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When learning isn't easy: Dr. Ed Hamlin provides a crash course in brain functioning and outlines holistic treatments for ADD/ADHD.

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The human brain is arguably the most complex entity in the universe. This relatively small, three-pound mass is what permits humans to be the most creative and adaptive species living on the planet. Our brain is largely molded through its interactions with the environment. It continues to develop throughout life and functions as the primary organ of learning. In fact, one of the brain's main functions is to help us learn and solve problems to facilitate our survival and development. It accomplishes this critically important task by growing and strengthening connections between the 100 billion brain cells (neurons) that comprise its mass. Each neuron may have between 1,000 and 10,000 connections with other brain cells. Throughout its lifetime, the brain reorganizes itself by creating new connections. So, the old adage "use it or lose it" applies as much to the brain as it does to muscle mass (1).

The brain contains specialized areas for gathering information through its sensory channels, developing meaning through the association areas, creating new ideas by means of the executive centers, and acting on these new meanings through the motor cortex. The flow of activity from the input, association, processing, and output channels of the brain depends on good connections between the different areas involved and the precise timing of their operations. Most learning problems and disabilities are due to insufficient connectivity between brain regions or disparities in the timing of their operations (2).

A common problem encountered in this learning process is attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD). Government estimates from community samples suggest that five to 15 percent of children from ages four to 17 years have ADD or ADHD. Recent studies have shown that a high percentage of these children will continue to have symptoms of these disorders into their adulthood (3). Though there are different types of attention disorders, neuroimaging studies of both children and adults with ADD/ADHD show that the frontal lobes of their brains are underactive relative to other areas of the brain. The frontal lobes are the seat of executive functioning where priority of focus is assigned, distractions and impulses are inhibited, tasks are planned and organized, persistence until completion is maintained, and internal rewards are dispensed for a job well done. In individuals with ADD/ADHD, underactive frontal lobes don't adequately communicate with other important regions of the brain and coordinate their relevant functions (4).

The DSM-IV (the current diagnostic manual for psychiatry and psychology) describes the essential features of ADD/ADHD as "a persistent pattern of inattention and/or hyperactivity/impulsivity." The core features of ADD/ADHD interfere with an individual's ability to give close attention to details, which leads to careless errors, makes sustaining attention and following through on tasks more difficult, increases forgetfulness, contributes to disorganization, and results in a person not always hearing what they're told. The more impulsive and hyperactive forms result in increased fidgetiness and squirming, difficulty engaging in quiet activities, excessive talking, interrupting others and impatience.

Beyond these obvious impairments to academic and vocational performance caused by ADD/ ADHD, other common problems may include an increased risk for substance abuse, increased incidence of automobile accidents in adolescence and adulthood, higher tendency to engage in high risk behaviors, relationship problems due to unreliability and inconsistencies, poor self-esteem, depression and anxiety (5).

Treatment of ADD/ADHD has tended to focus on medication primarily involving psychostimulants (e.g., Ritalin, Adderall, Concerta, Focalin and others). Many individuals have good response in some areas of cognitive functioning to medications, but their role in the overall treatment of attention deficits appears somewhat limited. As with many prescription medications, adverse side effects are sometimes encountered. These may include loss of appetite, increased headaches, disrupted sleep, reduced stature, anxiety and tics. There are also limitations of the medications. It appears that attention can be improved by low doses of the medication while the reduction of impulsivity requires higher doses. These higher doses of psychostimulants frequently do not improve attention. Also, long-term outcomes for individuals treated with psychostimulants don't show reduced risk of automobile accidents or substance abuse. Finally, there are cognitive aspects of ADD/ADHD that are not improved by medication. One major cognitive deficit encountered in attention deficits is working memory. Working memory is the ability to hold information in awareness long enough to perform necessary operations to complete a task.

This capacity is essential for many complex cognitive tasks, including reading comprehension, problem solving, and the control of attention. Unfortunately, important aspects of working memory generally show little or no benefit from psychostimulant medication. For all of these reasons, implementing a more holistic approach in treating ADD and ADHD is advantageous or necessary.

There is significant emerging evidence that behavioral strategies, lifestyle factors and cognitive enhancement training can have strong and lasting beneficial effects on both children and adults with attention deficits. A large study conducted by the National Institute of Mental Health concluded that medications were highly effective in the treatment of ADD and ADHD; however, only 50 percent of the children with whom behavioral strategies were used first were eventually referred for medication evaluations (6). A significant advantage of behavioral treatments and cognitive training is that they produce lasting effects. The benefits derived from using medications disappear when the medications are stopped while behavioral changes and cognitive enhancement training improvements continue.

It's clear that regular exercise, good nutrition and regular sleep can improve attention and cognitive functioning overall. Evolution didn't shape our brains to function maximally in today's largely sedentary environment, where we are fueled by processed food and largely sleep deprived. Steps need to be taken to improve these basic lifestyle factors to increase the brain's health and maximize the positive impact of other interventions that may be utilized.

Behavioral training includes developing strategies for specific problem identification, goal setting, prioritization, time management, reducing procrastination, breaking large tasks into smaller ones, reward systems and social skills training. Cognitive skills training involves exercising specific cognitive abilities, such as working memory, which results in improved attention, fluid reasoning and improved impulse control (7).

Another exciting advancement for creating lasting improvement in attention functioning is EEG biofeedback, also called neurofeedback. In this approach, computer/brain interfaces are used to train underactive areas of the brain to be more active. Accumulating research indicates lasting changes in both activity level and connectivity in the brain from EEG biofeedback training (8).

One of the major advantages of using a more holistic approach to addressing ADD and ADHD is an improved sense of self-control and empowerment. Using skills instead of just pills permits individuals to learn more about their own potential and can increase their confidence to be able to tackle and overcome other life problems that inevitably arise.

Sources: (1) Train Your Mind, Change Your Brain by Sharon Begley (2) A Comprehensive Guide to Attention Deficit Disorder in Adults by Kathleen Nadeau (3) www.add.org/articles/HowoftenDoesADHDPersistintoAdultbood.html (4) Getting Rid of Ritalin by Robert Hill and Eduardo Castro (5) Delivered from Distraction by Edward Hallowell and John Ratey (6) Attention Deficit/Hyperactivity Disorder: Concepts, Controversies, and New Directions by William Pelham (7)"Improving fluid intelligence with training on working memory" by Susanne Jaeggi, Martin Buschkuehl, John Jonides and Walter perrig in the Proceedings of the National Academy of Sciences (8)A Symphony in the Brain by Jim Robbins

Obtaining an accurate diagnosis for ADD/ADHD is very important for successful treatment and intervention. Many factors have an impact on attention, such as life circumstance disruptions, anxiety, depression, and an array of medical problems. Also, symptoms of ADD exist on a continuum and only become a disorder when the intensity and/or frequency of the behaviors or problems reach a level of severity. The symptom picture can also vary with gender, age and from person to person, making it difficult to assess by any single means.

A comprehensive evaluation performed by a professional trained in the identification of ADD is advised. Though aspects of the assessment may vary, it should include a detailed history from the person being evaluated and from caregivers and teachers, or from a spouse, friend or other family member in the case of an adult. A thorough review of medical and pediatric histories should be performed. Aspects of specialized neuropsychological and/or psychoeducational testing should also be performed. The addition of a quantitative EEG or SPECT scan can add significant information to a diagnostic assessment.

* Doesn't seem to listen when spoken to

* Makes frequent careless errors in schoolwork

* Has a short attention span at home and at school

* Tends to lose things frequently

* Has trouble concentrating

* Has trouble completing and turning in homework

* Tends to squirm, fidget or leave seat frequently

* Gets "excited" easily

* Is constantly on the "go" as if driven by a motor

* Has trouble seeing consequences of behavior

* Has difficulty managing paperwork at work or home

* Is chronically forgetful

* Has problems controlling temper

* Tends to interrupt others in conversation

* Takes on far too many tasks or projects

* Has a tendency to make impulsive decisions

* Is disorganized in many aspects of life

* Blurts out without considering consequences

* Moves or changes jobs frequently

* Gives up easily on long-term or difficult projects

If any of the above problems are sufficient to cause problems in life, it's important to become educated about ADD/ ADHD and learn about the options available for diagnosis and treatment. More comprehensive information can result in a broader, more holistic approach to treatment. Several excellent informational resources are available, including Delivered from Distruction by Edward Hallowell and John Ratey, Out of the Fog by Kevin Murphy and Suzanne LeVert, The A.D.D. Book by William Sears and Lynda Thompson, and You Mean I'm Not Lazy, Stupid, or Crazy by Kate Kelly and Peggy Ramundo. Online resources include www.addresources.org, www.help4adhd.org and www.addvance.com.

Ed Hamlin, Ph.D., is the clinical director of the Pisgah Institutes Center for the Advancement of Human Potential. In addition to his dinical work, he conducts research and presents workshops on brain/mind relationships, consdousness and self-regulation. The dinic and Dr. Hamlin can be reached at 828-251-2882 or by email at ehamlin@pisgahinstitute.com.
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Author:Hamlin, Ed
Publication:New Life Journal
Date:Aug 1, 2008
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