Non-Medical Treatments for ADHD. Susan D. Ayarbe PhD

Transcription

1 Non-Medical Treatments for ADHD Susan D. Ayarbe PhD

2 Sources ADHD in Children and Adults: Advances in Psychotherapy Evidence Based Practice (Rickel and Brown, 2007) ADHD State of the Science/Best Practices (Jensen and Cooper, 2002) ADHD, A Handbook for Diagnosis and Treatment (Russell Barkley, 2006) Review of recent articles on APA Database/pub-med database

3 Objectives To give parents up-to-date evidence-based information on the non-medical treatments for ADHD To identify other elements to consider when making treatment decisions Question/Answer

4 Treatments Psychosocial Interventions Diet and Nutritional Supplements Neurofeedback/Biofeedback Essential Fatty Acid Supplementation Working Memory Training

5 Psychosocial Interventions Behavior Therapy Three decades of research suggest that appropriately implemented behavioral interventions can be equivalent to low to moderate dose of stimulant medication Focus on improvement on key domains of impairment associated with ADHD and believed to mediate long-term outcome

6 Behavior Therapy Parent Training Improves parenting skills, key child behaviors in the home setting (following parent requests, rules, decrease in defiant/aggressive behavior) Generally moderate to large effect size on functional outcomes versus specific symptoms of ADHD Children more frequently studied than adolescents Most effective with co-occurring diagnoses One of the most well-validated interventions in the field of childhood behavior problems (particularly aggression and conduct problems)

7 Behavior Therapy Classroom Interventions Majority of studies have investigated intensive treatment in special class settings; children ages 5-12 Compelling evidence to support the effectiveness of behavioral approaches in the classroom 1. Daily Report Cards 2. Token and Point Systems 3. Interventions targeting specific behaviors (seatwork productivity and accuracy)

8 Behavior Therapy Academic Interventions Focus on achievement over time Most studies are single subject design which support short term effects. Preliminary evidence supports the following approaches: 1. Modification of task demands 2. Providing task choices 3. Peer Tutoring 4. Parent tutoring 5. Computer Aided Instruction Need for replication with experimental designs

9 Behavior Therapy Peer Interventions Less well studied Interventions focused on increasing social skills, social problem solving and behavioral competencies while decreasing undesirable behaviors Considerable evidence for intensive summer camp programs. Result in medium to large acute effects. (5-14 years of age)

10 Limitations of Behavioral Interventions They do not work to the same degree for all children not sufficient for some children Labor intensive and may be expensive Acute versus long-term outcome Must be implemented across settings Must be implemented by trained individuals

11 Diet Feingold Diet Other Elimination Diets (few foods diets, oligoantigenic) Elimination of Sugar

12 Feingold Diet Rationale children are sensitive to dietary salicylates and artificially added colors, flavors, and preservatives. ADHD symptoms could be eliminated/decreased through elimination of these substances Significant amount of research since 1982 Still controversial/research still continuing. Most ADHD experts do not believe the research supports efficacy claims

13 Elimination Diets In 8 well-controlled studies, 10% of children with ADHD demonstrated allergies to food dyes 2% responded to the elimination of food dyes with behavioral improvements Profile of probable responders: 1. Middle to upper class preschooler 2. Prominent irritability/sleep disturbance 3. Hyperactive

14 Elimination of Sugar No convincing scientific support Studies show parent s perception of behavior is what changes rather than the behavior itself Some studies have found correlations between hyperactivity/inattention and sugar/refined carbohydrate intake Remember: correlation does not equal causation

15 Nutritional Supplements Essential Fatty Acid Supplementation Rationale: Approach based on documented lower levels of long chain polyunsaturated fatty acids (e.g., Omega 3 ) in blood of individuals with ADHD Mixed results

16 Omega 3 Fatty Acids Study published in Pediatrics and Child Health (February 2009) Randomized, double blind, placebo controlled 37 children Results: 8 patients showed clinically significant improvement in inattention

17 Omega 3 Fatty Acids Journal of Child Adolescent Psychopharmacology (April 2009) Double blind, randomized, placebo controlled (7 week study) 73 unmedicated children (7-13 years old) diagnosed with ADHD Results: both treatments ameliorated symptoms somewhat no significant difference in treatment effects

18 Omega 3 Fatty Acids 2009 Review Dev Med Child Neurology 1. Thorough review of clinical studies and review papers of EFA blood levels and supplementation trials 2. Medline PubMed database and references of these articles 3. Uncontrolled studies show benefit BUT randomized controlled studies have not Conclusion: Current findings do not support the use of EFA supplements as a primary or supplementary treatment of ADHD

19 Other Nutritional Supplements Megadose vitamins ineffective and potentially unsafe RDA vitamins ineffective unless child has very poor diet Mineral Supplements no solid evidence Problem very little good research

20 Neurofeedback/EEG Biofeedback Rationale: Some children with ADHD had more theta and less beta rhythms than controls Applied Psychophysiology and Biofeedback, June 2005: EEG Biofeedback rated as Probably efficacious: Clinical EEG Neuroscience (2009): Meta-analysis of selected studies. Conclusion: large effect for inattention and impulsivity and a medium effect for hyperactivity J Child Psychol Psychiatry: 2009: randomized controlled clinical trial came to similar conclusions

21 EMG Biofeedback, Relaxation Training and Massage Typically used in combination Hypnotherapy alone has no impact Some improvement with relaxation and EMG protocols Research is dated waning interest

22 Working Memory Training An executive function Mental Workspace i.e. information is briefly (2-3 seconds) stored and manipulated in the service of another cognitive activity Facilitates the ability to control attention and resist distractions Rationale: Working memory deficits consistently found in ADHD, learning disabilities and specific language impairments

23 Working Memory Has limited capacity Tasks demanding large amounts of information make learning more difficult Working memory weaknesses strongly associated with academic problems in literacy and numeracy

24 Working Memory Training Research J of Am Academy of Child/Adol Psych (2004): randomized controlled study with 53 children diagnosed with ADHD Results 1. Gains in non-trained measure of working memory, non-verbal reasoning, and response inhibition 2. Significant reductions in parent ratings of ADHD symptoms but not teacher ratings 3. Gains evident after 3 months

25 Working Memory Training Research Society for Research in Child Development 2007: Presentation by Notre Dame researchers Twelve year old adolescents all treated with medication. No control group was used. Results: 1. Significant gains in non-trained measure of working memory and a measure of fluid intelligence 2. Significant reduction in parent ratings of ADHD 3. Teacher ratings approached significance

26 Working Memory Research Training Physiology and Behavior (2007): Changes in cortical activity after working memory training Science (2009): Changes in cortical dopamine D1 receptor binding associated with cognitive training

27 Working Memory Training Research Developmental Science (2009): 42 children with working memory deficits assigned to high or low intensity training. Results: Children with high training exhibited 1. Significant gains on non-trained working memory 2. real world gains on listening skills 3. At 6 months, significant gains in a measure of math achievement

28 Working Memory Training Research Applied Cognitive Psychology (2009): examined impact of medication treatment and working memory in twenty five 8-11 year olds Results: 1. Medication improved performance on visuo-spatial WM but no verbal short term memory, visuo-spatial short-term memory of verbal working memory 2. WM Training led to significant gains on all four memory tasks and moved children's performance into the average range 3. No impact on IQ for either treatment 4. Six months f/u: gains in working memory had persisted

29 Unproven RDA vitamins Single-vitamin megadosage Herbals and other homeopathic remedies Laser acupunctures Channel-specific perceptual training Vestibular stimulation

30 Ineffective/Unsafe Various forms of megadose multivitamins Amino acid supplementation Simple sugar restriction

31 Indicated Only for Selected Etiologies Chelation ( deleading ) Treatment for thyroid abnormality (2-5%) Correction of demonstrated deficiencies of any nutrient (zinc, iron, magnesium, vitamins) Few foods diet

32 Proven Efficacy assuming the following: Treatment protocols are followed, provider is trained and treatment lasts long enough to have an effect. 1. Medication typically moderate to large 2. Behavioral treatments as discussed moderate to large 3. EMG biofeedback -small 4. Neurofeedback/EEG biofeedback - moderate

33 What the Heck I ll Try It Meditation RDA vitamins for children with junky diets Omega 3

34 Let s Keep Our Fingers Crossed Working Memory Training

35 Remember: Proven Efficacy does NOT mean Your work is done with your child. Even the best treatments do not eliminate symptoms Most treatments impact on ADHD symptoms and less on functional impairments. These children need far more support/assistance than they look like they need Parents must continue to be watchful, provide high levels of support to their child with ADHD and continue to act as their child s primary advocate and number one cheerleader

36 Aspects to consider when making a treatment decision Safety of treatment always check with your child s physician before starting treatment Efficacy of treatment Cost of treatment 1. Dollar amount 2. Demand on time of child 3. Demand on time of parent Child s willingness to engage in treatment Impact on other members of the family