In the past decade there has been a tremendous upsurge of
scientific and public interest in Attention-deficit Hyperactivity Disorder (ADHD). The
interest is reflected not only in the number of scientific articles but in the explosion
of books for parents and teachers. Great strides have been made in understanding and
managing this common childhood disorder. Children with ADHD who would have gone
unrecognized and untreated only a few short years ago are now being helped, often with
dramatic, positive results.
It is critical for parents to seek the best in evaluation, as
well as the best in treatment. Evaluations that consist of a single checklist or ten
minute discussions, will likely run the risk of mis-diagnosis of the disorder or in fact a
misunderstanding of co-occurring problems that often present for children with ADHD.
Symptoms of inattention, restlessness, impulsivity, social and academic difficulties, can
reflect a variety of childhood disorders. It is essential to obtain a thorough
understanding of problems before attempting to intervene, especially since many children
with ADHD also experience co-existing learning and behavior problems. A good treatment
plan follows logically from a thorough evaluation.
There continues to be many questions in need of answers
concerning the developmental course, outcome and treatment of ADHD. Although there are a
number of effective treatments, they may not be equally effective with all children
experiencing ADHD. In their efforts to seek effective help for their children, parents may
become desperate. In their desperation and confused by misinformation in the marketplace,
parents may turn to treatments which claim to be useful but have not been demonstrated to
be truly effective in accordance with standards held by the scientific community. We refer
to such treatments as controversial. That is, they are marketed beyond their proven worth.
Unfortunately, most parents, no matter how intelligent or
well-educated, do not have the training nor expertise necessary to identify and evaluate
relevant scientific findings concerning the effectiveness of various treatment which have
not as yet met scientific standards for effectiveness. Some of these treatments merit
continued research, others do not. We do not recommend these as proven treatments. We know
that parents need to be informed about them because they may be offered as proven and
accepted approaches to the treatment of ADHD which they are not.
How Are New Treatments Evaluated?
The road by which a particular treatment is shown to be
effective can be long and arduous. The process begins with the formulation of a hypothesis
or idea. This hypothesis is usually based upon an existing body of knowledge. The second
step is the development of a protocol to evaluate the effectiveness of the proposed
treatment. The treatment itself and the way in which it will be implemented must be
carefully defined. The researcher must also specify the way in which the effectiveness of
the treatment will be evaluated. Care must be taken to be certain that the effects of the
treatment are not simply due to placebo. It has been well documented in scientific
research that people respond to all sorts of ineffective treatments as long as they
believe that the treatment has the power to help them. Placebo effects can be more
dramatic than most people realize.
The researcher must also take care that all who participate,
researchers and research subjects alike, are blind or unaware, whether they receive the
active treatment or the placebo. Otherwise the expectancies of either party could
influence the findings. Appropriate measurement techniques and statistical tests must be
built in so that the entire scientific community can evaluate the findings. Finally, the
results must be subjected to the scrutiny of this group, published and substantiated by
others attempting to replicate the findings.
Alternative Treatments: Another Path
There is also a second path which some practitioners follow,
sometimes in an effort to shortcut the longer, more accepted process. This path,
unfortunately, is fraught with many problems. On this path, proposed treatments stem from
concepts which are outside of the mainstream of existing knowledge or just along its
border. They may be instituted long before there is any research which supports their
effectiveness - often after only brief, poorly designed trials involving a small number of
subjects. Measurement techniques and means of evaluation are scanty at best and often
single case studies are offered as proof of the effectiveness of a treatment.
This treatment approach is usually publicized in books or
journals which do not require independent review of the material by recognized experts in
the field. Often, in fact, the advocate of a particular treatment publishes the work. This
method of self-publication should raise a warning for consumer parents. Additionally,
although parent support groups have an essential role the in treatment of childhood
disorders, parent support groups advocating one and only one treatment for a disorder,
unfortunately substitute enthusiasm for careful scientific research.
These alternative treatments and interventions commonly claim
effectiveness for a broad range of problems. When asked for proof to support these claims,
however, proponents are unable to produce more than scanty documentation. Proponents may
also claim to have access to knowledge and information not shared by the medical community
at large and when their treatments are criticized they may explain this as reflecting a
conspiracy against them in a scientific community.
Controversial Treatments for ADHD
Among the best known dietary interventions, the Feingold
Diet has advocated that children sensitive to a variety of foods and food colorings,
including preservatives, may develop symptoms of ADHD as a toxic reaction to these
substances. Over the years advocates of these dietary interventions have made dramatic
claims. They have stated that additive free diets will improve most if not all children's
learning and attention problems. They describe case studies in which children could be
removed from drug therapy if their diet was maintained. They also report improvements in
school for these children and subsequent deterioration in learning and behavior when the
diet is not followed.
Although dietary interventions are popular, few studies have
reported success and for most of these, statistical problems abound. The lack of well
controlled studies is also true for those who propose a relationship between allergies and
behavior or learning problems. Although proponents of these dietary approaches may
acknowledge that careful scientific studies are necessary, such studies have not yet been
A large number of studies, however, have examined the
relationship between sugar and ADHD. However, most of them are difficult to interpret. A
few well-designed studies have found some effects of sugar on behavior but these effects
are very small and only a small percentage of children with ADHD appear vulnerable.
After careful analysis of the existing evidence, numerous
researchers have concluded that there is limited, if any, support for a link between diet
and children's learning and behavior. Of course, like all children, we know that children
with ADHD require a healthy, well-balanced diet. At this time, however, it has not been
shown that dietary interventions offer significant help for children with learning and
Megavitamins and Mineral Supplements
The use of high doses of vitamins and minerals, including
currently marketed anti-oxidants such as vitamins A and E, pycnogenol and ginkgo biloba
are based on the precepts of orthomolecular psychiatry. According to this theory, some
people have a genetic abnormality which results in increased requirements for vitamins and
minerals. The anti-oxidants are marketed as substances that remove "free
radicals" from the bloodstream which are hypothesized to cause learning, attention
and behavioral problems as well as accelerate aging.
In the early 1970's it was claimed that treating hyperactive and
learning disabled children with high doses of vitamins could decrease these problems.
Proponents of this theory also claim that learning and behavior difficulties are also due
to deficiencies in minerals such as potassium and sodium as well as trace elements such as
zinc and copper.
Although vitamins are synonymous with health leading to an
intuitive appeal to this approach, there is a lack of scientific evidence to support that
these additives exert a significant difference in the lives of children with ADHD.
Although these substances are natural which lends an aura of safety, excessive use of
these substances can in fact cause health problems.
Anti-Motion Sickness Medicine
Advocates of this theory believe that ADHD is caused by
problems in the inner ear system. They believe that there is a relationship between ADHD
and problems with coordination and balance. This theoretical relationship is thought to
reflect a dysfunction in the inner ear system since this system plays a major role in
balance and coordination. To treat ADHD, a mixed array of medications, including
anti-motion sickness medications and several vitamin like substances are recommended.
Using these medications,proponents of this approach have claimed a success rate in excess
of 90%. Unfortunately,these results are unpublished and not subject to verification.
This theory is not consistent with what is currently known about
ADHD. There is no body of research that supports a link between the inner ear system and
attentional processes. Anatomically and physiologically there is no reason to believe that
the inner ear system is involved in attention and impulse control in other than marginal
ways. In the single controlled study of this theory, researchers evaluated the use of
anti-motion sickness medication to treat developmental reading disorders. The results
failed to support the theory. This approach to treating ADHD is inconsistent with current
knowledge and is not supported by research findings.
Candida albicans is a type of yeast which lives in the human
body. Normally yeast growth is kept in check by a strong immune system and by friendly
bacteria in the body. When the immune system is weakened or when friendly bacteria killed
by antibiotics,candida can over grow. This may lead to the vaginal yeast infection known
as candidias is and less commonly in infections of the skin, nails, and mouth.
Those who support this model believe that toxins produced by
yeast over growth weaken the immune system. This makes the body susceptible to many
illnesses, including ADHD and other psychiatric disorders. The treatment program is
designed to discourage the growth of candida in the body. This two-pronged approach
includes the use of anti-fungal medication such as nystatin and a low sugar diet. Other
aspects of the treatment approach include an elimination diet to rule out food allergies
and the use of vitamin and mineral supplements.
Although it is recognized that candida can cause infections of
the vagina, mouth, and skin, there is little evidence to support the idea that it also
causes the host of other illnesses listed by advocates of this approach. Little evidence
is provided to support these theories. Instead, anecdotal data and testimonials are
offered as proof that the approach is effective. The theory is not supported by evidence
and is not suggested as a helpful treatment for ADHD.
Proponents of this approach believe that children with
ADHD can be trained to increase the type of brain wave activity associated with sustained
attention and to decrease the type of activity associated with daydreaming and
distraction. They claim the result is improvement in attention and reductions in
hyperactivity and impulsivity.
The technique of EEG biofeedback involves measuring levels of
electrical activity in various regions of the brain. This information is fed into a
computer which transforms it into a signal, such as a light, tone or video game. Using
this signal as feedback, the child is taught to increase certain kinds of brain wave
activity and decrease other kinds (increase beta, decrease theta). Training involved
between forty and eighty treatment sessions according to the proponents of this program.
Each session lasts up to forty minutes or more. Since sessions are held two to three times
per week, treatment can extend over three to ten months or longer.
Although this treatment has become quite popular and is marketed
throughout the country, there continues to be limited, published peer reviewed research to
support its use. Although there is an increasing interest in research in this area, the
extensive claims initially made by proponents of this treatment (e.g., dramatic
improvements in intelligence scores, dramatic reductions in ADHD symptoms) seem almost too
good to believe. Many of the initial studies published were seriously flawed by the use of
small numbers of children with ambiguous diagnoses. Further more, published studies thus
far have not included appropriate control groups to rule out the effects of maturation or
Biofeedback technology is not new. Although some believe it holds
great promise in the treatment of ADHD, at this time it must be considered at the very
most an ancillary treatment used to support other treatments. From a research prospective
it must be considered unproven. Parents are advised to proceed with caution. It is an
expensive approach whose effectiveness, until better studies have been completed, has been
not consistently demonstrated.
Other Controversial Treatments
Among other treatments that parents may hear about on the
radio, view on television or read about, are the use of applied kinesiology (the
manipulation of bones in the body, particularly plates of the skull to improve body and
brain functioning), optometricvision training (exercises to improve eye tracking) and
auditory training (enhancing the capacity to listen to and process certain frequencies of
sounds). All three of these approaches have been marketed as effective for ADHD. However,
there is limited if any scientific support that any of these three will exert a
significant, positive impact on the functioning of children with ADHD.
In this paper we have reviewed approaches which have been
offered as effective for ADHD which have not met scientific standards which would justify
their inclusion as mainstream treatments for this childhood disorder. Some of these
controversial treatments merit continued research while others likely do not. Although
these treatments may be offered in the marketplace as proven and accepted approaches, they
are not. Parents are cautioned when considering these treatments that time and money might
be better spent on treatments with proven track records. Among the most effective means to
date are the judicious use of medication and behavior management. Parent education and
appropriate classroom settings, as well as helping children locate areas of success in
their lives, are also effective for children with ADHD.
How Can A Parent Be A Wise Consumer?
If you are the parent of a child with ADHD you know how
difficult your job can be. You want to obtain the very best treatment for your child. In
the spirit of "how can it hurt to try" you might be tempted to throw caution to
the wind when you hear about a new treatment that promises to help.
Promises are not enough. You also have the responsibility to
invest your family's resources of time, money and energy wisely. This means that as with
any large purchase,you must become an informed consumer.
In this paper we have provided general guidelines for evaluating
new treatments. Listed below are additional tips to help you recognize treatments that are
- Overstatement and exaggerated claims are red flags. Be suspicious of any product
or treatment that is described as astonishing, miraculous or an amazing
breakthrough. Legitimate health professionals do not use words like these. Nor do they
boast of their success in treating huge numbers of patients.
- Be suspicious too of any treatment that claims to treat a wide variety of ailments.
Common sense tells us that the more grandiose the claim the less likely it is that there
is any real merit behind it.
- Do not rely on testimonials from people who say they have been helped by the product or
the treatment. Enthusiasm is not a substitute for evidence and legitimate health
professionals do not solicit testimonials from their patients.
- Be skeptical about claims that a treatment is being suppressed or unfairly attacked by
the medical establishment. Legitimate health professionals eagerly welcome new knowledge
and better methods of treatment for their patients. They have no reason to oppose
promising new approaches.
Dr. Goldstein is a member of the faculty at the University of Utah and in
practice at the Neurology, Learning and Behavior Center. He has authored twelve texts,
book chapters, articles and training videos dealing with a range of child development
Correspondence to Dr. Goldstein can be addressed c/o the Neurology, Learning and
Behavior Center, 230 South 500 East, Suite 100, Salt Lake City, Utah 84102, (801)
532-1484, FAX (801) 532-1486, e-mail: email@example.com,