ADHD treatments

      • Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder in which genetic/developmental and environmental factors interact very early in life resulting in difficulties with attention and executive inhibition (e.g., impulse control). ADHD can be further sub-classified according to whether symptoms of inattention, hyperactivity/impulsivity, or a combination of both predominate. Often the term Attention-Deficit Disorder (ADD) is applied when symptoms of inattention predominate and when there are few symptoms of hyperactivity/impulsivity. Adult ADD often refers to this type although subtle “adult-type” symptoms of hyperactivity/impulsivity (e.g., restlessness and frequent job changes) are often present.
      • Acquired brain injury (e.g., traumatic brain injury) very often can cause problems with attention.
      • Progressive diseases (e.g., Alzheimer’s, multiple sclerosis) can also cause attention symptoms.
      • Mood disorders (e.g., depressive and bipolar disorders), anxiety disorders, and other mental disorders can interfere significantly with normal attention.
      • Numerous other medical conditions can affect attention including chronic stress, insomnia or insufficient sleep, chronic pain, and numerous diseases that can affect metabolism and energy levels (e.g., hypothyroidism).
      • Drugs, both medications and illegal drugs of abuse, can significantly impair attention. As examples, alcohol (even in amounts under the DUI levels) interferes with attention; and even low doses of minor tranquilizers (e.g., Xanax) have been found to impair driving and divided attention.
      • Fortunately, much information about disorders of attention can be found on the Internet and in libraries; and there are numerous treatments including several that are considered alternative and holistic. The Brain Therapy Center also provides free information, treatment, current research information, and tips.

Typical inattention symptoms of ADHD include:

      • Failing to pay attention to details and making frequent careless mistakes
      • Difficulty sustaining attention
      • Difficulty listening when spoken to
      • Difficulty in following through on instructions and failing to complete work
      • Difficulty organizing tasks and activities
      • Avoiding, disliking, or being reluctant to engage in activities that require
      •   sustained attention
      • Losing items frequently
      • Being easily distracted
      • Being forgetful

Typical hyperactivity/impulsivity symptoms of ADHD include:

      • Fidgeting or squirming in seat
      • Leaving seat when remaining seated is expected
      • Running about or climbing inappropriately
      • Having difficulty engaging quietly in activities
      • Being “on the go” as if “driven by a motor”
      • Talking excessively
      • Blurting out answers before questions are completed
      • Having difficulty awaiting one’s turn
      • Interrupting or intruding on others

Various co-morbid conditions exist with ADHD including mood and anxiety disorders, specific learning disabilities, impulse control disorders, and substance abuse/dependence disorders. ADHD persists into adulthood in approximately 50 % of affected individuals. Many adults with ADHD have grown up not knowing they have ADHD and, therefore, have developed maladaptive “coping” skills or ineffective ways of functioning. ADHD in adults is associated with a five-fold risk of substance abuse, a twenty-five-fold increase in institutionalization for delinquency, and a nine-fold increase in incarceration.

Regardless of cause or exact diagnosis, attention impairments can significantly impair other cognitive functions such as memory and executive functions. If a person is not paying optimal attention, the memory storage system cannot work optimally. This is so important that attention is usually one of the very first impairments to receive targeted treatment in neuropsychological rehabilitation programs for patients with acquired brain injury.

What tests are available for diagnosing attention problems such as ADHD?

Currently there are no simple laboratory tests, but there are no such tests for any mental illness. Instead, what is required for accurate diagnosis is a competent, thorough psychological or neuropsychological assessment. At the minimum, this includes a thorough interview of the patient and of the parents or significant others (if the child is the patient), and an ADHD behavioral rating scale. Optimally, it also includes a broad screening instrument for assessing the presence of other mental disorders (e.g., BASC, MMPI-A, MMPI-2, MCMI-III) and a continuous performance test (IVA Continuous Performance Test, TOVA). Depending on the results of the above, still other tests may be performed to gain an even more comprehensive understanding of the various factors involved in the patient’s difficulties. Sometimes the assessment may indicate that the patient does not actually suffer from an attention disorder but rather suffers from another disorder or from an additional co-morbid disorder. At the Brain Therapy Center, each report offers insights and very specific recommendations that can be implemented at the Center or elsewhere. There is no substitute for careful assessment because ADHD can be over-diagnosed or under-diagnosed.

What treatments are available?

Numerous medications are available for patients with ADHD including:

      • Psychostimulants such as methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine), and racemic amphetamine (Adderall)
      • Antidepressants such as atomoxetine (Strattera), bupropion (Welbutrin), and fluoxetine (Prozac)
      • Various alternative drugs including carbamazepine (Tegretol), clonidine (Catapres), and guanfacine (Tenex)

Numerous studies have demonstrated the general efficacy of these medications for improving attention and impulse control for ADHD patients. This usually results in better performance at school and at home. However, approximately 25 % of children and adolescents do not respond to these medications, and another 25 % have ADR’s (adverse drug reactions) that are so severe that medications must be discontinued. Sometimes switching from one medication to another medication will allow a therapeutic effect. There is some abuse potential (at least of the psychostimulants), but this usually occurs only when an individual “snorts” or takes the drug in excessive doses. Unfortunately the long-term effects of most of these medications is not known.

Behavioral therapy is the systematic application of scientific principles of learning theory to change behavior. By reinforcing desired and appropriate behaviors and punishing maladaptive behavioral patterns, some of the most disabling and disruptive behaviors of ADHD can be ameliorated. Behavioral therapy has been found effective, but generally this is less effective than properly-managed medication for the core symptoms of ADHD. However, at the Brain Therapy Center, behavioral therapy is usually offered as part of an overall plan that usually includes education of the parents, medication, and/or neurofeedback. When used in this fashion, such treatment can be very effective in helping the patient and her/his family to cope with ADHD.

Also effective is behavioral management in conjunction with education of the parents (and sometimes teachers) in developing a behavior modification plan with environmental accommodations. Central to this approach is educating everyone involved about ADHD. “Coaching” is a related technique. It involves the use of ADHD coaches (either professionals or peers) who can help provide structure, reinforcement, and encouragement for the patient.

EEG biofeedback (neurofeedback) is a cutting-edge technology that appears to be more holistic and is not reliant on medications. EEG biofeedback provides information to the client about his/her own nervous system so that she/he can self-regulate more effectively. Efficacy studies continue to be published with improved methodological designs, and many well-educated and well-trained clinicians have found this modality to be an effective adjunct to the multi-disciplinary treatment of patients with deficits in attention and other cognitive functions.

What diagnostic/treatment modalities are offered at the Brain Therapy Center?

We specialize in psychological assessmentneuropsychological assessmentindividual behavioral therapyneurofeedbackneuropsychological rehabilitationpsychotherapy for adults with ADHD, and education of the parents of children/adolescents with ADHD. We also work with virtually any patient with an attention problem, whatever the etiology. Each patient is offered an individually-tailored treatment plan with specific modalities based on the needs of that patient.

We at the Brain Therapy Center also have the requisite knowledge to allow us to have a close working relationship with physicians who may be prescribing antidepressant medications. (Dr. Harold Burke, Director of the Brain Therapy Center, has earned an M.S. and a Ph.D., has completed two years of basic medical sciences, and is currently enrolled in a post-doctoral Master of Science program in Clinical Psychopharmacology.)

Some Helpful Hints

      • Seek help from a mental health professional if you or a loved one is suffering from the above symptoms. Please, do not procrastinate in seeking such help. You may believe that ADHD is simply the “diagnosis of the decade” or a fad. However, do you really want to risk your child’s future without really knowing if she/he really has it or not? Possibly you may believe that your child may simply “outgrow” these symptoms. However, 40% – 60% of children with ADHD will not “outgrow” it and will continue to suffer from symptoms throughout their lives. Furthermore, even if your child eventually is one of the fortunate ones, the damage that will likely occur until that time may be significant. The academic difficulties alone justify your seeking help if at all possible. Similarly, if you suspect that you may have ADHD that may not have been diagnosed and treated, you owe it to yourself to investigate this with the assistance of a mental health professional. It is not too late for treatment just because you are an adult. Adults can also benefit from the above treatments. Work can be more productive and less stressful, marital and family relationships can improve, and life can be less chaotic and effortful.

There are several reasons why it is particularly important to seek the help of a mental health professional in the case of attention-deficit problems. First, diagnosing these disorders correctly can be difficult. Many of the symptoms overlap with other disorders, and reaching the correct diagnosis often requires a thorough and sophisticated interview and at least some limited neuropsychological testing. For example, mood disorders (i.e., depressive or bipolar disorders), anxiety, or family difficulties can affect one’s ability to concentrate. Second, these disorders may be life-long. You do not want to get the wrong diagnosis especially if you or your child may be placed on medication(s) for years. One example of such a mental health professional would be a licensed clinical psychologist with extensive education and training in diagnosing and treating attention-deficit disorders. Another important example would be a psychiatrist who would be able to evaluate the appropriateness of psychotropic medications. These medications can make a tremendous difference in a patient’s life. However, they can have significant side effects. Your primary care physician or pediatrician is certainly licensed to prescribe medications that may help treat these symptoms. However, psychiatrists have had much more training and experience in prescribing such medications and in differentiating attention-deficit disorders from other disorder.

 

      • Structure and consistency are very important for individuals with attention problems, especially ADHD. This applies to individuals of all ages. As mentioned above, ADHD impairs executive functions involved in planning, organization, and the ability to deal with novel situations (i.e., cognitive flexibility). Therefore, anything you can do to decrease such demands will help the affected individual. This does not mean that the individual should not be given responsibilities and be expected to meet standards. It just means that additional help and accommodations may need to be provided to allow the individual to realize her/his potential and to demonstrate what he/she knows.

 

      • Creating an environment which reflects structure and consistency offers the optimal environment for the individual affected by attention-deficit problems. One of the best ways to help those suffering from ADHD is to surround them with an environment which has very few distractions. The affected person should be allowed to take frequent breaks because she/he may have difficulty sustaining attention and concentration for long periods of time. Whenever feasible, the ADHD person should be allowed extra time to complete assignments because information processing speed is often slow in these individuals.

 

      • Children and adolescents with ADHD may require help in maintaining their motivation and consistency of performance. Adopting a formal reward/punishment system may be very helpful. Rewarding desirable behavior and effort should be the primary goal while appropriate punishment should be the secondary goal. Very importantly, both rewards and punishments should be consistent, should be delivered as close to the given targeted behavior as possible, and should be clearly understood by the individual as relating to a specific behavior. Avoid yelling and repeated speeches (e.g., “I’ve told you a thousand times to…”). Knowing the rules is not the problem. It is the application of those rules in controlling one’s own behavior at any given moment that is the problem. This is where reward/punishment comes in. A clinical psychologist would be particularly helpful in assisting you in creating or modifying such a contingency management (behavior modification) system.

 

      • Due to restlessness and the need for self-stimulation, ADHD individuals often need to move about and to be physically active. This is particularly critical in the classroom and can be allowed if the teacher is not too rigid and is creative in applying necessary classroom rules. Sports can be quite good in this regard and can improve self-esteem which is often seriously impaired in these individuals.

 

      • Consider music lessons. Learning an instrument can be excellent for the stimulation and self-esteem noted above. In fact, music may become the most rewarding and positive activity in the individual’s life especially if academic grades have been suffering. In addition, music requires perseverance, discipline, and concentration. It also “teaches” the individual that many of the most enjoyable and self-fulfilling things in life take time and are not achieved in an instant. This is especially true of classical music. In addition, classical music can reduce stress and can help dissipate frustrations. The only caution here is that an untreated individual with an attention deficit may have too much difficulty with the required practice. Frequent short practice sessions would be particularly important in this case. However, the obvious answer is to first get professional treatment and then start music lessons when the symptoms have sufficiently decreased. Individuals with an attention deficit can learn musical instruments, and the very act of practicing may improve their cognitive and attentional systems.

 

      • Decrease your stress levels as much as possible. This applies whether you are the ADHD patient or your child is. Stress may exacerbate ADHD symptoms and may decrease your ability as a parent to cope with an ADHD child. Psychotherapybiofeedbackexercise (e.g., aerobic, yoga, Tai Chi) and meditation/prayer have been shown to be effective in decreasing stress.

 

      • Try to practice good, healthy sleep hygiene. This applies to you or your loved one with an attention-deficit problem. As examples of good sleep hygiene, get sufficient amounts of sleep, keep a regular sleep schedule, avoid stimulants (e.g., coffee, tea, chocolate) late in the day, exercise regularly, and avoid activities in the bedroom that may interfere with sleep (e.g., making business contacts on the telephone, working on your laptop in bed). If you are taking a psychostimulant for ADHD, you may experience insomnia as a side effect. You should report this to your doctor.

 

    • People with ADHD need to be sure to avoid the use of illegal drugs and alcohol. If you are the parent/guardian of an ADHD child, be sure to monitor illegal drug use by your child very closely. Illegal drug use among children and adolescents is high enough, but among ADHD individuals it is even higher.

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