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 Focusing
The Mind
Interest rises in non-drug therapies for attention deficit in
children.
by Benedict Carey, L.A. Times, September 15, 2003
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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
about 50% 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."
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