Focusing the Mind
[By Benedict Carey, LA Times.]
http://www.latimes.com/features/health/la-he-add15sep15,1,6789284.story?coll=la-headlines-health
Some parents of children diagnosed with attention deficit disorder will try just about anything to avoid drug treatment — homeopathy, chiropractic, massage, even faith healing. “There’s a label, a stigma that goes with drug treatment,” said Dr. Regina Bussing, a child psychiatrist at the University of Florida who conducted a recent survey of 1,600 families in that state.
Although national statistics are not available, some doctors and other experts say that more than half of families coping with ADHD, or attention deficit hyperactivity disorder, now try alternatives before considering treatment with drugs, such as Ritalin or Adderall. The trend is on the rise, doctors say, as more children are diagnosed with attention problems and more ADHD products and programs crowd the marketplace. These include not only restrictive diets, vitamin and mineral supplements, but brain wave-measuring technology, and biofeedback.
Parents’ wariness of drug therapies is partly due to suspicions about the diagnosis of ADHD. There’s no single test for the condition, and doctors don’t always agree on the diagnosis. Nor are they sure how the standard treatment — Ritalin, a powerful stimulant — actually calms people and improves mental focus. “Many parents are worried about being ridiculed about it, by relatives or friends saying, ‘You better be careful, kids turn into zombies if they’re over-sedated,’ “ Bussing said.
The growing popularity of alternative treatments for ADHD may further confound the understanding of one of the most common diagnoses in child psychiatry. Because no one is tracking these families closely to see what alternatives are effective and in whom, nontraditional therapies remain largely untested. In the meantime, they can prevent families from considering proven therapies: drug treatment, which can help about 70% of children with ADHD, and family counseling, which improves symptoms in about50% of them. The result, psychiatrists say: Many children may be getting worse as their parents sample treatments.
Dr. James McGough, director of ADHD programs at UCLA’s Neuropsychiatric Institute, is disturbed by the tendency of parents to discount drug treatment that has been shown to work. “The saddest cases I see are parents of sixth- or seventh-graders who are dejected about school, who want to drop out, who’re doing nothing but ride their skateboard — and the parents say, ‘The doctor told us to try medication in third grade and we didn’t want to do it.’”
For only in recent years have researchers begun to evaluate nontraditional therapies in a scientifically rigorous way. “What you find is that the evidence for these alternatives ranges from fair to none at all,” said Dr. L. Eugene Arnold, professor emeritus of psychiatry at Ohio State University in Columbus, who recently reviewed studies of alternative therapies for ADHD. “I think people simply need to proceed with the understanding that, when it comes to alternatives, they’re experimenting.”
Among the popular alternatives that have been studied:
• Diet. The notion that food dyes, preservatives and other ingredients can cause mental problems in youngsters goes back some 50 years. There is some evidence that children on so-called “elimination diets” may become more focused and settled. Such diets exclude processed and other foods thought to prompt allergic or other problematic reactions. A typical diet might include lamb, chicken, potatoes, rice and a variety of fruits and vegetables, such as apples, broccoli and celery.
In one widely cited study, researchers at the University of Alberta in Calgary found that an elimination diet improved behavior in 12 of 24 hyperactive preschool-age boys, according to their parents’ reports. The improvements were noticeable within the first month on the diet. In another, German researchers in 1997 found that 12 of 49 school-age children with ADHD showed similar improvements.
But overall, the studies have been small and not convincing to many doctors who treat attention problems. Many other parents are reluctant to consider a program that may involve battle with a defiant, finicky eater over every meal. For them, imposing a diet could worsen already strained family relations.
But for those families who can manage a change in diet without drawn-out turmoil, some doctors say that well-balanced elimination regimens are at least worth a try, Arnold said. He estimates that 5% to 10% of children diagnosed with ADHD might respond. This group appears to include many preschoolers with allergies, irritability and sleep problems, according to Arnold. Scientists have found no good evidence that another popular alternative treatment — a dietary program that strictly limits artificial sugars — is helpful.
• Supplementation. Over the years, researchers have examined blood samples of children diagnosed with attention or learning problems, looking for deficiencies in vitamins, minerals or other nutrients. The theory is that perhaps hyperactive, highly distractible children aren’t absorbing nutrients properly or may not be getting sufficient nutrition in their diets. Some studies have picked up low levels of fatty acids, such as omega-3 and omega-6; others have discovered deficiencies in minerals, such as iron or zinc. Some children who take supplements to make up for a specific nutritional shortfall become noticeably more settled in school and at home, several small experiments have found. And now there are dozens of supplements marketed for attention and brain function, with names like Pedi-Active and Focus Factor.
Yet there’s little good evidence that supplement regimens help well-nourished children concentrate any better or longer, or improve in school. Typically, researchers say, supplements marketed for ADHD-like complaints include a list of ingredients that have each been linked to attention problems in some children. But no one knows how to identify children who might benefit, what doses they would need, or whether even then it would make a noticeable difference. When it comes to large, “mega”-dosing of single nutrients — another strategy that some alternative therapists favor — there are real risks. In large doses, vitamin A, zinc and iron can all be toxic.
• Biofeedback. The idea behind biofeedback is that people can train themselves to focus more deeply and continuously by controlling the electrical activity in their own brain. Using electroencephalogram, or EEG, technology, doctors have found in several studies that people with ADHD diagnoses tend to have a distinct, lower-frequency wave pattern in their frontal cortexes. By concentrating on patterns and mazes while receiving “neurofeedback” signals from an EEG, people can consciously alter the activity, inducing better focus, some researchers report.
Biofeedback techniques have been used to treat ADHD for years, and there are more than 500 practitioners using the techniques, according to the International Society for Neuronal Regulation, a professional group. In two small experiments conducted in the last year, doctors reported that a 40-minute course of biofeedback each week improved symptoms significantly, in both children on Ritalin and those with ADHD who were not taking drugs. The treatment programs ranged between three months and a year.
“We’re seeing increased interest in neurofeedback right now,” said David Rabiner, a researcher at Duke University who operates a Web site, http://www.helpforadd.com , that tracks studies of alternative treatments. “We’re still in need of better studies but I think even some who are skeptical of the treatments would agree that the theory behind them makes some sense.”
The problem for parents is that there are no accepted standards or guidelines by which to evaluate the effectiveness of biofeedback treatments. Each doctor, psychologist or therapist has his or her own methods and machines. Some have children solve puzzles, or try to recognize patterns while tracking brain waves; others have them concentrate on a certain point on a video screen while attempting to focus; still others are marketing video machines for in-home use.
The cost of biofeedback therapy varies widely. Some clinics charge $50 to $100 a session, and recommend two or three sessions a week, and a total of 50 sessions or more. All that effort and attention may itself deliver a powerful placebo effect, some researchers say. Or deliver nothing at all. For all the promise of biofeedback, therapists still don’t know which methods work best, and for whom.
The most critical thing for parents who decide to try biofeedback therapies is to closely monitor their child’s behavior at home and at school — and judge for themselves whether it’s worth the money and time, Rabiner said. “You can’t overemphasize how important it is to systematically monitor how well your child is doing,” he said. “If the child is getting on track — and particularly following class rules and doing good and consistent academic work — that’s the most important thing.”
For Dana Walth, a 19-year-old college student in Des Moines, the answer was none of the above. Dreamy, restless, unable to concentrate for more than a few minutes at a time, Walth was diagnosed with ADHD when she was a sophomore in high school. Against the advice of school counselors, she refused to go on medication. “I just didn’t know how it would affect my personality,” she said. “I didn’t want to change; I wanted to be who I am.”
Instead of worrying about brain waves or food preservatives, she eliminated almost any free time from her daily schedule. She scheduled herself from 7 a.m. to bedtime: dance practice, cheerleading, choir, volunteer activities and various athletic and scholastic competitions. Children with attention problems sometimes thrive on a headlong rush of activity. Walth’s grades improved after she began doing homework in 15-to 30-minute gasps, between practices, between classes, before and after dinner. “It’s the only way I could do the work,” she said. “I’d end up doing about three hours of studying a day, but always broken up; if I gave myself an hour or more, I’d stop. I’d procrastinate, and I’d lose focus.” Working with her parents, she set daily goals, made use of lists and bulletin boards, set deadlines.
In effect, the Walths successfully carried out a program of behavioral therapy. In scores of rigorous studies, doctors have found that intensive use of goal setting, organizing skills and time management can help 30% to 50% of children with attention problems do better in school and at home. This approach can be as exhausting and disruptive to a family as imposing a strict diet, therapists say. “We didn’t have to rely on a pill,” said Laura Walth, Dana’s mother, who leads a support group for other families dealing with ADHD. “But at the same time, we knew it was out there, we saw the advantages, and I just tell people to try to be open-minded. You do what it takes.”
Re: On treating ADHD with "alternative" methods...
The single category of medicines historically most closely associated with the temporary reduction of ADHD symptoms in some people (not all people) is the central nervous system stimulants/alerting agents. The weakest central nervous system stimulant/alerting agent perhaps is coffee/caffeine compounds; the strongest is perhaps Adderall; the best known is perhaps Ritalin.
The ADHD meds do not work for everyone.
http://www.nimh.nih.gov/publicat/adhd.cfm
A major problem with many alternative methods is that the alternative methods don’t work or work well for most of those with classic ADHD vs the ADHD meds which do. That’s my view.
Re: On treating ADHD with "alternative" methods...
Actually, I believe it is more complex than just that…
Long before ADHD was formally defined (such as it is) stimulants like dexedrine and cocaine were known to increase attention span and focus. When ADHD was first being thought of as a condition which could be medicated, naturally medical science took what they already knew and applied it to this new group of patients. Because it worked in varying degrees with many of these (older) kids, a protocol was established and we went from there.
The problem I have with the use of strong stimulants is not that they do not or cannot work; on the contrary, recent research backs up not only that they CAN work to improve concentration and attention span in people with ADHD, but that they will do the same for nearly all of us, regardless of condition. The problem I have is that the medical community refuses to acknowledge that these are still powerful medications, that they can and do have predictable adverse effects to dependancy and damage to the cardio system (even at theraputic dosages), and that we are using them on younger and younger children haphazardly without the benefit of safety and efficacy studies being conducted (what works well on older people may not be so benefitial to younger people, case in point aspirin).
The reason I think that “alternative” treatments are not so predictable (especially when compared to protocols like stimulants) are twofold… 1) they are applied haphazardly without the benefit of established protocol, or are only partly followed (as in the parents keeping to a strict diet but the schools, granparents or other places allowing the children to eat “bad” foods) especially when compared to the ease of dispensing pills, and 2) there is little built-in impetus for the medical community to explore treatment alternatives that do not give them patients. Call me cynical, but the only preventitive medicine most medical persons religiously follow is vaccination (where again they deny that bad things can happen), and most of the money for research gets poured into drug therapies, not in lifestyle changes. Additionally, many health plans will cover the cost of medication (less copays, etc.) whereas lifestyle changes, regardless of how difficult or expensive to enact are almost always NOT covered.
When one study conducted by a reputable university in Calgary finds a 50% rate of improvement using dietary intervention, and you compare that to a 70% rate of improvemnt using stimulants, that is not so very different. The fact the Calgary Study involved so few kids is not a reason to dismiss it out of hand, but rather a call for additional studies.
One thing that this author did do is to carefully word his/her statements. For instance, when he speaks of the success rate of Ritalin, s/he says “which can help about 70% of children with ADHD”. What the author fails to say is that medication alone is not the most proven therapy; a recent report published by the NIMH (can’t recall the authors now) gave the 70% figure to a combined approach of medication and behavioral therapy, and that medication alone was about 50% successful.
Nor does this cover the percentage of children who may get labeled ADHD erroneously and then recieve stimulant treatment. Children with HFA/Asperger’s, CAPD or dyslexia are all frequently first diagnosed by the most obvious behavioral manifestations, inability to focus on school work, and inability to sit still. Best estimates place about 4 - 5 million children as having ADHD/ADD, yet nearly 8 million pediatric prescriptions for Ritalin are written each year. I find this especially troubling when you consider that the only legitimate use for Ritalin is ADHD, and that it is only being tested now on children younger than puberty, yet many children as young as 5 are being put on it.
Do not take my posts wrong; I am not “playing ball” or in any way to be seen as “anti-dope” per se. I just like for medical practice to be done as accurately as possible, and do not like it when doctors may hasty judgements or use trial and error methods when the patients are children (who do NOT have the right to decide what happens, that call is made by their parents who may or may not always have their child’s best interest in mind.) Most importantly, I do believe that ll diagnosies which may mask as ADHD should be clearly ruled out before strong psychotropics are employed.
Re: On treating ADHD with "alternative" methods...
I tend to discount most studied be cause I think the result is often determined before the study has begun.
I also think that stimulants have been a dismal failure. I base this on the pooree acedemic performances since the wide spread introduction of stimulant therapy. Of course there are other factors but the numbers seem to follow.
Psycho-stims calm children but they have the opposite effect on teenager and adults. I think the reason teenager are not bouncing out of their shoes is that they have built up a tolerance the same way a coffee drinker does.
I would like to see Ritalin banned like it has been banned in Sweden. I think it has been well proven that no long term positive effect has come from the use of this drug but what is well established is it’s numerous and dangerous side effects.
Re: On treating ADHD with "alternative" methods...
Diet doesn’t work on any significant % of children.
“Based on seven studies involving approximately 190 children, there have been no instances of consistent, dramatic deterioration in behavior in hyperactive children challenged, under double-blind conditions, with artificial food colorings… . There are three … exceptions to these generally negative conclusions, but, in all three cases, the deterioration is reported by the mother with no other objective, confirming evidence available… . Without the confirming evidence of objective tests and/or outside observers, even these exceptions cannot be considered as definite evidence that there may be an occasional, genetically determined, sensitivity to food colorings. Though one cannot prove that no such children will be found, sufficient numbers of highly selected children have been studied to feel confident that such specific sensitivity, if found, will be rare. ”
These negative findings stand in sharp contrast to the 32-60 percent of children reported by Dr. Feingold and others to improve dramatically under non-blind conditions without the use of placebo controls. In 1983, the review team’s co-chairman and another colleague reviewed additional studies and concluded that no more than 2% of children respond adversely to dye additives, and even that statistic was questionable. Since that time, experimental findings have been mixed. Some researchers have reported no effect
and some have reported worsening behavior during challenge experiments. However, it remains clear that the percentage of children who may become hyperactive in response to food additives is, at best, very small. Sugar and aspartame (an artificial sweetener) have also been blamed for hyperactivity, but well-designed studies have found no evidence supporting such claims.
Real Risks
Because the Feingold diet does no physical harm, it might appear to be helpful in some instances. However, the potential benefits should be weighed against the potential harm of (1) teaching children that their behavior and school performance are related to what they eat rather than what they feel, (2) undermining their self esteem by implanting notions that they are unhealthy and fragile, (3) creating situations in which their eating behavior or fear of chemicals are regarded as peculiar by other children, and (4) depriving them of
the opportunity to receive appropriate professional help.
Every parent I know has tried diets and suppliments, with the exception of some short term placebo effects. They just don’t work. I wish they did. Medicines aren’t a cure, just a band aid. If you want to keep your child off medicines, it will be a travisty if you don’t make life long accomodations, compensations and exceptions for your child, they’ll need it.
Re: On treating ADHD with "alternative" methods...
[quote=”pgd”]
The ADHD meds do not work for everyone.
http://www.nimh.nih.gov/publicat/adhd.cfm
A major problem with many alternative methods is that the alternative methods don’t work or work well for most of those with classic ADHD vs the ADHD meds which do. That’s my view.[/quote]
Gee, PGD, you better stop offending all the true believers in alternatives with your inconvenient facts.
Re: On treating ADHD with "alternative" methods...
I tried natural remedies and even fiengold. Salmon oil, calcium, vitamine B, Iron, becalmed, attend…the list goes on. They don’t do anything. I don’t need some study to see the effects of meds over these placebos. I don’t blame anyone for trying and if it helps 1 out of 100 kids, Giddiyap! But lets not kid ourselves. How many of us have’nt tried naturals alternatve? A good diet, a good nights sleep and a good mom can do a lot more than these money making schemes. While meds don’t work for every child, they work for 80x more kids than natural alternatives. That might be a conservative number, if I do say so. Save your money, thats my opinion.
What works?
I must say, I feel a little uncomfortable with the generalized statements about alternative treatments. Even if they have not worked for you personally, there are others that swear by them. You would not want others to denigrate your choice to medicate - I believe others have a right to decide what works for them.
I think it is important to remember that the definition of “works” depends on your goals. Medication works in the short term to reduce the “core symptoms”, but even the most pro-med experts have had to concede that medications don’t improve long-term acedemic outcomes overall. If the goal is to make life more sane and manageable in the present, then medications can be said to work, but we all know there is a lot more to learn about how to help these youngsters become productive adults.
I find the most interesting part of that article to be the statements regarding biofeedback. If kids can learn through biofeedback to change their brain function, that means to me that there is no biological reason why all of these kids can’t learn to exert more control over their brain function.
I have actually applied this idea with my youngest without the benefit of the biofeedback machines. Kevin (now age 7), who clearly would have met the full criteria for ADHD had I ever had him evaluated, has always had a hard time settling down for bed. So when he was about 4 or 5, I started betting him on how long he could stay still. I started out with a minute, and built it up over a few weeks to 3 or 4 minutes at a time. Once he was able to do this, I pointed out to him that he CAN choose to be calm, because he had just proven it. So at bedtime, I wanted him to choose to be calm. We came up with the term “calm brain” to describe the condition he had been able to accomplish. Now I can ask him to “put on his calm brain”, and he (usually) will take a deep breath and quiet his body down, which makes him much more able to listen.
He is even teaching other kids! We have a neighbor boy who is on medication for ADHD, who was being wild at our house, despite reminders from me. When I asked him why, he said “I ate something with red dye, which cancels out my medicine, so I can’t control myself.” I told him I disagreed and believed that he could still chose to control himself, even though it might be harder than usual. Kevin immediately chimed in his support, telling his friend (who is 11!) that he can choose to be calm if he really wants to, because he has learned to do it.
This is not an immediate result, it took a lot of thought and energy (and a few dollars in lost bets) to achieve, and it doesn’t work automatically every time, but what is important is that Kevin has learned that he is able to manage his own behavior. There is no medication, flower essence, allergy treatment, or nutritional supplement that can teach that. In fact, I believe the more we emphasize external treatments, whether “standard” or “alternative”, the more we risk teaching the lesson that Kevin’s friend seems to have learned: that he is defective and unable to control themselves without an external agent.
While I am not going to deny the impact of biology on making it more difficult for some kids to function in certain settings or in general, I think it is vital to have children learn the maximum amount of responsibility for their behavior, and well as developing the INTERNAL skills to manage whatever biological or psychological challenges they will face. Everyone needs to make up their own minds about what “treatments” to consider (and I know many folks who HAVE found alternative treatments to be helpful), but there is no treatment that can match empowering the child to manage their own behavior. I think this is the variable that makes the difference between a successful and an unsuccessful child, whether or not they are medicated. It can be a difficult path, but it is worth it. Responsible children make responsible adults.
–— Steve
Re: On treating ADHD with "alternative" methods...
There are effective treatments besides psycho stimulants for ADHD. If anyone suggests otherwise they are either badly misinformed or they are lying.
If you judge success of a therapy by how compliant a child is after the therapy is administered then you will never believe anything but psycho stimulants works.
People can trash everything that is not speed. I can do the same thing regarding speed. The difference is I can back it up with 100s of unbiased studies and unbiased statistical data.
I just wonder what those poor misinformed Europeons do who rarely drug their children do to have schools that out perform ours and a lower juvenile crime rate.
A little decorum, please!
It is not very helpful in my mind to use the term “speed” to refer to stimulants. It is unnecessarily inflammatory. It also harms the argument that alternatives may be viable by making you look narrow minded. I have appreciated your posts to date, but I think this is over the line.
Just my opinion…
–- Steve
Interesting. With alternatives available I would think that a responsible doctor would be trying diet etc. prior to giving medications that may have adverse side effects.