For the child no one wants to play with, for the parent who is screaming inside with frustration, for the student who is locked in his or her room unable to finish an essay, and for the doctor who has run out of pills to prescribe, we hope this book makes a difference in your lives.
Consumers, families, and health care providers are all searching for better ways to treat attention-deficit/hyperactivity disorder (ADHD) because anyone who deals with this baffling condition knows that our current treatments do not work well enough. In this book you will find treatments other than stimulant medications, for which there is enough evidence of safety and effectiveness to justify their use in ADHD. The treatments we describe include special herbs, nutrients, mind–body practices, brain stimulation, and neurofeedback techniques—all of which can help millions of people live, love, and work more successfully.
The National Survey of Children’s Health, under the aegis of the Centers for Disease Control and Prevention (CDC) randomly surveyed the parents of 70,000 children throughout the United States. In 2003–2004 7.8% of the children and adolescents of the parents interviewed had been diagnosed as having ADHD. In 2007–2008 the figures increased to 9.5% (Zoler, 2010). Estimates of the prevalence of ADHD in adults in the United States range from 1% to 5%. Given that ADHD impacts every facet of life, including psychosocial development, peer relationships, family dynamics, and academic and job performance, the need for better—that is, safer and more effective—treatments is urgent. Of even greater concern are studies showing that children with untreated ADHD are at greater risk for substance abuse, unemployment, accidents, and criminal behavior. These children also show a higher incidence of additional disorders such as learning disabilities, anxiety disorders, social phobia, depression, and bipolar disorder. On the upside, individuals with ADHD often bring a lot of energy, enthusiasm, and creativity to the tasks they undertake. They deserve the opportunity to fulfill their potential. This usually entails overcoming distraction, restlessness, and impulsivity in order to focus on learning, task completion, and understanding social cues.
Although we still have a great deal to learn about ADHD, we know that relying on only one approach will not solve all the problems. Because there are multiple contributing causes—genetic, nutritional, chemical, psychological, trauma-based, environmental—treatments must be strategically combined and tailored to the unique needs and sensitivities of each person. Andy’s story shows how the best results come from combining multiple treatment approaches.
Eight-year-old Andy was in the emergency room for the fifth time with yet another broken bone. As usual, he was recklessly climbing something—a tree this time—and had taken another fall. By the age of 8, Andy believed he was a bad boy. If he wasn’t climbing on and over things (often breaking a bone or two in the process), he was driving his family crazy asking questions, interrupting, and noisily banging about the house. Like most children, Andy believed what he was told by the grownups in his life. Now an adult, Andy reflected back on those trying times: “Adults told me I needed too much attention. I felt there was something wrong with me—that I was not very smart, that I was lazy. These are things I was told. Sometimes my parents or my teachers got impatient with me—and I got impatient with myself. As I got older, I learned to deal better with the ADHD feelings and symptoms, but they never went entirely away.”
In fact, Andy is extremely intelligent. Considering how difficult it was for Andy to sit still or read a book, people were shocked when they heard he was accepted to medical school. While studying medicine, he realized that his lifelong problems were due to ADHD. He used prescription stimulant medication to study, but he never liked the way it made him feel speeded up. Over the years he figured out ways to manage his symptoms without medication by trying many different treatments, including herbs, supplements, exercise, and mind–body practices to focus his mind, enhance his information-processing abilities, quell his constant worries about people disliking him, and relieve his restlessness. Now a successful orthopedic surgeon, Andy has a wide circle of close friends and a family he adores. Two of his four children have ADHD. Based on his own experience, Andy has provided them with the treatments they need. More importantly, he and his wife are giving them love, understanding, and support to develop their many talents and to feel good about themselves.
In the coming chapters you will read about many of the non-drug treatments that have helped Andy. In the final chapter, we go into more detail about how each treatment helped with the specific symptoms Andy experienced.
Stimulant medications have become a mainstay of treatment. They often improve some symptoms, but not others, and they can cause unacceptable side effects. You may be feeling pressure from others to use medication or you may be a veteran of medication trials, in which case you are already familiar with the side effects and therapeutic limitations of taking drugs for ADHD. We briefly review medicines commonly used to treat ADHD and compare them with non-drug approaches.
The relatively new field of complementary and alternative medicine (CAM) covers a wide range of biological, psychological, and mind–body treatments that can augment the benefits of prescription drugs and sometimes reduce or obviate the need for those drugs. CAM therapies should be considered in every treatment because, overall, they have fewer side effects than drugs, and many actually have additional health benefits. Concern about drug side effects is one of the major issues driving consumers and clinicians to explore these promising new nonpharmacological treatments.
There are many answers to the question “What is ADHD?” It has many facets and it can be seen in many different ways. Here we consider ADHD from several points of view. The official description of the condition by the American Psychiatric Association evolved from the “hyperkinetic child” in the 1968 Diagnostic and Statistical Manual of Mental Disorders (DSM-II) to attention-deficit/hyperactivity disorder in the DSM-III (1980), DSM-IV (1994), and DSM-IV-TR (text revised; 2000). Updates of the diagnostic criteria, which we describe later in this chapter in detail, should appear in the DSM-V due out in May 2013.
During the early years following the recognition of ADHD, children with a wide spectrum of learning and behavioral problems were given the diagnosis. This meant that instead of being seen as “naughty”, “disobedient,” “disruptive,” “irresponsible,” “lazy,” or “unmotivated,” they could be viewed as having a disorder that needed to be understood and treated. However, this paradigm shift did not change the predominant perception that the traits of people with ADHD were at best, undesirable, and at worst, disastrous.
Eventually, people began questioning the negative view of ADHD. Parents realized that although their inattentive, hyperactive children were more difficult to manage, they were also highly creative, kind, and generous. Understanding the strengths and weaknesses involved in a disorder such as ADHD is important when it comes time to choose a career. For example, many adults who recognized that they had undiagnosed ADHD knew that they had achieved more success by working as independent entrepreneurs than they would have by working in someone else’s businesses. Others have become famous by channeling their energy and creativity into the performance arts.
With the explosion of stimulant medication prescriptions—and the selling, trading, and misuse of these pills by adults and school children who do not have ADHD but who want to improve focus and test performance—the perception of ADHD swung again from stigma to diluted generalization. One parent complained that when she tells other parents that her child has ADHD, they think nothing of it because they don’t realize the vast difference between mildly overactive children and those with serious or even disabling ADHD symptoms.
More recently another facet has been added to public perceptions of ADHD as magazines have begun publishing stories about highly successful people with this disorder. Websites collected lists of hundreds of famous people whose biographies suggest that they might have had ADHD. Prominent names on such lists include Christopher Columbus, Thomas Edison, Gen. George Patton, Theodor Roosevelt, the Wright brothers, Samuel Clemens (i.e., Mark Twain), Ernest Hemingway, and Elvis Presley. Today, ADHD has “come out of the closet.” Interviews of celebrities, business executives, performing artists, and athletes who overcame the challenges of ADHD to achieve success are appearing in the media. Here are a few representing a wide range of talent: billionaire Charles Schwab; David Neeleman, founder of JetBlue Airways; Paul Orfalea, founder of Kinko’s; political pundit James Carville; Karina Smirnoff of Dancing with the Stars; Olympic gold medalist Michael Phelps; Olympic decathlon gold medal winner Bruce Jenner; NFL quarterback Terry Bradshaw; baseball’s Pete Rose; golf prodigy Luke Kohl; Grammy-winning singer Justin Timberlake; comedian Jim Carrey; comedian/actor Howie Mandel; and starlet Paris Hilton. Many of their interviews appear in ADDitude Magazine, Parenting, and Attention (published by CHADD).
By scanning these names, we get a sense of the qualities that contribute to success in people with ADHD: their thirst for novelty and adventure, the capacity to channel tremendous energy in pursuing a goal, ability to think outside the box, creativity, disregard of conventional attitudes, belief in their own talents, willingness to take risks, courage, altruism, determination, and commitment to their ideas and values. While these traits are also found in people without ADHD, the point is to recognize that the very qualities that can cause problems in ADHD can also be used in positive ways. For example, rather than struggling to contain and suppress excess energy, direct it toward increased work productivity or sports performance. Think of outlets for creative energy, such as art projects, theater, dance, music, and community service. Finding ways to help yourself and your children engage in positive activities can be the best antidote for self-doubt and low self-esteem.
Like many parents, Jane and Allen have overcome enormous obstacles in diagnosing, treating, and educating their son Brad, who was born in 1969, before ADHD was recognized as a diagnosis. Through their struggle, they pursued every possible avenue to learn more about the disorder, to find knowledgeable professional guidance, and to address their son’s educational and vocational needs. Beyond this, they organized with other consumers to make the information they gathered available to everyone dealing with ADHD.
No crib, no playpen could contain Brad, the perpetual motion child. He could climb out of anything and tended to run continuously around whatever room he occupied. No meal could be completed without dishes on the floor. Terrified that he might climb out a window or up onto the stove, his mother watched him every minute and bolted his door shut when he slept at night—her only chance for peace. Yet she described him as “the sunniest, funniest, sweetest, most upbeat child.”
In the early 1970s, when Jane and Allen took Brad, then 3 years old, to a pediatric neurologist for evaluation of his “mushy language,” neither they nor their health care providers knew much about the “hyperkinetic child,” and the diagnosis of ADHD had not yet been created. The first pediatric neurologist glared at them and made them feel that their child’s problems were their fault. The second pediatric neurologist was kind and supportive, suggesting a trial of a stimulant medication, methylphenidate (Ritalin). The drug turned Brad into an expressionless zombie and had to be stopped. The doctor did not know what else to try and just suggested retesting the child at intervals.
Although Brad seemed to be a little better as he got older, kindergarten was a disaster. Brad was in perpetual motion, unable to focus or follow instructions, requiring constant attention. The school insisted that he enter therapy. A series of therapists ended with a psychiatrist who advised major tranquilizers. The parents refused to tranquilize their son.
They read about special schools that were successfully educating children with ADHD using an environmental approach, creating an atmosphere that contained their behavior and addressed their special needs. A long search led them to the Eagle Hill School where Brad blossomed in a noncritical, supportive, customized, multi-sensory environment. Unfortunately the family could afford the tuition ($36,000/year) for only 2 years. From 9th to 12th grade, Brad attended a highly structured, value-based school with a peer-behavioral approach that stressed personal responsibility and integrity. In addition to ADHD, he was found to have serious problems with cognition (processing information) and decoding (e.g., understanding the meaning of verbal information). Without any medication to help control the ADHD, Brad tried extremely hard to do his best. Jane recalls, “He’d scrunch up his eyes and say over and over, ‘I have to control myself.’”
Learning about ADHD and working with professionals, Jane and Allen provided a consistent, structured, supportive, and loving home environment that brought out Brad’s most endearing qualities. His mother describes their 6-feet 2- inches-tall son as “a gentle giant” because he is very kind and empathic.
Like many students with ADHD who leave home for the first time, Brad lost his bearings in the unstructured life at college. His impulsivity and low self-esteem got him into more and more trouble as he tried to impress the wrong set of friends. Experimentation with drugs led to multiple arrests. Yet, his sunny, outgoing, positive personality convinced judges not to incarcerate him. Eventually, Brad left college to try to settle into a job. Unable to sit still at a desk for even a few minutes, Brad worked as a salesman, but never managed to last a year in any job. His mother encouraged him to try to get a degree in substance abuse counseling, and he began the torture of trying to study for classes.
After hearing Dr. Brown lecture about CAM treatments, including a medicinal herb called Rhodiola rosea (R. rosea see Chapter 3), at an ADHD resource center, Mrs. Allen decided to give Brad a trial of the herb. His response was immediate. Taking 150 mg of Rhodiola rosea in the morning enabled him to focus his mind, stop fidgeting, follow through on tasks, become productive, understand and retain material, and slowly complete his counseling degree with the help of an ADHD coach. His writing, which had previously been unintelligible, improved to the point where he could write clear clinical notes. Eager to succeed, he readily accepted and implemented advice. In his customarily sunny way, Brad is full of gratitude for the help he received and for all that he has finally achieved. In Chapter 3, we provide an update on how Brad is doing now.
Jane and Allen searched for all the knowledge they could find about ADHD to help their son. They joined with other parents to disseminate information so that other families might not have to run the gauntlet of getting services for their children. This led to the formation of a consumer support group: Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), a nonprofit organization founded in 1987 that promotes education, advocacy, and support for individuals with ADHD. Today CHADD represents 20,000 members, mostly families of children and adults with ADHD. About 2,000 members are professionals providing clinical and other services to persons with ADHD. The websites for CHADD and other educational organizations are listed in the Resources section at the end of this chapter.
The need for information and resources to help individuals and families living with ADHD is being recognized by professional and academic groups throughout the country. For example, the Center for Children and Families at the University of Buffalo maintains a website rich in information for individuals as well as for the professionals who work with them. Anyone can visit their website—http://ccf.buffalo.edu—and find detailed descriptions of parent training, classroom interventions, treatment plans, home behavior management plans, daily and weekly reports, and many other practical tools. At the end of this chapter you will find a list of resources to support your efforts.
Sociologists, geneticists, and psychologists wondered about why the traits of ADHD evolved and whether they helped humans adapt and survive. Thom Hartmann, founder of the Hunter School for children with ADHD, coined the phrase, “the Edison gene.” This phrase is shorthand for a presumed set of genes that conveys traits associated with ADHD: enthusiasm, creativity, disorganization, nonlinear thinking, innovativeness, distractibility, hyperfocus, determination, eccentricity, prone to boredom, impulsivity, energetic. These characteristics can be seen to enhance the work of explorers, inventors, discoverers, and leaders in a variety of fields. Hartmann (2003) explains that in hunter-gatherer societies, people with ADHD-like traits would have made terrific hunters because they would scan their environment, react quickly and fearlessly, happily keep moving, and excel in the pursuit of quarry. Unfortunately, the postindustrial structure of our school systems and many work settings does not favor these qualities. Having to sit in a chair for long periods of time studying and memorizing facts can be excruciating for a child whose nature is to move, explore, and notice all the distracting stimuli in the world around him or her.
As noted above, the current standard definition of ADHD used by most health care professions is provided in the DSM-IV-TR (American Psychiatric Association, 2000). This descriptive approach relies upon lists of symptoms or characteristics, rather than underlying causes, to establish the presence of absence of ADHD. In other words, it does not attempt to explain what is different about the brain or what factors might influence the occurrence of ADHD. We briefly review the DSM criteria and some of the current discoveries and theories that may help us develop better treatments. Understanding some of the underlying causes will help you decide whether certain treatments make sense based on how likely they are to correct imbalances associated with ADHD.
Table 1.1 lists the criteria for ADHD based upon three subtypes:
1. Predominantly inattentive
—Six or more symptoms are in the inattention category
—Fewer than six symptoms of hyperactivity/impulsivity
2. Predominantly hyperactive/impulsive
—Six or more symptoms are in the hyperactivity–impulsivity categories
—Fewer than six symptoms of inattention
3. Combined hyperactive/impulsive and inattentive
—Six or more symptoms of inattention and 6 or more symptoms of hyperactivity-impulsivity
For the sake of simplicity, we use ADHD to include all three subtypes. When we are limiting the discussion to only the inattentive form, we call it ADD.
The best way to address this crucial question is to start gathering information from reliable sources. These “sources” include your own behavior—for example, what you are doing right now—as well as reading books by experts, and going for consultations or evaluations from professionals who are experienced in diagnosing and treating ADHD. Although reading will give you valuable information and insights about both the diagnosis and management of ADHD, it is always wise to consult professionals because they will help you put your situation into perspective, objectively evaluate your symptoms, help you overcome any obstacles to treatment, and discuss with you a range of treatment options.
Inattention may appear in any of the following ways:
• Often fails to pay attention to details or makes careless mistakes at school, work, or other activities.
• Often has difficulty sustaining attention on tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow instructions or complete schoolwork, chores, or work. (This is not due to oppositional behavior or inability to understand directions.)
• Often has difficulty organizing tasks and activities
• Often avoids or dislikes tasks that require sustained mental effort (schoolwork)
• Often loses things needed to complete tasks (pencils, toys, school assignments, tools)
• Often is easily distracted by external stimuli
• Often is forgetful in daily activities
Hyperactivity can manifest in the following ways:
• Often squirms or fidgets with hands or feet
• Often leaves seat in classroom or other settings
• Often runs about or climbs excessively. Adolescents and adults may feel restless.
• Often has difficulty playing quietly
• Often is “on the go” as if “driven by a motor”
• Often talks excessively
Impulsivity can appear in the following ways:
• Often blurts out answers before questions have been completed
• Often has difficulty waiting turn
• Often interrupts or intrudes on others (butts into conversations or games)
Q: What are ADHD symptoms?
A: The core symptoms of ADHD are inattention, hyperactivity, and impulsivity. All children have these qualities to some degree. Watch any 3-year-old. What makes children with ADHD different is that they have these traits to a greater degree compared to other children of the same age and that these symptoms cause impairments in two or more settings (i.e., school, work, and/or at home). There must be evidence of significant impairment in social, academic, or occupational functioning. Some symptoms must be evident by 7 years of age. Although ADHD may not be recognized until a child is older, particularly the inattentive type, careful exploration of the history usually reveals some symptoms before the age of 7 years. Furthermore, the symptoms cannot be explained by some other physical or mental disorder, such as anxiety, depression, or schizophrenia (see Table 1.1).
Q: Can I use a symptoms list to diagnose ADHD?
A: As you read this list of symptoms in Table 1.1, you may be wondering whether you or a family member has ADHD and, if so, is it severe enough to warrant treatment. You can use this list to determine whether ADHD is a possibility, but it will not give you a definite diagnosis.
Q: What is meant by “often”?
A: If the behavior or symptom occurs every day in at least two settings (home, school, and/or work), then it is considered “often.”
Q: What is evidence of significant impairment?
A: Significant impairments in school include difficulty learning at a level commensurate with the person’s IQ when that difficulty in learning is due to inattention, inability to focus, disorganization, distractibility, or disruptive classroom behaviors. Social impairments involve difficulty in making or keeping friends or in engaging in age-appropriate activities. These difficulties may be due to aggressive–impulsive behavior, inattention to what others are saying, or problems focusing and following social communications, to note a few possibilities. Examples of work impairments include low productivity due to inattention and disorganization; inability to focus on what is being said by coworkers, supervisors, or clients; and inability to sit at a desk for required periods of time.
Q: I checked off only five symptoms of inattention and three symptoms of hyperactivity/impulsivity. Does that mean that I don’t have ADHD?
A: It sounds like you are concerned about some problems you have with inattention and perhaps a little hyperactivity/impulsivity. Based on your checklist score, we cannot say that you do or do not have the diagnosis of ADHD. However, you have enough difficulties in this area that you could have an attention disorder that does not meet all of the criteria for the full diagnosis of ADHD. If you feel that these symptoms may be interfering with your achievement, happiness, relationships, or fulfillment in life, then you might want to consult a professional to help you decide if you could benefit from the many options available, including coaching, counseling, cognitive therapy, non-drug complementary treatments, or medication.
There are both similarities and differences in assessing ADHD in adults versus children. One of the challenges in evaluating adults for this disorder has been the absence of appropriate diagnostic instruments; most of these tools were primarily designed for assessing children. In an adult, some of the symptoms may be less obvious because the person may have learned how to control or mask the behaviors. For example, by the time a squirmy, restless, overactive child reaches adulthood, he or she may have developed enough self-control to sit still in a chair, rather than running around the room, or he or she may have learned how to burn off excess energy through vigorous exercise. Another common coping mechanism is to pursue physically active jobs and avoid situations requiring long periods of attentive stillness. For these reasons it can be harder to identify the number of symptoms required to qualify for the full ADHD diagnosis. Yet, such individuals may struggle with symptoms that adversely affect their relationships, such as interrupting other people’s conversations or talking too long without awareness of the interest (or disinterest) of others.
Although there are many ADHD scales, there is no single standardized test that can definitely establish, by itself, the ADHD diagnosis. Additional information is always required, and tests must be interpreted in the context of the individual’s history, including social and educational influences. Professional advice is needed for a thorough evaluation, interpretation of test results, and discussion of treatment options. The following components should be included in the diagnostic process (Weisler & Goodman, 2008; Weiss, 2010):
1. Assess core ADHD symptoms: inattention, hyperactivity, and impulsivity.
2. Take developmental history of symptoms, including prior to age 7.
3. Elicit family history of similar behaviors in parents, siblings, and other relatives.
4. Ask about social history of problems in relationships.
5. Elicit educational history of difficulties in academic achievement.
6. Ask about the extent to which symptoms significantly impair functioning at home, school/work, or in relationships.
7. Assess character strengths and positive qualities that may contribute to a better prognosis (future outcome). This information will provide material for building positive self-esteem as well as for career counseling. The Strengths and Difficulties Questionnaire (www.sdqinfo.org) includes assessment of positive qualities.
8. In assessing children, obtain information from parents and teachers. In assessing adults, it is helpful to get information from close relatives who know the person well.
9. Use psychiatric history and assessment to identify comorbid (coexisting) disorders of anxiety, mood, learning disabilities, personality, or substance abuse.
10. The person should undergo a complete physical examination to identify possible medical causes of symptoms, such as head injury, seizures, thyroid disorders, diabetes, vitamin deficiencies, or cardiovascular disease.
Different standardized measures are designed to be completed by a clinician (clinician-administered), a patient, a parent, or a teacher. Scales that are completed by the patient are called self-administered or self-reported. Table 1.2 lists some of the commonly used ADHD assessment tools. Brief tests are used for screening, whereas more detailed tests help to identify more specific areas of impairment. These tests can also be used to evaluate progress over time and in response to treatments.
Table 1.2 Sample of ADHD Rating Scales
Clinician Administered Scales
Conners Adult ADHD Diagnostic Interview (Conners, 1997)
Brown ADD Scale Diagnostic Form
http://www.drthomasebrown.com/assess_tools/index.html
Test of Variables of Attention (TOVA; Greenberg & Kindischi, 1999)
Self-Administered ADHD Scales
WHO Adult Self-Report Scale (ASRS) (World Health Organization)
www.hcp.med.harvard.edu/ncs/ast.php.
Barkley’s Current Symptoms Scale (Berkley & Murphy, 2005)
Weiss Functional Impairment Rating Scale Self-Report (WFIRS-S)
(www.caddra.ca/cms4/pdfs/caddraGuidelines2011WFIRS_S.pdf)
Parent Rating Scales
Conners Parent Rating Scale (CPRS; Conners, 1997)
Weiss Functional Impairment Rating Scale for Parents (WFIRS-P)
www.caddra.ca/cms4/pdfs/caddraGuidelines2011WFIRS_P.pdf)
Teacher Rating Scales
Conners Teacher Rating Scale (CTRS; Conners, 1997)
The World Health Organization maintains a widely used simple screening tool, the Adult ADHD Self-Report Scale—Version 1.1 (ASRS-v1.1) screener. You can check the boxes that best describe how you have felt and behaved over the past 6 months. If you check four or more boxes in the gray area, there may be reason for you to seek further evaluation for ADHD (see Table 1.3 Adler & Weiss, 2004).
The six questions in this table were found to be the most predictive of symptoms consistent with ADHD.
If four or more marks occur in the darkly shaded boxes, then the symptoms are highly consistent with ADHD in adults and further evaluation is warranted. To pursue the evaluation consult your health care provider.
Your doctor or other care provider may review the screener and evaluate the level of impairment associated with each symptom as it occurs in work/school, social, and family settings.
If symptoms are frequent, you will be asked to describe how these problems have affected the ability to work, take care of things at home, or get along with other people such as your spouse/significant other.
Table 1.3 Adult ADHD Self-Report Scale (ASRS-vl.1) Screener
Reprinted with permission from the World Health Organization. The ASRS-v1.1
Screener is available at: www:hcp.med.harvard.edu/ncs/asrs.php.
The next step is to assess the history, the presence of these symptoms or similar symptoms in childhood. Adults who have ADHD need not have been formally diagnosed in childhood. There may be evidence of early-appearing and longstanding problems with attention or self-control. Some significant symptoms should have been present in childhood, but full symptomatology is not necessary.
Dr. Margaret D. Weiss (2010) of the Canadian ADHD Resource Alliance points out that although the DSM-IV helps identify symptoms and diagnostic criteria, it is just as important to evaluate the individual’s difficulties in specific functions within six domains: home, self-concept, learning and school, activities of daily living, social activities, and risky activities. The Weiss scales can also help pinpoint the main problems that continue to affect the person’s life in each of the six domains after medications have been stabilized. This information is useful in choosing non-drug treatments to target the remaining ADHD symptoms. These scales can also be used to evaluate how ADHD continues to affect the person’s life. Table 1.4 reproduces the Weiss Functional Impairment Rating Scale—Self-Report (WFIRS-S) for adults and adolescents; Table 1.5 reproduces the Weiss Functional Impairment Rating Scale—Parent Report (WFIRS-P) for evaluating children.
Visitors to the website of the Canadian ADHD Resource Alliance (see www.caddra.ca) will find a wealth of information on diagnosis, treatment, and resources for consumers and clinicians. The website offers detailed treatment plans as well as copies of assessment scales. A membership fee may be required for access to all documents.
For each item on these scales, a score of 2 or 3 is considered clinically significant. A child or adult is considered to have significant impairment in an area (domain) if at least two items are rated 2 or one item is rated 3. To calculate the total scores, add up all the numbers circled in each domain and divide by the number of items in that domain to get the mean (average) score. Omit any items rated n/a (not applicable). At the end of the test, fill in the mean score for each domain (A–G on the self-report scale; A–F on the parent-report scale). This scale is well validated and available in 14 languages.
The many contributing causes of ADHD are roughly divided into those that are genetic and those that are due to environmental influences. However, in some cases genetic variants affect susceptibility to environmental effects. Conversely, environmental factors can influence the expression of genes. Here you will be introduced to the role of genetics in ADHD symptoms and the influence of major environmental factors including maternal health, nutrition, exposure to neuro-toxic substances, media exposure, and the family milieu.
 | Table 1.4 Weiss Functional Impairment Rating Scale—Self Report (WFIRS-S) |
Circle the number for the rating that best describes how your emotional or behavioural problems have affected each item in the last month.
Although it is well-known that genetics play a role in the inheritance of ADHD, only a few of the specific gene variants have been identified. ADHD is not 100% inheritable. In many families, one child may develop ADHD whereas his or her brothers and sisters do not. However, most people with ADHD have at least one first-degree relative with ADHD. Only 30% of men who had ADHD during childhood will have children with ADHD. Studies of twins suggest that heredity may account for about 75% of the etiology (the assignment of causes) of ADHD (Blum et al., 2008).
The variations that can occur in a single gene are called polymorphisms. Researchers are finding that polymorphisms in some children with ADHD are associated with reduced brain tissue volume in areas involved in attention, the activity of neurotransmitters, and the patterns of electrical activity (Cubillo et al., 2010; Konrad et al., 2010; Monastra, 2008; Wang et al., 2007). Already, studies are finding that some of these variations improve naturally with time, while others respond to specific treatments.
In contrast to genetic effects that stem from the body’s DNA code, environmental effects associated with ADHD include dietary, physical, chemical, and psychological influences from outside the body. This traditional division between genes and environment, however, is becoming less distinct because, as you will see in Chapter 2, scientists are finding that environmental factors can affect the function and expression of genes involved in ADHD.
We know that nutrition affects brain development in infants and children. Researchers are trying to understand why some people with ADHD are sensitive to certain foods whereas others are not, why some people with ADHD have specific micronutrient deficiencies whereas others do not, and how certain nutrients can improve symptoms. These issues are explored in Chapter 2 on scientific developments and Chapter 4 on food issues.
| Table 1.5 Weiss Functional Impairment Rating Scale—Parent Report (WFIRS-P) |
Circle the number for the rating that best describes how your child’s emotional or behavioural problems have affected each item in the last month.
Some studies suggest associations between maternal health during pregnancy and the risk of developing ADHD. We know that a mother’s nutrition affects the rapidly developing brain of her child, and poor oxygenation in utero may also affect brain development. Similarly, toxic substances such as cigarette smoke, alcohol, and legal or illegal drugs can adversely affect neuronal development. Following head injury, some children show behaviors similar to those seen in ADHD. In children, exposure to high levels of toxic metals, such as lead or cadmium (in old plumbing fixtures or paint) or organic pesticides in food, also increases the risk of developing ADHD. A recent study of 1,139 children by the Department of Environmental Health, School of Public Health, Harvard University found that children with higher concentrations of organophosphate pesticides (dialkyl phosphate concentrations, especially dimethyl alkylphosphate (DMAP) in their urine were more likely to be diagnosed as having ADHD. Children with levels higher than the median for the pesticide DMAP metabolite, dimethyl thiophosphate, were twice as likely to have ADHD compared with children whose levels were undetectable. Most of the pesticides found in children come from food. These results support the theory that organophosphate exposure, at levels common among American children, may contribute to ADHD prevalence. The authors indicate that further studies are needed to firmly establish a causal association between pesticides and ADHD (Bouchard, Bellinger, Wright, & Weisskopf, 2010).
We don’t usually think of television or computers as having environmental effects, but research is indicating that they do. Dr. Mary G. Burke, associate professor in child and adolescent psychiatry at the University of California (2010), points out that screen media provide neurologically arousing input to the developing brain. Their adverse effects are mediated by sensory organs. When used wisely, televisions and computers can enhance learning, deliver educational material, and provide social resources. However, excess exposure, particularly to media violence, can adversely affect language development, attention, and behavior. Screen media are the most detrimental during the first 5 years of life. The risk of being diagnosed with ADHD at age 7 increased with every hour of television viewed per day at ages 1 and 3 (Christakis, Zimmerman, DiGiuseppe, & McCarty, 2004). Although the American Academy of Pediatrics recommends no screen media use for children under age 2, in the United State the average baby is exposed to 2 hours daily. While limiting and monitoring television and videogame exposure makes sense for all children, particularly young children, it is even more crucial in those who are vulnerable due to ADHD. Overly stimulating and violent media content can delay development of language and reading skills and exacerbate core ADHD symptoms of inattention, impulsivity, and aggressive behavior. Furthermore, when television substitutes for interaction with family and peers, it can impair development of interpersonal and communication skills.
The home environment can also affect the expression of ADHD symptoms. Homes in which the family is able to provide stability, consistency, calmness, and structure enable the child with ADHD to function at his or her best capacity. Furthermore, the family’s cooperation in creating and maintaining treatment plans is critical for the success of treatment (Bussing & Lall, 2010). Children with ADHD naturally have greater difficulties when there is a lot of conflict or instability in the home. They tend to react to conflict, anger, and uncertainty with anxiety, which further impairs their ability to focus and worsens many of their symptoms. Being susceptible to overstimulation from intense emotions, they may react to anger by becoming even more excited, hyperactive, and impulsive. If children with ADHD are subjected to abuse, they may develop dissociative symptoms that make them even more distractible, unfocused, disorganized, and forgetful.
Most families benefit from professional guidance regarding how to better understand their child’s behavior, set appropriate limits (including effective rewards and punishments), provide consistent love and patient reinforcement, and shepherd their child through the school years toward appropriate, achievable vocational goals. Being able to talk with health care providers, other people with ADHD, and other parents about the struggles and mixed feelings that occur while living with ADHD can help to dispel fears and misinformation, put things in perspective, relieve feelings of guilt or inadequacy, and clear the path for learning new and better ways to handle the situation.
The main differences between medication and non-drug treatments are their mechanisms of action, potential side effects, and additional health benefits. The most widely used and well-known treatments are prescription medications and behavioral therapy. Although behavioral therapies are an important component in ADHD treatment, they are not discussed in detail in this book. Our focus is on new and less familiar approaches such as the use of herbs and nutrients, mind–body practices, neurofeedback, and brain stimulation techniques.
Medication classes commonly used to treat ADHD are stimulants and antidepressants. The three main forms of stimulants are Ritalin (methylphenidate), amphetamines, and alpha-adrenergic stimulating agents. The Ritalin group contains different forms of methylphenidate in commonly used brands: Concerta, Metadate, and Focalin. The amphetamine group includes Dexadrine (dextroamphetamine), Adderall (mixed amphetamine salts), and Vyvanse (lisdexamfetamine). The adrenergic stimulanting agents, clonidine (Catapres) and guanfacine (short-acting Tenex and long-acting Intuniv), reduce the flow of messages from the stress response system that lead to the physical expressions of stress reactions, for example, increased heart rate, shaking, or stomach pain.
The Ritalin group has stronger effects in stimulating the neurotransmitter norepinephrine, and lesser, but still significant, effects on dopamine. In contrast, amphetamines have greater effects on dopamine and lesser, but significant, effects on norepinephrine. The alpha-adrenergic stimulators increase levels of norepinephrine. In Chapter 2 we explain how increasing these key neurotransmitters improves attention, mental focus, and behavior in ADHD.
Although many people are able to take stimulant medications without serious adverse effects, the Ritalin and amphetamine groups can cause overstimulation, difficulty sleeping, agitation, loss of appetite, rapid heart rate, increased blood pressure, and other problems. While they are in the body, stimulant medications can have powerful effects on reducing ADHD symptoms, but they have the disadvantage of wearing off. It is necessary to allow them to wear off at night to enable sleep, but when the wearing off occurs too abruptly, the result can be a crash into irritability, bad mood, tantrums, and insomnia.
Several classes of antidepressants can be beneficial for ADHD, particularly the tricyclics (imipramine, nortriptyline, and desipramine) and bupropion (Wellbutrin), an atypical antidepressant that is the only one in its class. Another class of antidepressants are the monoamine oxidase inhibitors (MAOIs) including selegiline (Deprenyl), phenelzine (Nardil), and tranylcypromine (Parnate). Tricyclics act mainly by increasing levels of norepinephrine and sometimes serotonin. Unfortunately, they have many side effects, such as dry mouth, constipation, and heart palpitations. Nevertheless, they can be useful, often in low doses. A newer drug, Strattera (atomoxetine), was designed to increase norephinephrine, but it is also prone to cause side effects including agitation, manic reactions, and difficulty urinating.
Bupropion (Wellbutrin) is not as effective as Ritalin, but it can be a useful alternative way to affect norepinephrine and dopamine. Generally well tolerated, bupropion can cause insomnia, rash, and other side effects. Until recently, MAOIs were avoided because they could trigger serious adverse reactions if the patient ate the wrong foods or took certain medications. However, one of the MAOIs, Emsam (selegiline), now available in a skin patch, does not require a special diet when used in low doses. However, the patient must avoid certain over-the-counter and prescription medications to use it safely.
Complementary and alternative treatments have a vast array of mechanisms of action that can treat specific ADHD symptoms by improving overall brain function, cellular metabolism and repair, energy production, autonomic nervous system activity, and stress response system balance. Mind–body practices help by calming down the over-reactive stress response system and by improving mental focus, body awareness, and emotional regulation. Overactivity of the stress response system burns a lot of energy, generates free radicals that damage tissues, and increases inflammation. Mild brain stimulation techniques and neurofeedback (a form of biofeedback using signals from the brain’s electrical activity as feedback) can correct brain-wave imbalances, thereby improving brain-wave patterns and facilitating calmer mental states and better communication among the different parts of the brain. Over time, mind–body and brain stimulation techniques can potentially induce brain development through neuroplasticity. Furthermore, because many CAM treatments improve cellular health and reduce excess wear and tear on our systems, they provide health benefits such as slowing disease progression and improving cardiovascular and immune function. Although there are possible side effects with any intervention, in general, the adverse reactions to properly used CAM treatments are far fewer and less severe than those that can occur with prescription medications.
Although prescription medications and behavioral therapy can be very helpful, they do not cure many of the problems of ADHD, as was demonstrated by the Multimodal Treatment Study of Children with ADHD (MTA). This large randomized study by the National Institute of Mental Health (NIMH) evaluated the effects of stimulant medications and behavioral therapies on 579 children with ADHD between the ages of 7 and 10 (Swanson et al., 2008a, 2008b). In a nutshell, this is what they did and what they found after about two years: All of the students with ADHD were divided into four groups. One group received routine community care from their local doctors. The other three groups were treated by the research staff: the second group got stimulant medication; the third group was given intensive behavioral treatment; and the fourth group received combined behavioral and medication treatments. How did the groups compare after 2 years of treatment?
• Children receiving both medication and behavioral treatments improved the most.
• Stimulant medications brought greater improvements in attention, hyperactivity, and impulsivity compared to behavioral treatments.
• Stimulant medications were no better than behavioral treatments for oppositional behavior, peer relations, and academic achievement.
How did the children, who were treated between ages 7 and 10, do when they reached adolescence? Eight years after the first testing, the outcomes for 436 of the original group of children with ADHD were compared with those of 261 children of the same ages who did not have ADHD (Molina et al., 2009)
• The children who responded well to treatment during the first 3 years continued to do better in adolescence.
• Despite initial symptom improvement during the first 3 years of treatment (and maintenance of treatment in most cases), children with the combined-type of ADHD (inattention plus hyperactivity/impulsivity) showed significant impairment in adolescence and performed worse on 91% of measures of academic, behavioral, and social functioning than their peers who did not have ADHD (Molina et al., 2009).
Would children treated in a regular community do as well as children treated in a research study? Probably not. Analysts of this study point out that the success of the medications depended on closer monitoring and dosage adjustments than most children receive in community treatment. Many doctors providing treatment in community settings do not optimize the medication regimens and therefore do not get as much improvement in the ADHD symptoms. Similarly, the magnitude of the benefits of the behavioral interventions used in the study would be unlikely to occur in most community treatment settings (Murray et al., 2008). Even though better treatments have been developed, it can take years for new information to be absorbed by the medical community. What does this study mean and what can we do about it?
• Combining both medication and behavioral treatments is likely to be more effective than either alone.
• It is best not to rely only on medication and behavior treatments. Although they are beneficial, they fall short of solving many of the long-term problems of ADHD. Additional innovative treatments are needed. That’s what this book is all about.
• You or your child may not be getting the most out of your current treatments because your doctor may not have the training to determine the type of medication and the dose that would work best in your case. If you are concerned about this, it might be worth getting a consultation with a specialist who could help fine-tune your medication regimen.
• The same may be true for behavioral treatments. Health care providers in community settings do not have all the resources of a research facility. Although they are doing their best within the constraints of their time, if you feel that more could be achieved for you or your child, then you could request a consultation and take time to look into new and additional approaches that might lead to better results.
Q: If non-drug treatments are so good, why don’t more doctors use them?
A: Only a minority of doctors knows about the benefits of complementary treatments. At the time these doctors went to medical school, there were no courses in CAM. Although many younger doctors are interested in innovative, non-drug treatments, only a few medical schools have added CAM to their curriculum. Consumers can play a major role in bringing this information to the attention of their health care professionals.
On the positive side, in the past 30 years since ADHD has been accepted as a diagnosis, a great deal has been learned and numerous treatments have been developed. Studies of behavioral and family therapy are improving treatment outcomes, and studies of genetic variants may someday enable us to predict who is more likely to respond to particular treatments (see Chapter 2). Research using brain-imaging techniques is increasing our understanding of the biological basis of ADHD. The possibility that the brain of a child or adult with ADHD is different from the brain of other children or other adults can be frightening. No one wants to feel that something is “wrong” with their brain or the brain of their child. Yet, if we are to understand the underlying causes and possible cures for ADHD, researchers must intently scrutinize the brain structures that mediate our mental and emotional responses to daily activities, events, and interactions. More and more sophisticated brain-imaging studies are focusing on the neuroanatomical and neurophysiological variations found in people with ADHD.
Modern research is showing us that the brain is capable of changing, growing, and healing. Plasticity is the term used to describe the ability of cells to grow and develop new neural connections that can change the way the brain functions. Just as physical exercise can enlarge the size and efficiency of muscles, so, too, areas of the brain that may be underdeveloped can be strengthened and even enlarged. Although discoveries that specific areas of the brain may be thinner or less developed in people with ADHD may be disturbing, remember that this area of research is also finding ways to stimulate and improve functioning where it will make the greatest difference. Rather than fear such discoveries, we can take this information and use it to fuel hope, future research, and our determination to help ourselves and our children find even better solutions to ADHD. Many of the treatments discussed in this book are aimed at increasing the brain’s plasticity and growth.
For those interested in learning the basic scientific explanations for understanding and treating ADHD, we provide essential concepts in Chapter 2. We encourage you to read Chapter 2 because it will provide you with the vocabulary and foundation to understand the symptoms and treatments that are available now and that will become available in the future. You will need this knowledge to make good decisions about your health and your family’s health. In Chapters 3 through 7, you will learn about innovative treatments using herbs, brain boosters, dietary changes, vitamins, nutrients, supplements, mind–body practices, and brain stimulation techniques to help relieve many of the symptoms of ADHD so that you can improve relationships with the people you love and pursue your personal goals in life, whatever they may be. This is such a rapidly changing field that by the time our book is published, there will be new discoveries for you to learn about. We want to prepare you to keep seeking new information, to understand and evaluate what you are hearing and reading, and to be able to make the most of the many new treatment approaches as they emerge.
In addition, many people with ADHD have discovered their own strategies for overcoming the challenges they face due to distractibility, disorganization, forgetfulness, inability to complete tasks, social anxiety, relationship issues, hyperactivity, and impulsive behaviors. They are sharing their solutions through websites such as ADDitude. com, organizations such as CHADD, and publications including blogs, magazines, and books. For example, bridging the doctor–patient gap, Dr. Ed Hallowell highlights the positive aspects of ADHD in Driven to Distraction (Hallowell & Ratey, 1995) and Delivered from Distraction (Hallowell & Ratey, 2006). Writing about his own struggles with ADHD, he demonstrates that people with this condition have a great deal to contribute to their families and their work, but that they also need understanding and patience from those who are close to them. Dr. Hallowell shows how a sense of humor, honesty, nondefensiveness, and determination enable him and many of his patients to achieve joyful, fulfilling lives—which is what we hope for all our readers.
In this last section of the chapter we provide various sources of information and support for assessing, treating, and living with ADHD.
Attention Deficit Disorder Association (ADDA): www.add.org.
Provides information and networking to help adults with ADHD. Active in raising awareness, advocacy, outreach and education.
Canadian ADHD Resource Alliance: www.caddra.ca.
Information on diagnosis, treatment, and resources for consumers and clinicians, detailed treatment plans, assessment scales.
Center for Children and Families at the University of Buffalo: www.ccf.buffalo.edu.
Information on diagnosis, treatment, and resources for consumers and clinicians, and detailed treatment plans.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD): www.chadd.org (800.233.4050).
Provides education, advocacy, and support for children and adults with ADHD.
Hallowell, E. M., & Ratey, J. J. (2006). Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder. New York: Ballantine Books.
Provides practical advice and lists of additional resources, including state by state. Empowers people with ADHD to leave negative thinking behind and provides many creative ways to move forward.
Hallowell, E. M., & Ratey, J. J. (2010). Answers to Distraction: New York: Ballantine Books.
Provides extremely helpful practical advice for many aspects of life. Helps people with ADHD understand and deal more effectively with the challenges they face.
ADDitude: www.additudemag.com.
This excellent newsletter covers many topics relevant to home, school, work, parenting, and relationships.
The ADHD Report: www.guildford.com.
Provides expert coverage of current developments.