Alternative Treatments for ADHD Katherine Kiker, M.S.

Elimination Diets “Feingold hypothesis” “Feingold hypothesis” Children are sensitive to dietary salicylates and artificially added colors, flavors, and preservatives Children are sensitive to dietary salicylates and artificially added colors, flavors, and preservatives Learning and behavior problems (including ADHD) can be reduced or eliminated by removing these substances Learning and behavior problems (including ADHD) can be reduced or eliminated by removing these substances

Elimination Diets At least 8 controlled studies have demonstrated significant improvement (w/elimination diet) compared to a placebo condition, or deterioration after introducing offending substances At least 8 controlled studies have demonstrated significant improvement (w/elimination diet) compared to a placebo condition, or deterioration after introducing offending substances Typical elimination diet: lamb, chicken, potatoes, rice, apple, banana, cabbage, cauliflower, broccoli, brussel sprouts, cucumber, celery, carrots, salt, pepper, calcium, and vitamins Typical elimination diet: lamb, chicken, potatoes, rice, apple, banana, cabbage, cauliflower, broccoli, brussel sprouts, cucumber, celery, carrots, salt, pepper, calcium, and vitamins

Elimination Diets Although some people seem to respond well, more research is needed to determine who are diet responders Although some people seem to respond well, more research is needed to determine who are diet responders What proportion are responders from the whole ADHD population? What proportion are responders from the whole ADHD population?

Elimination of Sugar & Candy Good news- No Effects!!! Good news- No Effects!!! Controlled 3-week trial of a sugar-restricted diet (Wolraich et al., 1994) Controlled 3-week trial of a sugar-restricted diet (Wolraich et al., 1994) Cross-sectional studies: ADHD children don’t consume more sugar than Non-ADHD children (Kruesi et al., 1987) Cross-sectional studies: ADHD children don’t consume more sugar than Non-ADHD children (Kruesi et al., 1987) Not a widely applicable tx for ADHD Not a widely applicable tx for ADHD But, may help for those children who are responders to “elimination diet” But, may help for those children who are responders to “elimination diet”

Discussion: Modifying Diets to Improve ADHD Symptomatology??

Nutritional Supplements Amino Acid Supplementation Amino Acid Supplementation Reportedly low levels of amino acids in ADHD Reportedly low levels of amino acids in ADHD Short-term benefit for tryptophan, tyrosine, or phenyalanine Short-term benefit for tryptophan, tyrosine, or phenyalanine However, no benefit beyond 2-3 months, as tolerance develops However, no benefit beyond 2-3 months, as tolerance develops Essential Fatty Acid Supplementation Essential Fatty Acid Supplementation Lower levels in ADHD kids Lower levels in ADHD kids Further control studies needed Further control studies needed

Nutritional Supplements Glyconutritional Supplements Glyconutritional Supplements In open trial (n=17) with these supplements, parents reported reductions in inattention, hyperactivity-impulsivity, and oppositional behavior In open trial (n=17) with these supplements, parents reported reductions in inattention, hyperactivity-impulsivity, and oppositional behavior Placebo-controlled trials needed Placebo-controlled trials needed Vitamin Supplementation Vitamin Supplementation Megadose: no effects, risk of toxicity Megadose: no effects, risk of toxicity Iron Supplementation Iron Supplementation Open 30-day trial with 17 non-anemic ADHD boys, improvement in parents Conners’ scores (Sever et al., 1997) Open 30-day trial with 17 non-anemic ADHD boys, improvement in parents Conners’ scores (Sever et al., 1997) Zinc supplementation Zinc supplementation Little research Little research Magnesium Supplementation Magnesium Supplementation 50 kids with ADHD and magnesium deficiency; 6 months; significant decrease in parent and teacher Conners scores 50 kids with ADHD and magnesium deficiency; 6 months; significant decrease in parent and teacher Conners scores

Chinese Herbals Chinese Herbals Chinese herbal cocktail compared to methylphenidate Chinese herbal cocktail compared to methylphenidate Significant improvement rates comparable to stimulate meds, but more improvement on IQ scores and fewer side effects Significant improvement rates comparable to stimulate meds, but more improvement on IQ scores and fewer side effects Need placebo-controlled, double-blind studies Need placebo-controlled, double-blind studies Acupuncture Acupuncture Little data on its efficacy Little data on its efficacy Loo (1998) found decreases on parent and teacher Conners Loo (1998) found decreases on parent and teacher Conners Noted that kids with most severe ADHD could not comply with tx Noted that kids with most severe ADHD could not comply with tx

Meditation Mental training that can regulate attention and brain training? Mental training that can regulate attention and brain training? Research in non-clinical samples has shown improvements on attentional blink tests Research in non-clinical samples has shown improvements on attentional blink tests Rationale for using mindfulness meditation with ADHD: can impact symptoms of inattention and impulsivity, associated neurocognitive deficits of inhibition, and help with stress, anxiety, and depression Rationale for using mindfulness meditation with ADHD: can impact symptoms of inattention and impulsivity, associated neurocognitive deficits of inhibition, and help with stress, anxiety, and depression

Mindful Meditation 3 steps: bringing attention to an “attentional anchor” (usually a sensory input such as a breath Noting that distraction occurs and letting go of distraction Refocusing or reorienting attention back to the “attentional anchor” Pilot Study (Zylowska et al., 2007) 8 week mindful meditation group w/ adults & adolescents Pre–post improvements in self-reported ADHD symptoms and test performance on tasks measuring attention and cognitive inhibition Next steps: controlled clinical study

“Neurotherapy” EEG Feedback, Neuro feedback Basis: ADHD kids produce greater EEG slow wave (theta) activity, and less beta activity compared to normal controls Basis: ADHD kids produce greater EEG slow wave (theta) activity, and less beta activity compared to normal controls Neurotherapy: teach ppl to normalize their brainwave responses to stimuli Neurotherapy: teach ppl to normalize their brainwave responses to stimuli EEG responses to stimuli on a computer are analyzed, then feedback is provided (visual displays, auditory tones) to show how well they are doing EEG responses to stimuli on a computer are analyzed, then feedback is provided (visual displays, auditory tones) to show how well they are doing “good candidates”: stimulant non-responders, parents afraid of long-term affects on stimulant meds “good candidates”: stimulant non-responders, parents afraid of long-term affects on stimulant meds Need assessment: neurometric assessment with computer analysis of a minimum of 19 active scalp electrode sites necessary to confirm or disconfirm greater theta and less beta activity to key attentional tasks Need assessment: neurometric assessment with computer analysis of a minimum of 19 active scalp electrode sites necessary to confirm or disconfirm greater theta and less beta activity to key attentional tasks

New technology: video games!! New technology: video games!! Game becomes more difficult as brain waves of ADHD child show that attention is waning Game becomes more difficult as brain waves of ADHD child show that attention is waning Child is “rewarded” for decreasing time spent in slow wave activity, and increasing time spent in fast activity required for focused attention and concentration on tasks Child is “rewarded” for decreasing time spent in slow wave activity, and increasing time spent in fast activity required for focused attention and concentration on tasks Does it work? Does it work? Barkley 1995, CHADD newsletter: "there is not enough evidence from well controlled scientific studies to support the effectiveness of EEG biofeedback for AD/HD children" Barkley 1995, CHADD newsletter: "there is not enough evidence from well controlled scientific studies to support the effectiveness of EEG biofeedback for AD/HD children"

However: However: Studies using different control groups (waitlists, stimulant meds, cognitive therapy) have demonstrated that neurofeedback reduces inattention, impulsivity, task performance variability, and hyperactivity (Rossiter, 1998) Studies using different control groups (waitlists, stimulant meds, cognitive therapy) have demonstrated that neurofeedback reduces inattention, impulsivity, task performance variability, and hyperactivity (Rossiter, 1998) Outcome studies with samples as large as 530 show reductions in ADHD symptoms Outcome studies with samples as large as 530 show reductions in ADHD symptoms Studies used objective test data (CPT, IQ tests, TOVA) + behavior rating scales Studies used objective test data (CPT, IQ tests, TOVA) + behavior rating scales Limitations: Limitations: Time-consuming (need 6-8 months, up to 80 sessions) Time-consuming (need 6-8 months, up to 80 sessions) Need to identify who works better for this treatment Need to identify who works better for this treatment Must have assessment: some practitioners don’t use the neurometric assessment Must have assessment: some practitioners don’t use the neurometric assessment

Instant Alert Hypnosis! Barabasz & Barabasz: “intended to enhance vigilance performance for either focused attention or optimal situational awareness depending on the specific hypnotic instructions given” Barabasz & Barabasz: “intended to enhance vigilance performance for either focused attention or optimal situational awareness depending on the specific hypnotic instructions given” experimentally controlled studies show that Instant Alert Hypnosis can increase frontal EEG beta activity independent of neurofeedback experimentally controlled studies show that Instant Alert Hypnosis can increase frontal EEG beta activity independent of neurofeedback procedure procedure patient instructed to roll eyes up, as if trying to look at forehead patient instructed to roll eyes up, as if trying to look at forehead Instructed to look at psychologist’s thumb as thumb is slowly moved from nose to forehead Instructed to look at psychologist’s thumb as thumb is slowly moved from nose to forehead instructions are then given to take notice of “breathing, relaxation, calm confidence and special calm alertness” instructions are then given to take notice of “breathing, relaxation, calm confidence and special calm alertness” Once clinician observes subjective signs of hypnosis, patient given instructions: "in this special state of alertness you will be able to focus your attention anyway you like, you can concentrate as completely as your desire.” Once clinician observes subjective signs of hypnosis, patient given instructions: "in this special state of alertness you will be able to focus your attention anyway you like, you can concentrate as completely as your desire.” Then, patient told to let their eyes roll down and enjoy state of alertness Then, patient told to let their eyes roll down and enjoy state of alertness Finally, specific attentional task is done Finally, specific attentional task is done

Efficacy? Efficacy? Instant alert hypnosis w/neurofeedback: significantly better than neurofeedback alone Instant alert hypnosis w/neurofeedback: significantly better than neurofeedback alone Positive and substantial clinical changes in average of 23 sessions (3-14 weeks of treatment for subjects) Positive and substantial clinical changes in average of 23 sessions (3-14 weeks of treatment for subjects) Decreases in inattentiveness, hyperactivity, impulsivity Decreases in inattentiveness, hyperactivity, impulsivity

Other treatments… for which I could find no information! Mirror feedback Mirror feedback Antifungal treatments Antifungal treatments

Discussion How would you respond to a parent who mentioned wanting to try one of these alternative treatments? How would you respond to a parent who mentioned wanting to try one of these alternative treatments?

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