Saturday, September 29, 2007

When Does Somebody take Non-Pharmacological solutions seriously

Qualitative versus Quantitative: Technological and Non- pharmacological approaches to the diagnosis and treatment of Attention Deficit Hyperactive Disorder


This annotated bibliography takes broad overview of the technology and non-pharmacological approaches used today to diagnosis and treat Attention Deficit Hyperactive Disorder. The DSM-IV (1994) states clearly that no laboratory tests or specific physical biological features have been established to identify Attention Deficit Hyperactive Disorder. Despite this fact, hundreds of case studies including use of such technologies as SPECT, fMRI, QEEG, Neurotransmitter urine panels, and specific attention tests which include computerized T.O.V.A., provide ample evidence that ADHD can be more accurately diagnosed and treated via the latest technologies and milder vitamin supplements. The critical aspect, of these approaches, is despite not being part of the DSM-IV literature, these alternative approaches provide in many cases a more quantitative analysis than current traditional methods. Though not in the scope of this bibliography, hopefully this annotated bibliography provides a thoughtful counterpoint to the current over prescribing of drugs to children for the treatment of ADHD.

Sterman, M. Barry (2000) EEG Markers for Attention Deficit Disorder: Pharmacological and Neurofeedback Applications Child Study Journal 30.1

This first citation provides both a history and an overview of approaches to ADHD. Dr. Sterman is emeritus professor of Neurobiology at UCLA. He is considered one the founding fathers of Neurofeedback along with Dr. Joel Lubar. Most papers on the use of QEEG or Neurofeedback will usually cite Sterman and/or Lubar who interned under Sterman. Sterman was the first to have peer reviewed research on biofeedback on animals and humans in the 1960’s. This article includes startling data on the over prescribing of methylphenidates which include Ritalin. Estimates made during the late 1990’s put the amount for Americans consuming Ritalin at 8.5 tons per year. The paper begins by pointing out that the DSM-IV describes ADHD as a qualitative cognitive issue, that lacks any physical evidence or biological supporting facts. Most prescriptions for ADHD simply need to fall within the typical list of observed behaviors of impulsivity and inattention. Dr Sterman then lays out several cogent points for the use of QEEG, primarily pointing out that EEG analysis of ADHD generally display several dominant features. These features include; increased slow rhythm activity known as Theta 4-8 Hz in the frontal, prefrontal and Sensorimotor regions, and reduced activity 12-20 Hz known as the more alert Sensorimotor Rhythm, or SMR in similar brain areas. Also many subjects display hypercoherence between left and right frontal cortex and between frontal/temporal regions within each hemisphere. Hypercoherence is when two regions of the brain are too “in sync” and their EEG rhythms spike and dip in near perfect phase, preventing flexible and independent reactions one would expect in different brain regions to display. Dr Sterman’s final well cited argument is that QEEG studies help increase the accuracy of treatment. An example is that of mild deep brain epileptic seizures, which might appear to cause individual attention problems externally. While EEG is an established diagnostic tool for such brain activity, Sterman points out that prescribing a stimulant like Ritalin to an epileptic could create severe reactions. Included in his paper are dozens of case studies showing the efficacy of Neurofeedback as a diagnostic tool and treatment of ADHD.

Bone, Kerry (2003, October 1)The Potential Role of Phytotherapy for ADHD.(Phytotherapy Review & Commentary)Townsend Letter for Doctors and Patients

This is another broad overview of ADHD and its history. What is critical is the clarity of documentation of phyto-nutrients that Mr. Bone elucidates with his claims. One of the most effective of the claims is a double blind study measuring speed and accuracy of college students in cognitive tests. Ginko Biloba and Ginseng were used in combination, and showed significant improvement over placebo users. Also, Mr. Bone cited studies of decreased Essential Fatty Acids in a subset of ADHD children, as opposed to normal levels in non-ADHD children. Though there are many broad case studies and research papers on Ginko for increase cerebral blood flow, the stimulant effects of Ginseng, and the protective qualities of Essential Fatty Acids to nerve myelination. Mr. Bone had one of the few referenced uses of Bacopa. Bacopa is an Ayurvedic herb that has been used in India for memory and learning difficulties. He cites an Australian double blind study where Bacopa clearly demonstrated increased scores in the Rey Auditory Verbal Learning Test over placebo subjects. The significance of this article is the fact that Mr. Bone relied solely on solid double blind research as opposed to case studies where multiple factors are rarely considered. In the realm of supplement and phytonutrient claims, Mr Bone refused to use weak research to make any significant justifications despite his general thesis that phytonutrients can be an effective adjunct to treatment of ADHD symptoms.

Westerberg, Helena (2005, February 1) Computerized training of working memory in children with ADHD--a randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry

Ms Westerberg outlines a Swedish double blind study, where children who were diagnosed with ADHD were randomly given ‘Working Memory’ exercises that ran off a Personal Computer CD-Rom. These exercises included recollection of the position of items in a 4 X 4 grid as well as verbal tasks remembering phonemes, letters, or digits. The subjects used a computer mouse to select and navigate the tasks for about 40 minutes per day, everyday for several weeks. The test group contained only fifty subjects, yet the results were impressive. Those receiving the treatment increased their visual-spatial working memory by an average of 19%. This increase sustained itself 5-6 weeks after treatment. In addition, evaluations of hyperactivity and poor attention as noted by parents through psychologists showed decrease in symptoms as compared to the placebo group. The group of 7-12 year olds were selected based on symptoms of ADHD and were eliminated if defiance disorder, low IQ, or were under the influence of prescription drugs such as methylphenidates. Various tests were given to subjects including WISC-III, Raven, Stroup and Conner’s Rating scale tests during treatment, pre-treatment and post-treatment. The most surprising aspect was the post-treatment score, of the group to be within .3 of the standard deviation mean for cognitive reasoning ability of the population norm. The only troubling aspect Ms. Westerberg admits to is that of teacher evaluations that saw little change in ADHD behavior. Clearly, as Ms. Westerberg admits further research needs to continue to study the aspects of exercising working memory regions of the brain.

Shapiro, Theodore (1997, December 1) Evolution and revolution in child psychiatry: ADHD as a disorder of adaptation. Journal of the American Academy of Child and Adolescent Psychiatry

Theodore Shapiro advances the theory that ADHD may have been an evolutionary adaptation. As this may seem to be beyond the scope of this bibliography, his arguments are persuasive enough that if plausible add to the thesis that ADHD has genetic and biological underpinnings that the DSM-IV has yet to acknowledge. But rather than ignore the symptoms described in the DSM-IV, Shapiro uses them to make the argument that these symptoms are adaptive. Impulsivity, attentional processes (scanning and rapidly, shifting attention), vigilance and increased motor activity (hyperactivity) are all adaptations that are highly effective on the savannah or dark jungle, but not for sitting at a desk quietly reading. These set of ADHD behaviors form what Shapiro calls “the response ready” child. Here is where his hypothesis enters the realm of this paper. Shapiro suggests adapting the environment with tools and technologies that utilize rather than punish the “response ready” child. The child is given tasks that enable his scanning abilities and use of interactive tasks that are more physical in nature. This could reward the child and help to eventually mainstream the child into an average classroom. Such technologies exist, for example; video games that track body movements could be combined with math or reading skills. Even Shapiro admits that his theory can not allow teachers, parents, or administrators to romanticize these behaviors as premature noble savages.

Vaidya, Chandan J.(2005) Brain Imaging of Attention Deficit
Hyperactivity Disorder: What have We Learnt? Cognition, Brain, Behavior Vol. IX(3), 287-300

Vaidya paper reviews the evidence that is clear that ADHD has biological markers that are apparent via several imaging technologies. These technologies include single photon emission computed tomography (SPECT), positron emission tomography (PET), functional magnetic resonance imaging (fMRI) Vaidya covers the ethical dilemmas of using radioactive isotopes in children and thus tends to favor fMRI studies. What is clear about the research that is covered is there is comprehensible evidence that children with ADHD have abnormalities that can be detected through computer imaging. Her review of the evidence includes aspects such as metabolic action was reduced in ADHD subjects in an array of regions implicated by the structural anatomical findings including in the frontal and parietal areas. SPECT/PET studies illustrated that during an auditory attention task, ADHD subjects demonstrated hypoperfusion (decreased blood flow) in the periventricular regions, representing low metabolic activity in the frontal (premotor and prefrontal) and striatal (caudate, putamen) regions. The research cited over 50 published papers on neurological imaged deficits of children and adults.

Dige, N., & Wik, G. (2005). Adult Attention Deficit Hyperactivity Disorder Identified by Neuropsychological Testing. International Journal of Neuroscience, 115(2), 169-183.
This research paper used a double blind study to test whether the use of specific neuropsychological testing was an accurate indication of adult ADHD. Niels Dige’s team were able to successfully diagnosis ADHD with over an 85% accuracy. Dige used over a dozen tests to measure the various disabilities in the test group. These tests checked for working memory, including auditory and verbal working memory, and logical sequential tasks. What is striking, is the fact that despite using over a dozen tests 25% of the controls were miss identified as having symptoms of ADHD. This raises an interesting problem, where as cognitive test use clear quantitative statistics, little to no statistical data of accuracy exists in any substantial form for neuroimaging diagnosis. Dige’s work though instructive illuminates the fact that more work needs to be done linking neuropsychological tests with neuro-imaging.

Grizenko, Natalie Bhat, Mamatha Schwartz, George (2006, January 1) Efficacy of methylphenidate in children with attention-deficit hyperactivity disorder and learning disabilities: a randomized crossover trial. Journal of Psychiatry & Neuroscience, Vol. 31 Issue 1, p46, 6p

This is a standard double-blind, placebo-controlled, randomized, 2-week crossover trial of methylphenidate usage in children with ADHD. Grizenko’s research in ADHD and psycho-stimulants is not at the surface notable. Dozens of studies, drug trials, FDA reports have looked at the efficacy of Ritalin and other stimulants for children and adults with symptoms of ADHD. The critical issue was the lack of efficacy for children with ADHD and learning disabilities. Particularly in mathematics, where over 63% of those medicated displayed no cognitive improvement at all. Statistically speaking those with reading disability faired only slightly better, with 45% or nearly half showing no improvement. On average half of the learning disabled students with ADHD showed little to no improvement. Whereas, 75% of the ADHD children with no learning disability showed improvement with the addition of methylphenidate. It is important to note that despite being given psycho-stimulants, the research did not include any biological tests to see if there had been any changes in levels of catecholamines which are typically raised due to the introduction of a stimulant. Thus there is no way other than cognitive testing to see if any biological metabolic marker differs between the two groups.

Ross, Brian M. McKenzie, Ivor Glen, Iain et al (2003 October)Increased Levels of Ethane, A Non-invasive Marker of n-3 Fatty Acid Oxidation, in Breath of Children with Attention Deficit Hyperactivity Disorder. Nutritional Neuroscience; Oct2003, Vol. 6 Issue 5, p277, 5p

This report concludes that children with ADHD exhale larger amounts on average of a chemical known as ethane. Ethane is produced by the oxidation of Omega 3 class of fatty acids. The oxidation process which appears accelerated in ADHD children, has no known direct causes. But Ross cites numerous studies that show that polyunsaturated fatty acids which included the various omega class of fatty acids 3-6-9, are low in ADHD children. If this is true that ADHD children are low in PUFA’s, and are producing a byproduct of oxidation of PUFA’s then dietary supplementation seems like a logical remedy. Ross recommends a combination of fatty acids and anti-oxidants to counter the breakdown and release of ethane. Where as many ‘new age’ prescriptions by various so called health care providers tout essential fatty acids and anti-oxidants, Ross provides real scientific evidence that these supplements might be effective for children with ADHD.

Wooltorton, Eric (2005, December 6) Suicidal ideation among children taking atomoxetine (Strattera) CMAJ: Canadian Medical Association Journal; Vol. 173 Issue 12, p1447-1447, 1p

This citation is to force home that even the newer psycho-stimulants have serious side effects. The side effects of stimulants like Ritalin have been well documented. And their efficacy is sometimes no better than a 50/50 proposition. Wooltorton examines the increase in suicide ideation among users of Strattera. Strattera or atomoxetine acts as a selective norepinephrine reuptake inhibitor. Norepinephrine is produced by the adrenal gland and has stimulant like effects on the central nervous system. Suicidal ideation is reported to have occurred in 5 (0.37%) of 1357 children given atomoxetine but none of 851 children given placebo. All reports of suicidal ideation were in children aged 7–12 years; one attempted suicide.

Heuser, G, Mena I, (2002)Treatment of Neurogically Impaired Adults and Children with "Mild" Hyperbaric Oxygen The proceedings of the 2nd International Symposium p 109-115

This is one of only a few published papers of the use of Hyperbaric Oxygen Treatment for what is considered “off label” use. HBOT is used for divers and for diabetics by established protocols in hospitals across the world. Typically, HBOT treatment uses nearly pure oxygen, and very high levels of air pressure at nearly 4 times normal levels. In cases of open wounds from advanced type two diabetes it can help wounds heal by bringing much needed oxygen to the wound. Mild HBOT, uses lower pressure and lower oxygen levels. This case study by Dr Heuser a UCLA professor and medical doctor specializing in neuro-toxicology shows the reversal of neurological impairment. Included in the case studies are pre and post treatment SPECT studies which clearly demonstrate increased metabolic function in the cerebral cortex. Also Heuser offers pre and post T.O.V.A scores which also show quantitative improvement ranging from 2-23% increase in attention achievements. The logic behind the treatment of HBOT, is that some ADHD symptoms may be due to brain regions in idle mode. This idle mode may be due to earlier stress to the system. By increasing air pressure and oxygen levels previously injured brain areas may ‘awaken’. By increasing air pressure more oxygen is released as changes in pressure make the cell walls more permeable to the release of oxygen.

Thomas R. Rossiter and Theodore J. La Vaque (1995) A Comparison of EEG Biofeedback and Psychostimulants in Treating Attention Deficit/Hyperactivity Disorders Journal of Neurotherapy, p 48-59

The study contrasted the outcomes of EEG biofeedback and stimulant medication in reducing AD/HD symptoms. The intriguing result of Rossiter’s research was there was no difference between the two groups. Both displayed improvements, in attention scores and overall behavioral changes. EEG patients were seen three to five times a week for 45-50 minute treatment sessions that included 30 minutes of EEG biofeedback. Biofeedback consisted of responding to both visual and audio cues to suppress theta activity and increase SMR or low beta. Patients in the ‘MED’ set were started or restarted on methylphenidate or dextroamphetimine prescribed by their personal medical doctors following the baseline assessment. Though not a double blind study, the results were intriguing. Ritalin has many side effects including sleeplessness and nausea, while EEG has few if any.

Robbins, Jim (2000) A Symphony in the Brain. New York: Grove Press

This is an entire novel that covers the history of Neurofeedback. It takes the reader through the early days with Dr. Sterman, and finishes with the Othmers. It is included here because there is a fork in the school of thought concerning neurofeedback. Dr. Sterman and Dr. Lubar are on one side, and the Othmers and Margaret Ayers are on the other. The book deals with both the science and the personalities involved in this budding science. Sue and Siegfried Othmer have the largest training facility of EEG practitioners in the United States. Margaret Ayers and Sue Othmer both worked under Dr. Sterman yet neither ever finished getting even a PhD. The Othmers use EEG as broad tool to affect many different mental disorders including epilepsy, autism, neurotoxic insults, ADHD, anxiety, and depression. Whereas Sterman and Lubar both take a much more conservative approach, applying EGG or neurofeedback to ADD and epilepsy. The Othmers come to neurofeedback from desperation to help their son Brian Othmer who had epileptic seizures and behavioral problems. The book on a whole does go into detail of protocols and precise treatments of specific disorders and how they com about. From testing cats’ brainwaves in the 1960’s to helping children with severe autism, the book delights as much as it enlightens.

Amen, Daniel G. (2001) Healing ADD New York: Berkeley Publishing Group

This is quintessential book on brain scans and Attention Deficit Disorder. Dr Amen has a massed over 10,000 SPECT scans of various patients over the years. Amen is not only a neurologist but also has a PhD in psychology. He has developed six types of ADD based on the thousands of brain scans in his practice. Along with the quantitative data from the scans he has also developed a series of over 100 questions that statistically match your ADD profile with your SPECT exam. In this book, he breaks down all six types by SPECT and behavior. Each type he describes and offers both pre and post medication SPECT studies. In addition, to the various medications, Amen also recommends various supplements for each ADD type. Some types such as inattentive type 2 require stimulants such as Adderall while others such as limbic type 4 require inhibitory supplements like GABA.


The objective of this annotated bibliography was to examine various aspects of non-pharmacological and technological aspects of diagnosis and treatment of ADHD. We covered various technologies including breath tests, hyperbaric oxygen, computerized neurofeedback, and several brain imaging approaches. We also looked at effectiveness of treatments of both technological and phytonutrient approaches versus stimulants. Supplements such as Essential Fatty Acids, Bacopa, and Ginseng were covered and dissected. Despite reviewing over a dozen sources, the surface has barely been scratched. Yet clearly, the evidence here has added to the argument that other more effective treatments and diagnostic analysis exist for the health care provider and for the patient to receive the best care possible.

1 comment:

  1. The research for neurofeedback is larger than indicated here. Decades of clinical practice show neurofeedback to be the treatment of choice. Diagnosis is not important, neurofeedback generally improves brain functioning.
    Gary Ames