From Parenting New Mexico May 1999

ARTICLE THREE OF FOUR ARTICLES ON
ATTENTION DEFICIT/HYPERACTIVITY DISORDER

ADHD Treatments:
What Works

In the last two issues of Parenting New Mexico we have discussed correctly diagnosing Attention Deficit/Hyperactivity Disorder and the many other mental health issues which can look like ADHD or co-exist with it. This month our topic is treatment.

There are many treatments for ADHD. Following the classification system used by the leading ADHD organization, CH.A.D.D. (Children and Adults with Attention Deficit Disorder, an organization about which more information will be available in next month's article), treatments can be divided into those which are well researched and established and those which may be helpful but do not yet have adequate scientific data to be considered fully validated. We examine both here. All of the treatments discussed are available in Albuquerque.

Well-Established Treatments

The following two treatments, behavioral programs and medication, have long been shown through rigorous scientific studies to be beneficial remedies. They represent the most commonly recommended therapies.

Behavioral Programs: Almost all ADHD children, adolescents, and adults can learn better self control over their attention, impulsive nature, and hyperactivity. To do so, however, requires a strong commitment and follow through over weeks and months. The programs should not be complex, and many can be designed by parents and teachers without the necessity of professional assistance. Persistence, starting with a very limited scope, and building on small successes are the keys.

The primary components to a successful program are:

• Pick one or two very specific daily situations with which to begin
• Establish baseline data - what is typical performance now
• Set small, incremental goals to achieve
• Track performance on a chart or other highly visual means
• Have clear, fixed rewards for achieving goals.

As an example, a behavioral program I have helped many families to successfully institute trains longer sustained attention during homework. In this program we carefully define when and where homework is done, who will work with the child on this program, and, a crucial component, what is the exact definition of sustained attention (something like, not looking away from the work at hand for more than 1 second). Then we use a timer on the table with the child over a week or so to learn how long attention is typically sustained now. Once we have this baseline, the average time the child can attend successfully, we then set a goal for a longer average attention span, say 30 seconds longer, and coach the child in trying to achieve this goal. When the new goal is achieved, say for five consecutive days, we then up the goal another 30 seconds or even one minute. Of course, we keep a chart of progress and the rewards given. Good daily rewards are extra time to watch TV or a longer bedtime story.

Programs like these require a great amount of parent and child effort, but they work! Learned improvements last far into the future, especially if "booster" training sessions are done periodically.

Medical Treatment: Beginning in the 1920's the most common medications helpful in treating ADHD, Ritalin and Dexadrine, came into use. For the majority of ADHD sufferers of all ages, these medications activate brain centers which are involved in self control. The result is marked improvement in sustaining attention, patience, and physical calmness. While these medications do not cure ADHD, they allow the ADHD sufferer to more successfully participate in and benefit from behavioral, social, and academic learning opportunities around them.

Fortunately, the potential side effects from the small dosages of Ritalin and Dexadrine used are seldom dangerous and almost always transient. The most common side effects are loss of appetite and trouble getting to sleep. Because of these, evening dosages are usually not considered until it is established that dinnertime and bedtime will not be adversely affected. Uncommon side effects can be agitation, tremor, constipation, a slight motor tic, and sedation. Concerns from some years ago about short term growth suppression in a few children have not been found to be a major problem. Since these medications have been used for over 70 years we know that serious and long term adverse reactions are very rare.

When Dexadrine and Ritalin are ineffective there are other related compounds which may be tried. A few antidepressant medications have also been the found to be excellent in the treatment of ADHD.

Less Well-Established Treatments

The following therapies are espoused by many, but have limited scientific evidence and patient outcome reports to support them. They are not as well understood as medical and behavioral therapies.

EEG Biofeedback: Research over two decades has established that training in producing and sustaining brain waves associated with concentration and physical calmness can result in better self control. I worked in a lab doing such research in the 1980s.

Training using electroencephalograph (EEG) biofeedback involves placing a few electrical leads on the scalp and then measuring and analyzing the person's brain wave patterns. The information is "fed back" to the ADHD sufferer via a computer screen to let them know when they are producing the desired patterns, ones associated with concentration and calmness in the case of ADHD, and when they are not. Over repeated training sessions the child or adult can learn to sustain the desired pattern and its associated behavior.

EEG Biofeedback has been distinctly shown to work. Some children, adolescents, and adults have dramatic behavioral improvements. However, problems arise for many in transferring the learning from the training sessions to daily situations. Additionally, this treatment requires great commitment from the patient and family since it involves many office training sessions over a period of months. There are no physical side effects to EEG Biofeedback.

Auditory Integrative Therapy: A number of years ago a French physician, Dr. Tomatis, developed an auditory healing method which has since bee applied to ADHD. AIT works to correct poor integration between the sensory modalities. Through the presentation of special sounds and music over several office sessions the treatment stimulates the brain in a way designed to integrate sensory functioning and thus lessen distractibility and hyperactivity. Like Biofeedback, AIT has been able to demonstrate dramatic improvements in some individuals. Presently there is not adequate scientific research to classify AIT as a leading treatment for the majority of ADHD sufferers, but it does show promise for some individuals. Often individuals are screened to see if they have the particular ADHD pattern which is most likely to benefit from AIT.

Special Diets: A number of special diets to treat ADHD have been proposed over the past four decades, most notably the Feingold Diet which restricts tomatoes and a variety of other common foods from the diet. Very rigorous research since the 1970s has shown these diets to be of little use, including diets which restrict the intake of chemical preservatives, food colorings, and foods suspect for causing ADHD through allergic reactions. One recent study, however, has shown promise for a diet eliminating all dairy, wheat, corn, soy, citrus, eggs, chocolate, nuts, preservatives, and artificial colors. Unfortunately, the diet is so restrictive - fresh fruits, vegetables, and meats are about all the child can eat - that it has drawn little interest.

An old dietary adage is that removal of sugars is a treatment for ADHD. Extensive research has shown only that there may be a slight benefit for a small number of children. Remember, children who believe they will be hyper after eating sugar usually are, but the effect is mostly psychological.

Dietary Supplements: There are a plethora of natural food additives and mega-vitamin supplements which are touted as being treatments for ADHD. I have looked into to the evidence on several and have failed to find significant support. A professional colleague tells me that a couple of substances have limited research support. Recently, one natural products company assured me that they had "major scientific studies" to back up their assertions. The research copies which came in the mail were certainly major ADHD studies, several of which I already had in my files, but sadly not one of the studies had anything to do with additives in their product! In this area, I can only advise proceeding with great caution knowing that there is little evidence other than anecdotal reports from other ADHD sufferers.

Which therapy or therapies will be best for you or your child is often difficult to predict. Certainly commitment to a sound trial of any treatment increases the chances of success. Next month I will provide a reference list of books, web sites, and organizations to assist you in learning more about which treatments might be best in your case. Living and Coping with ADHD will be the topic of June's article.

ADHD Treatments Defined

Auditory Integrative Training
A form of sensory integration treatment designed to stimulate the auditory system in ways which alter brain function and result in improved attention and self control.

Behavioral Program
A structured daily plan or procedure designed to gradually train better self control. Such programs have specific goals, behaviors which are carefully tracked, and well-planned rewards for meeting daily goals.

Dietary Supplement
The addition of nutritional supplement to the daily diet such as vitamins, minerals, amino acids, hormones, plant or animal extracts, or naturally occurring chemicals.

EEG Biofeedback
The use of an individual's own bodily information to train better self control. Electronic equipment measures brain waves, and this information is "fed back" to the patient visually or auditorily. With practice sustained brain wave patterns associated with calmness and attentiveness are learned.

Medical Treatment
The prescription of a medication which has been established by medical research to improve self control over attention, impulses, or excessive motoric movement.

Special Diet
Application of a diet which typically removes foods or chemicals thought to cause or exacerbate ADHD.

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Dr. Zieman is an Albuquerque psychologist who specializes in the evaluation of child and adolescent disorders. He also works with families and teachers regarding childhood behavior problems and learning disabilities.

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ADHD Articles
Part 1 | Part 2 | Part 4

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Copyright by Parenting New Mexico and Gayle L Zieman PhD. This article may not be published in part or in its entirety in any medium without written permission from Gayle L Zieman PhD or Parenting New Mexico magazine. Links to this page are welcome.