Behavioral Medicine Associates, Inc.

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Attention Deficit Hyperactivity Disorder

When is a difference in attentional style, activity level and/or interest level a disorder?

When are these differences an advantage, simply an Attention Difference Difficulty?

What alternatives are there to stimulant, anti-convulsant and anti-depressant medicines?

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a condition that results in easy distractibility, impulsiveness, and for some persons, greatly increased activity levels. This increased activity may be a learned compensation for a very under aroused central nervous system. The activity levels range from being “fidgety” to being in constant motion, tapping feet and fingers, getting into things, and disrupting others’ studying, work and play. Moderate to severe levels of the disorder are accompanied by poor school and social performance. Children and adults with the disorder are likely to be seen as underachievers. Often there are academic problems surrounding poor reading comprehension, difficulty with completing tasks, and not turning in work on time or at all. Check our ADHD problem checklist.

These children and adults may be forgetful, may appear or become uncooperative and typically develop negative self images as they experience failure and are given negative messages about themselves by schools, parents and peers. They often appear not to be listening or to lose interest easily. They are easily hurt or "oversensitive." They may appear to lack judgment in social situations, failing to take others needs and social conventions into account.

I don't really like the term "Attention Deficit Hyperactivity Disorder," since it is really just a label for a set of complaints, sort of like saying your car has CWGUHD (Car Won't Go Up the Hill Disorder) when it coughs, sputters and slows down going up hills. Nonetheless, the complaints can be bad enough to really interfere with who a child (or and adult) could be, what they could accomplish for themselves. So we'll say it is a disorder when the symptoms are extreme enough. But it would be very good if we could see some real physiological problem going on with people who have trouble with attention, distractibility and/or hyperactivity and impulse control. And we have the technology that can reveal exactly that.

Sleepy Brain Waves

ADHD, which can occur with or without hyperactivity, is usually related to “under arousal" of the frontal and prefrontal brain systems that regulate attention and impulse control. Children with ADHD symptoms often show smaller and/or slower than normal physiological reactions to stimuli and signs that their brains are operating at lower levels of excitement. That's why physicians started trying stimulant medication with ADHD in the first place. The most common finding in people with ADHD is more "sleepy" (low frequency) patterns appearing in the brain electrical activity. This is seen in the image, below, which was recorded with a 19 channel digital EEG while a teen with ADHD symptoms was listening:



This excess slow wave activity is often most pronounced during reading or listening tasks. During this high amplitude low frequency activity, the person will "miss" what was being said. If these slow waves are more predominant over the prefrontal regions of the brain that regulate impulsivity, the person will probably be reactive to anything that happens and "not think twice" about the consequences. That may be why the amphetamine-type medications create the so-called paradoxical effect of calming down the behavior of ADHD children. What seems to be happening is that their brains are getting stimulated enough by the drug to allow them to regulate impulses, focus and pay attention.

The hyperactivity may also in part be a coping mechanism to maintain something like normal arousal. We have observed that when we first get hyperactive children to sit still, they rapidly drop off into a drowsy state. These folks seem to live at the edge of sleep, much like a driver who is getting tired and involuntarily dropping off, even though fighting it.

The brain activity can look much like Stage 2 sleep ("theta"activity) while the person is trying to read. ADHD is often marked by increased "sleepy waves" in the EEG. You can, however, always see brief periods of activation in the raw EEG. These "operants" of focus and alertness spontaneous periods when the brain becomes more activated are the moments which neurotherapy identifies and reinforces.

Many young children with "ADHD" show this excessive theta activity, particularly over the front end of the brain. The frontal and prefrontal (behind your forehead) regions do "executive" things: planning, motivation, impulse control. The systems behind those in frontal cortex regulate attention, ignoring distractions, persistence and precise motor (muscle) control as well as "mirroring." There are specialized neurons in part of the frontal cortex (mirror neurons) that allow us to copy what we see others do, even down to letting us feel what others feel. That's empathy. So if the whole region is really too underexcited ("sleepy") to do the jobs, you're going to have some problems.

Other people have too much "alpha" activity over frontal systems. The systems are awake, but they are just "hanging out," again, not doing their jobs. These patterns are common in teens and adults with ADHD. Neurofeedback in this situation simply lets the person know when their brain is a little bit more "on the job."

  • An important teaching to these children (and adults) is that their natural condition is not bad, even though it can create tough situations.
  • If a person with ADHD is reasonably smart, well loved and learns how to use his or her unique traits, great things may happen.
  • Having the tendency to get easily bored may lead to creativity. In fact, we often teach adults to make slower, synchronized brain activity to enhance relaxation and creativity.
  • We teach that it is helpful not to be "stuck" in one state of awareness. The natural state of these children seems to be to go into a wide field type of attention- hence the easy distractibility.
  • We take the point of view that our clients are learning a new, useful skill of focused attention not eliminating some defect. However, we recognize that if a child is too overactive, or simply cannot keep the attention focused for long enough to succeed in class or to do homework, something must be done to help.

  • The problems with drugs:
    1. Even advocates of drug solutions for ADHD admit only 70-80% of children are helped by the medicines.
    2. Medicines always have side effects. These include appetite suppression, sleep disturbance (the medicine isn't completely out of the child by bed time). Another common side effect is irritability and angry reactivity as the medicine wears off. Motor tics and twitches have also been associated with stimulant use, although there is ongoing argument regarding whether the stimulant started the problem or just "released" or worsened the problem in people who were already prone to tic disorders.
    3. There is clear evidence that some of the drugs (Straterra, Cylert) can cause very serious side effects, including liver failure. These side effects are not well predicted even when regular tests of liver function are done. Cylert Warning
    4. The clinically effective dose level will disappear by evening, so there is usually no help for homework. Further, teenagers with ADHD end up being out and eventually driving, going to parties, etc. long after the effectiveness of the medicine has worn off. So they are out in the world with no treatment at all after 9 or 10 PM.
    5. There is clear evidence that the stimulants can and are abused, overused and sometimes sold or traded amongst teens.
    6. There is recent evidence of increased rates of violence and suicidality with a wide range of psychiatric drugs, including the stimulants and the antidepressants.
    7. There is now a long term study, the National Institutes of Health Multi-modal Treatment of ADHD (MTA) 3-year Follow-up Study, that has failed to show ANY long term improvement with intensive medication compared with no medication (behavior therapy only), medication plus behavior therapy, or just following your pediatrician's advice. All groups improved slightly in three years. The medicated groups were 1 inch shorter and 4.5 pounds lighter, however, than the non-medicated group. This is being "spun" as showing long term safety of the drugs, but there is very little publicity regarding the actual findings, which are that even aggressive medication management failed to make a difference in ADHD symptoms, Oppositional Defiant Disorder symptoms, Wechsler Individual Achievement Test (WIAT) reading scores, parent and teacher-rated total social skills and overall functional impairment.
    8. Despite these problems, in severe cases of impulsivity, hyperactivity and inattention, when the child is truly suffering and people are getting angry and blaming with the child, I will still occasionally recommend medication. There is very good evidence that medication will temporarily suppress extreme hyperactivity. This, however, is recommended only as "first aid" until self-control training with neurofeedback can be instituted and the effects of training begin to take hold. I also suggest making sure that child actually has the type of brain activity that is known to respond best to stimulant medications: the "sleepy" (excess theta) frontal brain. Other medications may work better with the "alpha wave-rich" brain, or with brains that show too much high frequency beta activity or too much synchronization. I can talk with you and your physician about this if need be.

    Neurofeedback

    Neurofeedback is an advanced form of biofeedback which allows the development of self control over the person’s brain wave activity. The electrical signals from the brain are picked up by metal disks placed on the scalp in a simple, painless procedure. A computer analyses the brain waves and lets the person know when they are producing desirable patterns consistent with alertness. The computer is set up to make sounds and changing screen displays which act as “feedback” about the brain waves. This "BIO-feedback" makes learned self control possible.

    Biofeedback means we measure some important biological activity - like muscle tension, heart rate, or EEG activity - and “feed it back” to you. The principle has been around since the 1950's and has been widely used to help people reduce headaches, muscle tension, regulate blood pressure, even treat migraines.

    The biofeedback principle is how we learn almost everything. For example, you learn to throw a ball more or less accurately by throwing it, then watching where it goes. With some practice, you can get it to go where you want. Biofeedback is the same idea. Most headaches, for example, are caused by too much tension in the forehead, jaw and/or neck muscles. Easy to say, but “seeing is believing.” Muscle tension biofeedback, for example, actually shows you the tiny, changing amounts of activity in your muscles, right on a computer screen. Once you see it, you can really start taking control of it. After a short time, you can also recognize your own internal feedback - the sensations of muscle tension - so you don’t continue to need the computer. We couple biofeedback with home relaxation practices aimed at getting you the skill to feel more relaxed and comfortable more of the time.  Biofeedback coupled with home practice of simple relaxation methods quickly gives people relief from symptoms as well as a terrifically rewarding sense of self-control - something you don't get from suppressing symptoms of pain or fear with medications.
     
    Biofeedback can be a powerful part of non-drug treatment for anxiety, sleep problems, “stage fright”, test or performance anxiety. We also use it as part of the treatment of chronic pain problems from accidents or from chronic stress.

    Neurofeedback applies the biofeedback principle to regulating brain activity, allowing learned control of the attention and mental/emotional states in general.

    More about neurofeedback

    A related problem: DEVELOPMENTAL VISUAL DISORDERS

    Developmental or behavioral optometrists provide advanced assessment and treatment of developmental visual disorders. Too frequently, assessment of children’s and adult’s vision is limited to measurement and correction of acuity, or clarity of vision. Further, in typical school vision assessments, only distance vision, not close visual acuity is assessed. Acuity is only one of many elements of good vision. Normal acuity near and far, binocular coordination, eye movement skills, peripheral awareness and eye/hand coordination are all critical vision skills needed for success in school.

    Unfortunately, some eye doctors have claimed that optometric vision therapy can "cure" ADHD, or that ADHD is "nothing but" a visual disorder. This is simply not so. ADHD is a genetic tendency of the brain to get into states that are not compatible with good attention. This usually involves the frontal part of the brain. Part of the control system for the aiming of the eyes is also in frontal cortex and that system is probably going to be just as "sleepy" as the rest of the so-called "executive" systems in the frontal brain. So perhaps that's why poor convergence and divergence is pretty common in kids and adults with ADHD. The point, however, that is important is that improving the coordination of the two eyes so that better depth perception and aiming occurs commonly improves reading, sports performance and therefore improves active interest in the world. This will be helpful, but not curative, in kids and adults with ADHD. Vision training is a behavior modification issue and perception was one of the earliest areas of scientific study in psychology.
    Dr. Nash has extensive graduate training in perception and psychophysics and was trained and supervised in binocular vision therapy for 3 years by a very experienced senior behavioral optometrist, Clayton Johnson, O.D. (now sadly deceased). Dr. Nash's credentials to do binocular vision assessment and training are registered with the Minnesota Board of Psychology.
    Complex cases and those needing treatment for eye diseases and corrective lenses are referred to appropriate eye specialists, for example, Four Seasons Eye Care in Plymouth, MN.

    Clinical Effectiveness of these Non-Drug Therapies for ADHD

    Neurotherapy is a relatively new approach to ADD/ADHD. The earliest reports of success with it were published in the mid to late 1970’s. Few well-controlled clinical research studies had been done until recently. The few that were published, however, were impressive. One study by Joel Lubar, Ph.D. showed that training for decreased theta reduced or eliminated ADHD symptoms. Reversing the training (trainng for increased theta) brought the symptoms back! Training for decreased theta again reduced or eliminated the symptoms. Michael Tansey, Ph.D. has published small, but similarly impressive studies for over 15 years.

    Increasing numbers of reports on the effectiveness of neurotherapy been published recently and presented at national conferences.  A very comprehensive bibliography containing most of the studies of neurotherapy on ADHD, brain injury, anxiety, epilepsy and and other disorders can be seen at 

    Two organizations have substantial annual conferences to provide a professional forum for discussion, presentation of papers and teaching. These are the International Society for Neuronal Regulation and the EEG Section of the Association for Applied Psychophysiology and Biofeedback. The latter organization has been in existence for 25 years, focusing on biofeedback research and practice. Dr. Nash is part of a certifying board, the National Registry of Neurofeedback Providers, which certifies health care providers in the practice of neurotherapy.

    Unlike many forms of therapy in clinical settings, generalization of neurofeedback training to real world environments is very deliberate and very effective. Generalization to the real world is accomplished in three ways:

    One of the major satisfactions to me personally is seeing the children blossom into more self aware, outward-oriented, sociable people. One mother explained to me that she and her husband were thrilled by the fact that their 17-year-old son could now carry on a conversation, and that he was interested in dating and in having a summer job for the first time. Another parent of a 13 year-old girl, with ADHD who has been completely withdrawn from 40 mg Ritalin a day for two years now, told us her daughter has been transformed. She is still very high energy, but instead of being an annoyance to teachers and an underachiever, she is now a star of her small hometown. She is getting A’s and B’s and is proud to have been elected by her school to go to NASA Space Camp the summer after her neurotherapy. An 18 year old girl with ADD has become outgoing, and is achieving well in college three years after her treatment. When we asked ‘what had changed,’ an 11 year old boy told us very simply: "I can pay attention all the way through class. Before I couldn’t." These are typical of the stories we hear from parents of our kids. They bring us tremendous gratification.

    Costs and Cost Effectiveness

    We think several arguments can be made supporting the cost/benefits of neurofeedback treatment for ADHD. First, these clients incur significant ongoing expenses when they are treated with Ritalin. Since the drug is usually only taken during school hours, and rapidly wears off, the child’s behavior at home evenings, weekends, and during vacations is unlikely to improve, so medication treatment at best provides only partial relief in a complex clinical picture. Many parents are uncomfortable with teaching their children to rely on drugs to perform well. Finally, medications always produce side effects. 

    Summary

    Neurotherapy and vision training should not be seen as a "cure" for ADHD, or as an immediate substitute for necessary medications, but rather as a component of treatment that may allow children to learn to activate and focus their attention, while calming themselves physically. If the child is depressed, over anxious, or having serious conduct problems, or if parents lack solid behavioral parenting skills, there may be a need for individual and/or family therapy, and possibly psychiatric medications. If there are deficits in academic or social skills, it is very important that these be addressed through traditional means, with behavioral therapy and specialized academic skills training. The improved attentive skill acquired through neurotherapy should make this kind of learning more rapid, but we must remember that the child may have effectively missed important academic and social learning.

    The course of treatment with neurotherapy is 3-5 months, depending on scheduling. We strongly encourage parents to work closely and cooperatively with schools and teachers. We also urge parents to involve themselves in support groups to get much needed encouragement and emotional support, as well as continuing education surrounding the parenting of these children.

    If you have an ADHD child, or if you have ADHD yourself, you might enjoy a solid relaxation break. I utilize deep relaxation as part of ADHD treatment. In particular, it is useful for coming to terms with your own easy boredom, and with staying awake with your eyes closed while you relax. Holding your focus and alertness while deeply relaxed takes practice. You can help focus your mind while "Learning to Relax."

    CYLERT (pemoline, Abbot Laboratories). I have been making my patients aware of a communication from Abbot Laboratories in December, 1996. Abbot issued a warning describing 10 cases of liver failure in children in the U.S. taking Cylert for ADHD. The warning stated "Because of its association with life threatening hepatic failure, CYLERT should not ordinarily be considered as first line drug therapy for ADHD. .. Of 13 cases reported as of May, 1996, 11 resulted in death or liver transplantation, usually within 4 weeks of the onset of signs and symptoms of liver failure."

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