0.39 | 0.51 | 0.50 | 0.31 | 0.73 |
WMT-ctrol | 0.93 | 0.28 | 0.37 | 208.78 | 0.56 | 208.78 | 1.00 | 0.73 |
CT-NF | 0.69 | 0.87 | 0.07 | 0.41 | 0.62 | 0.96 | 0.52 | 0.74 |
CT-ctrol | 0.60 | 0.32 | 1.31 | 1.57 | 0.71 | 1.60 | 0.66 | 0.74 |
MAP-PE | 0.08 | 0.56 | 0.16 | 0.45 | 0.08 | 0.72 | 0.91 | 0.74 |
MAP-ctrol | 0.82 | 0.29 | 0.74 | 0.66 | 0.08 | 0.72 | 0.91 | 0.74 |
MC-ctrol | 1.07 | 0.55 | 0.23 | 447.18 | 0.85 | 447.18 | 1.00 | 0.73 |
VM-ctrol | 1.79 | 0.46 | 0.49 | 365.30 | 2.28 | 365.30 | 1.00 | 0.73 |
VI-ctrol | 0.92 | 0.54 | 0.38 | 445.12 | 0.54 | 445.12 | 1.00 | 0.73 |
MI-ctrol | 0.97 | 0.40 | 0.33 | 282.72 | 0.64 | 282.72 | 1.00 | 0.73 |
PUFA-PE | 0.35 | 0.84 | 0.22 | 0.43 | 0.57 | 0.94 | 0.55 | 0.74 |
PUFA-ctrol | 0.54 | 0.26 | 1.67 | 1.59 | 1.13 | 1.61 | 0.49 | 0.74 |
NF-BF | 0.31 | 0.46 | 0.09 | 366.36 | 0.40 | 366.36 | 1.00 | 0.73 |
NF-SPT | 0.00 | 0.55 | 1.19 | 0.70 | 1.19 | 0.88 | 0.18 | 0.73 |
NF-ctrol | 0.25 | 0.25 | 0.96 | 0.40 | 0.71 | 0.47 | 0.13 | 0.73 |
SB-ctrol | 0.63 | 0.60 | 0.66 | 448.17 | 0.03 | 448.17 | 1.00 | 0.73 |
PE-ctrol | 0.65 | 0.39 | 0.70 | 0.49 | 0.05 | 0.63 | 0.94 | 0.74 |
SPT-ctrol | 1.56 | 0.66 | 0.37 | 0.59 | 1.19 | 0.88 | 0.18 | 0.73 |
CBT: cognitive behavioral therapy; WMT: working memory training; CT: computer training; MAP: meditation; MC: meditation and cognition; VM: vitamin and mineral; VI: vitamin; MI: mineral; PUFA: polyunsaturated fatty acid; NF: neurofeedback therapy; BF: biofeedback therapy; SB: school-based exercise; PE: psychological education; SPT: sport intervention; ctrol: control group.
The results of the inconsistency model test show that both the local inconsistency and loop inconsistency test prove that there is a high consistency among the studies included in the network evidence model. Therefore, the subsequent analysis results are based on the consistency model.
In order to adhere to the assumption of transitivity and reduce the risk of biased estimates, the distribution of methodological variables that may act as effect modifiers across treatment comparisons has been compared such as age and nonpharmacotherapy. Most of the participants had a similar mean age from 10 to 20, but there were a few comparisons which had relatively low or high age. Additionally, the comparison of baseline severity also showed that the baseline severity distributed in a similar range on this network analysis, even though this analyses might suffer from ecological bias. See Figure
Assessment of transitivity.
In traditional meta-analysis, because there is only one effect size, funnel plots are drawn using the standard error of effect value as the vertical axis and effect size as the horizontal axis [
Comparison-adjusted funnel plot and Egger test for each outcome.
As there was no direct comparison between sport intervention therapy and many nonpharmacological therapies in the included studies, head-to-head comparison was used to provide indirect evidence for the studies that lacked direct comparison [
The results of network meta-analysis for efficacy and tolerability.
Figure
Treatment ranking and SUCRA plot for efficacy and tolerability.
Taking into account the efficacy and acceptability of each nonpharmacological therapy, the following results were obtained by ranking the area under the cumulative probability curve: in 14 kinds of nonpharmacological intervention therapy, sport intervention therapy (SPT) effect on the improvement of the patients with ADHD attention deficit disorder is superior to the other 12 kinds of nonpharmacological treatments, only secondary to vitamin (VI) supplements and cognitive training (MC) based on meditation, and the overall ranking is third. However, the pairwise comparison of Figure
The overall ranking of all kinds of the nonpharmacological therapy is as follows: (1) medication and cognitive (MC); (2) sport intervention therapy (SPT); (3) vitamin and mineral (VM); (4) cognitive behavioral therapy (CBT); (5) computer training (CT); (6) psychological education (PE); (7) working memory training (WMT); (8) nerve feedback therapy (NF); (9) polyunsaturated fatty acids (PUFAs); (10) mineral (MI) supplements; (11) meditation (MAP); (12) vitamin (VI); (13) biofeedback therapy (BF); and (14) school-based training (SB).
A total of 86 studies were included in this network meta-analysis, involving 68 double-blind studies and 1 single-blind study. A total of 4,998 study samples were collected. Of these, 2,538 patients were randomly assigned to 14 nonpharmacological treatments and 2,460 to a control group. Through a detailed search of published and unpublished research data, the efficacy and acceptability of each therapy were compared directly and indirectly, and the overall ranking provided the latest and comprehensive structured mathematical evidence for the clinical advantages of exercise intervention therapy.
The study indicates that all of the 11 nonpharmacological treatments were found to have superior curative effect on the control group (SMD = (−1.79, −0.14)). Among them, the improvement effect of sport intervention therapy (SPT, SMD = −0.90(−1.76, −0.04)) on attention deficit was only secondary to working memory training (WMT, SMD = −0.93 (−1.47, −0.38)), which reached the high effect size level. The vitamin and mineral (VM) supplementation was significantly better than other treatments (VM, SMD = (−1.79, −1.11)). A comparative analysis of the acceptability of nonpharmacological therapies found that there was no significant difference in acceptability between the sport intervention and other nonpharmacological therapies. The acceptability of meditation therapy alone was significantly better than vitamin (VI, RR = 0.1 (0.01, 0.73)), neurofeedback (NF, RR = 0.39 (0.15, 1.00)), and biofeedback (BF, RR = 0.22 (0.07, 0.70)). The acceptability of biofeedback therapy was inferior to that of the control group (ctrol, RR = 2.86 (1.14, 7.16)). Thus, when efficacy was considered only, there was no significant difference in the effect of each therapy, and sport intervention therapy was not the best choice, only ranking the fourth (Figure
In order to make the abovementioned results as robust as possible to provide reference information for clinical practice, this study focuses on the results of head-to-head interaction comparison under the condition that the retrieved information is completely reliable. Figure
In conclusion, although meditation and cognitive therapy (MC) ranks first in the overall ranking, the results of clinical significance still have very high uncertainty. Not all people with ADHD have the external conditions of receiving psychological therapy and dietary supplements. Sport intervention therapy from economy and applicability are accepted for the majority of the population; therefore, in this study, the sport intervention therapy is recommended as the best intervention means. Existing studies have confirmed that [
There are also limitations in this study. (1) the sample size of individual nodes in the network evidence map is too small, so the statistical efficacy is limited. (2) The overall inconsistency test is not significant, and the quality evaluation of some studies is still low. (3) Despite a detailed search of published and unpublished literature, complete collection of existing data cannot be ensured. (4) Due to the lack of comprehensive demographic data of patients, it is not possible to conduct subgroup regulation effect analysis.
This network meta-analysis showed that although meditation and cognitive therapy (MC) ranked first overall, the effect size of its efficacy was at a marginal significant level, so its results need to be carefully interpreted in clinical practice. Sport intervention therapy is not only very close to meditation and cognition (MC) in terms of efficacy but also has high acceptability and economic practicability. Therefore, sport intervention therapy is preliminarily judged to be the best nonpharmacological intervention means for the treatment of attention deficit in ADHD patients. In addition, meditation and cognitive therapy (MC), cognitive behavioral therapy (CBT), and computer training (MC) can also be effective complementary tools.
Although this analysis incorporates the most comprehensive literature currently available evidence about nonpharmacological treatment for ADHD, a small number of preregistered studies are still unavailable to us even though we have try our best to collect reliable information about the most recent published studies. Still, we cannot rule out the possibility that some studies are absent in literature retrieval or recalculate the results of the same study in our analyses. Beside, considering the influence of the small-sample effect on the results, a large number of high-quality research designs are still needed to provide evidence to support the results of this study. We welcome any information that might help clarify any limitations in our manuscript.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no known conflicts of interest.