The Amen Approach to ADHD
Dr. Daniel Amen, author of “Healing ADD,” talks about his methods for diagnosing ADHD, his controversial use of SPECT scanning, and the “seven types of ADD.”
Daniel Amen, a double-board-certified psychiatrist and best-selling author, is perhaps America’s most in-demand psychiatrist. His methods, however, are frowned upon by some of his peers. As the founder and medical director of Amen Clinics, with six clinics coast to coast, Dr. Amen’s approach revolves around his controversial system called SPECT, or single-photon emission computed tomography, which tracks blood flow in the brain and shows areas of high and low activity. Amen says two scans — one taken at rest and one taken after a concentration test — along with a series of questionnaires and a clinical history, can paint an accurate picture of a person who has ADD. Amen claims his brand of psychiatry gives hope to those who have tried and failed with everything else.
“One of the biggest lessons I’ve learned through SPECT scanning is that ADD is not a single or simple disorder,” says Amen. “One treatment does not fit everyone with the condition.”
ADDitude caught up with Dr. Amen recently to ask him about his novel approach to diagnosing and treating ADD.
When you boil it down, can ADD be healed?
There’s a specific reason the book is called Healing ADD. I’ve gotten a fair amount of grief for the title. It’s like, “Oh, you can’t cure ADD.” The book isn’t called “ADD Cure.” Healing is a process. It’s like my new program, Healing ADD At Home in 30 Days. If you do the things that I ask, you are going to be feeling – or your child is going to be feeling — so much better in 30 days that you’re going to keep doing those things. It’s not the “ADD cure,” but it’s a process of making things better, which is the definition of healing.
When did your first learn about SPECT scans and why do you think they play such an important role in treating ADHD?
I went to my first lecture on brain SPECT imaging in 1991. SPECT looks at blood flow and activity in the brain. It looks at how the brain works. It shows us three things: areas of the brain that work well, areas of the brain that are low in activity, and areas of the brain that are high in activity.
I had been doing quantitative EEG before I started doing SPECT scans. We saw on our quantitative EEG studies that when people with ADD tried to concentrate, they got a surge of slow-wave activity in their frontal lobes — the harder they tried to concentrate, the worse things got for them.
After that first SPECT lecture, I headed to a hospital room where one of my patients named Sally was staying. She had tried to kill herself the night before. I was absolutely convinced she had ADD.
Sally had a son who had ADD. She was bright, but never finished college. She was disorganized and sought out conflicts. Sally didn’t believe in ADD and didn’t want to take the medication that I recommended for her. So, I said, “How about if I scan you?” And she said, “OK.”
Several days later, when I put the scans on the table in her hospital room, she started to cry. She said, “You mean it’s not my fault?” I said, “Yes. Having ADD is just like people who need glasses. People who need glasses aren’t dumb, crazy, or stupid; their eyeballs are shaped funny. They need help getting focused.” When she got it, she started, and stuck with, treatment and got better.
How is an MRI different than a SPECT scan?
An MRI is an anatomy study. It shows what the brain physically looks like. SPECT is a nuclear medicine study that looks at blood flow and activity in the brain. It’s a functional study. To put it in concrete terms, an MRI shows you what the car engine physically looks like. The SPECT scan shows you how it works when you turn the engine on.
The hardest part about getting the SPECT scan is that it requires inserting a little tiny needle in a vein in your arm and injecting medicine into your arm that helps light up the brain when it is being scanned. It gives us beautiful 3D images of the brain.
How expensive is a SPECT scan, and does insurance cover it?
The cost of an evaluation at the Amen Clinics, which includes five different steps, is about $3,700. The cost of an individual SPECT scan is about $1,300. Insurance companies don’t cover it because they categorize attention deficit as a behavior problem. They don’t see it as a brain problem.
How many scans have you done to arrive at your ADD types?
At the Amen Clinics we’ve done nearly 87,000 SPECT scans on patients from 111 countries. These types aren’t something I thought up after seeing 50 patients at a research center. We do this every day. We find that when we know the ADD type, the right treatment can be helpful.
What did you learn from doing all those scans?
One of the most important early lessons I learned from SPECT imaging is that all psychiatric illnesses — ADD, anxiety, mood disorders, addictions, autism, schizophrenia, bipolar disorder, PTSD — are not single or simple disorders in the brain. They all have multiple types.
If we look at two different patients who have ADD, one may have low activity in their brain, the other high activity. Do you think they’ll both respond to the same treatment? No. The low-activity types tend to do better with stimulants. People with high activity in their brains often do worse with stimulants. So, over time, I realized I could break all of these scans down into different types of ADD.
It was around 2001 when I wrote my book Healing ADD, in which I talked about six different types of ADD. I just published the newly revised version of the book and added a seventh type. When you know the ADD type, you can target treatment specifically to that symptom cluster.
Tell us about the seven types of ADHD.
They are called Classic ADD, Inattentive ADD, Over-Focused ADD, Temporal Lobe ADD, Limbic ADD, Ring of Fire ADD, Anxious ADD. When I explain each type, keep in mind that my thinking centers on three different neurotransmitters in the brain: dopamine, which helps with focus and motivation; serotonin, which is involved in sleep, mood, and shifting attention; and GABA, which helps calm the brain.
I call the first type Classic ADD. This is what most people think of when they think of ADHD. Just as a side note, I hate the term ADHD. I hated it when the DSM-III-R changed it from ADD to ADHD. My reason? Most people who have this type aren’t hyperactive. So, why would a book for professionals highlight something that doesn’t include hyperactivity?
The symptoms of Classic ADD are short attention span, distractibility, disorganization, procrastination, and poor impulse control. I think those are actually the five symptoms that are hallmarks of all the different types of ADD. But, in addition, the patient is restless and hyperactive. They can’t sit still.
When a person with Classic ADD tries to concentrate, he has decreased, not increased, activity in the front part of his brain, especially in an area called the inferior orbital prefrontal cortex. This is statistically significant. It’s probably the most important finding that we see on SPECT scans in all of the ADD types, except for the Ring of Fire, which I’ll talk about later.
What treatment works for Classic ADD?
The treatment goal for this type of ADD is to boost dopamine. You can do it either with stimulating medications — Ritalin, Adderall, Vyvanse, Concerta — or stimulating supplements, like rhodiola, green tea, ginseng, and L-Tyrosine. In the last 15 years, I’ve become much more interested in using natural supplements to optimize brain function because medicines can have side effects and can be toxic. Exercise also helps with ADD. In addition, we put almost everybody at the Amen Clinics on an elimination diet. A higher-protein diet is very important. We have them take fish oil, but a very specific kind of fish oil that’s higher in EPA than DHA. People think of DHA as helping the brain, but DHA does not work for ADD patients. It doesn’t work on depression either.
What about the second type of ADD? How do the symptoms differ from those of Classic ADD?
We call it Inattentive ADD. In fact, the first two types have been described in the DSM since 1980. People with this type have the hallmark symptoms of ADD —short attention span, distractibility, disorganization, and procrastination — but they’re not hyperactive or terribly impulsive. They are more introverted. It tends to be more common in girls, who are often not diagnosed until later because they have fewer behavior problems. It’s also associated with low activity in the prefrontal cortex.
Take my daughter Brianne. I always feel bad when I tell this story. She’s beautiful, sweet, and cooperative. She’s a great kid. But the truth is, I never thought she was very smart. I hate saying that, but that’s what I thought. I’d have to teach her the same thing over and over again. It took her a long time to do homework. She didn’t hold on to concepts well.
In third grade, I brought her to a colleague of mine. She tested Brianne for learning disabilities. The tests were negative. She said that Brianne was not very smart — she tested with an IQ of around 90-and added, “You have high expectations for her because you are a high achiever.”
She said that Brianne would be OK because she overcame challenges by working hard. In tenth grade, Brianne became depressed because she stayed up every night until 1 or 2 in the morning to get her homework done. She came to me one night in tears and said, “Dad, I don’t think I can ever be as smart as my friends.” Her words broke my heart. When I scanned her, I saw that she had low activity in her brain.
I put her on ADHD medication the next day and she seemed better. Within a week, Brianne noticed a huge difference in her ability to get through school. Three months later, she brought home straight A’s for the first time in her life. For the next 10 years, she was a straight-A student. She got into the University of Edinburgh’s veterinary school, the best veterinarian school in the world.
We treat Inattentive ADD the same way we treat Classic ADD-boosting dopamine, switching to a higher protein diet, using stimulating supplements or medication.
I think most people are aware of the first two types. What about the third?
I call it Over-Focused ADD. I learned about this through my work with children and grandchildren of alcoholics. With this type, there’s too much activity in an area of the brain called the anterior cingulate gyrus. The cingulate gyrus is the brain’s gear-shifter. It allows you to move from thought to thought, idea to idea, to be flexible. This group of patients experiences too much activity in the anterior cingulate and too little activity in the underside of the frontal lobe. This group has low levels of both serotonin and dopamine.
When we balance both neurotransmitters, patients do amazingly well. The hallmark symptoms of this ADD type are difficulty with shifting attention, along with many of the core symptoms of Classic ADD.
As I said, the cingulate gyrus is the brain’s gear-shifter. It allows you to go with the flow. It is also involved in error detection. In other words, it helps you know when something is wrong. When the cingulate gyrus works too hard, a person gets stuck. He or she worries and holds grudges. If things don’t go their way, they get upset. They tend to be argumentative, oppositional, and see all kinds of things wrong in situations and people.
The treatment for this type is not ADHD stimulants, which, when taken by themselves, usually make a person more anxious and worried. We use supplements or medications that boost both serotonin and dopamine. Serotonin-boosting supplements include 5-HTP, saffron, L-Tryptophan, and inositol. When we use medications, we use selective serotonin reuptake inhibitors (SSRIs). People with Over-Focused ADD do not do well on a high-protein diet. It will make them mean. Adapting a person’s diet to his specific type of ADD is important.
What are Ring of Fire ADD and Temporal Lobe ADD?
One of the most important contributions I think I’ve made to this whole ADD thing is defining Ring of Fire ADD and Temporal Lobe ADD. Your temporal lobes are located underneath your temples and behind your eyes. The scans indicate that the activity in these lobes is very low in some patients who have ADD. So people with Temporal Lobe ADD have Classic ADD symptoms, plus TL symptoms. This group has learning and memory problems, mood instability, irritability, and temper problems. They may hear or see things that aren’t there.
I saw this in Chris, a 12-year old boy diagnosed with ADD when he was six. He was put on Ritalin. It caused him to hallucinate. At eight years old, he attacked another child. He was put on Desipramine, an antidepressant. It made him worse. Then he attacked another kid at 12. When we scanned Chris, he had low activity in his temporal lobes and his frontal lobes. I put him on an anti-seizure medicine. It stabilized his temper problems. I also put him on a stimulant. The combination of medications stabilized Chris. He was headed for jail and juvenile hall for hurting someone else or himself. This treatment turned him around.
The treatment goal for this type of ADD is supplements or medications to boost GABA, which stabilizes the temporal lobes. After that, I prescribe a medication to boost dopamine. This ADD type also does well on a higher protein diet and healthy fats.
It seems like most people do well with higher-protein/healthy fat diets, except for the Over-Focused type. What about the fourth type of ADD?
The next type is called Limbic ADD, a combination of dysthymia, or chronic low-level sadness, and ADD. People with this type have too much activity in the limbic, or emotional, part of the brain and low activity in their frontal lobes. We treat this type with stimulating supplements like SAM-e or medications like Wellbutrin to boost the brain and enhance mood. We also highly recommend exercise, fish oil, and diet to help.
Ring of Fire ADD didn’t fit my preconceived notion about ADD, which is low activity in the brain. With this type, the entire brain is overactive. Eight times out of ten, patients with this type do worse on stimulants. They tend to be moody, easily distracted, and have too many thoughts. It’s like ADHD plus. They tend to be overly sensitive to lights, sounds, and touch.
Jared is a classic Ring of Fire patient. He was diagnosed with ADD at two, was prescribed six different stimulants, all of which made him worse. He had social problems, behavioral problems, and learning problems. At 12, the doctor was going to put him on an antipsychotic, but his mother brought him to see me. We did a scan, and he was indeed a Ring of Fire type. We put him on a combination of GABA and serotonin and L-Tyrosine. It made a big difference in his life.
It’s important to know that Ring of Fire ADD may be caused by allergies, inflammation, or an infection. At the Amen Clinics, we put patients on an elimination diet with the Ring of Fire type, to see if allergies may be involved. We prescribe supplements or medications that boost both GABA and serotonin.
The last type is Anxious ADD. A patient with this type has the hallmark symptoms of ADD, plus he is anxious, tense, nervous, hates speaking in public, and freezes on timed tasks. This person has too much activity in an area of the brain called the basal ganglia.
At the clinic we use deep relaxation techniques and also boost GABA and dopamine. Hypnosis, meditation, and biofeedback can be helpful. Stimulants alone usually make a patient with this type more anxious.
Can you have more than one type of ADD at the same time? Can you have a combination? Can you move from one type to another?
It’s very common to have more than one type. You could be Over-Focused, Limbic, and Anxious, say. In Healing ADD I talk about what you should do when you have more than one type.
If you have this trio of ADD types, I would treat the Over-Focused type first because the serotonin and dopamine together will help Over-Focused symptoms, as well as the Limbic symptoms. Odds are increased serotonin will also help the Anxious symptoms. You do it in steps. I talk about that in the book.
There’s a new type of ADD showing up in the research. Russell Barkley calls it Concentration Deficit Disorder. Is that a different type, or do you think that’s one of your seven types renamed?
It sounds like Inattentive ADD. When you look at someone’s brain who has CDD, they often have low activity in the cerebellum and the frontal lobe. One of the big things that almost all of these researchers never talk about is the cerebellum. SPECT scans show that it is often a troubled part of the brain.
There’s a treatment called Interactive Metronome that I really like Interactive Metronome. If I see low activity in the cerebellum, I always recommend coordination exercises, dancing, table tennis, and Interactive Metronome training because they can activate the cerebellum, which is connected to the frontal lobes. Keeping your cerebellum healthy is important.
You use supplements a lot in treating the seven types of ADD. Can you give specifics about them?
I’m a big fan of omega-3 fatty acids. When researchers have specifically looked at ADD and omega-3, the EPA component has worked better for ADD than the DHA component. EPA tends to be more stimulating. DHA tends to be more sedating. I’m not a fan of flaxseed oil. It doesn’t give you EPA and DHA. It gives you ALA. You have to take 10 times the level of flaxseed oil to get the same benefit as you do from taking fish oil.
GABA is an inhibitory neurotransmitter, which means it settles things down. It helps with Ring of Fire ADD, Anxious ADD, and the Temporal Lobe type. It not only settles things down, it helps to stabilize the iring of nerve cells. One of my favorite medications for doing this is Neurontin. Its generic name is gabapentin. The reason I get excited about supplements is that, after reviewing thousands of SPECT scans, I saw that some medications hurt brain function.
What’s the best kind of fish oil to take and what is the ideal ratio of EPA to DHA?
The ratio should be 60/40, EPA to DHA. I think kids should take 1-2 grams of fish oil daily with that 60/40 ratio and adults 3-4 grams. We have our own brand, so I’m biased. But some other brands I like. I like Coromega. It tastes like orange pudding, so it’s easy to take. It’s sweetened with Stevia. Barleans makes an omega swirl that tastes really good. Ours is called Omega-3 Power.
One caveat: Why bother taking fish oil if you feed your children like crap? It’s critical to eat a super-healthy diet because your brain is the most energy-hungry organ in your body. Your brain uses 25 percent of the calories you consume. So, if you’re on a fast-food diet, you are going to have a fast-food mind.
In relation to diet, you mentioned an elimination diet early on. What is that exactly?
Basically, you get rid of the foods that hurt you and eat the things that can help you. At the Amen Clinic we put people on an elimination diet for three weeks. You can’t have sugar, corn, dairy, soy, wheat. A cheese pizza is out. If you’re thinking, “Oh, I can’t eat anything, then,” I say, “No, there are a whole bunch of great things you can eat.” It’s just amazing how many adults and kids feel better when they eliminate foods that contain dairy, wheat, corn, soy, or sugar.
Dr. Sandy Newmark, a contributor to ADDitude, believes that checking the iron and zinc levels in kids with ADD is a good idea. What do you think?
I totally agree with him because iron and zinc make dopamine. If your iron levels are low, you’re not going to make enough dopamine. If zinc levels are low, you’re not going to make enough dopamine. We take a detailed history of a patient at the Amen Clinic. People fill out 25 pages of information when they come to see us-biological information, psychological information, social information (“Who do you hang out with?”), and spiritual information (“Why do you care?”), and a battery of lab tests. Zinc and iron will be part of that, but so will thyroid hormone and vitamin D levels. And then we put it all together and give you a very specific diagnosis and targeted treatment for your brain. We don’t stop there. We outline brain-healthy habits — things like diet and exercise, developing certain thinking skills, and so on.
One of the things I want to say about ADD is that a lot of people with the condition who show low activity in their frontal lobes do a lot of things to turn themselves on. They seek conflict, excitement, and drama. I saw this in my daughter Kaitlyn. When she was two years old, she’d run up to her brother and kick him as hard as she could. If he didn’t chase her, she would kick him again. She was clearly seeking the fight. Teenage girls with ADD are often drama — driven in their relationships. They fall in love, fight, breakup, sometimes try to kill themselves. They love scary movies.
Many people with ADD use negative thoughts, even horrible thoughts, to stimulate themselves. If I have a loving thought about my wife, it’s nice. But if I have a hateful thought about her, that stimulates my frontal lobes. Unfortunately, many people with ADD who are untreated, head toward those awful, terrible thoughts and they start fights for no reason. Learning how to get rid of the automatic negative thoughts that pop up in the ADD brain is important.
Is there a specific age that is ideal for SPECT scanning?
When it comes to ADD, 30 percent of two-year-olds look like they have ADD, but only 5-10 percent of four-year-olds do. I tend not to diagnose ADD before four unless it’s rampant in the family. I’ll prescribe exercise, diet, and fish oil, though. Six or seven years of age is when we typically start scanning kids, unless they’re violent and aggressive. In that case, we’ll scan at four years of age.
For those of us not living near an Amen Clinic, are there neurologists or doctors around the country who use SPECT scanning?
There are SPECT cameras at every major hospital in the world because they are used to look at hearts, bones, lungs, and so on. There’s probably a group of about 15 of us around the country and Canada who use SPECT scans. There are groups in Toronto and Vancouver. There’s a group in Chicago and then there are my six clinics — three on each coast.
If you do not live near one of these groups, I developed a “Healing ADD Brain Type Questionnaire” that helps predict what your type might be. If you can’t afford to get a scan — and I’m always very sensitive to that because I want my work to help as many people as possible — the questionnaire is valuable.
Any last stories about how your treatment techniques have helped those with ADD?
Yes. I have so many stories. I had one 15-year-old girl who was suicidal. She cut herself and was failing in school. Her parents were about to send her away to get residential treatment. They heard about my work, and I met with her. When she tried to concentrate, her brain’s activity levels slowed down. She tested with an IQ of 90. She attended a demanding college prep school and was failing just about every course. When I balanced her brain, she did much better.
The follow-up scan showed that her brain was in better shape after treatment. But it wasn’t as good as I wanted, so I made another adjustment. It made her more emotionally stable. This is what I live for.