Commanding Attention: A Parent and Patient Guide to More ADHD Treatment

By Tess Messer

Are you a parent or caregiver for someone who’s been diagnosed with ADHD? Are you wondering if medication is the only treatment that will help the troublesome symptoms of this condition? Are you looking for other treatments that may enhance the medication that you have been prescribed?

In COMMANDING ATTENTION, author Tess Messer presents an organized, well-researched guide for parents and patients dealing with ADHD. She has dealt with the condition firsthand as a Physician Assistant and the editor of the award winning Primarily Inattentive ADD blog as well as in in the treatment of own her sons, who have managed extremely well with a combination of therapies drawn from her broad research.

Beginning with an explanation of the causes of the condition to a discussion of how to best evaluate the symptoms, to detailed descriptions of multiple treatments, the author makes the case for a shift in our approach to treating ADHD. Not so quick to rely on medications alone, the author proposes other treatments that, alone or in combination with medication, successfully treat the symptoms of ADHD while helping those with the condition achieve a level of normalcy not possible in years past.

Delving into the findings from research, the benefits of various treatments, the costs, side effects, and the limitations of these therapies, COMMANDING ATTENTION reads like a laymen’s guide to understanding and treating ADHD. The book also provides an extensive bibliography of resources and references for use by readers.

For so many, ADHD is a condition that, on a daily basis, hinders their ability to succeed. While drug treatments for ADHD are advancing, some of these treatments come with side effects that make medication treatment an unacceptable option for some patients and parents. Because of this, many patients discontinue their medications, jeopardizing their health, their mental well-being, and their quality of life.

As more people continue to look for ways to improve the quality of life for those with ADHD, combination therapies are emerging and being pushed to the forefront of treatment. COMMANDING ATTENTION presents these remedies in a concise, easy-to-read format for parents, patients, and professionals.

• Language: English
• Publisher: Tess Messer
• Release date: Dec 3, 2012
• ISBN: 9781301608263

Tess Messer

Teresa is the founder and editor of the award winning ADHD blog, Primarily Inattentive ADD. She has published hundreds of articles on the topics of parenting, health care, and ADHD. Tere-sa writes about ADD and ADHD from both a medical and a personal perspective. Her formal training includes a Master's degree in Public Health and an undergraduate degree in Medicine. She has worked as a Primary Care Physician Assistant for adults and children for over 25 years. Teresa had the symptoms of Inattentive ADHD as a child and now has one biological son with Predominantly Inattentive ADHD and one adopted son with Hyperactive/Impulsive type ADHD. She has first-hand experience dealing with the symptoms of ADHD as a parent of children with ADHD, a health care provider and a person with symptoms of ADHD. In addition to her blog, Teresa has published the books, Ten Tips to Help Your ADHD Student Succeed and Commanding Attention: A Parent and Patient Guide to More ADHD Treatment. Teresa has a large, extended family that is a big part of her life. When she is not fishing on Flori-da's Forgotten Coast, she lives with her two boys and her spouse in Georgia. You can contact Teresa at: [e-mail].

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COPYRIGHT, LEGAL NOTICE AND DISCLAIMER INFORMATION

The right of Tess Messer to be identified as author of this Work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in retrieval system, copied in any form or by any means, electronic, mechanical, photocopying, recording or otherwise transmitted without written permission from the publisher. You must not circulate this book in any format.

This book is based on personal experience and anecdotal evidence and is for your personal enjoyment only. Although the author and publisher have made every reasonable attempt to achieve complete accuracy of the content in this guide, they assume no responsibility for errors. You should use the information in this book only under the guidance of your own health care provider and at your own risk. Your particular situation may not be exactly suited to the examples illustrated here; in fact, it is likely the will not be the same. You should adjust your use of the information and recommendations accordingly.

Any trademarks, service marks, product names, or named features are the property of their respective owners, and are to be used for reference only. The author has no formal endorsement arrangement with any of these products or services. The author does allow the Google Adsense program to place advertisement on her blog. Google decides what ads will be placed. The author has no endorsement arrangement with any of the companies chosen by Google.

This eBook may not be resold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each recipient. If you’re reading this book and did not purchase it, or it was not purchased for your use only, then you are reading a pirated copy, please return the book, and purchase your own copy. Thank you for respecting the hard work of this author.

Finally, use your common sense. Nothing in this guide is intended to negate your need to obtain legal, medical, or other professional advice. This guide is intended to inform and entertain the reader; it is not to be used for any other purpose. It is the author’s hope that you enjoy this material and find it useful.

DEDICATION

For my children who teach me something new every single day. For Pascale who makes every part of my life easier. For my siblings and Terry who have always said that I should write a book and most importantly, for my mother who believed in my talents long before there was any obvious indication that I had any.

PREFACE

In 2009, I started writing a blog about the inattentive subtype of Attention Deficit Hyperactivity Disorder (ADHD-PI). My eldest son had just been diagnosed with ADHD-PI, and though I had been a primary care Physician Assistant for over 10 years, I had never heard of this medical problem. I, like most people, thought ADHD was a disorder of children who could not sit still.

I went to the medical library and began to read everything that I could find about inattentive ADHD. It did not take much reading to come to the conclusion that I too had ADHD-PI and that this was the reason that I had done so poorly in school.

I was evaluated by physicians, and even specialists, as a child. My IQ was normal, but my grades were barely passing. I was never placed on medication and continued to academically struggle until I was in my twenties. It was then that I started drinking a couple of shots of good Cuban coffee every morning and found that my motivation, focus, and ability to learn improved.

By the time my second son was in second grade, he too had been diagnosed with ADHD. He was hyperactive, impulsive, loud, and combative. He was diagnosed by our pediatrician as having combined type ADHD. Both my sons were started on stimulant medication, and while my youngest son has done well on the medicine, my eldest became depressed and withdrawn and his teachers suggested that we look into other treatments. So began my exploration into other therapies for ADHD.

Both my sons have some of the co-conditions that often accompany a diagnosis of ADHD. My eldest son has Sleep Onset Insomnia, and he has been treated for visual convergence problems, and my youngest son has struggled with depression, anxiety, and Auditory Processing problems.

My boys go to a fantastic school, a regular school that knows how to reach and teach children with ADHD, and this has really helped them grow and progress as students and people. Many people with ADHD struggle socially, and my sons are no exception. In Commanding Attention, I discuss treatments that help people with ADHD succeed not only academically, but also with other life skills that are, as I will discuss, as important as academic skills to achieving happiness and success.

I believe that my own ADHD symptoms are mostly controlled. I still drink several cups of coffee daily, exercise regularly, and use technological tools to keep myself organized. Many people remind be that I am, in fact, medicated with caffeine. I agree. There are biological and physiological reasons why caffeine helps my son and me. Caffeine will not help everyone. In Europe, thirty years ago, coffee was regularly recommended by Psychiatrists for symptoms of ADHD, but you rarely read about coffee as a possible treatment for ADHD today. This was one of the many reasons why I decided to write this book.

Neurologists have found that any activity that allow people with ADHD to practice their attending and focusing strengthen our moldable brains. This book has required a lot of focus and attention, and I am happy to report that since I began this over a year ago, my cell phone has been filed away in my dishwasher only once.

INTRODUCTION

"Life is not about waiting for the storms to pass...

It's about learning how to dance in the rain."

Vivian Greene

Commanding Attention is a book about Attention Deficit Hyperactivity Disorder (ADHD) treatments that you may have never heard of. In this book, I discuss what scientific research has taught us about the benefits, costs, and limitations of these treatments. I also discuss what the research findings from human and animal studies have reported about the biology of these treatments. The treatments in Commanding Attention offer parents, clinicians, and patients more tools to treat ADHD. These tools can be used in combination with drug therapy, or sometimes alone, to help ADHD.

The reason that you may not have heard much about other ADHD therapies has as much to do with pharmaceutical marketing and a physician’s familiarity with drug treatment as it has to do with the fact that patients and parents are often in need of a quick fix for troublesome ADHD symptoms and for the majority of patients, the stimulant drugs improve symptoms immediately. When you compare the ease of starting drug treatment to the ease of starting other treatments such as diet changes, Neurofeedback, working memory training or aerobic exercise for example, medication wins hands down. The only easier treatment might be a vaccine that immunized you against ADHD but that treatment does not exist. For many patients, drug therapy is:

<> Affordable

<> Quick

<> Easy

<> Effective

<> Safe

Given all the benefits of drug therapy, you might ask why I bothered to write a 200 page book on other therapies. There are two reasons. The first reason is that drug treatments are not necessarily the best treatment for ADHD. Other treatments may, in the long term; better address the complex neurological processes that result in ADHD symptoms. The second reason is that not everyone can or will take medication for their ADHD symptoms. Explaining the benefits that other treatments may provide is what Commanding Attention is about.

Commanding Attention is not an anti-drug therapy book. The debate in the ADHD community for and against drug therapies can be contentious and divisive. As you will learn in the executive function skills section of this book, flexible thinking does not come easily to people with ADHD and many of them see drug treatment as a black and white issue. This is a shame.

It is my belief, as a parent of children with ADHD, and as a clinician, that, for many patients, prescription therapy is necessary. Many patients, because of their age, their environment, their genetics, or their particular symptoms, will get the greatest, the most immediate and most appropriate symptom improvement from drug therapy. Other patients, for a variety of reasons, may find that drug therapy is not the best answer for their symptoms.

The people who take medication are not right. The people who do not take medication are not wrong. ADHD is a medical condition that affects everyone in a unique way. Not everyone can control their blood pressure by taking ACE inhibitors or by taking a beta blockers, some require both. Some people have side effects when they take either drug. Some have side effects no matter what drugs they take. Just like not everyone will be able to control their blood pressure with the same treatment plan, not everyone will be able to control their ADHD symptoms with a one size fits all treatment plan. Some patients may find that their symptoms improve with therapies that are not prescription drugs. For the majority of patients, a combination of treatments is the best solution.

Patients who have improved with drug therapy will find additional therapies in Commanding Attention that may enable them to further improve their symptoms. Other patients will find that these other ADHD treatments provide enough symptom improvement to allow them to decrease the dose or eliminate their prescription medication.

The majority of patients with a diagnosis of ADHD are not on any treatment. Of the patients prescribed medication, two thirds of them, despite debilitating ADHD symptoms, will no longer be taking their prescription medication a year after it is prescribed. Some will stop because of side effects, for some, the medicine will not help their symptoms, and others will stop for other reasons. For patients who cannot or will not take prescription medication, other treatments must be tried, and Commanding Attention contains valuable information for these patients.

With or without drug therapy, ADHD must be treated. The toll that ADHD symptoms take on the lives of children and adults with this disorder is staggering. People with ADHD are less educated, more likely to perform poorly at work, and have less occupational stability than people without ADHD. When ADHD symptoms are properly treated, however, education, work performance, and work stability often improve.

Research studies have indicated that therapies such as increased exercise, Neurofeedback, elimination diets, behavioral therapies, and cognitive therapies may all help the symptoms of ADHD. In Commanding Attention, I discuss what is known about the benefits, side effects, costs, and limitations of non-drug ADHD therapies.

Time and Time and Time Again

This book has hundreds of footnotes. I realize that the footnotes may make the book seem more like a textbook than a book you might sit down and enjoy, but I included them all for a good reason. It all has to do with a story I heard when I first started my medical training. In my first year of medical schooling, I heard a lecture from a well-respected neurologist that I have never forgotten.

Before he began speaking to us on the treatment of neurological conditions, he cautioned us to beware of lecturers who tried to convince us to use new treatments that had not been rigorously studied. He explained that some physicians would use unconventional or untested treatments and then go on to report on the great success they had with this therapy though the treatment had only been successfully prescribed to one or a few patients. These physicians, after they had treated only one patient successfully with some new remedy, would state, In my experience, this drug is an excellent treatment for the relief of ...

When two patients had responded to the treatment, the experts changed their lecture and would say, In the series of patients that I have studied, this drug is an excellent treatment for the relief of ...

When they had treated three patients with this treatment, their lecture was changed once again and now they would say, I will show you time and time and time again that this is an excellent treatment for the relief of ...

The footnotes are my way of showing you that I am not that type of expert. When I discuss a certain therapy or treatment, I try to back up what I am saying with the medical references that support the conclusions that I have come to, and the statements that I have made.

This book is divided into six sections. In the first section, I give a background of current ADHD diagnosis and treatment. The second section describes lifestyle treatments that have been used successfully to treat ADHD. The third section describes treatments and therapies that teach skills that strengthen the brain weaknesses seen in ADHD; I call this section Tools of the Mind. Section four, Vitamins and Essential Nutrients, is divided into two parts. In part A, I discuss the vitamins that must be in place, and in adequate supply, for our brains to function normally and in part B; I discuss nutrient deficiencies that sometimes occur in people with ADHD. In the fifth section I write about what the medical literature has reported on herbal Treatments for ADHD, and in the last section, Emerging Therapies, I discuss ADHD therapies that are on the horizon.

Each section is divided into sub-sections with descriptions of the specific treatment, a discussion of the studies that have been performed on the treatment and a review of the biological reason why a therapy might be helpful. The side effects and appropriate doses for each therapy are also discussed. Some therapies such as Neurofeedback or Executive Function Training programs can be costly. When applicable, I discuss the cost of each therapy and give a list of resources where you can find free or affordable alternatives for that particular treatment. When the effect size, (the amount of benefit a person can expect), for a treatment is known, this information is included as well.

There are stories in this book about real patients. The majority of these stories are about people that I have met through my blog, in my clinical practice, through my family, in my neighborhood, or at my children’s school. The stories are a composite of the experience of a set of patients. I am conscious of the need to protect the confidentiality of medical information and for this reason all the names used in these stories are fictional. The ADHD details of the stories have not been altered but I have changed any information that could potentially identify the people in the stories. To protect my children's privacy, I write using a pen name. I do not use this name to hide my identity; I believe my children have a right to their privacy and that it is not my right to tell their stories.

It is my sincere hope that you enjoy and gain valuable insights from this book. Thanks for reading!

SECTION 1: ADHD TODAY

Risk more than others think is safe. Care more than others think is wise. Dream more than others think is practical. Expect more than others think is possible.

Claude Bissell

In the United States, Attention-Deficit/Hyperactivity Disorder (ADHD) affects an estimated nine and a half percent [1]of children and four percent of Adults.[2] Prescription drug therapy is considered the gold standard of ADHD treatment, but as many as two-thirds of children and adults prescribed ADHD Medication stop taking their medication within a year.[3][4]

The reasons that ADHD patients stop their medication are varied, but a distrust of the medical system[5], medication ineffectiveness, medication side effects, inconvenience and/or cost[6][7] are a few of the reasons that patients have given for not continuing prescription drug therapy.

The patients that do take their medicine often do so because of a belief that the medication will cure their ADHD.[8] While most researchers agree that ADHD drug therapies improve behavior, it is less clear whether these medications have any lasting benefits. In 2009, findings published from a study that lasted more than a decade[9] reported that there was no evidence that medication produced any long lasting academic or behavioral benefits in children with ADHD.

The Multimodal Treatment Study of Children with ADHD (MTA) aimed to determine what ADHD treatment regimen worked best to lessen the symptoms of ADHD. The researchers in this study randomly placed children with ADHD symptoms in four treatment groups. One group took only prescribed medication, another group was treated with medication and behavioral therapy, the third groups were treated with only behavioral therapy, and the last group, the control group, was enrolled in regular community enrichment, an after school program. The researchers then observed them for many years.

The initial results, published in 2001, indicated that the best academic and behavioral outcomes were seen in children that received a combination of medication coupled with behavioral therapy. These research findings validated the physician’s practice of prescribing ADHD medication; a practice that the ADHD medical community had been using for some time.

Twenty-two months after the initial evaluation, the participants were evaluated again, and the research findings indicated that the medication and behavior therapy group was still doing better than the other groups[10], but the findings were not as strong as they had been before. After observing the study participants for 36 months, the results changed.

The findings from the MTA, published in 2009[11], reported that, 36 months into the treatment, there was no benefit academically or behaviorally for the participants who were in the stimulant therapy group. Those findings would have been bad enough, but the study findings actually were even worse than that. The researchers discovered that continued stimulant treatment actually resulted in worsening ADHD symptoms.[12]

In 2010, the MTA study researchers published findings that reported homework improvement in the children in the behavioral therapy arm of the study.[13] Results showed that only participants who received behavioral treatment (behavioral treatment or combined drug and behavioral treatment) demonstrated any continued improvements in homework, but these findings did not get the attention of the medical community in the same way that the original findings of drug benefits had.

The reason that these results were largely ignored may have to do with physician perceptions of non-drug ADHD therapy. Many physicians and ADHD authorities believe that non-drug ADHD treatments simply do not work. When a study is published indicating a positive effect from exercise, behavioral therapy, or from computerized working memory training, the findings are often ignored or discounted.

ADHD authorities often report that the design of studies performed on non-drug therapy is flawed. Some of the most commonly reported problems with these studies have to do with the sample size of the study (too few participants), the lack of an appropriate control group, or the lack of a properly measured outcome. These study concerns are valid, but these same concerns also apply to the research performed on accepted drug treatments.

Recently, the U.S. Department for Health and Human Services Agency for Healthcare Research and Quality (AHRQ) set out to critically review all the ADHD studies that had been performed from 1980 to 2010, looking at the benefits of behavioral therapy and stimulant ADHD treatment.

AHRQ is this country's healthcare watch dog agency; they look at disease treatments to determine what interventions work. When the AHRQ looked at 30 years’ worth of ADHD research, they found that, of the studies performed over the last 30 years, most did not meet the criteria necessary to be deemed 'good' studies. From their review of 30 years of properly performed published studies, the agency was only able to conclude that¹²:

<> Parent training worked well for diminishing the ADHD behaviors of preschoolers.

<> Primary school age boys with ADHD combined type showed improvements in behavior when they were treated with methylphenidate (Ritalin) or Atomoxetine (Strattera).

That’s it, only two proven findings. Most medical providers will tell you that the findings of the AHRQ are preposterous. They have personally seen symptoms improvements in adults and children treated with drug therapy. Of course they have. Stimulant drugs help everyone’s cognitive skills. This is the reason why college age students fake ADHD symptoms in the hope of getting an Adderall prescription.[14] The findings of the AHRQ point to the difficulty of designing a perfect study, and my belief is that if you are going to discount the findings of non-drug therapy studies because of flaws, you must also discount the findings of the majority of drug studies.

Both drug and non-drug treatments help certain subsets of individuals with ADHD symptoms. What may help one patient may not help another. Factors such a genetics, coexisting problems, ADHD sub-type, and circumstances specific to each person will all impact the relative effectiveness of one therapy over another.

Today, when a parent or patient decides to stop taking their ADHD medication, they are likely to be told by their health care provider that the benefits of alternate or supplemental therapies are questionable or short lived. Given the findings of the Agency for Healthcare Research and Quality, it appears that, unless you are a preschooler or a 10 year old elementary school aged boy with combined type ADHD, the same can be said for drug therapy.

There is a lack of willingness on the part of many health care providers to consider alternative or supplemental treatments for ADHD, but this is short sighted. Almost one in ten children in today’s schools will be diagnosed with ADHD, and some of them cannot or will not take medication. For those children and adults, we need other therapies.

THE LIMITATIONS OF RESEARCH

"The man with insight enough to admit his limitations comes nearest to perfection."

Johann Wolfgang von Goethe

All treatments for ADHD, whether they are behavioral, cognitive, and pharmaceutical, vitamins, or supplements, attempt to do the same thing. They attempt to diminish or remove the debilitating symptoms of ADHD.

The success or failure of these treatments is measured by determining the amount of diminished ADHD symptoms that is brought about by the use of each therapy. If the remedy works to relieve symptoms more than a placebo (a sugar pill) or if the study group does better than the control group (a group that did not receive the therapy), it is considered to be a good treatment for ADHD.

The problem of determining improvement is complicated because there are three different subtypes of ADHD and by the fact that the symptoms of the different subtypes of ADHD are different. A treatment that helps hyperactivity but not inattention may be seen as ineffective for one patient and very effective for another, for example.

The combined type of ADHD is the most commonly diagnosed subtype of ADHD, and it is estimated that more than fifty percent of people diagnosed with ADHD will have this type. Combined type ADHD is more likely to be linked to behavioral problems and to Oppositional Defiance Disorder (ODD). It is estimated that forty to eighty percent of children with combined type ADHD will have co-existing ODD[15] with symptoms of:

<> Losing one’s temper a lot.

<> Arguing with adults or refusing to comply with adults’ rules or requests.

<> Often getting angry or being resentful or vindictive.

<> Deliberately annoying others; easily becoming annoyed with others. Often blaming other people for one’s own mistakes or misbehavior.

A therapy may be deemed ineffective because it does not diminish oppositional symptoms or hyperactivity even if it improves attention. The subtype called predominantly inattentive ADHD (ADHD-PI) includes roughly thirty percent[16] of all patients diagnosed with ADHD. People with ADHD-PI are rarely hyperactive or oppositional, unless ADHD treatment studies are performed with controls in place that separate the subtypes of ADHD, the results regarding the benefits of the therapy will be flawed. Given the differences in symptoms of the different subtypes of ADHD, it is easy to see how a study might report that a certain treatment was a success or failure when, in fact, the treatment was successful (or useless) for only a certain subtype of ADHD.

Because most patients with ADHD have at least one other co-existing behavioral or mental health problem, therapies that help co-existing ADHD problems, such as sleep disorders and depression, may reduce the total number of ADHD symptoms as well. These treatments may help the symptoms of ADHD by diminishing other symptoms such as sleepiness that can make a core symptom of ADHD, such as inattention, worse.

Another limitation of ADHD studies has to do with having a good blind control group for the treatment group comparison. A blind control group is a group of people that are not receiving the treatment but that are also not aware that they are not receiving the treatment. The way blind studies are generally performed is that two groups are given a pill that looks exactly the same. One pill has the active drug and the other does not. The groups are then tested to see which group does better on