ADHD and Neurofeedback

Until recently, there have been no well-done studies on the use of neurofeedback for ADHD. However, the January 2005 edition of, "Child and Adolescent Psychiatric Clinics of North America," had an excellent review in the article, "Elelectroencephalographic Biofeedback (Neurotherapy) as a Treatment for Attention Deficit Hyperactivity Disorder: Rationale and Empirical Foundation," by Vincent Monastra.

Although there have been many single case studies, there have now been four controlled group studies. Response was comparable to response to medications, with about 75% responding positively. Approximately 50 - 80 % of responders to neurofeedback were able to reduce (not stop) their medications.

While neurofeedback is more enduring, with decreased symptoms persisting much longer after discontinuation of treatment than after discontinuation of medications, it is not "permanent," and many people return for intermittent "booster" sessions.

Just as with the use of medications, the children who did the best were part of a comprehensive treatment program that included nutritional counseling, medications, parent counseling to improve parenting skills and improve social functioning at home, individual educational plans with the schools, and social skills training. Neurofeedback or medications should be just one small part of a comprehensive treatment plan.

I have an associate who is an ADHD expert and uses neurofeedback. We sometimes share patients. My impressions are that if someone is cooperative with it (all children aren't) and complete the required number of sessions, that about 70% have some response. However, as with medications, a certain percentage don't respond, and of those that do it might be a small, medium, or significant response. Those with a minimal or moderate response often respond better to the combination of a medication and neurofeedback.

There are other new treatments that are promising but not yet proven. Cerebellar stimulation, such as with the Interactive Metronome, is promising, and we're learning that the cerebellum is more involved with ADHD than once believed. Some studies show that omega-3 fatty acids help, while others don't, and the same is true for antioxidants such as super blue-green algae. Dr. Hallowell's new book, "Delivered from Distraction," addresses many of these treatments.

If you want to try neurofeedback yourself, I believe there is a home version available.

Related Topics: Vitamins for ADHD?, Effects of ADHD Treatment May Vary Over Time

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Side Effects, Strattera and Stimulants: The Differences

Strattera

Strattera and imipramine increase norepinephrine in contrast to stimulants that increase dopamine, and potential effectiveness and side effects varies widely between norepinephrine and dopamine drugs.

Imipramine is often more effective for hyperactivity and impulsivity than for inattention and distractibility, but only works in about 50% of children and very high doses are often required. High doses are related to cardiac side effects in children, as well as often severe sedation and other side effects.

Strattera is generally well-tolerated and has a much greater chance of treating AD/HD. However, unless started at very low doses and then increased only very slowly, many children experience sedation and lethargy. I generally start children on 10 mg doses of Strattera, then after at least a week, increase the dose to 10 mg AM and 10 mg around 4 PM.

Splitting the daily dose into two doses decreases side effects and allows tolerance to side effects to develop. Someone weighing 105 pounds might require up to 60 mg/day of Strattera for it to be effective, but I'd take 4 - 6 weeks to slowly work up to that dose and continue to split the dose into two doses as long as there were side effects. If sedation continues to be an issue, often 1/3 - 1/2 of the total daily dose can be given an hour or so before bedtime, which will improve sleep.

Stimulants

If someone is sensitive to stimulant medications, I never start with longer-acting preparations. Concerta is equivalent to taking three doses of short-acting Ritalin per day, and Metadate CD is equivalent to taking two doses per day (although 1/3 of the dose is released immediately and 2/3 three hours later).

Generally, overfocused behavior is related to too high of a dose of medication. In very young children, or in children who have been sensitive to side effects, I'd prefer to start with one small dose of a medication once per day.

Of the stimulants similar to methylphenidate or Ritalin, Focalin is often the best tolerated, so I might start a child on 2 1/2 mg (occasionally half that dose) once per day, and after a week try adding a second dose about 4 hours later. If you can slowly work up to a therapeutic dose without side effects, I might then change to Focalin XR, which is an eight hour preparation.

If not effective or not tolerated, I'd start with extremely low doses of short-acting Adderall. The bottom line is "starting low and going slow" with the hope of tolerance developing to irritating side effects. Sometimes, combinations of medications need to be used for people who are extremely sensitive to side effects.

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"Long-Acting" Stimulants

In reality, there is no such thing as a "long-acting stimulant." Almost all stimulants are short-acting, including caffeine, nicotine, cocaine, Ritalin, or Adderall.

However, manufacturers put short-acting stimulants in various containers (capsules or tablets) that release short-acting medication two or more times a day. Essentially you're getting the same old wine in a different bottle.

The Concerta container is much like a capsule with three chambers, two containing methylphenidate (Ritalin) and one an absorbent material. There are laser-drilled holes in the container. As liquid from your GI tract is absorbed into the container, an osmotic plunger pushes the medication out of the holes.

Ritalin LA is a capsule that contains beads, half with a coating that dissolves immediately and half with a coating that dissolves four hours later. Short-acting Ritalin is contained within the beads. Adderall XR uses the same bead technology as Ritalin LA.

Although longer-acting preparations contain the same medication as shorter-acting preparations, some people prefer short-acting medications. They are digested and absorbed quicker with a more rapid increase in blood levels. Some people prefer the way they "feel" the medication "kicking in," and don't "notice" the "smoother" longer-acting medications "kicking in" and "wearing off."

Related Topics: Reducing Side Effects of ADHD Medications, Once-a-Day Concerta: Less Abuse Risk?

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