The Best Alternative Therapies for Managing ADHD Symptoms

What you need to know about complementary treatments to improve ADHD symptoms — fish oil, neurofeedback, nutrition, exercise, and working-memory training.

"Asking if you should use medication or a complementary therapy to treat attention deficit disorder (ADD ADHD) is like asking whether you should eat fruit or vegetables,” says Barbara Ingersoll, Ph.D., a clinical psychologist and author of Daredevils and Daydreamers: New Perspectives on Attention Deficit/Hyperactivity Disorder (Main Street Books). “Many ADHD children do very well on stimulant medications like Ritalin or Concerta. Others have limited success and may need something else to help.”

“Parents of ADHD children are always looking for ways to help them,” says David Rabiner, Ph.D., senior research scientist and the director of psychology and neuroscience studies at Duke University. “Adults with ADHD are also very self-motivated in finding ways to deal with symptoms.” The key question is how do you separate legitimate therapies from those that are scams or dangerous.

In this special report, we explore several therapies — neurofeedback, nutrition and omega-3 fatty acids, exercise, and working-memory training — to help readers make informed decisions about what is right for you and your child or teen. Remember, these are not necessarily alternative treatments, that is, they may be adjuncts to medication, not substitutes for it.

It goes without saying that the effectiveness of any treatment for attention deficit disorder varies by individual, and that you shouldn’t begin any new course of treatment before a discussion with your doctor.

Keep in mind that ADDitude’s staff and scientific advisors never endorse any form of treatment, including those covered editorially or in advertising in the magazine. To make an informed decision, stay on top of the research on ADHD by watching ADDitude's online news column, subscribing to news alerts from Google and Yahoo, and reading up on any therapy you’re considering via a PubMed search.

Neurofeedback: Train Your ADHD Child's Brain

Cody Miller was diagnosed with ADHD in first grade. While her behavior improved with medication, she experienced unacceptable side effects. “I didn’t care about anything,” says Cody, now 14. Her parents stopped the meds, and Cody began behaving aggressively toward her parents, her friends, even her pets. Her mother turned to neurofeedback, which uses brain exercises to reduce impulsivity and increase attentiveness. After eight months of sessions, Cody’s grades improved and her aggressive behavior subsided. Two years later, Cody’s gains are holding. She uses a low dose of meds during the school year, and receives neurofeedback “tune ups” during stressful periods.

Every year parents, like Cody’s, seek out therapies for their ADHD children because medication has stopped working (or never worked), produces unwelcome side effects, or, most commonly, doesn’t manage all the symptoms of the condition. Approximately 10,000 children are currently receiving treatments in the U.S., according to Cynthia Kerson, executive director of the International Society for Neurofeedback and Research. Seventy-five to 80 percent of them have some type of attention deficit condition.

While sessions are brief (approximately 30 minutes) and painless, they are expensive. The average course of treatment can range from $2,000 to $5,000. One promising aspect of neurofeedback is that its benefits seem to remain after the treatment is ended. Vincent Monastra, Ph.D., founder of the FPI Attention Disorders Clinic in Endicott, New York, and author of Parenting Children with ADHD: 10 Lessons That Medicine Cannot Teach (American Psychological Association), conducted a year-long, uncontrolled study with 100 children who were taking medication, half of whom also received neurofeedback.

Monastra’s results indicate that “patients who did not receive the therapy lost most of the positive effects of treatment one week after they were taken off medication.” Those who combined medication with neurofeedback, he says, maintained their ability to control attention. In fact, says Monastra, who is a practitioner of neurofeedback and other therapies at his clinic, “after the year of neurofeedback therapy, some patients were able to reduce medication dosage by about 50 percent.”

TREATMENT SPECIFICS
Neurofeedback is based on a simple principle. “The brain emits different types of waves, depending on whether we are in a focused state or day-dreaming,” explains Siegfried Othmer, Ph.D., chief scientist at the EEG Institute in Woodland Hills, California. The goal of neurofeedback is to teach the patient to produce the brain-wave patterns associated with focus. The result: Some symptoms of ADHD — impulsivity, distractibility, and acting out — diminish.

Here’s how the treatment is structured. After a practitioner takes a detailed history of the patient, he “maps” the patient’s brain. The patient dons a cap lined with electrodes and sits with his eyes closed for several minutes. He is then asked to perform a complex cognitive task, such as reading aloud. The results are shown as a color-coded map on a computer screen, indicating areas of the brain where there is too much or too little brain-wave activity — the sources, theoretically, of the patient’s ADHD symptoms. This digital map enables a person’s brain activity to be compared with other brain-wave patterns stored in databases — and can help fine-tune a treatment plan by delineating sites for the electrodes.

During treatment, the child wears the same headgear while sitting in front of a video screen. His goal: to move the characters in a computer or video game (goals vary, depending on the protocol the practitioner uses) by producing short bursts of sustained brain-wave activity in those areas of the brain thought to be under-aroused. The software generating the game monitors and records brain activity. Loss of focus will cause the game to stop. It plays only when the child exercises that portion of the brain that is deficient in focus.

Neurofeedback has its share of critics, many of whom have valid objections. Unlike medication, the therapy hasn’t been rigorously tested in large, double-blind studies. Some experts also claim that it isn’t clear from studies that have been done whether improvements in children are due to the therapy or to one-on-one time with a therapist. Another criticism is that, while neurofeedback may sharpen attention in some children, it doesn’t always improve the other problems associated with ADHD.

While some experts admit that neurofeedback has promise, they believe that it should be used only in combination with medication. “If I had a child with ADHD, I might use neurofeedback as one part of the treatment regimen,” says David Rabiner, Ph.D., senior research scientist at Duke University’s Center for Child and Family Policy. “But I wouldn’t use it instead of other treatments that are better supported [by research].”

Some parents tried well-researched therapies first and found that they weren’t the total solution for their child. Richard Kramer’s parents stopped his meds when the drugs didn’t control his impulsive behavior or his emotions. After Richard received nine months of neurofeedback, his teacher reports that he is now more focused and rarely gets frustrated. Recently, his national achievement test scores placed him two grade levels higher in both math and reading over last year. “For the first time in his life,” says his mom, “he feels good about himself.” —by Pamela V. Michaels

(Names have been changed to protect the child's privacy.)

ADHD Supplements: Facts About Fish Oil

Can this common supplement sharpen your child’s focus? Countless studies have centered on the potential benefits of nutritional supplements as treatment for ADHD. Vitamins, minerals, and even some odd-sounding plant compounds — vinpocetine, a derivative of the periwinkle plant, and yerba mate, derived from evergreen trees in South America — have been studied for their ability to boost mental focus. But so far only one supplement seems to have some evidence supporting its use for ADHD: omega-3 fatty acids.

This article comes from the December/January 2008 issue of ADDitude.

To read this issue of ADDitude in full, purchase the back issue and SUBSCRIBE NOW to ensure you don't miss another issue.

ADHD Treatments: Alternative Therapies, Part 2

Found mainly in cold-water, fatty fish, such as sardines, tuna, and salmon, omega-3s are believed to be important in brain and nerve cell function. The body cannot make omega-3 fatty acids by itself, and because the American diet is heavy on beef and chicken — not fish — most people don’t consume enough of them to derive benefits.

“I tell my patients that there are two things they need to do for their health: Exercise and consume omega-3s,” says John Ratey, M.D., associate clinical professor of psychiatry at Harvard Medical School and coauthor of Driven to Distraction (Touchstone).

While omega-3 fatty acids seem to improve anyone’s mental focus, the compounds may be especially helpful to those with ADHD. One study, published in 2003 in Nutritional Neuroscience, showed that omega-3s tended to break down more readily in the bodies of patients with ADHD. Another study, published in 2004 in The Journal of Nutritional Biochemistry, suggested that children with ADHD were more likely to have low blood levels of omega-3 fatty acids than children with no symptoms of the condition. Although both studies were small, the results led scientists to surmise that increasing omega-3s can help control symptoms.

Edward Hallowell, M.D., founder of the Hallowell Center for ADHD in Massachusetts, recommends that all of his patients take omega-3 supplements and notes that “it seems to help most with mental focus, not hyperactivity or impulsivity.” Ratey advises that it may take up to six weeks for patients to begin seeing benefits.

PICKING THE RIGHT PILL
If you decide to add omega-3s to your diet, how do you determine which brand is best? There are two main types of omega-3 fatty acids in fish oil: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Both seem to help brain function, but, because they are slightly different compounds, they work in different ways.

Early studies that tested the impact of either EPA or DHA in children with attention problems produced mixed results. Only recently have researchers begun to look at supplements that combine the two. In a small study, published this year in Nutrition Journal, for example, nine children with ADHD were given supplements containing both EPA and DHA every day. After eight weeks, the children showed significant improvements in ADHD symptoms.

The most popular omega-3 supplements differ in the amounts of EPA and DHA they contain. Based on the most recent research, Ratey recommends that you choose a supplement that has at least three times the amount of EPA to DHA. “The data seem to show that those using supplements containing higher ratios of EPA get a better response in ADHD symptoms, including mood swings and aggression,” says Ratey.

Be aware that high doses of omega-3s may cause nausea, diarrhea, and other gastrointestinal discomfort. Consult your doctor before adding this supplement to your routine. —by Karen Barrow

ADHD Nutrition: Balanced Meals, Better Behavior

Hyperactivity has long been associated with sugary sodas and cheeks full of candy. It is no surprise, then, that food seems to play a major role — good and bad — in ADHD. Choosing the right foods — or cutting back on the wrong ones — may be a proactive way to prevent ADHD symptoms from swinging out of control.

“The role of nutrition in the treatment of any chronic condition is important,” says Helen Rasmussen, Ph.D., a research dietician at Tufts University.

Faye Berger Mitchell, a registered dietician from Bethesda, Maryland, has a nine-year-old daughter who was diagnosed with ADHD five years ago. While her daughter takes stimulant medicine to control her ADHD, Mitchell concluded that a pill is not enough.

She finds that when her daughter eats a well-balanced ADD-friendly diet, including vegetables, carbohydrates, fruits, and plenty of protein, her behavior tends to be more consistently under control.

“The biggest challenge is to get my daughter to eat protein,” she says. Protein is key, says Mitchell, because it can prevent surges in blood sugar, which may increase hyperactivity. For Mitchell, something as simple as slipping a little chicken or lean beef into every meal (and even into snacks) has made a difference for her daughter.

“Her overall behavior is so much better,” she says. Dr. Edward Hallowell advises all of his patients to think about their plates when preparing a meal. Half of the plate, he recommends, should be filled with fruits and vegetables, one-fourth with a protein, and one-fourth with carbohydrates. This combination is a balanced diet, and it may control swings in behavior caused by hunger, surges in blood sugar, or a shortfall of a particular nutrient.

In addition to the balanced plate, Hallowell advocates eating several servings of whole grains each day to prevent blood sugar levels from spiking and then plummeting and cutting back on foods that contain dyes and excess sugar. Several studies have suggested that artificial food coloring and sugar may cause increased hyperactivity in some children with ADHD. —K.B.

ADHD Exercise: A Med Without Side Effects

For ADHD adults and parents of children with ADD/ADHD, physical activity may be good for focus. Plus, it’s inexpensive, self-prescribed, and accessible to everyone.

"Think of exercise as medication,” says John Ratey, M.D., an associate clinical professor of psychiatry at Harvard Medical School. “For a very small handful of people with ADHD, it may actually be a replacement for stimulants, but, for most, it’s complementary — something they should absolutely do, along with taking meds, to help increase attention and improve mood.”

While most of us focus on exercise as a way to trim our waistlines, the better news is that routine physical activity firms up the brain. “Exercise turns on the attention system, the so-called executive functions — sequencing, working memory, prioritizing, inhibiting, and sustaining attention,” says Ratey, author of the forthcoming Spark: The Revolutionary New Science of Exercise and the Brain (Little, Brown). “On a practical level, it causes kids to be less impulsive, which makes them more primed to learn.”

The latest news about exercise is that it helps kids push through past failures and attack things they didn’t succeed at before. “The refrain of many ADHD kids is, ‘No matter what I do, I’m going to fail,’” says Ratey. “Rat studies show that exercise reduces learned helplessness. In fact, if you’re aerobically fit, the less likely you are to learn helplessness.”

So how, exactly, does exercise deliver these benefits to the ADHD brain? When you walk, run, or do a set of jumping jacks or pushups, your brain releases several important chemicals.

Endorphins, for one, hormone-like compounds that regulate mood, pleasure, and pain. That same burst of activity also elevates the brain’s dopamine, norepinephrine, and serotonin levels. These brain chemicals affect focus and attention, which are in short supply in those with ADHD. “When you increase dopamine levels, you increase the attention system’s ability to be regular and consistent, which has many good effects,” explains Ratey, like reducing the craving for new stimuli and increasing alertness.

You don’t have to be a marathoner, or even a runner, to derive benefits from exercise. Walking for 30 minutes, four times a week, will do the trick. “Get your child involved in something that he finds fun, so he will stick with it,” suggests Ratey. Team activities or exercise with a social component are especially beneficial.

Studies have also found that tae kwon do, ballet, and gymnastics, in which you have to pay close attention to body movements, tax the attention system. “A very good thing for kids and adolescents with ADHD,” says Ratey.

More schools are including exercise in their curricula to help kids do better in the classroom. A school in Colorado starts off students’ days with 20 minutes of aerobic exercise to increase alertness. If they act up in class, they aren’t given time-outs but time-ins — 10 minutes of activity on a stationary bike or an elliptical trainer. “The result is that kids realize they can regulate their mood and attention through exercise,” says Ratey. “That’s empowering.” —ADDitude editors

ADHD Working Memory: Programmed for Success

Software designed to increase working memory may improve attention and decrease hyperactivity.

One complaint about complementary therapies is that there are no controlled studies to support their claims. Not so with working-memory training, which was developed by a company called Cogmed, in conjunction with the Karolinska Institute, a medical university based in Stockholm. A 2005 study conducted by the institute showed that five weeks of therapy reduced symptoms of inattention and hyperactivity in children. An uncontrolled study, published earlier this year by the University of Notre Dame, found similar results. ADDitude talked with Bradley Gibson, Ph.D., lead author of the Notre Dame study, and Barbara Ingersoll, Ph.D., a clinical associate professor in West Virginia University’s department of behavioral medicine and psychiatry and a Cogmed trainer, to find out how the program works.

What is working memory? It’s the ability to hold onto information long enough to accomplish a specific goal. You hold a phone number in your mind as you dial it, or you hold a task in mind — organizing your room, say — as you work on it. We use working memory throughout the course of a day.

How does improving his working memory help a child become more focused? When you improve working memory, you improve fluid IQ — the ability to solve problems or adapt to situations as they occur. Most kids who complete memory training become more alert to their surroundings. They are also more aware of social cues. Parents often report that their kids become more “mature.” They take charge of their hygiene and do chores without being nagged. They remember to bring books and materials to and from school.

How does Cogmed working-memory training work? A child logs on to the working-memory program, which is downloaded on his home computer. He completes eight exercises, each consisting of 15 trials. The exercises are in a video game format — with colorful graphics and crisp sound. In one exercise, he shoots down floating asteroids; in another, he recalls numbers in the reverse order in which they are given; in another, he remembers the sequence in which rows of lights turn on. The child uses his computer mouse to punch in the answers — and earns points along the way. The program stays a step ahead of the child’s ability, making exercises increasingly harder. A trainer calls once a week to talk with the parents, troubleshoot, and encourage the child.

Does the training work as well with girls as with boys, for both children and adults? It has been successful with young and old, and with both sexes. The training is rigorous, so few children under seven can stick with it. Children who have recently been diagnosed with ADHD should have their medication titrated before beginning training.

How long is the training, and how much does it cost? The training runs five weeks, five days a week, an hour a day. It ranges in price from $1,500 to $2,000, and it is not covered by most medical insurance plans.

What percentage of kids show improvement after the training? About 75 to 80 percent of kids show improvement — that is, inattention and hyperactivity are reduced. Karolinska Institute researchers did functional MRIs of the children they studied. The MRIs showed physical changes in the brain’s pre-frontal and parietal regions after completing the training. At six-month and one-year follow-ups, about 80 percent of subjects maintained their working-memory gains or improved on them.

Are there any side effects? There have been no observed side effects. It doesn’t affect other therapies. Most kids who participate in the program are on ADHD medication.

Is working-memory training a substitute for medication? The program does not claim to replace medication. While many kids get good results on meds, drugs don’t usually manage all symptoms. Improving working memory can address those problems. —ADDitude editors

This article comes from the December/January 2008 issue of ADDitude.

To read this issue of ADDitude in full, purchase the back issue and SUBSCRIBE NOW to ensure you don't miss another issue.