Behavioral Medicine Associates, Inc.
Attention Deficit Hyperactivity
When is a difference in attentional style, activity level and/or
level a disorder?
When are these differences an advantage, simply an Attention Difference
What alternatives are there to stimulant, anti-convulsant and
Attention Deficit Hyperactivity Disorder (ADHD) is a condition
results in easy distractibility, impulsiveness, and for some persons,
increased activity levels. This increased activity may be a learned
for a very under aroused central nervous system. The activity levels
from being “fidgety” to being in constant motion, tapping feet and
getting into things, and disrupting others’ studying, work and play.
to severe levels of the disorder are accompanied by poor school and
performance. Children and adults with the disorder are likely to be
as underachievers. Often there are academic problems surrounding poor
comprehension, difficulty with completing tasks, and not turning in
on time or at all. Check our ADHD problem
These children and adults may be forgetful, may appear or
uncooperative and typically develop negative self images as they
failure and are given negative messages about themselves by schools,
and peers. They often appear not to be listening or to lose interest
They are easily hurt or "oversensitive." They may appear to lack
in social situations, failing to take others needs and social
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
to stimuli and signs that their brains are operating at lower levels of
excitement. That's why physicians started trying stimulant medication
ADHD in the first place. The most common finding in people with ADHD is
"sleepy" (low frequency) patterns appearing in the brain electrical
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
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
the so-called paradoxical effect of calming down the behavior of ADHD
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
The hyperactivity may also in part be a coping mechanism to
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
who is getting tired and involuntarily dropping off, even though
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
You can, however, always see brief periods of activation in the raw
These "operants" of focus and alertness spontaneous periods when the
becomes more activated are the moments which neurotherapy identifies
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
An important teaching to these children (and adults) is
condition is not bad, even though it can create tough situations.
If a person with ADHD is reasonably smart, well loved and
to use his or her unique traits, great
things may happen.
Having the tendency to get easily bored may lead to
we often teach adults to make slower, synchronized brain activity to
relaxation and creativity.
We teach that it is helpful not to be "stuck" in one
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
skill of focused attention not eliminating some defect. However, we
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,
must be done to help.
The problems with drugs:
- Even advocates of drug solutions for ADHD admit
only 70-80% of
children are helped by the medicines.
- Medicines always have side effects. These
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
- There is clear evidence that some of the drugs
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
- 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.
- There is clear evidence that the stimulants can
and are abused,
overused and sometimes sold or traded amongst teens.
- There is recent evidence of increased rates of
suicidality with a wide range of psychiatric drugs, including the
stimulants and the antidepressants.
- 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
- Despite these problems,
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.
an advanced form of biofeedback which allows the development of self
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,
procedure. A computer analyses the brain waves and lets the person know
when they are producing desirable patterns consistent with alertness.
computer is set up to make sounds and changing screen displays which
as “feedback” about the brain waves. This "BIO-feedback" makes learned
Biofeedback means we measure some important biological
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.
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
brain activity, allowing learned control of the attention and
mental/emotional states in general.
More about neurofeedback
related problem: DEVELOPMENTAL VISUAL DISORDERS
or behavioral optometrists provide advanced assessment
and treatment of developmental
visual disorders. Too frequently, assessment of children’s and
vision is limited to measurement and correction of acuity, or clarity
vision. Further, in typical school vision assessments, only distance
not close visual acuity is assessed. Acuity is only one of many
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
Non-Drug Therapies for ADHD
Neurotherapy is a relatively new approach to ADD/ADHD. The
reports of success with it were published in the mid to late 1970’s.
well-controlled clinical research studies had been done until recently.
The few that were published, however, were impressive. One study by
Lubar, Ph.D. showed that training for decreased theta reduced or
ADHD symptoms. Reversing the training (trainng for increased theta)
the symptoms back! Training for decreased theta again reduced or
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
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
forum for discussion, presentation of papers and teaching. These are
for Neuronal Regulation and the EEG Section of
for Applied Psychophysiology and Biofeedback. The latter
been in existence for 25 years, focusing on biofeedback research and
Dr. Nash is part of a certifying board, the National Registry of
Providers, which certifies health care providers in the practice of
Unlike many forms of therapy in clinical settings,
of neurofeedback training to real world environments is very deliberate
and very effective. Generalization to the real world is accomplished in
One of the major satisfactions to me personally is seeing the
blossom into more self aware, outward-oriented, sociable people. One
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
interested in dating and in having a summer job for the first time.
parent of a 13 year-old girl, with ADHD who has been completely
from 40 mg Ritalin a day for two years now, told us her daughter has
transformed. She is still very high energy, but instead of being an
to teachers and an underachiever, she is now a star of her small
She is getting A’s and B’s and is proud to have been elected by her
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
These are typical of the stories we hear from parents of our kids. They
bring us tremendous gratification.
- Performing actual school tasks with school
books during the
- Coaching the parents to notice and reward
in memory, improvements in follow through, improvements in impulse
- Coaching the child to notice changes in
with the aim of enhancing voluntary increasing of alertness as the
becomes more skillful at this.
- Working with the family to help them turn
what is often a
into a cooperative adventure in coaching, tolerance, ups and downs,
communication and JOY.
Costs and Cost Effectiveness
We think several
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
off, the child’s behavior at home evenings, weekends, and during
is unlikely to improve, so medication treatment at best provides only
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.
Neurotherapy and vision training should not be seen as a
ADHD, or as an immediate substitute for necessary medications, but
as a component of treatment that may allow children to learn to
and focus their attention, while calming themselves physically. If the
child is depressed, over anxious, or having serious conduct problems,
if parents lack solid behavioral parenting skills, there may be a need
for individual and/or family therapy, and possibly psychiatric
If there are deficits in academic or social skills, it is very
that these be addressed through traditional means, with behavioral
and specialized academic skills training. The improved attentive skill
acquired through neurotherapy should make this kind of learning more
but we must remember that the child may have effectively missed
academic and social learning.
The course of treatment with neurotherapy is 3-5 months,
on scheduling. We strongly encourage parents to work closely and
with schools and teachers. We also urge parents to involve themselves
support groups to get much needed encouragement and emotional support,
as well as continuing education surrounding the parenting of these
If you have an ADHD child, or if you have ADHD yourself, you
enjoy a solid relaxation break. I utilize deep relaxation as part of
treatment. In particular, it is useful for coming to terms with your
easy boredom, and with staying awake with your eyes closed while you
Holding your focus and alertness while deeply relaxed takes practice.
can help focus your mind while "Learning
CYLERT (pemoline, Abbot Laboratories).
been making my patients aware of a communication from Abbot
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
"Because of its association with life threatening hepatic failure,
should not ordinarily be considered as first line drug therapy for
.. 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
of liver failure."