HOW TO TREAT ADHD
Changing the brain and mind of persons with ADHD (affecting the core symptoms)
Medication given for ADD/ADHD includes stimulants (Ritalin = methylphenidate, Adderall = amphetamine, etc.), so-called non-stimulants such as Strattera, and channel blockers like Intunive. Perhaps 60-70% of patients respond, though the effect is usually partial. Some brain types (phenotypes) respond to antidepressants or antiseizure medication and may get worse with stimulants.
Mindfulness of attention/inattention, a mental practice, has been shown to have an effect on the brain (using neuroimaging techniques like fMRI and PET). Studies of Buddhist monks who have practiced for years shows enormous changes in brain waves, with greatly increased “gamma” (fast activity from 30-80 cycles per second). Transcendental Meditation (TM), although not taught in our clinic, also has evidence of effectiveness for ADHD.
Neurofeedback, or training of brainwaves via a brain-computer interface, has considerable empirical evidence of effectiveness. While older approaches are better researched, they require more sessions (perhaps 40 or more); newer techniques like z score neurofeedback, utilizing 19 channel EEG, seem to be faster. Brain waves are assessed via QEEG, 1 or 19 channel EEG, to guide practice in training brain levels of activation and cortical communication. See David Rabiner’s 2014 very positive review of two recent studies on neurofeedback for ADHD here .
Frontal lobe temperature (HEG) is another variable that can be controlled with effects on the functioning of the brain. Jeff Carmen, in particular, has pioneered this practice which he first used for migraine headaches and then extended to ADHD and other conditions. Some years ago, Jeff published a series of 100 migraines treated with HEG. Over 90% showed significant improvement in an average of 6 sessions. The practice has also been found to work with ADHD and other disorders of frontal or executive function.
Working memory training has been researched intensively over the past twenty years. Because problems with working memory are characteristic of many (though not all) ADHD clients, this is an important area to assess and treat. Research is best for Cogmed (cogmed.com), with some evidence for Brain HQ (brainhq.com), and Lumosity (lumosity.com), though there are many other techniques. Generally both verbal and visual-spatial working memory are trained.
Psychotherapy to address depression or helplessness is used when needed, and is based on mindfulness and cognitive behavioral approaches, for instance practicing a more rational and less catastrophic attitude toward one’s condition. Dreamwork is frequently used in our clinic, along with short-term depth psychological techniques based on art therapy, sandplay, and therapeutic writing.
Cultural psychotherapy to address the image of moral inferiority projected onto individuals with ADHD is always part of our approach to ADHD. The cultural significance of ADHD is rapidly changing at the present moment due to its association with the “normal” situation of electronic overload. See our PowerPoint presentation.
Changing the person’s secondary symptoms (affecting the consequences of ADHD)
Mindfulness for stress/anxiety is very frequently called for, and becomes more important the older the client has become. It appears that, although compensatory skills are gained in living with ADHD, the stress of coping with the condition increases with age, perhaps as our basic neurological capacity declines after the twenties. Nevertheless, it is possible to regain much that we lose with ageing, and the stress response in particular can be reduced via learning and practice. Here, breathing practices and peripheral biofeedback are important, and may need to be practiced more than before. Both HRV breathing and other sorts of biofeedback (e.g., thermal or hand warming biofeedback) are employed.
Altering the home and school environment to improve ADHD symptoms
It is our view that ADHD must be treated on several levels. One of these is altering the environment to provide a more optimal level of external guidance, and to reduce blaming the child or adult with ADHD for their symptoms. In cases where the environment is unable or unwilling to change on its own it may be necessary for the ADHD individual or their family to intervene on their behalf.
Home.
The first and most essential part of parenting children with ADHD is to understand that “ADHD is a disorder of self-regulation with disturbance of executive functions and motivation.” It is not, in essence, a moral disorder—laziness or irresponsibility—though ADHDers can also show moral disabilities just like anybody else. It is essential to recognize the neuropsychological differences these children carry and to discriminate them from freely chosen transgressions (for which all children have to learn responsibility). As Werner van den Berg points out, “parents of children with ADHD who are better able to understand” this basic fact about the brain “adhere better to the treatment following . . . neurobiological assessment” like the one done in our clinic and described above.
It will be necessary to give ADHD children “accommodations” at home similar to the ones mandated by the law for the school system. Because these children have difficulty keeping themselves focused on even rather short-term goals, it is usually best not to give too many instructions at the same time. Input through more than one modality (e.g., both verbally and in writing), and having the child repeat the tasks out loud, will often help. Giving breaks more frequently is necessary, and having the child check off completed tasks on a chores chart will increase their percentage of completion. A clear and well understood daily organization of activities, with not too many things packed into too little time, is beneficial. Especially around homework and bedtime it is essential to have a clear structure including the times of various activities, when they end, and how parents can know that they were accomplished. For homework, we recommend doing it in the same place and same time each day, and for the same number of minutes at a minimum. One way to improve attention to the process of doing homework is to use a stopwatch, starting it when an assignment is begun, then stopping when the child notices distraction, stops for a break, etc., and starting the watch again as focused work resumes. The total working time for each subject is written by the child on a sheet that we provide and initialed daily by a parent. Bedtime, likewise, involves a ritual starting at the same time daily and involving a relaxation component like slow breathing, enjoyable activities like reading or storytelling, and lights out at a well-known, predetermined, time.
School.
Some teachers—often those with ADHD in their own families—are quite knowledgeable about ADHD and are already prepared to give accommodations to help these children succeed. Others fall into our culture’s all-too-prevalent tendency to blame ADHD children for laziness or unwillingness to take responsibility for their behavior. When they fail to turn in homework that is in their backpack, such teachers may refuse to accept it—often crumpled and with no name—when the student eventually remembers it the next day or the next week. The thought is that the child simply hasn’t accepted the rules or doesn’t take them seriously enough. It is appropriate to punish them by giving a zero on the work because this will teach them to try harder next time. But for children with ADHD the shame and sense of inferiority that this approach entails will be all too familiar and the impossibility of correcting it by an act of will is deeply understood. As in the home, more supportive structures in the school environment must be installed. This is where a “504 Plan” or “IEP” (individualized education program) come in. Mandated by two separate federal laws (ADA = “Americans with disabilities act” and IDEA), it is incumbent on schools to modify requirements and educational practices for students with ADHD and other differences. Extra time for tests and assignments, minimizing distractions, and making sure assignments are written down and turned in are only a few such accommodations.
Culture and society.
The final modification of environment is one that parents, school, and the child him/herself must cooperate in asserting. This is the ability to resist stereotyping or bullying by those who would blame persons with ADHD for a failure of ethics or socially appropriate manners. Children with ADHD can be difficult to live with, and peers and adults alike tend to blame them for their differences and punish them when they do not act as they are expected. ADHDers need to learn to stand up for themselves, not to put themselves down for having ADHD but rather to be proud of their differences to the extent that they may be beneficial (e.g., capability for hyperfocus when interested, creativity, enthusiasm over new challenges) and to claim their entitlement to receive help in overcoming the symptoms that get in the way of success (distractibility, etc.).
ADHD, culture, and electronic technology
Cultural training for parents and teachers is fundamental, and it is particularly essential to help adults to distinguish between the stereotyping laid on individuals with ADHD (similar to sexism and racism) and the pervasive sense of inadequacy we all share when forced by technological demands into being like persons with attention deficits: unable to keep up with too much data. The demands on attention are enormous for almost everybody living in the wired world, and it is natural to “turn passive into active” by blaming ourselves for being unequal to the challenge. The image of data-driven, overworked Internet slaves unable to escape the demands of our iPhone has gotten confounded with the picture of ADDers incapable of organizing even modest demands for remembering, resisting distraction, and finishing tasks on time. Our sense of inadequacy over not being able to keep up makes it all too easy to project our negative self appraisals onto those with ADHD, who appear even more morally challenged than ourselves. We must separate our technological circumstances from the biological fate of those who have “real” ADHD, although some of the treatments for ADHD may turn out to be the same as ways to cope with our cultural stress.
Treating concomitants and consequences of ADHD/ADD
Because of the profound life challenges the condition entails, mood and affect treatments (Cognitive Behavioral Therapy, Heart Rate Variability breathing, mindful attention, psychotherapy) are needed for most with ADHD or ADD. Because people with ADHD are like everyone in most respects, we frequently add short term dynamic psychotherapy or Jungian analysis (looking at early life, imaginations and fantasies, one’s life story, dreams, etc.) In parallel, skill building of two sorts is necessary. On the one hand, training in “metapsychological” skills aims to enhance consciousness of what is going on in the mind and brain so that unhelpful behaviors can be identified and resisted, and better ones put in their place. The basic skill, as we see it, is “mindfulness” (also termed “mindful awareness”), the capability to witness one’s mind/body, and especially ADHD symptoms—without emotional reaction, to accept its quirks while (somewhat paradoxically) also being able to release oneself from them and choose to do something better.
Study skills are important for all students, but for those with ADHD they are particularly crucial. A set of four basic techniques should be taught and practiced. 1. Active learning rather than passive absorption of material. Repeating information being learned to oneself in other terms, mind-mapping, multisensory learning, are all helpful. 2. One of the most helpful practices is to make regular use of self testing. Each study session ideally will involve assessing one’s mastery and relearning when testing shows deficits. 3. Distributed practice, i.e., learning every day for regular periods of time, and preferably at the same time and in the same place. Waiting until the last night (or even last weekend) to cram material into one’s frightened brain is the worst way to learn. 4. Metacognitive skills, i.e., a general attitude of self-monitoring or taking a step away from oneself in order to view one’s performance objectively. This is just another way of talking about mindfulness, but in the specific context of studying.
Coaching
Individuals with ADHD or ADD can benefit from coaching, either in one-on-one sessions or in groups. Self organization and monitoring, positive self talk, active confrontation of stereotyping, and self advocacy for accommodations are some of the skills that can be taught and practiced using a coaching model. Coaching differs from therapy mostly in degree rather than substance, but it can be useful to view work on ADHD from this perspective, as it minimizes the sense of being “sick” or deficient, and focuses on improvement within what is easier to see as a “normal” spectrum.