Introduction

Attention deficit hyperactivity disorder (ADHD) is a brain disorder that affects attention span, behavioral control, and a person's ability to sit still. ADHD can impede social, emotional, and academic development in children and young adults if not adequately dealt with early on.¹ Symptoms of ADHD include attention deficit, hyperactivity, lack of self-control, forgetfulness, poor emotional control, and lack of motivation.² With no clear consensus on the direct causes of ADHD, some experts point to genetic deficiencies Rubia 2018 et al.³, while others suggest premature birth or poor dietary health led to possible exacerbation of existing ADHD symptoms McCann et al. ⁴ Diagnosis of ADHD has increased among those aged 11 to 21 across all demographic areas, including age, gender, and ethnicity, over the past twenty years.^2,5-7 A particular prevalence of ADHD is found within young boys; about 8.4% are affected with ADHD.5 In addition, recent studies have shown that 1 in 5 high school boys and 1 in 11 high school girls have been diagnosed with ADHD, pointing to an upward projection in ADHD cases.⁵

Like many mental impairments, ADHD is treated with various medications and pharmacological treatments, which include the use of stimulant medications such as methylphenidate.⁸ The long-term effects of medications, like methylphenidate, have not been adequately assessed⁹. In addition, Solmi et al. ⁹ found that studies involving these medications and children only investigate the efficacy of the drug, not any safety concerns. Furthermore, Solmi et al. ⁹ found no studies that assessed the safety of these medications in children over an extended period. On the other hand, psycho-social interventions have been found to have no adverse side effects and are effective ways to combat ADHD in adolescents.¹ In addition, the scientific community is mostly united on the effectiveness of psycho-social interventions concerning reducing ADHD symptoms.^1,10-20

Psycho-social interventions are non-pharmacological ways to cope with mental health issues through social, personal, and physiological training that aim to provide a reduction in symptoms to those affected by mental health disorders.¹ Typical interventions for ADHD include exercise, increased social interactions, reduced screen time, and mindfulness activities to help cope with ADHD symptoms and possible symptoms from medications.¹ Developments in non- pharmacological treatments for ADHD have shown the effectiveness of psycho-social interventions in ADHD treatment.¹

This is the first systematic review, to the author’s knowledge, to detail multiple effective psycho-social interventions that reduce ADHD symptoms in adolescence. Previous primary and secondary research on the topic of psycho-social interventions and ADHD only analyzed one to two interventions and their effects on ADHD symptom reduction. Research indicates that exercise, mindfulness, increased social activities, and reduced screen time yield the highest decrease in specific ADHD symptoms when regularly practiced .^1,10-16 This review aims to detail how these psycho-social interventions reduce ADHD symptoms, whether that be a broad reduction in symptoms or a reduction of a specific symptom.

Literature Review

Considering the emotional and behavioral disparities of those with ADHD and the possible adverse effects of ADHD medication on adolescents there is a need for alternative and supplementary methods to reduce ADHD symptoms. ^9,21 ADHD is typically treated with stimulant medications like methylphenidate that work by increasing levels of dopamine and norepinephrine; these are key neurotransmitters for attention, behavior regulation, and cognitive function.⁹ However, stimulant medications can have adverse effects that include weight loss, hypertension, nausea, abdominal pain, and anorexia.⁹ Other treatments for ADHD, like behavioral counseling, work to improve behavior, self-control, and self-esteem through tailored counseling.¹¹ However, newer treatments like psycho-social interventions are non-medication interventions used to help treat personal, social, and psychological aspects of mental health disorders like ADHD. Recent treatments using psycho-social interventions have focused mainly on utilizing exercise, mindfulness activities, increased social interactions, and reduced screen time in adolescents with ADHD.1, ^10-16

To summarize research concerning ADHD and screen time, which includes video games, social media usage, and watching television, research shows that higher screen times, typically the average of six to nine hours a day for those aged 11 to 21, can exacerbate ADHD symptoms Wallace et al.¹⁴ In addition, higher screen times correlate with increased symptoms for those with mental health disorders, including obsessive-compulsive disorder (OCD), ADHD, post-traumatic stress disorder (PTSD), anxiety, and depression.¹⁵ Looking into the demographics, Andreassen et al.¹⁵ found that being male was associated with more addictive video usage and correlated to increased levels of ADHD, OCD, depression, and anxiety in patients with these conditions. On the other hand, addictive behavior on social media, which is found mainly in young females, exhibited increased symptoms of ADHD, OCD, and anxiety as a result of high screen time.¹⁵ Subsequent research by Wallace et al.¹⁴ echoes these, stating that addictive screen time correlates with increased levels of ADHD. Wallace et al.¹⁴ also found that addictive screen usage can impair neurophysiological development and lead to digital dependence and behavior disorders. Finally, it is important to note that digital platforms like Instagram, TikTok, and Snapchat are explicitly designed to tap into human attention, impulses, and reward processes.¹⁴ Considering that those with ADHD are known to exhibit hyperactivity, decreased attention span, and impulsivity these digital platforms can be very problematic for adolescents with ADHD and can even increase their symptoms.^{14, 22}

While decreasing screen time can be an effective psycho-social intervention for some, mindfulness activities like yoga, prayer, and meditation might be more enjoyable for others. Mindfulness activities are a set of activities meant to promote well-being, reduce stress, and promote focus, as shown through Bogel et al. ¹¹ and Meppelink et al. ²³ Mindfulness activities come in various forms, all with similar ADHD symptom reduction. Those activities can include mindful parenting, meditation, yoga, prayer, and self-reflection, among other activities which have been shown by Meppelink et al.²³ to decrease levels of anxiety and depression and reduce neurophysiological defects like ADHD.

Ongoing research finds that mindfulness techniques have comparable effects to stimulant medications like methylphenidate in reducing ADHD symptoms.¹¹ Mindfulness activities like mindful parenting have yielded beneficial results like decreased stress levels, improved mood, and better quality of life for both the adolescents with ADHD and their parents.¹³ Additionally, when mindfulness was combined with exercise, research by Bigelow et al.²⁴ found that both psycho- social interventions created a broad reduction in ADHD symptoms, with mindfulness helping to improve all executive functioning tasks and skills critical for success in school and, later, the workforce.

Another psycho-social intervention, namely increasing social interactions, has shown promising results in reducing ADHD symptoms. While research like that of Fox et al.¹⁶ maintained that there is insufficient evidence to draw a definite conclusion on whether increased social interaction has had a beneficial effect on those with ADHD, more recent research like Nguyen et al.²⁵ has displayed promising results for this psycho-social intervention. Supplementary research by Nguyen et al.²⁵ showed peer-based interactions, sometimes facilitated by a clinician, have resulted in decreased depressive symptoms and improved self-conception or self-image, which resulted from therapy, prosocial behavior, and intergroup relations.²⁵ Some preliminary research into proper ADHD parenting techniques like mindful parenting (i.e. developing organizational skills with a child) has shown that for children ages three to five with an ADHD diagnosis, there was a major improvement in ADHD symptom expression including hyperactivity, impulsivity, and emotional dysregulation DuPaul et al.¹³

Exercise consists of either aerobic or anaerobic activities over an extended period of time and can also benefit those with ADHD. Regular exercise or physical activity has been related to decreased ADHD symptoms.²⁶ It has been linked to additional benefits outside of general symptom reduction, like weight loss, increased energy levels, and improved mood.¹² Exercise has been adopted as a psycho-social intervention for those with ADHD to deal with core neurophysiological deficits like decreased attention span and poor inhibitory function, which are caused by insufficient dopamine and norepinephrine secretion, as shown by Chan et al.¹² Moderate to high-intensity exercise has been shown to stimulate the neurophysiological responses to induce the synthesis of neurotransmitters like norepinephrine, secrete brain-derived neurotrophic factor (BDNF), and increase the blood flow to the brain.¹² Increased blood flow to the brain can increase dopamine and norepinephrine levels by stimulating the synthesis of neurotransmitters, which leads to a possible reduction in neurophysiological deficits Chan et al.¹² It has also been shown that exercise increases neuroplasticity and enhances the brain's information-processing capacity, helping stimulate brain growth and improve possible ADHD symptoms like impulsivity.¹²

This is the first systematic review, to the best of the author’s knowledge, to detail multiple psycho-social interventions to reduce ADHD symptoms focused mainly on adolescents. Previous primary and secondary research on the topic of psycho-social interventions and ADHD only analyzed one to two interventions and their effects on ADHD symptom reduction. Research indicates that exercise, mindfulness, increased social activities, and reduced screen time yield decreases in specific ADHD symptoms when regularly practiced .^10-16 This review aims to investigate effective psycho-social interventions for reducing ADHD symptoms, whether that be a broad reduction in symptoms or a reduction of a specific symptom.

Methods

The current systematic review used the National Library of Medicine (NLM) and Stony Brook University Library (SBU), from October 20th, 2024, to November 20th, 2024. A systematic review will allow for a comprehensive search for all the literature in these databases. The following search terms were used: effective adolescent psycho-social interventions, specific psycho-social interventions, reduced screen time, exercise, and mindfulness. Initial results from these reviews found 3,071 articles across the three databases. 210 articles were found to be duplicates and were removed. This resulted in 2,861 articles that were then screened by their title and abstract to see if they met the inclusion and exclusion criteria.

Inclusion criteria focused on studies over the past 25 years focusing on psycho-social interventions (i.e., mindfulness, exercise, increased social interaction, and reduced screen time) either in conjunction with medication or without. Studies within the past 25 years were included to maintain relevancy and accuracy and to provide a broad range of available information. Additionally, older sources used within 25 years provided a precedent for current research being conducted, giving this review a better scope of the issue. Medications included within the study are methylphenidate, a stimulant medication used to control hyperactivity and impulse control. Studies that included methylphenidate and other stimulant medications were included as these medications are among the most used to treat ADHD. Studies were included from all over the world, such as Canada, the United States, and the Netherlands, as well as all age groups ranging from 8 to 88, both sexes, and various socioeconomic backgrounds to account for the prevalence of ADHD in varying demographics. Further, all studies included adolescents, but two of the studies included in this systematic review did include those aged over 21. This was done due to the lack of literature found about solely adolescent populations.

As a result of screening, 2,573 articles were removed, leaving 288 articles for full-text review. A total of 282 articles were found to not meet the inclusion criteria. The reasons they were not included were as follows: bias (research results that benefited funding companies), irrelevant studies (irrelevance to research question or specific psycho-social interventions), and did not match inclusion criteria (did not detail psycho-social intervention). This current review developed the exclusion criteria to provide unbiased and accurate data to the average reader. This resulted in six articles to be included in the study as seen in Table 1 below. The results were analyzed by extracting the relevant data from each study and creating Table 1. The studies were analyzed qualitatively and quantitatively through extracting data from the studies and assessing overall trends.

Figure 1. Screening Process

Source: Page MJ, et al. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/

Results

Table 1. Psycho-social Interventions' Effectiveness in Reducing Specific symptoms

The results of the systematic review indicate that psycho-social interventions lead to a reduction in ADHD symptoms across all six studies included in Table 1, with each intervention helping to reduce a problematic symptom of ADHD. Andreassen et al.¹⁵ and Wallace et al.¹⁴ found that with a moderate decrease of about two to three hours in screen time (e.g., social media, television, video games, etc.), adolescents saw a reduction in hyperactivity, impulsivity, and attention span. In addition, Andreassen et al.¹⁵ found a strong association between the addictive use of technology and increased comorbid psychiatric disorder symptoms (i.e., ADHD, OCD, etc.). Andreassen et al.¹⁵ found strong associations between addictive use of technology and increased comorbid psychiatric disorder symptoms (i.e. ADHD, OCD, etc.). A value of (p < .01) shows a significant correlation between addictive social media usage and increased ADHD symptoms.

However, according to Wallace et al.¹⁴, computer usage (i.e., computer work, internet searches, etc.) did not play a significant role in ADHD symptom propagation. Yet, results found in Wallace et al.¹⁴, reported through Bayesian multivariate and MLM models, showed that increases in screen time each year were associated with an exacerbation of ADHD symptoms within that same year within participants (p <.05) and between participants (p <.05). In addition, Wallace et al.¹⁴ found that increased social media usage in the previous year implied that ADHD symptoms would be negatively affected within the following year. Impulsivity was found to be the strongest mediator in the relationship between screen time and ADHD symptoms, both within participants and between participants. Notably, only the use of social media showed a significant delayed impact on ADHD symptoms of about one year, with impulsivity serving as the mediating factor. Additionally, the adverse effects of social media are further demonstrated through changes in response inhibition measured by a Go/No-Go task, which requires participants to press a button when they see a “go” signal and not respond when they see the “no-go” signal (p < .05).

Mindfulness activities have also yielded promising results in ADHD symptom reduction. Bogels et al.¹¹ shows that daily mindfulness activities (e.g., meditation, prayer, self-reflection, etc.) significantly reduce inattention and impulsivity. In addition, Bogels et al. found that mindfulness activities yielded results comparable to stimulant medications for ADHD treatment, leading to a significant decrease in attention deficit and impulsivity. (Bogels et al.)¹¹ Results showed that when used in both short- and long-term treatments for ADHD patients saw a significant reduction in ADHD symptoms. (short term) < 0.01 and (long term) < 0.01 with improvements found in every category of the Youth Self Report total (YSR) with a p value of <0.01 as shown by Table 1.

In addition, Bigelow et al.²⁴ found that when mindfulness is used with other psycho-social interventions like exercise, these activities broaden the reduction in most core ADHD symptoms. Bigelow et al.²⁴ found that when both children with ADHD and their parents participated in mindfulness treatments, adolescents saw a significant reduction in ADHD symptoms. Mindfulness meditation increased performance on all executive functioning tasks, and exercise enhanced positive mood and self-efficacy. Short-term effects were moderate (d = 0.22-0.35), and long-term effects were strong (d = 0.55-0.86), with the p-values for both parents and children being < .01. Additionally, children who underwent the program saw a significant boost in overall happiness, self-control, and overall symptom reduction. For children with ADHD, the implementation of ten minutes of both mindfulness and exercise daily showed a significant decrease in ADHD symptoms (p < .01), with mindfulness activities reducing inattention and impulsivity and enhancing executive functioning tasks (e.g., organization, emotional regulation, and problem-solving). Exercise also showed significant improvements in ADHD symptom reduction (p < .01), helping to increase positive mood, self-efficacy, and energy levels. Further, a pilot study by Fritz et al.²⁶ found that acute exercise helped to lead to a statistically noticeable improvement in motivation (p = .027), depression (p = .027), fatigue (p = .030), and confusion (p = .046). However, according to the study, exercise did not result in noticeable improvements in other ADHD symptoms.

Similarly, a reduction in ADHD symptoms was seen in peer-based interventions.²⁵ Peer- based interventions yielded similar reductions in depressive mood and self-control with (p =.0076) and Cohen's d-value of (d = 0.63), indicating a significant effect on the reduction of ADHD symptoms. Results showed that when used in both short-term (p > .01) and long-term (p > .01) treatments for ADHD patients, they saw a significant reduction in ADHD symptoms.

Discussion

Concerning reduced screen time, this current review found that most forms of screen time, whether that be increased social media usage or video games, correlated with an increase in ADHD symptoms, such as lower attention span, increased impulsivity, and hyperactivity.^14-15 This current review recommends reducing screen time, mainly using social media and video games, and replacing online activities with other psycho-social interventions that the adolescent may enjoy, such as increased physical activity or spending time with family and friends. Decreasing screen time leaves more time for adolescents to focus on other areas like increased social interaction, which DePaul et al.¹³ was found to have a positive effect on ADHD symptoms.

This current review found that a reduction in screen time works by limiting the exacerbation of existing symptoms like attention deficit and impulsivity caused by high social media usage, this point is echoed by Andreassen et al.¹⁵ and Wallace et al.¹⁴ Due to high screen time, behavioral issues often associated with ADHD can be exacerbated not through the fault of the adolescent but due to the high levels of impulsivity and hyperactivity that increased screen time can cause. A reduction in screen time does not induce a specific mental or physical process to reduce ADHD symptoms, it only eliminates exacerbations that increased screen time might cause, which in some cases can be serious.^14-15

As for the effectiveness of mindfulness activities, as shown in Table 1, practicing mindfulness is very effective in reducing inattention and impulsivity in adolescents with ADHD, which can impair focus in school, leading to frustration and irritability.¹¹ This is shown in Bogels et al.¹¹, displaying benefits outside of ADHD symptom reduction. For example, when parents participated in mindfulness activities with their children in the study, they reported increased clarity, mood improvements, and lower stress levels.

Several explanations exist for the effectiveness of mindfulness techniques in reducing ADHD symptoms. One way is by supporting response de-automatization, which is the ability to respond to situations in a flexible way consistent with what a situation demands instead of relying on habitual automatic responses.^27-28 This is especially helpful for individuals with ADHD, as they often struggle to inhibit responses that may not be conducive to current situations. Secondly, mindfulness meditation may support reductions in physiological stress by inducing relaxation, which in turn may help counteract inappropriate impulses caused by ADHD.²⁹ Regarding mindfulness recommendations, the results from the current review suggest partaking in mindfulness routines with others, such as group meditations, which might make mindfulness practices more enjoyable for younger adolescents. Additionally, incorporating religious practices into meditation and mindfulness might add an additional layer of interest for parents wanting to participate in this activity with their children.¹² These findings are in line with current research and echo concerns provided by previous studies (Bigelow et al.)²⁴

Similarly, when both parents and their children with ADHD participated in behavioral parenting interactions, both parties saw a significant decrease in stress levels, as well as reduced inattention, emotional dysregulation, and poor social skills for adolescents with ADHD.^13,25 Additionally, increased social interactions can have benefits outside of general symptom reduction, which include a sense of belonging and lower rates of depression and anxiety. Increased social interaction with friends and family can add a layer of enjoyment for adolescents, helping them practice this intervention more regularly. This current review recommends additional research into areas of specific social interactions that can yield the most effective result in ADHD reduction; this point is echoed in a systematic review by Fox et al.¹⁶, which details the need for further research concerning social interactions and ADHD.

Exercise has also been shown to yield beneficial results for those with ADHD, but this still requires additional research. Exercise was particularly effective in reducing emotional dysregulation and impulsivity, as shown in Table 1, and further echoed by secondary research.^10,12,24,26 In addition, exercise has been shown to improve executive functioning tasks, such as organization and prioritization skills, which are critical for success in school and later in the workforce;¹² exercise also enhances mood and energy levels.^9,30 Additional benefits of exercise, like decreased depression, anxiety, stress, weight loss, and increases in confidence (Chan et al.)¹², can be additional benefits for ADHD patients outside of symptom reduction and provide an overall life improvement.

Exercise has been shown to increase dopamine and norepinephrine levels; these are key neurotransmitters for attention, behavior regulation, and cognitive function.¹² Through this increase of neurotransmitters, exercise may help to regulate ADHD symptoms which in certain cases are caused by a deficiency in these neurotransmitters.⁹ Incorporating exercise with other activities like mindfulness resulted in a broad reduction of ADHD symptoms.²⁴

The long-term effects of ADHD medications are unknown, and the current review has found little research concerning the developmental issues that these medications might cause for children.⁹ Additionally, taking ADHD medication two to three times a day in a public setting might be stigmatizing for adolescents, especially younger children, who might feel embarrassed by having to take this medication at school.²³ Adults who discontinue ADHD medication after symptomatic remission might still feel some mitigated symptoms of ADHD, which psycho-social interventions can help to curb, as shown by secondary research.³⁰

This current review recommends that specific psycho-social interventions be implemented on a case-by-case basis for adolescents with ADHD, either in conjunction with medication or on their own, to reduce ADHD symptoms. For example, suppose inattention was a significant problem for a fifteen-year-old male already taking ADHD medications. In that case, he might benefit from incorporating mindfulness activities or increased social interaction into his schedule. The current review recommends adopting a similar style as provided in the example to help better combat problematic ADHD symptoms. The current review found that, in terms of overall effectiveness in reducing ADHD symptoms, all psycho-social interventions mentioned within the study, exercise, peer-based interventions, mindfulness activities, and reduced screen time, were all somewhat effective in reducing specific ADHD symptoms, as shown in Table 1.

Limitations and Future Directions

This current review included varying demographic factors like race, gender, socio- economic background, and country of origin to represent a broad range of people affected by ADHD, yet the studies did not specifically investigate the impact of these variables. Future studies should investigate if these have an impact on psych-social interventions for those with ADHD. Limitations that affected the study were some methods used in certain research studies, like Visser et al.⁵, which used parent-reported improvements in the child, which are not first-hand accounts of changes and might be slightly biased. In addition, studies included in this paper did not differentiate between attentive and inattentive ADHD in their recommended ions and research findings.

In terms of future research, the current review strongly emphasizes future dietary research regarding ADHD, especially on nutritional supplements like omega-3 fatty acids, which have proven effective in impulse control and improved social behavior, as well as research into a reduction in artificial colors and sweeteners which has been shown to cause ADHD symptom exacerbation.⁴ Additionally, further research into the effects of sugars like high fructose corn syrup on ADHD should be investigated, as current reputable research is insufficient to make a conclusion. The current review also recommends that additional research be conducted regarding multiple applications of psycho-social interventions and their ADHD symptom reduction. Further research into specific exercises (e.g., flexibility, strength, aerobics, etc.) might yield more specificity into how particular exercises can be more effective than others in reducing ADHD symptoms.

Conclusion

While it might seem challenging to implement the current review's recommendations, psycho-social interventions should be implemented based on ADHD symptoms to develop healthy lifelong strategies to combat ADHD and reduce accompanying symptoms. Reducing screen time was associated with decreased hyperactivity, impulsivity, and feelings of isolation and improved attention span.^14,15 Increased positive social interactions effectively reduced emotional dysregulation and inattention and enhanced social skills.^13,16,25 Implementing regular exercise also helped emotional dysregulation and improved impulsivity.^10,12 Practicing daily mindfulness techniques helped to improve both impulsivity and inattention.^11,23

In addition, ongoing studies showed that mindfulness yielded results comparable to stimulant meditation in reducing ADHD symptoms (Meppelink et al)²³. Implementing one or more of these psycho-social interventions will benefit adolescents with ADHD. For example, if a thirteen-year-old female with ADHD suffers from emotional dysregulation and hyperactivity, reducing screen time and increasing social activity will help reduce those symptoms. In totality, the results of the current review are in line with current scientific research and further accentuate the need for the use of psycho-social interventions for those with ADHD.

References

1.     Eiraldi RB, Mautone JA, Power TJ. Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin. 2012;21(1):145-159.

2.     Sayal K, Prasad V, Daley D, Ford T, Coghill D. ADHD in children and young people: prevalence, care pathways, and service provision. Lancet Psychiatry. 2018;5(2):175-186.

3.     Rubia K. Cognitive neuroscience of attention deficit hyperactivity disorder (ADHD) and its clinical translation. Front Hum Neurosci. 2018;12:100.

4.     McCann D, Barrett A, Cooper A, et al. Food additives and hyperactive behavior in 3-year- old and 8/9-year-old children in the community: a randomized, double-blinded, placebo- controlled trial. The lancet. 2007;370(9598):1560-1567.

5.     Visser SN, Danielson ML, Bitsko RH, et al. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.

6.     Cuffe SP, McKeown RE, Jackson KL, Addy CL, Abramson R, Garrison CZ. Prevalence of attention-deficit/hyperactivity disorder in a community sample of older adolescents. J Am Acad Child Adolesc Psychiatry. 2001;40(9):1037-1044.

7.     Reinert M, Fritze D, Nguyen T. The state of mental health in America 2024. Published online 2024.

8.     Fulton BD, Scheffler RM, Hinshaw SP, et al. National variation of ADHD diagnostic prevalence and medication use: health care providers and education policies. Psychiatr Serv. 2009;60(8):1075-1083.

9.     Solmi M, Fornaro M, Ostinelli EG, et al. Safety of 80 antidepressants, antipsychotics, anti‐ attention‐deficit/hyperactivity medications and mood stabilizers in children and adolescents with psychiatric disorders: a large scale systematic meta‐review of 78 adverse effects. World Psychiatry. 2020;19(2):214-232.

10.  Berwid OG, Halperin JM. Emerging support for a role of exercise in attention- deficit/hyperactivity disorder intervention planning. Curr Psychiatry Rep. 2012;14:543-551.

11.  Bögels S, Hoogstad B, van Dun L, de Schutter S, Restifo K. Mindfulness training for adolescents with externalizing disorders and their parents. Behav Cogn Psychother. 2008;36(2):193-209.

12.  Chan YS, Jang JT, Ho CS. Effects of physical exercise on children with attention deficit hyperactivity disorder. Biomed J. 2022;45(2):265-270.

13.  DuPaul GJ, Kern L, Belk G, et al. Face-to-face versus online behavioral parent training for young children at risk for ADHD: treatment engagement and outcomes. J Clin Child Adolesc Psychol. 2018;47(sup1):S369-S383.

14.  Wallace J, Boers E, Ouellet J, Afzali MH, Conrod P. Screen time, impulsivity, neuropsychological functions and their relationship to growth in adolescent attention- deficit/hyperactivity disorder symptoms. Sci Rep. 2023;13(1):18108.

15.  Andreassen CS, Billieux J, Griffiths MD, et al. The relationship between addictive use of social media and video games and symptoms of psychiatric disorders: A large-scale cross- sectional study. Psychol Addict Behav. 2016;30(2):252.

16.  Fox A, Dishman S, Valicek M, Ratcliff K, Hilton C. Effectiveness of social skills interventions incorporating peer interactions for children with attention deficit hyperactivity disorder: A systematic review. Am J Occup Ther. 2020;74(2):7402180070p1- 7402180070p19.

17.  Tresco KE, Lefler EK, Power TJ. Psychosocial interventions to improve the school performance of students with attention-deficit/hyperactivity disorder. Mind Brain J Psychiatry. 2010;1(2):69.

18.  Shrestha M, Lautenschleger J, Soares N. Non-pharmacologic management of attention- deficit/hyperactivity disorder in children and adolescents: a review. Transl Pediatr. 2020;9(Suppl 1):S114.

19.  Power C, Freeman NC, Costello S. ADHD Assessment Recommendations for Children in Practice Guidelines: A Systematic Review. Psych. 2022;4(4):882-896.

20.  Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics. 2005;115(6):1734-1746.

21.  Strine TW, Lesesne CA, Okoro CA, et al. Emotional and behavioral difficulties and impairments in everyday functioning among children with a history of attention- deficit/hyperactivity disorder. Prev Chronic Dis. 2006;3(2):A52.

22.  Spencer TJ, Biederman J, Mick E. Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. J Pediatr Psychol. 2007;32(6):631-642.

23.  Meppelink R, de Bruin EI, Bögels SM. Meditation or Medication? Mindfulness training versus medication in the treatment of childhood ADHD: a randomized controlled trial. BMC Psychiatry. 2016;16:1-16.

24.  Bigelow H, Gottlieb MD, Ogrodnik M, Graham JD, Fenesi B. The differential impact of acute exercise and mindfulness meditation on executive functioning and psycho-emotional well-being in children and youth with ADHD. Front Psychol. 2021;12:660845.

25.  Nguyen T, Elkins SR, Curtis DF. Peer-based intervention for socioemotional concerns among children with ADHD. Child Psychiatry Hum Dev. 2023;54(5):1386-1395.

26.  Fritz KM, O’Connor PJ. Acute exercise improves mood and motivation in young men with ADHD symptoms. Med Sci Sports Exerc. 2016;48(6):1153-1160.

27.  Kessler RC, Adler LA, Barkley R, et al. Patterns and predictors of attention- deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication. Biol Psychiatry. 2005;57(11):1442-1451.

28.  Kang Y, Gruber J, Gray JR. Mindfulness and de-automatization. Emot Rev. 2013;5(2):192- 201.

29.  Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011;6(6):537-559.

30.  Tsujii N, Okada T, Usami M, et al. Effect of continuing and discontinuing medications on quality of life after symptomatic remission in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. J Clin Psychiatry. 2020;81(3):11514.