What Happens to ADHD Children?
Researchers Dr. Rachel Klein and Dr. Salvatore Mannuzza have conducted one of the most extensive prospective longitudinal studies of children diagnosed with ADHD. They followed 226 children over sixteen years to determine how long ADHD symptoms persisted, and if the children were at further risk for other problems as they were growing up. At the first follow-up evaluation, the children were average age 8, at the second follow-up they were average age 25. All of the subjects were boys, and none received treatment after the age of 13.
The following are some key findings from their work. Some of the statistics may be troubling, especially those having to do with substance abuse or criminal behavior. To parents questioning whether taking their ADHD child off medication will increase the adverse risks associated with ADHD, Dr. Klein says, "First, the question should only be posed in relation to adolescents who are still symptomatic. There is no reason to keep treating those who no longer have ADHD symptoms. Among the symptomatic adolescents, no one knows the answer. But we do know that treatment is effective in adolescence; therefore it makes sense to continue treatment if it's indicated. However, it would be premature to promise a positive outcome as a result."
Do Children Outgrow ADHD?
Other, smaller follow-up studies have shown consistently that hyperactivity or ADHD is a highly persistent disorder from childhood into adolescence. Short term studies have shown fairly consistently that children diagnosed with ADHD continue to experience significant academic, cognitive, and behavioral difficulties into their early to mid teens (13 - 15). Between 30 and 50 percent may continue to have the full disorder into late adolescence (16 to 19).
Klein and Mannuzza found that 37% of the ADHD subjects continued to have ADHD into adolescence, compared to only 3% of the controls. It seemed to drop off in adulthood to 7%.
However, the extent to which ADHD is likely to persist into adulthood is not easily determined from the long term studies, largely because the methods of measuring symptoms usually change as subjects grow up. Children and teenagers are more likely to be evaluated based in part on interviews with teachers and parents, while adult diagnoses are often based on self-reports, which tend to result in much lower rates of diagnosis.
Does ADHD Lead to Other Problems?
Many studies have shown that ADHD subjects often experience academic difficulties into adolescence. In one ten year follow-up study, researchers found that at age 19, ADHD subjects "completed less formal schooling, achieved lower grades, failed more courses and were more often expelled" than control subjects. Klein and Mannuzza found that ADHD children were less likely than control subjects to have graduated college or attained a graduate degree. (14% vs. 52%).
Other Mental Disorders
ADHD children may be at greater risk for developing other mental disorders later in life. Klein and Mannuzza found that ADHD children were more likely to have any psychiatric disorder in adolescence than control subjects. (50% of hyperactive children v. 19% of controls).
Thirty percent of the ADHD subjects in their study later developed Conduct Disorder, compared to 8 percent of the controls. Those subjects whose ADHD continued into adolescence were more likely than either the controls or those whose ADHD remitted by adolescence to develop CD.
ADHD subjects were no more likely than the control subjects to develop mood or anxiety disorders, however.
Klein and Mannuzza found that in adolescence, the ADHD subjects were more likely than the controls to develop Substance Use Disorder. (SUD) (17% v. 2%). Interestingly, however, it was only those who subsequently developed Conduct Disorder who showed this increased risk, so it was not the ADHD itself that predicted the SUD.
It is also interesting to note that the discrepancy between the ADHD subjects and the controls only existed for substances other than alcohol; they were no more likely than the control subjects to have a problem with drinking.
ADHD children may be at higher risk for criminal behavior. Klein and Mannuzza found that 39% of their ADHD subjects had been arrested in adolescence or early adulthood, compared to 20% of the controls. Conviction rates for the former ADHD children were also higher, 28% v. 11%. However, as with substance abuse, the arrest and conviction rates among the ADHD subjects were higher only for those who also had developed Conduct Disorder or Anti-Social Personality Disorder later in life.
Four percent of the ADHD subjects were incarcerated in adulthood, while none of the controls were.
"Longitudinal Course of Childhood ADHD," Rachel Klein, Ph.D.
Presentation at New York University Medical School, March 30, 2001.
"Longterm Prognosis in Attention-Deficit/Hyperactivity Disorder," Mannuzza, Salvatore and Klein, Rachel; Child and Adolescent Psychiatric Clinics of North America, Volume 9, Number 3, July 2000
"Attention Deficit Hyperactivity Disorder: Long-Term Course, Adult Outcome, and Comorbid Disorders," Russell A. Barkley, Ph.D.
"Adolescent and Adult Outcomes in Attention Deficit/Hyperactivity Disorder," Mannuzza, Salvatore and Klein, Rachel in H.C. Quay and AE Hogan (Eds) Handbook of Disruptive Behavior Disorders. New York: Klumer Academic/Plenum Publishers. 1999 pp. 279-294
What is Attention-Deficit Hyperactivity Disorder?
Attention-Deficit Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder that affects an estimated 3% to 7% of Canadian school-age children. This means that in any classroom of 25-30 children, it is likely that at least one will have ADHD. Boys are about three times more likely than girls to be diagnosed with ADHD, though it's not yet understood why.
The most recent data for the United States released by the Centers for Disease Control and Prevention in August 2011 show that percentage of children diagnosed as having ADHD increased from 6.9% in 1998-2000 to 9.0% in 2007-2008.
ADHD was first described in 1845 by Dr. Heinrich Hoffman, a physician who wrote numerous books on medicine and psychiatry as well as children’s poetry. Since then, several thousand scientific papers have been published on the disorder, providing information on its nature, course, possible causes, associated impairments, and treatments.
Children with ADHD act without thinking, are hyperactive, and have trouble focusing. They may understand what's expected of them but have trouble following through because they can't sit still, pay attention, or attend to details.
ADHD symptoms begin in infancy and can continue into adulthood, causing difficulties for people at home, at school, at their jobs, and within their communities. In about 70% of children diagnosed with ADHD symptoms will continue into adulthood and persist for life, although hyperactivity will usually diminish significantly by about age 21 or so.
Untreated ADD/ADHD prevents school-aged children from achieving their full academic potential and is associated with serious psychosocial problems into adulthood. Over half of all adults with ADHD have a comorbid behavioral disorder.
What Are the Symptoms?
The principle characteristics of ADHD are inattention, hyperactivity, and impulsivity. This disorder used to be known as attention deficit disorder (ADD) but was renamed attention-deficit/hyperactivity disorder (ADHD) in 1994 and broken down into three subtypes, each with its own pattern of behaviors:
ADHD – Predominantly Hyperactive-Impulsive Type, that does not show significant inattention, but with signs that include:
fidgeting or squirming
difficulty remaining seated
excessive running or climbing
difficulty playing quietly
always seeming to be "on the go"
blurting out answers before hearing the full question
difficulty waiting for a turn or in line
problems with interrupting or intruding
ADHD – Predominantly Inattentive Type, that does not show significant hyperactive-impulsive behavior, but with signs that include:
inability to pay attention to details or a tendency to make careless errors in schoolwork or other activities
difficulty with sustained attention in tasks or play activities
apparent listening problems
difficulty following instructions
problems with organization
avoidance or dislike of tasks that require mental effort
tendency to lose things like toys, notebooks, or homework
forgetfulness in daily activities
ADHD - Combined Type, which involves a combination of the other two types and is the most common.
To be considered for a diagnosis of ADHD:
a child must display behaviors from one of the three subtypes before age 7
these behaviors must be more severe than in other children the same age
the behaviors must last for at least 6 months
the behaviors must occur in and negatively affect at least two areas of a child's life (such as school, home, day-care settings, or friendships)
The behaviors must also not be linked to stress at home. Children who have experienced a divorce, a move, an illness, a change in school, or other significant life event may suddenly begin to act out or become forgetful. To avoid a misdiagnosis, it's important to consider whether these factors played a role in the onset of symptoms
How Is ADHD Actually Diagnosed?
Some parents see signs of ADHD in their toddler long before the child enters school but, in the majority of cases, it is the child’s teacher in the first two years of school who will suspect ADHD and bring it to the attention of the parents and recommend that the child be seen by an appropriate professional for diagnosis.
Although there are a number of different health professionals—including psychologists and psychiatrists—that may have the training to diagnose ADHD, in the vast majority of cases it is diagnosed and treated by primary care physicians.
As with the majority of psychiatric disorders, ADHD is diagnosed on the basis of subjective behavioral ratings and the elimination of alternative medical or psychological explanations for the observed behaviors. This subjectivity often leads to persistent doubts concerning the validity of the diagnosis and its neurobiological causes.
Because there is no single test that can determine the presence of ADHD, a diagnosis depends on a comprehensive evaluation that is primarily focused on excluding alternative reasons for the child’s behavior, such as a stressful change in life, hearing or vision problems, Tourette’s syndrome, undetected seizures, a learning disability, anxiety or depression, or other medical problems.
Your family physician should perform a physical examination of your child and ask you about any concerns and symptoms, your child's past health, your family's health, any medications your child is taking, any allergies your child may have, and other issues. This is called the medical history, and it is important because research has shown that ADHD has a strong genetic link and often runs in families.
The physician should also gather information on the child’s ongoing behavior to compare to the symptoms and diagnostic criteria listed in the Diagnostic and Statistical Manual of Mental Diseases, 4th Edition (DSM-IV).
You will also likely be asked many questions about your child's development and his or her behaviors at home, at school, and among friends. Other adults who see your child regularly (like teachers, who are often the first to notice ADHD symptoms) will probably be consulted, too. An educational evaluation, which usually includes a school psychologist, may also be done. It's important for everyone involved to be as honest and thorough as possible about your child's strengths and weaknesses.
No one can properly diagnose ADHD in a single brief visit.
What Causes ADHD?
There is at this time little compelling research evidence that ADHD can arise purely from social factors or child-rearing practices. Most substantiated causes appear to fall in the realm of neurobiology, genetics, and environmental factors.
Environmental Agents. Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD in the child. Another environmental agent that may be associated with higher risk for ADHD is high levels of lead in the bodies of preschool children. But with the removal of lead from paints and gasoline, lead is no longer as prevalent an environmental pollutant and is less likely to play a significant role in most cases today. Very recently, American and Canadian health authorities have focused their attention on food coloring used in processed foods and beverages.
Brain Injury. A popular theory in the 1970s was that ADHD was caused by subtle brain injury possibly occurring in the womb before birth. Certainly some number of children do suffer accidents leading to brain injury and signs of behavior similar to that of ADHD, but only a very small percentage of children diagnosed with ADHD have ever been found to have suffered a brain injury.
Food Additives and Sugar. Another commonly heard theory suggests that ADHD is caused or its symptoms aggravated by refined sugar or food additives in the child’s diet. A 1982 National Institutes of Health sponsored scientific consensus conference on this issue concluded that dietary restrictions only help about 5% of children with ADHD, mostly young children with diagnosed food allergies. More recent research studies have also shown that refined sugar in foods has no significant effects on behavior and learning. [Note: Of much greater real concern is the negative impact of too much sugar and high fructose sweetners on children’s weight and diabetes risk.]
That said, there has recently been some renewed concern in Canada and the United States about the many additives used to color processed foods.
Television and Computers. Some recent studies have even suggested a link between excessive early television watching and future attention problems. It is theorized that the developing brains of young children are being influenced by the high stimulation and fast-pace of television and computer games to be easily bored by slower-paced, low stimulation tasks like reading.
This view is still quite controversial. It is possible that excessive television watching and video game playing may be another symptom, not a cause, of ADHD. It is a form of stimulation that helps children with the disorder sustain focus and control internal feelings of agitation via a mechanism similar to that at work with medication.
However parents might be wise to follow the American Academy of Pediatrics' (AAP) guidelines, which say that children under 2 years old should not have any "screen time" (TV, DVDs or videotapes, computers, or video games) and that children 2 years and older should be limited to 1 to 2 hours per day, or less, of quality television programming.
Genetics. Attention disorders clearly run in families, so there are likely to be genetic influences. Research indicates that ADHD is hereditary in more than half of all cases and that 30% of ADHD individuals have at least one parent with ADHD. Approximately 25% of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5% in the general population. Twin studies also support a strong genetic influence in ADHD. A family history of alcoholism and other mood disorders seems to be associated with an increased risk of ADHD. This may imply some type of genetic commonality between these disorders. The odds are about 75% that an adult male with ADHD will have at least one child with ADHD.
Most recently, research is pointing to a dysfunction in a gene that plays an important role in the transportation of the neurotransmitter dopamine in certain areas of the brain, including the brain’s “pleasure/reward” centers.
Brain Function. Some knowledge of the structure of the brain is helpful in understanding the more recent research on the physical basis for ADHD.
One part of the brain that scientists have focused on is the frontal lobes of the cerebrum. The frontal lobes allow us to solve problems, plan ahead, understand the behavior of others, and restrain our own impulses. The two frontal lobes—the right and left frontal lobes—communicate with each other through a set of nerve fibers that connect the right and left hemispheres of the brain called the corpus callosum.
The basal ganglia are the interconnected gray masses deep in the cerebral hemispheres that serve as the connection between the cerebrum and cerebellum, and together with the cerebellum is responsible for motor coordination.
All of these parts of the brain have been studied using various brain imaging technologies such as quantitative electroencephalography (QEEG), functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT) that give us some insight in how the brain functions and the differences in functioning between normal individuals and various diagnostic groups, such as ADHD children and adults.
Such studies are showing that ADHD is a brain-based disorder involving relatively characteristic patterns of abnormal functioning involving a number of different brain structures and systems.
It is postulated that ADHD is characterized by relative underactivation of the left hemispheric anterior-ventral dopaminergic system combined with overactivation of the right hemispheric posterior-dorsal noradrenergic system. This overactivation of the right hemisphere is most likely a result of a lack of inhibitory control by the underactive left hemisphere (Malone, 1994).
The left brain hemisphere is normally biased in the direction of carrying out routine and repetitive activities. A dopamine neurotransmitter deficiency in the fronto-mesolimbic system of the left hemisphere results in problems with tonic cognitive processing— the type that requires slow, serial effort. It is the kind of cognitive processing that may be improved with stimulants such as caffeine or amphetamines.
On the other hand, the right brain hemisphere is involved in the general maintenance of attention and arousal and regulates information processing requiring peripheral vision, spatial location, and rapid shifts in attention. These aspects of attention appear to involve the noradrenergic neurotransmitter system. Excessive noradrenergic stimulation to the right cerebral hemisphere accentuates phasic attentional processes— automatic processes that are fast and simultaneous. It has also been noted that overactivation of the noradrenergic system in the right hemisphere is associated with extroversion, histrionic behaviour, impulsivity, and mania. Such overactivation of the noradrenergic system may be dampened by drugs such as Clonidine.
As a result of this functional brain imbalance, persons with ADHD show attentional processes that are biased towards novelty and change but cannot sustain focus during tasks that require slow, serial cognitive processing.
With the EEG one can observe that as a task becomes boring, the person with ADD will drift off task. There is an increase in slow wave EEG activity. This is similar to the slowing of EEG that occurs normally as we become drowzy. In ADD it is really a modulation of the functions that is the primary problem. On the one hand, arousal may increase and actions without reflection may occur; on the other hand, the tolerance for routine, boring activities is low in these individuals and their arousal may suddenly drop. These characteristics may be improved by stimulant medications or EEG neurofeedback.
What Are Some Related Problems?
One of the difficulties in diagnosing ADHD is that it's often found in conjunction with other problems. These are called coexisting or comorbid conditions, and about two thirds of all children with ADHD have one. The most common coexisting conditions are:
Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). At least 35% of all children with ADHD also have oppositional defiant disorder, which is characterized by stubbornness, outbursts of temper, and acts of defiance and rule breaking. Conduct disorder is similar but features more severe hostility and aggression. Children who have conduct disorder are more likely get in trouble with authority figures and, later, possibly with the law. Oppositional defiant disorder and conduct disorder are seen most commonly with the hyperactive and combined subtypes of ADHD.
Mood Disorders (such as depression). About 18% of children with ADHD, particularly the inattentive subtype, also experience depression. They may feel inadequate, isolated, frustrated by school failures and social problems, and have low self-esteeem.
Anxiety Disorders. Anxiety disorders affect about 25% of children with ADHD. Symptoms include excessive worry, fear, or panic, which can also lead to physical symptoms such as a racing heart, sweating, stomach pains, and diarrhea. Other forms of anxiety that can accompany ADHD are obsessive-compulsive disorder and Tourette’s syndrome, as well as motor or vocal tics (movements or sounds that are repeated over and over). A child who has symptoms of these other conditions should be evaluated by a specialist.
Learning Disabilities. About half of all children with ADHD also have a specific learning disability. The most common learning problems are with reading (dyslexia) and handwriting. Although ADHD isn't categorized as a learning disability, its interference with concentration and attention can make it even more difficult for a child to perform well in school.
If your child has ADHD and a coexisting condition, it is important that your physician carefully consider that when developing a treatment plan. Some treatments are better than others at addressing specific combinations of symptoms.
How Is ADHD Treated?
Medical Treatment. Psychostimulant medication is the conventionally-accepted treatment for ADD/ADHD because this class of drug facilitates the release of dopamine in the brain, and increases left hemisphere processing speed while decreasing right hemisphere processing speed.
Experience with these medications in the 50-odd years since they were first introduced shows us that 60-75% of ADD/ADHD children obtain some improvement in attention, impulsivity and hyperactivity as long as they remain on these medications. But research has also shown that 70-90% of children taking psychostimulants experience undesirable side-effects, including such problems as loss of appetite, mood instability, growth reduction, and disturbed sleep. Recently, Health Canada removed one popular ADD/ADHD medication, pemoline (Cylert, ADDerall), from the Canadian market because of growing evidence that it can cause serious liver disease or failure in some children. Similarly, there is recent research out of the University of Texas suggesting that methylphenidate (Ritalin), the most commonly prescribed ADD/ADHD medication, may cause genetic abnormalities in children.
With increasing evidence that ADD/ADHD continues to be a serious problem into adulthood for up to 70% of those diagnosed as children, it is becoming increasingly clear that drug therapy does not cure ADD/ADHD but only treats the symptoms.
Behavioral Therapy. Research has shown that medications used to help curb impulsive behavior and attention difficulties are more effective when they're combined with behavioral therapy.
Behavioral therapy attempts to change behavior patterns by:
reorganizing your child's home and school environment
giving clear directions and commands
setting up a system of consistent rewards for appropriate behaviors and negative consequences for inappropriate ones
Here are some examples of behavioral strategies that may help a child with ADHD:
Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime. Post the schedule in a prominent place, so your child can see where he or she is expected to be throughout the day and when it's time for homework, play, and chores.
Help your child organize. Put schoolbags, clothing, and toys in the same place every day so your child will be less likely to lose them.
Avoid distractions. Turn off the TV, radio, and computer games, especially when your child is doing homework.
Limit choices. Offer your child a choice between two things (this outfit, meal, toy, etc., or that one) so that he or she isn't overwhelmed and overstimulated.
Change your interactions with your child. Instead of long-winded explanations and cajoling, use clear, brief directions to remind your child of his or her responsibilities.
Use goals and rewards. Use a chart to list goals and track positive behaviors, then reward your child's efforts. Be sure the goals are realistic (think baby steps rather than overnight success).
Discipline effectively. Instead of yelling or spanking, use timeouts or removal of privileges as consequences for inappropriate behavior. Younger children may simply need to be distracted or ignored until they display better behavior.
Help your child discover a talent. All kids need to experience success to feel good about themselves. Finding out what your child does well - whether it's sports, art, or music - can boost social skills and self-esteem.
EEG Neurofeedback. In 1978 Dr. Joel Lubar at the University of Tennessee discovered that children suffering with ADHD showed an abnormal brainwave pattern. The brainwave pattern found to be associated with ADHD is characterized by an excess of slower, lower frequency brain waves mostly in the frontal areas of the brain as compared to normal children with well-focused attention. It is this slower brain wave pattern that prevents the child from being able to focus attention for more than a few seconds at time. EEG biofeedback is the only therapy shown to actually normalize brainwave activity so that the child is able to maintain focused attention during learning-related activities.
Currently, the scientific literature on treatment of ADHD with EEG biofeedback consists of more than a hundred case studies representing treatment experience with thousands of children and adults over the last 35 years but only a handful of good quality multiple-case studies— i.e., Lubar, et al., 1995; Thompson & Thompson, 1998; Kaiser & Othmer, 2000; Heywood & Beale; 2003— and controlled group-studies— i.e., Rossiter & LaVaque, 1995; Linden, et al., 1996; Carmody, et al., 2001; Monastra, et al., 2002; Fuchs, et al., 2003— representing data on the treatment of a little over 500 individuals.
In a recently published Association for Applied Psychophysiology and Biofeedback (AAPB) “White Paper” based on a thorough review of the published research on the use of EEG biofeedback in the treatment of ADHD, the following conclusion was reached…
“Review of the scientific literature revealed both controlled case and group studies on the effects of EEG biofeedback in treating the core symptoms of ADHD. These studies examined the efficacy of well-defined treatment protocols in the treatment of patients diagnosed with hyperkinesis, as well as, those diagnosed with each of the primary subtypes of ADHD (Inattentive, Hyperactive-Impulsive, or Combined). The results of these studies indicated improvement on standardized tests of intelligence, attention, and behavioural control following EEG biofeedback. Increased level of cortical arousal was also reported during QEEG examination of patients treated with EEG biofeedback. As well fMRI studies of ADHD children treated with EEG biofeedback demonstrate that biofeedback has the capacity to functionally normalize the brain systems mediating selective attention and response inhibition in ADHD children. Comparisons with a bona fide treatment for ADHD (i.e., stimulant medication) indicated that EEG biofeedback yielded equivalent or superior results. The results of randomized, controlled group studies using a waiting list control also indicated the superiority of EEG biofeedback. Such findings suggest the efficacy of EEG biofeedback in the treatment of ADHD.”
Based on the Guidelines for Evaluation of Clinical Efficacy of Psychophysiological Interventions (LaVaque, et al., 2002), which have been accepted by both the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR) the use of EEG biofeedback in the treatment of ADHD is PROBABLY EFFICACIOUS.
An even more recent meta-analysis of the EEG neurofeedback for ADHD research that included RCT studies published as late as 2009, Arns and colleagues (Arns, de Ridder, Strehl, Breteler, Coenen, 2009) concluded that neurofeedback for ADHD is now proven at the higher level of EFFICACIOUS and SPECIFIC.
To read more about the treatment of ADHD with EEG Neurofeedback GOTO: EEG Neurotherapy
Parent Training. Parenting any child can be tough at times, but parenting a child with ADHD often brings special challenges. Children with ADHD may not respond well to typical parenting practices. Also, because ADHD tends to run in families, parents may also have some problems with organization and consistency themselves and need active coaching to help learn these skills.
Experts recommend parent education and support groups to help family members accept the diagnosis and to teach them how to help their child organize his or her environment, develop problem-solving skills, and cope with frustrations. Parent training can also teach parents to respond appropriately to their child's most trying behaviors and to use calm disciplining techniques. Individual or family counseling may also be helpful.
Dr. Mueller offers neurotherapy treatments for ADHD and many other brain-based disorders. For more information on the treatment of ADHD with EEG Neurofeedback and other neurotherapies return to the Index and click on Treatment Methods and go to the article on Treating ADHD with EEG Neurofeedback and other neurotherapies.
You can also go to Dr. Mueller's neurotherapy-specific website: www.edmontonneurotherapy.com
The Case Against Drugs and for
EEG Neurofeedback in
the Treatment of ADHD
Dr. Jonathan Walker, MD
The majority of practitioners treating Attention Deficit/Hyperactivity Disorder (ADHD) use one or more drugs to treat it. This preference is based on their belief these drugs are both effective and safe when used to treat ADHD. In this article, I will briefly review the abundant evidence that drugs are often ineffective, have frequent unfavourable side-effects, and that there are long-term problems associated with the use of stimulants. At best, these drugs do not eliminate ADHD, but temporarily suppress the symptoms. As well, complications may be quite severe with their long-term use.
In contrast, neurofeedback is usually effective in eliminating ADHD altogether, usually without side-effects or long-term complications. Neurofeedback is also useful in eliminating comorbidities associated with ADHD, such as learning difficulties, anxiety, depression, oppositional defiant disorder, sleep disturbances, and anger control issues. There is no problem with dependency, withdrawal or drug interactions. Neurofeedback can offer a permanent solution in the majority of cases. In the long run it is less expensive than prolonged drug therapy.
The alerting and euphoric effects of amphetamines were discovered in the 1920s. College students in the 1930s recognized they could be used to relieve fatigue and increase focus when cramming for final exams. Benedrine inhalers were banned in 1959 because of an epidemic of amphetamine abuse. Methylphenidate (Ritalin) was synthesized in 1944. It was found to decrease ADHD symptoms in institutionalized children first, and then in school children. With special-interest group support (the learning disability industry) , the creation of DSM-III and its revisions, and pharmaceutical industry front groups like CHADD and NAMI), stimulants such as Dexedrine and methylphenidate were approved for management of ADHD in children and adults. Pemoline (Cylert) is no longer available because of the risk of liver toxicity. Atomoxetine (Strattera) has recently also been associated with liver toxicity in some cases.
Animal research indicates that chronic administration of stimulants leads to many adaptive changes in the brain, including a persistent reduction in dopamine transporters in the striatum, a decrease of dopamine D2 receptors, alterations in gene expression (C-fos), and morphological changes in the brain, including dendritic lengthening, branching, and increases in cell density in the nucleus accumbens and frontal cortex (brain areas that play important roles in learning and addiction). These changes may result in interference with the acquisition of new skills and behaviour. They may be the basis of craving and addiction and/or psychotic features which occur in some individuals during periods of extended drug abstinence. PET studies have confirmed a reduction of D2 receptors and dopamine transporters in the striatum of human children. Chronic Ritalin use, followed by drug withdrawal, may induce a significant worsening of the original condition.
Many children develop tics during active treatment. Another long-term effect of stimulant treatment is heart disease, occasionally including sudden death. Anxiety and irritability are common side effects, and severe depression may be a consequence. Appetite suppression (about 25%), insomnia (about 15%) and stomach ache (about 11%) occur in significant numbers of children. Most clinical research trials of stimulant drugs have been short-term, acute studies. Only a few long-term treatment studies have been done. The best known of these is the NIMH Multimodal Treatment Study (MTA). Subjects remaining on treatment experienced a slight deterioration of medication effect. Only 68% of subjects remained on medication at 24 months. There was a significant worsening of symptoms when the drug Ritalin was stopped. Both parents and teachers rated behavioural therapy as superior to medications alone. Studies have shown that treatment with stimulant drugs does not reduce the incidence of conduct disorder and anti-social personality disorder seen in many ADHD children as they grow older. A study in Australia found growth retardation, with progressive declines in both height and weight, in 86% of children on Ritalin. In a Yale University study of children on Ritalin for 2 years or more without interruption, 76% of the males and 90% of the females experienced significant height suppression after three years of therapy, with an overall height deficit of 3-4 cm. There was also an average weight loss of 1.25 kg per year. Un-medicated patients demonstrated above average growth rates when the Ritalin was discontinued.
Most long-term studies have shown a waning of the beneficial cognitive effects of stimulants over the course of time. Seven percent of stimulant-treated children in one Canadian practice developed clear signs of psychosis after the initiation of therapy. The psychosis resolved on discontinuation of stimulant drugs in most of these patients. Many ADHD children on stimulants experience significant withdrawal symptoms (e.g., moodiness, excitability, insomnia, and excessive talking). This may result in the child being labeled as “bipolar”, when in fact the problem is iatrogenic.
The psychiatric literature has consistently minimized the addictive potential of psychostimulants. The reinforcing effects of intravenous Ritalin are identical to those of intravenous cocaine. In a high dose (80 mg), oral Ritalin may produce high levels of dopamine transporter blockade as quickly as intravenous doses.
Animal studies have documented that stimulant medications sensitize the brain to cocaine. In a study of 492 children begun in 1974, stimulant-treated subjects developed higher rates of cocaine dependence than non-medicated peers diagnosed with either ADHD or behavioural (conduct) disorders. The abuse potential and sensitizing effects of Ritalin are supported by over 60 studies of nonhuman and human subjects.
In the large MTA study mentioned previously, medicated and non-medicated children were given behavioural therapy, including classroom training, sports, social skills training, daily group sessions, tasks to promote cooperation, parent training with reinforcement systems, and daily report cards. After eight weeks of the therapeutic camp, the two groups showed no differences in overall improvement ratings. Other non-pharmacological approaches have documented similar benefit, including exercise, martial arts, massage therapy, music therapy, and cognitive therapy.
Direct comparisons of Ritalin and neurofeedback have shown equivalent efficacies but unlike drug therapy, the effects of neurofeedback persist after the training is completed. Moreover, there is no risk of dependency or adverse withdrawal effects with neurofeedback.
Neurofeedback offers the additional advantage of remediating the comorbidities of ADHD—anxiety, depression, learning disabilities, oppositional defiant disorder, conduct disorder, sleep disturbances, and anger control. QEEG-guided neurofeedback is very helpful in remediating these commonly associated disorders. Adverse effects of neurofeedback are extremely rare and no long-lasting complications have been reported. There have been no studies reported of the incidence of drug abuse or criminal behaviour in ADHD children remediated with neurofeedback, but we know that proper neurofeedback can be used to reduce drug-seeking behaviour and aggression in incarcerated individuals with ADHD. I suspect that we will see a decrease in drug-seeking and criminal behaviour in neurofeedback-treated ADHD children as they grow older. We still need to collect data in this regard.
The studies reviewed here indicate that neurofeedback treatment is a superior alternative to stimulant therapy in ADHD. It is usually curative of ADHD. It is extremely safe. Over the course of a lifetime it is less expensive than drugs. In truth it is a revolutionary approach to managing ADHD. We urgently need to educate our neurological, psychiatric, and pediatric colleagues about the advantages of neurofeedback.
Originally published in NeuroConnections Newsletter, April 2008. A joint newsletter from the ISNR and AAPB Neurofeedback Division.
EEG Neurofeedback for the Treatment of
Attention Deficit/Hyperactivity Disorder in Children and Adults
Electroencephalogram (EEG) biofeedback, also known as EEG neurofeedback, has proven itself to be a highly promising alternative treatment for children and adults with attention deficit/hyperactivity disorder (ADHD) who have not benefitted from medications or who do not wish to take medications.
There is now over 35 years of accumulated research comprising literally hundreds of published studies and thousands of anecdotal case histories and clinical reports documenting the effectiveness of EEG neurofeedback in the treatment of many thousands of ADHD children and adults in Canada and the United States, Europe, and Australia. Perhaps more importantly, there have been no published studies negating the effectiveness of EEG neurofeedback or showing it to be as potentially harmful as the stimulant medications most commonly used in the treatment of ADHD. While it is true that much of the earlier research on the use of EEG neurotherapy to treat ADHD suffered from various methodological weaknesses, more recent stronger randomized controlled trials (RCTs) have provided substantial support for the claim that EEG neurofeedback is efficacious and specific and can provide a good alternative to treatment with drugs. In many ways, EEG neurofeedback is an ideal therapy modality because it is effective, non-invasive and quite safe.
The Rationale for Treating ADHD with EEG Neurofeedback
ADHD affects approximately 3-5 percent of school-age children in Canada and the United States and is generally diagnosed in children who show attention difficulties, easy distractibility, impulsive behaviours, and extreme levels of hyperactivity. ADHD is classified as a developmental disorder and no single diagnostic test exists. It is generally viewed as disorder of brain functioning that is largely inherited but may be worsened by minor brain trauma, birth trauma, emotional and dietary factors, and inadequate sleep. Also, children with ADHD frequently exhibit a variety of physical problems such as headaches and immune system deficiencies, resulting in frequent illness, as well as various co-morbid psychobehavioural conditions such as anxiety, depression, oppositional-defiant disorder, and obsessive-compulsive disorder.
One important current theory about the biological basis for ADHD is that it results from underactivity in those brain areas that are most directly involved in behavioural inhibition—that is, the ability to refrain from acting immediately on impulse. The brain areas that are believed to be most important in the ability to inhibit or self-control behaviour are in the frontal cortex. Certainly, the fact that a majority of children and adults with ADHD are treated with and respond to stimulant medications indicates that this disorder is characterized by insufficient arousal.
Numerous EEG studies have shown that approximately 80-90 percent of persons diagnosed with ADHD display signs of “cortical hypoarousal,” quantitatively described as elevated relative Theta (4-8 Hz) power, reduced relative Alpha (8-12 Hz) and Beta1 (12-20 Hz) power, and elevated Theta/Alpha and Theta/Beta power ratios as compared to “normal” age and gender peers. These patterns are typically observed over frontal and central midline brain regions. A smaller subgroup of persons diagnosed with ADHD exhibits an EEG pattern suggestive of “cortical hyperarousal,” with greater relative Beta fast-wave activity, decreased relative Alpha activity, and decreased Theta/Beta power ratios diffusely across much of the cortex. This hyperarousal group has been found to respond poorly to stimulant medications.
The executive functions of the frontal lobes allow the person to focus, pay attention, concentrate, control their impulses and emotions, exercise judgment, plan, organize, and regulate motor behaviour (i.e. inhibit their impulses and sit still). Cortical hypoarousal disables the executive functions, severely compromising the person's ability to pay attention, focus, and inhibit their impulses. Brain imaging research has demonstrated that the brains of ADHD children and adults can best be described as “sleepy brains”, as their brains are typically like the brains of sleepy “normals”, with a preponderance of the drowsy brain wave frequency.
To see a YouTube video on “ADHD and the Brain” click on this link… YouTube Video
How is EEG Neurofeedback Done and What Can I Expect?
EEG neurofeedback treatment of ADHD essentially requires patients to learn to normalize their brain waves; especially in those brain regions thought to be responsible for attention and behavioural control. Essentially, patients learn to decrease production of Theta slow-waves activity and increase Beta1 fast-wave activity in the frontal and central midline regions of the brain.
In a typical EEG neurofeedback training session, the patient is seated in a comfortable chair in front of a computer video screen. One or more EEG electrodes are attached to the scalp by means of a sticky electrode paste and reference and ground electrodes are attached to the earlobes with earclips. These sensor wires are then connected to a signal amplifier and a computer with software capable of analyzing the EEG signals, performing various transformations, and displaying the relevant signals to the patient on the computer screen in “real-time”. The patient watches a computer-generated video display that provides continuous visual and auditory feedback and uses this information about how his/her brain is changing from moment-to-moment to learn increased control over the EEG signal.
To see a YouTube video on “What is Neurofeedback?” click on this link… YouTube Video
A typical course of EEG neurofeedback therapy involves at least 30-50 half-hour to full-hour biofeedback training sessions, administered over the course of about 12-24 weeks. With older children and adults, who are more cooperative and positively motivated, it may be possible to accomplish 15-20 minutes of actual EEG biofeedback training within a 30-minute session. But, with younger children, or those who are less cooperative or motivated or more severely hyperactive, it may require longer 45-60 minute sessions to accomplish the same amount of actual biofeedback training. Each biofeedback training session is usually divided into a number of relatively short (3-5 minute) training segments or trials with brief breaks between. Typically, it takes anywhere from 5-15 minutes to prep the skin and attach the electrodes and ensure appropriately low electrical impedance before beginning the actual training.
Although rates of progress vary from patient to patient, significant benefit is often observed within the first few weeks of therapy (i.e., approximately 15-20 therapy sessions). In general, EEG neurotherapy is more effective when training sessions occur more often in the week (3-5 times) as opposed to less often (1-2 times).
Numerous treatment outcome studies, replicated in many different clinical settings over the last 35 years, have shown that 75-85 percent of ADHD children treated with EEG neurofeedback typically increase their tested IQ scores by 10-15 points and improve significantly on measures of attentiveness, hyperactivity, academic performance, and parent/teacher behaviour rating scales. EEG neurofeedback has also been shown to be at least as effective as treatment with medication alone or behaviour therapy alone. Moreover, these positive EEG changes appear to be long term.
One recent study examined the effects of EEG neurofeedback on a sample of ADHD children with another brain scanning technology—functional magnetic resonance imaging (fMRI)—and found that EEG neurofeedback resulted in a distinctive activation of the right anterior cingulate cortex on the fMRI, which was not observed in untreated control subjects.
Some More Recently Published Research and Review Papers
Arns, M., de Ridder, S., Strehl, U., Breteler, M., Coenen, M. (2009). Efficacy of neurofeedback treatment in ADHD. The effects on attention, impulsivity, and hyperactivity: A meta-analysis. Clinical EEG & Neuroscience, Vol 40, pp. 180-189.
DeBeus, R., Ball, J., DeBeus, M. (2004). Attention training with ADHD children: Preliminary findings in a double-blind placebo-controlled study. Journal of Neurotherapy, Vol. 8, pp. 145-147.
Fox, D., Tharp, D., Fox, L. (2005). Neurofeedback: An alternative and efficacious treatment for Attention Deficit/Hyperactivity Disorder. Applied Psychophysiology & Biofeedback, Vol 30, Nr 4, pp 365-373.
Friel, P. (2007). EEG biofeedback in the treatment of Attention Deficit/Hyperactivity Disorder. Alternative Medicine Review, Vol 12, Nr 2, pp 146-151.
Fuchs, T., Birbaumer, N., Lutzenberger, W., et al. (2003). Neurofeedback treatment for Attention Deficit/Hyperactivity Disorder in children: A comparison with methylphenidate. Applied Psychophysiology & Biofeedback, vol 28, Nr 1, pp 1-12.
Gevensleben, H., Holl, B., Albrecht, B., et al. (2009). Is neurofeedback an efficacious treatment for ADHD? A multisite, randomized controlled clinical trial. Journal of Child Psychology & Psychiatry, Vol 50, Nr 7, pp 67-768.
Gevensleben, H., Holl, B., Albreacht, B., et al. (2010). Neurofeedback training in children with ADHD: A 6-month follow-up of a randomized trial. European Child & Adolescent Psychiatry.
Heinrich, H., Gevensleben, H., Strehl, U. (2007). Neurofeedback: Train your brain to train behaviour. Journal of Child Psychology & Psychiatry, Vol 48, pp 3-16.
Hirschberg, L. (2007). Place of electroencephalographic biofeedback for Attention Deficit/Hyperactivity Disorder. Expert Reviews in Neurotherapeutics, Vol 7, Nr 4, pp 315-319.
Levesque, J., Beauregard, M., Mensour, B. (2006). Effect of neurofeedback training on the neural substrates of selective attention in children with Attention Deficit/Hyperactivity Disorder: A functional magnetic resonance imaging study. Neuroscience Letters, Vol 394, pp 216-221.
Monastra, V. (2005). Electroencephalographic biofeedback (neurotherapy) as a treatment for Attention Deficit/Hyperactivity Disorder: Rationale and empirical foundation. Child & Adolescent Psychiatry Clinics of North America, Vol 14, pp 55-82.
Monastra, V., Lynn, S., Linden, M., et al. (2005). Electroencephalographic biofeedback in the treatment of Attention Deficit/Hyperactivity Disorder. Applied Psychophysiology & Biofeedback, Vol 30, Nr 2, pp 95-114.