Treatment Options for ADHD behaviours

Neurotherapy for ADHD Treatment

Neurotherapy training
Neurotherapy Session

Since the early 1970s, Neuroscience and Psychophysiology research and clinical practice have shown that through Neurotherapy, we can push our brain's plasticity and promote normalisation of the brain patterns that underlie ADHD behaviours. Neurotherapy has been shown in group studies to be as effective as stimulant medication for ADHD.

There are currently in excess of 20,000 clinicians worldwide using Neurotherapy for permanent remediation of around 80% of ADHD cases and many other mental disorders, without the use of drugs. The work of psychologists, psychiatrists, neurologists and medical practitioners practising Neurotherapy is largely unrecognised in mainstream. This is partly due to the lack of interest from medical and pharmaceutical community.  

Neurotherapy is a computer-based technique for retraining the brain to produce more normal patterns of electrical activity, and has been shown to be an effective treatment for around 80% of children with ADHD and Learning Difficulties.

Neurotherapy was developed at the UCLA Medical School EEG Laboratory by Professor Barry Sterman in the early 1970s as a treatment for childhood epilepsy. It was further developed extensively by Professor Joel Lubar of Tennessee University as a treatment for ADHD and Learning Difficulties. To date there are in excess of 300 studies indicating that Neurotherapy is effective in the treatment of ADHD and Learning difficulties. Treatment effects appear to last for years perhaps for life.

Neurotherapy research findings

The January 2000 issue of the journal "EEG and Clinical Electroencephalography", the journal of the EEG and Clinical Neuroscience Society was dedicated entirely to reviewing Neurotherapy. Professor Frank H. Duffy, M.D., the Neurology editor and a Paediatric Neurologist at Harvard Medical School, stated in the editorial that the scholarly literature suggests that Neurotherapy should play a major therapeutic role in many difficult areas. In his opinion "If any medication had shown such a wide range of benefits with no adverse side-effects it would be widely used and accepted."

Studies have revealed patterns in the QEEG of ADHD children, which are consistent with findings revealed by PET, fMRI, SPECT, LORETA and other neuro-imaging studies. ADHD children have consistently been found to have increased slow wave power in either Delta (1-4 Hz) or Theta (4-7 Hz) and/or Alpha (8-13 Hz) , and reduced fast wave Beta (16-30 Hz) activity in their EEG, when compared to age matched controls. However, in around 10% there is evidence of abnormally high Beta activity which is believed to be due to environmental toxins and/ a mutated COMT gene.

During Neurotherapy, real-time QEEG is displayed on a computer in the form of a game, and the patient is given contingent audio-visual rewards for producing less slow waves and more fast brainwaves. There is now significant evidence in the literature, which suggest that most ADHD children can learn to produce a brainwave pattern with more normal theta/beta ratios.

Improvements in theta/beta ratios of ADHD subjects following Neurotherapy have been found to correlate significantly with a number of empirical and subjective measures. Studies have shown improvement in "impulsivity", "attention", "response time" and "variability of response time" scores on the Test of Variables of Attention (TOVA) Continuous Performance Tasks . In addition there were reductions in hyperactivity and impulsivity on behaviour scales, increases in attention and cognitive skills in Individual Achievement Tests scores, and increases in IQ scores.

Overall, results of several studies indicate that Neurotherapy treatment is effective in over 80% of cases in significantly reducing the undesirable ADHD symptoms, and the effects appear to be permanent. In many of the studies cited, the ADHD subjects were on psycho-stimulant medication at the start of the study. In all of the studies when medication was involved, the subjects were able to significantly reduce their stimulant medication or completely come off the medication by the end of Neurotherapy treatment.

Many researchers, scientists and clinicians have expressed the opinion that Neurotherapy is not more widely used mostly because the largest research funding sources, the pharmaceutical companies, have no interest in promoting its research and its clinical application.

Studies Comparing Neurotherapy to Ritalin.

The neurobiological causes of ADHD suggest that the primary focus of treatment should address the core issue, namely promote the remediation of the neurological dysregulation. While medication chemically modulates neurotransmitter activity to affect changes in brain electrical activity, Neurotherapy attempts to challenge the brain to achieve self regulation of brain electrical activity by modulating the brain's plasticity. Methylphenidate and other stimulant medications that are used to enhance attention produce state dependent effects. This means that the medication works while it is in the person's system but that there is virtually no long-term carryover to the non-dependent state. On the other hand Neurotherapy works not only while doing training, but has a carryover effect that last for a very long time, perhaps even the whole lifetime (Lubar, 1997).

Rossiter and La Vague compared the effects of Neurotherapy to stimulant medication in reducing ADHD symptoms. The study compared the effects of a medical treatment program to 20 sessions of Neurotherapy. The Neurotherapy group of 23 subjects was matched with a stimulant group, also of 23 subjects, by age, IQ, gender and diagnosis. The Test of Variables of Attention (TOVA) was administered pre and post treatment. Both groups improved significantly on TOVA measures of inattention, impulsivity, information processing, and variability, and did not differ from each other on TOVA change scores. Rossiter suggested that Neurotherapy is an effective alternative to stimulants and may be the treatment of choice when medication is ineffective, produce unacceptable side effects, or when compliance to medication is a problem [5].

To compare the effectiveness of Neurotherapy to stimulant medication, 22 children from a Social-Paediatric Hospital, ranging from 8 to 12 years of age with a primary diagnosis of ADHD were assigned to a Neurotherapy experimental group and received thirty 45-minutes sessions of Neurotherapy to enhance SMR and/or beta activity and suppress theta activity, over a period of 10 weeks. The control group consisted of 11 children matched in age and sex and optimally medicated with methylphenidate. No other psychological treatment or medication was administered to either subject groups. The same test battery: an IQ test (HAWIK-R), T.O.V.A, paper-pencil-test (d2) and IOWA Conners Behaviour was administered pre and post-treatment. The ADHD children in both the Ritalin and Neurotherapy conditions showed comparable and significant improvements in attention and concentration abilities in the objective and subjective measurements. Performance IQ scores also improved significantly in both groups. While results indicate that Ritalin and Neurotherapy had comparable treatment effectiveness, the gains from Neurotherapy are expected to be permanent, while the gains in the medication group were expected to be dependant on daily continuation of medication treatment [1]

One hundred children diagnosed with ADHD, either inattentive or combined types ages 6-19, participated in a one-year, multimodal, outpatient program that included Ritalin, parent counselling and academic support at school. In addition, 51 of the children also received Neurotherapy. Pre and Post-treatment assessments were conducted both while on and off stimulant therapy. Significant improvements were noted on the TOVA and the Attention Deficit Disorders Evaluation Scale [2] when participants were tested while on Ritalin. However, only those who had received Neurotherapy sustained these gains when tested while off Ritalin. Only children who had received Neurotherapy had reductions in theta/beta power ratio and these changes were statistically significant. ADDES behavioural measures indicated that parenting style exerted a significant moderating effect on the expression of behavioural symptoms only at home and not at school [3].

In a European study, Fuchs and colleagues compared the effects of a 3-month Neurotherapy program which rewarded SMR (12-15 Hz) and beta activity (15-18 Hz) to methylphenidate treatment. Of the 34 children, with a diagnosis of ADHD aged 8-12 years, 22 were assigned to the Neurotherapy group and 12 to the methylphenidate group according to their parents' preferences. Both Neurotherapy and methylphenidate were associated with improvements on all subscales of the TOVA, and on the speed and accuracy measures of an Attention Endurance Test. Furthermore, ADHD behaviours were significantly reduced in both groups as rated by both teachers and parents on the IOWA-Conners Behaviour Rating Scale. The authors concluded that their findings suggest that Neurotherapy was as effective in improving some of the behavioural problems of ADHD as stimulant medication [4].

Study replication

Rossiter replicated an earlier study [5] with a larger sample of ADHD patients, with a wider age range, improved statistical analysis and more comprehensive behavioural data for the Neurotherapy group. Thirty one patients who chose methylphenidate treatment were matched with 31 patients who chose Neurotherapy treatment. Of the Neurotherapy patients, 14 received training in the clinic while the remaining 17 received training in their own home. This study design is one described by Kazdin as an "effectiveness research design" whereby patients chose assignment to either the Neurotherapy group or the Methylphenidate (active treatment) control group [6]. Methylphenidate dose was titrated for optimum effect using the TOVA. Both groups showed statistically and clinically significant improvement on TOVA measures of attention, impulse control, processing speed, and variability in reaction time. Clinically significant gains were made by the Neurotherapy and Medication groups based on the percentage of patients showing significant improvement over baseline (84% in each).

There were large effect sizes for Neurotherapy (1.01-1.71) and Medication (0.80-1.80), and the percentage of individual TOVA scores showing significant improvement (Neurotherapy: 55%, Methylphenidate: 56%). Post-treatment mean scores for both the Neurotherapy and the Methylphenidate groups fell within the average range of functioning. Both groups had clinically significant improvement in behaviours based on their large effect size The Neurotherapy group on BASC (1.15–1.75) and Brown ADD Scales (1.59) and the fact that these scores fell within the average range of functioning. There were no statistically significant differences in the TOVA gain scores between the Neurotherapy and Methylphenidate groups, and proportion of patients in the Neurotherapy group that significantly improved behaviourally was equivalent to that in the medication group. Confidence interval and non-equivalence null hypothesis testing confirmed that the Neurotherapy program produced patient outcomes equivalent to those obtained with stimulant drugs [7].

The results of this study [7], the statistical reanalysis of data from Rossiter and La Vaque (1995) and the other studies comparing Neurotherapy to Medication [1, 3, 4] support the view that Neurotherapy treatment in those studies produced patient outcomes that were equivalent to, or non-inferior to those obtained with Methylphenidate. However Rossiter quit rightly pointed out that the choice of an effectiveness research design limits the conclusions that can be drawn from these studies. Effectiveness studies are typically conducted in clinical settings and utilise patients who, more often than not, have co-morbidities. Consequently some compromises are made in research methodology and experimental controls have to be made for practical and ethical reasons. These studies allowed patients to choose between treatment groups, used patient groups with co-morbidities, and tailored individual protocols based on presenting symptoms and baseline EEG. These deviations from strict experimental controls are acceptable variations in an effectiveness study, although they would be considered flaws in an efficacy study. Despite the less stringent experimental controls, these studies clearly demonstrate that the Neurotherapy program is clinically effective. However, they do not clearly establish to what extent various elements (e.g., the nature of the treatment, patient expectations, therapist characteristics, placebo effect, etc.) may have contributed to the positive outcomes [7].

Effectiveness versus efficacy studies.

Nonetheless as others have argued [6], while efficacy studies place emphasis on the internal validity of the studies, effectiveness studies place greater emphasis on external validity, i.e. their effect in real life. Hence, effectiveness studies can evaluate treatments as they are actually provided in clinical practice, which efficacy studies do not and cannot. Therefore, effectiveness research design is necessary to demonstrate applicability in the real world to the broad spectrum of patients as they present for treatment in clinics and hospitals (Clarke, 1995). However, they do preclude attributing the improvement in the EEG group solely to Neurotherapy. The influence of nonspecific factors cannot be ruled out. This is not problematic if the goal is to assess the "real world" effectiveness of a treatment program with Neurotherapy as the primary component. It is significant that [1, 3, 4] independently obtained similar results with different clinicians, settings, patient populations, and treatment protocols [7]

1. Fuchs, T., Attention and Neurofeedback. 1998.
2. Adesman, A.R., The Attention Deficit Disorders Evaluation Scale. Journal of Developmental and Behavioral Pediatrics, 1991. 12(1): p. 65-66.
3. Monastra, V.J., D.M. Monastra, and S. George, The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Appl Psychophysiol Biofeedback, 2002. 27(4): p. 231-49.
4. Fuchs, T., et al., Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison with methylphenidate. Appl Psychophysiol Biofeedback, 2003. 28(1): p. 1-12.
5. Rossiter, T.R. and T.J. La Vaque, A comparison of EEG biofeedback and psychostimulants in treating attention deficit/hyperactivity disorders. Journal of Neurotherapy, 1995. 1(1): p. 48-59.
6. Kazdin, A.E. and M.K. Nock, Delineating mechanisms of change in child and adolescent therapy: methodological issues and research recommendations. J Child Psychol Psychiatry, 2003. 44(8): p. 1116-29.
7. Rossiter, T., The effectiveness of neurofeedback and stimulant drugs in treating AD/HD: part II. Replication. Appl Psychophysiol Biofeedback, 2004. 29(4): p. 233-43.

Dietary Changes and Nutritional supplementation

Diet is what you eat, while nutrition is what you absorb from your diet. Food is prepared through the digestive process by digestive enzymes, and broken down into nutrients in the small and large intestines by beneficial bacteria. If the bacteria profile is abnormal, characterised by a significant reduction in the count of beneficial bacteria and an increase in the count of other bacteria, then breakdown of foods may be less than optimal and the nutrient uptake inadequate.

The additives, artificial colourings, flavourings and other chemicals that we ingest daily may interfere with the delicate balance of beneficial bacteria in our gut, not to mention prescribed medications (including antibiotics), and antibiotics found in the food chain. Added to this list of "foreign" substances, which were not in the diet of our evolutionary ancestors, modern agricultural methods and food processing have significantly reduced the availability of nutrients in the foods that we eat.

The "Medline" medical database contains numerous references to studies highlighting the benefits of various specific vitamins and nutrients for a whole range of disorders.

The critical importance of Omega 3 Essential Fatty Acid (EFA).

Of all the nutrients that we are depleted in, none appear to have such widespread ill-effects as deficiencies in the Omega 3 EFAs derived from fish. Most book stores have at least a dozen books on the benefits of fish or fish-oil consumption. All modern diseases have been linked to deficits in fish derived Omega 3 fatty acid. This includes to name a few: childhood behavioural disorders such as ADHD and Learning difficulties, depression anxiety, bipolar disorder, schizophrenia, diabetes, cancer, cardiovascular disease and Alzheimer's. For a review of this literature we recommend the excellent book by Professor A. Stoll, the head of Psychiatric Pharmacology at Harvard Medical Centre, entitled: "The omega 3 Connection".

Several studies and reports by the World Health Organisation, the US. National Institute of Health and in Australia, the NHMRC, recommend that we should consume a ratio of Omega 6 to Omega 3 of around 2:1. Countries and communities who consume this ratio have a very low incidence of all the modern diseases. In our modern western diet we consume a ratio of Omega 6 to omega 3 which is between 20:1 to 40:1.

Every cell in the body has a lipid (Essential Fatty Acid) membrane which acts to protect the cell from substances outside of it. Omega 3 fatty acids play a crucial role in this protective system. A lack of Omega 3 EFAs renders every cell in the body vulnerable. The most vulnerable areas being the brain and the gut wall, and in younger children the ear and the mucous membranes of the nose throat and lungs.

Omega 3 EFAs and brain function

Fish in diet
Diet high in fish

The brain consists of 70% lipids and 40% of the brain is made up of Omega 3 EFAs (of the kind we get from fish). There are in excess of 8000 studies on Essential Fatty Acids in the scientific literature. Many are animal studies proving that deficiencies of the long chain Omega 3 EFAs (derived from fish) are associated with serious brain and systemic dysfunctions. Many prove that Omega 3 EFAs are essential for brain function. It is known that deficits are associated with all kinds of Psychiatric disorders including ADHD and Learning Difficulties.

Omega 3 EFAs and Gut function in ADHD

The gut cell wall, the epithelium, is constantly exposed to billions of organisms and toxins daily. The importance of the protective effect of the lipid membrane of each cell in the epithelium cannot be understated. If the lipid membrane is faulty, such as if there are deficits in Omega 3 fatty acids, the protection fails and unfriendly organisms, irritants and toxins irritate the gut wall. This may lead to a leaky gut and food sensitivities.

Of course it is not as simple as that, there are hundreds of nutrient interactions and systems at play. However, basically the lipid membrane hypothesis suggests that in genetically susceptible people, Omega 3 fatty acid deficiencies and deficiencies in associated nutrients may be the environmental triggers that start the chain of events that lead to most modern diseases. See Harvard Professor Andrew Stoll's book "The Omega 3 Connection" for more details.

Irritants and ADHD

In a double-blind placebo-controlled crossover study, twenty-seven children, whose behaviours had improved significantly on the Royal Prince Alfred Hospital elimination diet, which excludes food additives, natural salicylates, amines and glutamates, were either challenged with calcium propionate (preservative 282) or given a placebo in their daily bread.

There was a statistically significant difference in the proportion of children whose behaviours 'worsened' with challenge compared to placebo. Dengate and Ruben who conducted the study concluded that irritability, restlessness, inattention and sleep disturbance, in some children who are sensitive to salycilates, amines, glutamates and food additives, may be caused by this common preservative.

In addition to showing that additive 282 may exacerbate childhood behaviours, this study also highlighted that some children benefit significantly from a diet that exclude a number of substances including amines. In this study removing the irritants from the GUT helped reduce inappropriate behaviours. When reintroduced the behaviours returned.

Repairing the GUT wall

Gut wall
Repairing the gut wall

In addition to removing irritants from the diet, the gut wall needs to be repaired using specific nutrients, including Omega 3 EFAs and specific amino acids shown in the adjoining diagram. The balance of the gut bacteria also neds to be restored, by reducing sugar, refined carbohydrates, wheat and cereal grains and replacing these with legumes and vegetables. Although this can take several months, in our experience most children thrive physically and emotionally on this approach and parents and teachers report that their behaviours improve. Some of the children that we treat also need Neurotherapy to redress abnormal brainwave patterns and CBT to help them adapt to their environment and promote more beneficial behaviours.

Food allergies and abnormally high levels of some naturally occurring bowel bacteria can increase amine production in the gut. Recent research suggests that these trace amines trigger neurotransmitter receptors in the brain and may result in mental fog, fatigue and depression which is resistant to treatment by medication. This may explain why only 40% or people respond to anti-depressants, and 30% to placebo.

Omega 3 fatty acid supplements (from fish) are an important component of a nutritional supplementation protocol that the Behavioural Neurotherapy Clinic has devised as PART of the treatment for ADHD, Learning Difficulties and other Childhood Disorders, and for that matter many related disorders in adults.

Amines, depression and impaired mental function in ADHD

Amines are naturally-occurring substances in food, which the body can cope with in small amounts. However in larger amounts they can cause serious disturbances in the brain, triggering depression and reduced mental alertness. Recent studies have found amine receptors in the brain of mammals, including humans, suggesting that increased dietary amines, and increased amine production from overgrowth of some gut bacteria may cause depression, which is resistant to medication treatment, and a scrambling of brain messages, resulting in a foggy head and poor concentration.


Medication for ADHD

For decades, stimulant medications have been used to treat the symptoms of ADHD. Two of these medications are methylphenidate (Ritalin) and Dexamphetamine are effective in reducing symptoms in around 40-60% of children  with ADHD. However, most prescription psychiatric drugs also carry negative side effects and risks.

Meds for ADHD
Medication for ADHD

Ritalin and the other stimulants have sparked a great deal of controversy. The potential side effects should be carefully weighed against the benefits before prescribing the drugs. While on these medications, some children may lose weight, have less appetite, and may grow more slowly. Others may have problems falling asleep.

Some doctors believe that stimulant medications may also aggravate TICS and symptoms of Tourettes syndrome. Some doctors say if they carefully watch the child's height, weight, and overall development, the benefits of medication outweigh the potential side effects and that the side effects that do occur can often be handled by reducing the dosage. However, that is not necessarily true for all children. Hence, Parents should educate themselves on all aspects of the debate before making a decision.

Another debate is whether Ritalin and other stimulant drugs are prescribed unnecessarily for too many children. Remember that many things, including diet, low nutritional status, anxiety, depression, allergies, seizures, or problems with the home or school environment can make children seem overactive, impulsive, or inattentive. Critics of medication argue that many children who do not have ADHD are medicated merely as a way to control their undesirable behaviours, instead of the more appropriate dietary changes, nutrient supplements, Neurotherapy and counselling.

For some children, being scolded or punished is the only attention they ever get. They have few experiences that build their sense of worth and competence. Medication can help to control some of the behaviour problems that may otherwise lead to family turmoil. But more often, there are other aspects of the problem that medication can't improve. Even though ADHD primarily affects a person's behaviour, having the disorder has broad emotional and academic repercussions. There is no evidence in the literature that stimulant medication provides long-term improvements in academic output or cognitive skills.

Counselling ADHD children

Counselling child with ADHD
Counselling child with ADHD

If they're hyperactive, they are often told they're bad and punished for being disruptive. If they are too disorganized and unfocused to complete tasks, they may be called lazy. If they impulsively grab toys, butt in, or shove classmates, they may lose friends as a result. And if they have a related conduct disorder, they may get in trouble at school or with the law. Facing the daily frustrations that can come with having ADHD can make people fear that they are strange, abnormal, or stupid.

Often, the cycle of frustration, blame, and anger has gone on so long that it will take some time to undo. Both parents and their children may need special help to develop techniques for managing the patterns of behaviour. In such cases, a child psychologist can counsel the child and/or the family, helping them to develop new skills, attitudes, and ways of relating to each other.

In individual counselling, the psychologist helps children or adults with ADHD learn to feel better about themselves. They learn to recognise that having a disability does not reflect who they are as a person. The therapist can also help people with ADHD identify and build on their strengths, cope with daily problems, and control their attention and aggression. In counselling, people learn that they are not alone in their frustration and that help is available.

Sometimes only the individual with ADHD needs counselling support. But in many cases, because the problem affects the family as well as the person with ADHD, the entire family may need help. The psychologist assists the family in finding better ways to handle the disruptive behaviours and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behaviours.

Cognitive Behavioural Therapy (CBT) in ADHD

CBT refers to a group of therapies that aim to reduce dysfunctional emotions and behaviours by helping the person how to identify and alter the underlying thinking patterns that promote the abnormal behaviours. A basic concept in CBT is that a change in behaviour follows a change in thinking (or cognitive change) which is brought about by a variety of possible interventions, including the practice of new behaviours, analysis of faulty thinking patterns, and the teaching of more adaptive self-talk. There is no evidence in the scientific literature that CBT and Behaviour interventions are effective at bringing about permanent changes in the core symptoms of ADHD. In our experience however, CBT and behaviour interventions are very effective at promoting psychosocial skills and minimising poor self esteem in children with ADHD. However,  nutritional supplementation and Neurotherapy when done concurrently have been effective at minimising or eliminating the biological predispositions that drive the inappropriate behaviours of children with ADHD.

Family counselling for ADHD

Family counselling is used to help families learn the skills necessary for optimum interactions within the family. It involves training in communication skills, interpersonal relations skills, skills in preempting and defusing conflict, conflict resolution, setting of boundaries, discipline and the inappropriate use of punishment. Not all families need counselling and those who do may need help only in some of these areas.

Summary of Treatment modalities for ADHD.

  • Medications such as stimulants and antidepressants may be recommended in the short term.
  • Medication such as antibiotics may be used in cases of confirmed bacterial infections, together with and followed by probiotics to replace beneficial bacteria in the gut.
  • Neurotherapy, to redress abnormal brainwave patterns and promote more normal brain function.
  • Dietary interventions.
  • Nutritional supplementation including minerals, Omega 3 and vitamins
  • Family counselling.
  • Cognitive Behaviour Therapy and Behaviour Modification Program.