The mystery of AD/HD, its causes, and alternative treatments.

Attention-deficit/hyperactivity disorder (AD/HD) is currently defined as a neurological disorder (brain disorder) that affects both children and adults. It is characterized by symptoms of inattention, impulsivity, and hyperactivity. Conservative estimates indicate that AD/HD affects between three to seven percent of school age children, and between two to five percent of adults. The ratio of AD/HD boys to girls treated in clinical settings ranges from 4:1 to 9:1. Girls are often overlooked as they do not frequently display hyperactivity or behavioral problems. Girls are 2.5 times more likely to be diagnosed with a learning disability, more than sixteen times more likely to have repeated a grade in school, and almost ten times as likely to have been placed in a special class at school (Biederman, J. et al., 1999).

Most estimates indicate the United States has less than fifty percent of the AD/HD population in the developed world. Yet, the US is the world leader in AD/HD drug sales at 97 percent. A North Carolina study of Medicaid recipients found that eighteen percent of school-aged males were treated with psychostimulants between 1992 and 1998. Conversely, Europe, which does not readily accept AD/HD as a true disorder, labels only one percent of its child population as 'hyperkinetic.'

The mystery of AD/HD begins because the label, attention-deficit/hyperactivity disorder, is a misnomer of sorts. People with the disorder do not have a deficit of attention, but they do have diffused attention; attention that is fleeting and can be sustained only for short periods before moving to another stimulus. AD/HD is an umbrella category that frequently engenders controversy. This may be attributable to the fact that everyone periodically exhibits the characteristics used to diagnose AD/HD. These may include general problems with attention such as frequent distractibility, difficulty being organized or keeping track of things, making careless mistakes, and failing to complete tasks, etc. Common characteristics of hyperactivity can include excessive talking, constant fidgeting, or constantly being on the go as if driven by a motor. Since most everyone exhibits these characteristics, the AD/HD diagnosis is dependent upon the frequency that the characteristics are exhibited. Typically the diagnosis is determined by analysis of parent and teacher rating scales (behavioral checklists) and a patient interview. Thus, the diagnosis is quite subjective (Bird 2002) and can be easily mistaken for other problems like learning disabilities, unidentified mood disorders, or parenting problems. By labeling such problems as due to AD/HD, many children are given a quick fix via medication.

Immediate family members seem to be more vulnerable to AD/HD. If one identical twin possesses AD/HD, there is a 93 percent probability that his or her twin will possess it too. Data regarding heredity and AD/HD are primarily based on observation. Further long-term evaluation seems to be necessary, as conflicting data have been produced in various studies regarding AD/HD and specific genes.

BRAIN DIFFERENCES

For many years, researchers have reported structural and functional brain differences between subjects considered and those considered to have AD/HD. This has contributed to a belief that these measurable differences establish a neurological basis for AD/HD. This research has fundamental flaws and has greatly contributed to confusion regarding the cause of AD/HD. Since no test exists to determine the presence of AD/HD, and the diagnostic criteria are all subjective (and modified over the years), how does one select a group of normal subjects?

Assuming one could precisely find a normal group for comparative study, we still have the mystery analogous to the chicken and the egg. Available research supports that any measurable differences in brain wave electroencephalography (EEG) or structural MRI (brain scanning) simply are the consequence of (not the cause of) that define AD/HD or simply reflect personality differences.

PARENTING

It is a myth that poor parenting causes AD/HD. However, it is highly probable that poor parenting greatly contributes to the severity of AD/HD symptoms,

DIET

While much research has been done on the subject of food additives, diet, and AD/HD, this subject remains highly controversial. The National Institutes of Health (NIH) consensus conference (NIH 1982) concluded that controlled studies 'did indicate a limited positive association between defined [Feingold-type] diets and a decrease in hyperactivity." They subsequently reversed their statement later stating that restricted diets such as the Feingold diet "have not been shown to be effective in treating the majority of children or adults with AD/HD ... families risk spending time, money, and hope on fads and false promises." The NIH's current position concurs with that of the Food and Drug Administration (FDA) largely dismissing diet and food additives as agents that can trigger behavioral problems such as AD/HD. The FDA has published a booklet (cosponsored with an industry trade association) stating that "well-controlled studies conducted since then have produced no evidence that food color additives cause hyperactivity or learning disabilities in children," even though the FDA itself sponsored one study demonstrating that some children are affected by food dyes. Alternatively, The Center for Science in the Public Interest (CSPI) whose board consists of members of Georgetown Medical Center; Yale Medical School; and Public Health Nutrition, University of California, Berkeley; among others, has found "more than twenty controlled studies of diet and behavior. Most of the studies found that food dyes and, in some cases, other additives, and foods provoked symptoms of AD/HD or other behavior problems in some children." CSPI has urged the federal government to perform further research into the possible link between diet and AD/HD (Jacobson 1999).

TELEVISION AND VIDEO GAMES

While too much TV or video game play does not appear to cause AD/HD, these habits may exacerbate the condition. Two Japanese studies (Mori 2002 and Kawashima 2003) have demonstrated that chronic play of video games actually lowers metabolic rate in the frontal lobes, thus diminishing attention, impulsive control, and other executive functions. Another study performed by the Indiana University School of Medicine using functional MRI (Magnetic Resonance Imaging) scans found the brain activity of aggressive adolescents diagnosed with disruptive behavior disorders (DBD) is different from that of other adolescents when both groups viewed violent video games. Other studies have reported benefits from video game play, including faster response or reaction times to video stimuli as well as increased capability to recognize the number of figures on screen as compared to peers not playing video games. While further study is necessary, careful supervision, screening, and scheduling of television and video game play can be part of a successful home management program.

HEAVY METALS 

Studies have demonstrated that some people have adverse responses to heavy metal exposure. The level of exposure and its subsequent adverse reaction seems to vary individually. Proponents of heavy metal toxicity theory, suggest that. brain circuitry is disrupted in persons with AD/HD. Two culprits, lead and cadmium, are often blamed for AD/HD symptoms.

Advocates of this theory sometimes use hair mineral analysis as a simple, non-invasive way to determine body and cell mineral balance and toxicity. Cell biopsy is more accurate, but is much more invasive. If the patient is found to have heavy metal toxicity, an attempt is made to reduce the level by a process called chelation. Chelation therapy utilizes a substance, sometimes EDTA, a synthetic amino acid developed in the 1940s to reduce heavy metal toxicity. Scientifically controlled research related to heavy, metal toxicity and AD/HD is sparse but evidence of chelation therapy providing benefits was reported in the Journal of Advancement in Medicine (Cranton 1989).

ALTERNATIVE TREATMENTS

Currently medication is the primary treatment for AD/HD by the mainstream medical community. Prescribing stimulant medication often assists the clinician in a reverse diagnosis; if the medication works and reported symptoms are mitigated, then the diagnosis of AD/HD was correct. FDA clinical trials of AD/HD medications are often done in short order. In the six studies submitted to the FDA for approval of non-stimulant Strattera, Lilly pharmaceutical company (http://www.strattera.com) reports their longest study was conducted over a meager 10-week period.

News media have reported negative side effects and negative long-term effects of various AD/HD medications. Such reports have prompted some parents to seek alternative treatments.

NEUROFEEDBACK

Scientists have known for many years that the brain emits various brainwaves which are indicative of the electrical activity of the brain. Different types of brainwaves are emitted depending on whether the person is in a focused and attentive state or a drowsy/day-dreaming state.

Neurofeedback allows a person to view these brainwaves on a computer screen as they occur. By teaching a person to produce brainwave patterns that are associated with a relaxed, alert, and focused state, and having them practice this skill for many hours of training, neurofeedback practitioners contend that individuals with AD/HD can learn to maintain this state and that many symptoms of AD/HD will diminish.

Neurofeedback is based on the brain's ability to change when challenged and stimulated correctly. This reorganization is termed neuroplasticity. Feedback technology (neuro and biofeedback) has been utilized for at least thirty years. Numerous studies have been conducted reporting significant positive outcomes albeit with small groups and inadequate control groups. Positive effects are total reduction or extinguishment of AD/HD symptoms. No study has been reported of negative effects or side effects. Though neurofeedback is quite promising, the cost of neurofeedback is sometimes prohibitive to parents and it typically requires a lengthy time commitment.

DIET

The theory that nutrition and food allergies play a role in attention problems and hyperactivity has been debated since the 1920s. Recently, one of the strongest proponents of this theory was Dr. Ben Feingold, MD. Through a pragmatic approach, he determined that artificial food colors and flavors, some fruits and vegetables, and even aspirin can negatively affect the behavior of some children. He developed the Feingold diet, which totally restricts intake of these foods and food additives. The popularity of this diet declined when the NIH released contradictory data regarding the success of such a diet. Recent research has led to resurgence in its popularity as a growing body of evidence supports the food connection.

In a review of A Double-Blind, Placebo-Controlled Study of Zinc Sulfate as a Treatment for AD/HD (Rabiner 2003), Dr. Rabiner reports that significant positive changes occurred to the behaviors of AD/HD children given zinc sulfate. However, the children's attention problems remained unchanged.

Other carefully controlled studies are underway by the NIH and the future for dietary regulation of AD/HD as an adjunct intervention is likely, though years away. Currently, some complementary and integrative health practitioners report positive results from dietary regulation of their AD/HD patients.

HOMEOPATHY 

Homeopathic remedies for AD/HD are based on the theory that some plant, animal, or mineral substances cause AD/HD symptoms. Miniscule dilutions of the substances suspected to cause the symptoms are developed by the homeopath and administered to the patient "allowing the patient's immune system to naturally build a defense. The patient is monitored over several days or perhaps weeks. If the patient improves, the medication is continued. The prescription is altered if no improvement is made. The author can find little scientifically controlled research regarding the efficacy of this treatment and much of the treatment relies heavily upon the skill and subjective analysis of the homeopath or naturopath. Proponents claim rates as high as seventy percent efficacy in the reduction of AD/HD symptoms.

MEDICINAL HERBS

As more and more negative side effects of prescription medications are reported by the media, many people have turned to medicinal herbs to cure their ills. A variety of medicinal herbs can be found in stores. Some examples are linden flower, elder flowers, St. Johns wort, ginkgo biloba, german chamomile flowers, and blackberry leaves. While many advocates believe some herbs are particularly helpful for people with AD/HD, research in controlled scientific studies is contradictory. Varying results could possibly be attributed to the lack of control placed on the manufacture of herbal substances and nutritional supplements, which means that quality and quantity can vary greatly among products.

SUMMARY

Treatment of AD/HD is sometimes difficult because its cause is unknown and the disorder seems to be a catchall for a variety of varied symptoms. Although many of the alternative treatments mentioned in this article are being studied in NIH funded programs, it is unlikely they will reach mainstream medicine anytime soon.

It seems wise to educate oneself as much as possible about AD/HD and consider a variety of options such as those referenced as well as behavioral shaping programs. It is likely that you will have to try a combination of treatments, behavioral and otherwise, to find a solution right for you. Although it is time consuming and sometimes expensive, becoming an educated advocate for your child, self, or loved one, can help you select a course of action that will promote health and happiness.

BIBLIOGRAPHY

Journal of the American Academy of Child and Adolescent Psychiatry (Biederman, J. et al, (1999). Clinical correlates of AD/HD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 966-975.

Bird, H. R. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of AD/HD. In P. S, Jensen and J. R. Cooper, (Eds), Attention deficit hyperactivity disorder State of the Science--best practices (Chapter 2, pp. 2-3).

NIH Consensus Development Panel. (2000). National institutes of health consensus development conference statement: diagnosis and treatment of attention-deficit/hyperactivity disorder (AD/HD), Journal of the American Academy of Child and Adolescent Psychiatry Michael F. Jacobson, Ph.D., and David Schardt, M.S. (September 1999)

Diet, AD/HD & Behavior, A Quarter-Century Review, Center for Science in the Public interest, Washington, D.C.

Akio Mori, Ph D. (2002), University's Collage of Humanities and Sciences, Japan reported to The society for Neuroscience in the United States in autumn.

Ryuta Rawashima. PhD, (2003) Tohoku University, Japan

Dr. David Rabiner, Attention Research Update (2003), an online newsletter written by, a Duke University psychologist and former member of CHADD's Professional Advisory Board.

E. M. Cranton, J. P. Frackelton, Free Radical Pathology in Age-Associated Diseases: Treatment with EDTA Chelation, Nutrition, and Antioxidants, Journal of Advancement in Medicine, Vol. 2, Nos. 1, 2, Spring/Summer, 1989.1

AD/HD DIAGNOSIS

There is no single test for AD/HD, as the disorder is a catchall for many varied symptoms. Getting an accurate diagnosis requires a comprehensive AD/HD evaluation by a qualified health care provider. The following information is as an outline of the diagnostic process and is not intended to serve as a diagnostic instrument.

Frequently, comprehensive AD/HD evaluations include standardized rating scales (behavior checklists) for parents and teachers to complete. Parents and teachers typically spend the most time with the child in question. Therefore, they are typically the starting point in the evaluation process.

Secondly, a Continuous Performance Test (CPT) such as the Integrated Visual and Auditory Test of Attention (IVA) or the Test of Variables of Attention (TOVA) may be administered via computer to ascertain the child's degree of attention, prudence, impulsivity, etc. rated on a continuum with their peers.

A full physical examination including vision and hearing screenings may be appropriate to exclude the possibility that poor vision or auditory problems appearing as inattention.

A full interview with the child and parent is frequently performed to determine the following:

* if the child shows a sufficient number of ADHD symptoms

* if the symptoms could be attributed to another psychiatric condition.

* if the symptoms have persisted for at least six months

* if the child is older than seven, did the symptoms exist prior to this age?

* if the symptoms are at a level that is developmentally inappropriate

* if the symptoms cause problems in multiple settings like home and school

* if the symptoms cause significant difficulties in academic or social functioning

This outline is not all inclusive, but offers a starting point for a good clinical assessment.

Peter Freer is a veteran educator and holds a Master of Arts in Education. He developed and founded Unique Logic + Technology, Inc. (ULT) in 1994 and is currently CEO. ULT produces Play Attention, an international leader in educational attention training located at www.playattention.com.