Play Attention Rocks New Study

Research shows Play Attention to be highly effective

To read more: http://www.playattention.com/clinical-studies/

Once again in a randomized, controlled, long-term clinical study performed by the prestigious Tufts School of Medicine, Play Attention has shown to be highly effective.

The results are published in the Journal of Developmental Behavioral Pediatrics, this month. Play Attention (NF in the article) was tested in 19 Boston area schools and pitted against cognitive training (brain games) and a control group. Here are the high points from the researchers:

“Parents of children who received NF [Play Attention] training reported significant improvements in attention and executive functioning…Parents of children who received cognitive training (CT) did not report significant improvements compared to those in the control condition.

The parent-reported improvements of participants in the NF [Play Attention] condition on the learning problems subscale might reflect important generalization of skills to the academic setting. It is noteworthy that parents of children in the NF condition did not seek an increase in their children’s stimulant medication dosage, although these children experienced the same physical growth and increased school demands as their CT and control peers.”

It is noteworthy that the researchers found no significant improvement in students who did simple cognitive brain training alone. These students performed worse in many areas and had to increase medication dosages over the period of the study. Play Attention produced the exact opposite effect.

ADHD’s Genetic Link

What causes attention-deficit hyperactivity disorder – ADHD? Research in the English medical journal, The Lancet, says it’s not too much sugar, bad diet, or poor parenting. Professor Anita Thapar, lead author of the study, says it’s likely genetic.

Thapar and her group of scientists at Cardiff University in Wales compared 366 children with ADHD to 1,047 kids without ADHD. In particular, the researchers examined differences in the children’s DNA. They found that kids with ADHD were more likely to have small segments of DNA that were duplicates or missing (copy number variants or CNVs — either a deletion or duplication of genetic material).

"We hope that these findings will help overcome the stigma associated with ADHD," Professor Anita Thapar, the study’s lead author, said in a written statement. "Too often, people dismiss ADHD as being down to bad parenting or poor diet. As a clinician, it was clear to me that this was unlikely to be the case. Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children."

While being media friendly, Thapar’s last statement is a stretch in relation to her research. People and the media love statements that provide seemingly conclusive answers.

Let’s go beyond the media hype that says this research concludes there is a definite genetic link. The researchers really only say there seems to be a possible “genetic link.”  However, their research did not conclude that it is purely or even primarily genetic. What they truly are saying is that this study is evidence that ADHD is not purely social.

The authors conclude:

    “Our findings provide genetic evidence of an increased rate of large CNVs in individuals with ADHD and suggest that ADHD is not purely a social construct.”

This is logical because only 15% of the research subjects with ADHD demonstrated increased CNVs. So is it safe to conclude that genetic makeup may contribute, at least in some particular cases, to ADHD? Yes, but to be clear,  this research did not conclude that it is entirely genetically based and was only partially genetically based in a small segment of their study population. This is very similar to other genetic research.

Why is it, if ADHD is genetically based, at least in part, that 30% don’t have it as adults when diagnosed as a child? What happened? Where did it go? This is what is most  important to parents and professionals.

Epigenetic theory, now being widely embraced by the scientific community, maintains that human development  includes both genetic origins of behavior and the direct influence that environmental forces have on the expression of those genes (nature/nurture). Epigenetic theory regards human development as a dynamic interaction between these two influences.

Simply put, how our genes express themselves is greatly impacted by environment. This is likely why, over time, 30% of children don’t display symptoms as adults. The brain changes, rewires, or (a radical version of epigenetic theory) their genes change.

Do tools exist to do this? Yes. See support.playattention.net.

If I may quote Dr. Theodore Dalrymple, “What seems to have happened is that parents have lost the awareness that they had for decades – if not for centuries – that concentration and self-discipline do not come naturally to children, and have to be taught (as well, sometimes, as enforced).”

Training the ADHD Brain

For years, we at Play Attention, have trained thousands and thousands of people to better pay attention, learn the cognitive skills they need to succeed, and change their behavior. Our results have spoken clearly for us since 1994. Now science is catching up.

Two recent distinct studies validate the brain’s ability to change. While a vast plethora of research confirms these studies’ findings, they are noteworthy. The first study demonstrates the efficacy of skill training, and the second demonstrates how teaching skills rewires the living brain.

The first study, published in the August 25 Journal of the American Medical Association, was performed by researchers from Massachusetts General Hospital (MGH). They utilized cognitive behavioral therapy as a direct intervention for ADHD adults. Cognitive therapy teaches skills for managing life challenges.

The researchers at  MGH found that while medications were the first line of treatment, many patients still persist with underlying symptoms.  While previous studies on cognitive behavioral therapy for ADHD were small and short term, the researchers at MGH claim their study to be the first to conduct full-scale randomized, controlled trial of the efficiency of an individually-delivered, non-medication treatment of ADHD among adults.

“Medications are very effective in ‘turning down the volume’ on ADHD symptoms, but they do not teach people skills,” commented Steven Safren, PhD, ABPP, director of Behavioral Medicine in the MGH Department of Psychiatry, who led the study. “This study shows that a skills-based approach can help patients learn how to cope with their attention problems and better manage this significant and impairing disorder.”

“Sessions were designed specifically to meet the needs of ADHD patients and included things like starting and maintaining calendar and task list systems, breaking large tasks into manageable steps, and shaping tasks to be as long as your attention span will permit,” commented Safren, an associate professor of Psychology in the Harvard Medical School Department of Psychiatry. “The treatment is half like taking a course and half like being in traditional psychotherapy.”

Like Play Attention has been doing since 1994, the researchers provided training sessions mainly that included skills training in filtering of distractions, organization, problem solving, and planning.

Safren’s group receiving cognitive and behavioral training demonstrated advanced control of their symptoms over their control group.  This benefit had persisted when measured three and nine months after the training.

The second study, published in The Journal of Neuroscience (August 25, 2010, 30 34 11493-11500 doi 10.1523 JNEUROSCI.1550-10.2010), examined the brains of rats when they learned to control their impulses.  The researchers documented synaptic changes in the medial prefrontal cortex. They concluded that the rat’s brains rewired themselves to produce the impulse controls necessary to be successful in the tasks the scientists had established for them.

Other past studies have confirmed that the brain will rewire to make changes for skills, impulse control, organization, etc. We’re glad that science is catching up to an learning process that we’ve done at Play Attention for sixteen years now.  That’s beyond cutting edge; it’s leading the way for others.

Is ADHD all in your head?

A study published in the June 14 edition of the Journal of Developmental and Behavioral Pediatrics has sparked controversy regarding ADHD medication and the brain’s power to regulate itself.

The study was funded by the National Institutes of Health and conducted by Dr. Adrian Sandler, a developmental-behavioral pediatrician and medical director of the Olson Huff Center for Child Development at Mission Children’s Hospital in Asheville, North Carolina.  The research was performed over the course of eight years using 99 patients from Western North Carolina.

Sandler found that children with ADHD can do just as well on half their medication when the medication is combined with a placebo. They performed as well even when parents and children had full knowledge they were taking a placebo.

[Placebo –  A substance containing no medication and prescribed or given to reinforce a patient’s expectation to get well. The placebo in this research was akin to a harmless inert pill].

Previous studies have shown that common stimulant medication causes side-effects like tics, weight loss, stunted growth, and even heart complications in some instances. This often causes trepidation in parents afraid of the possible side-effects on their children.

Sandler compared fully medicated children, children on reduced medication, and children on reduced medication with a known placebo. The results were quite intriguing.  Both the fully medicated and reduced medication groups had increased side-effects while the reduced medication with placebo demonstrated decreased side-effects. Furthermore, the reduced medication group reported decreased control of their ADHD symptoms. However, the control of ADHD symptoms was no different in the reduced medication with placebo group than in the full dose group, i.e. the reduced medication with placebo performed as well as the fully medicated group with less side-effects as well.

“I’ve been getting a lot of calls and e-mails,” said Sandler,, who conducted the research with James Bodfish, a professor in the departments of psychiatry and pediatrics at UNC Chapel Hill School of Medicine, and study coordinator Corrine Glesne.

“Medications work,” Bodfish said in a statement. “The question is whether we always need to use them at the highest dose. Many parents are concerned about placing their child on medication. Some choose not to treat their child because of concerns about side effects.”

While the research doesn’t address it, the obvious question is, Why? Parents and children in this study knew they were taking a placebo. Why then did they perform as well as their peers without the side-effects — at essentially half the dose as their peers? While the placebo effect has been studied widely, the exact mechanisms are unknown. We do know that the mechanism is governed by the brain. This clearly tells us that having ADHD or not, our brain is still a powerful weapon in our arsenal.

We also cannot exclude the influence of the parents during this research. Did they expect their child to do better? The authors suggest that this was so. This dynamic cannot be overlooked in your family either.

The bottom line is that we likely have far more control over our behaviors and cognitive processes than we are given credit for. Modern medicine, as this research suggests, is just beginning to understand the brain’s role in shaping our lives. We’ve known this for years at Play Attention. Cognitive training. Memory training. Motor skills. Attention training. Behavioral shaping. It’s time to take control over our lives. We’ve all got the power to do it. It lies right behind our eyes.

The ADHD link to social dynamics

If I told you that women who received only basic education were 130 % more likely to have a child on ADHD medication than women with university degrees, you’d see a link, wouldn’t you? 

Well, that’s what a  study published this month in Acta Paediatrica found.  That implies that nearly half of the serious cases of ADHD  in children are closely tied to social factors. The study reveals that factors like single parenting and poor maternal education were directly tied to ADHD medication use.

While we know that a genetic propensity likely exists, the human brain develops based on a complex interplay between nature and nurture; between genetic endowment (nature) and environment/social factors (nurture). Epigenetic theory tries to explain this relationship.

Curiously, few large-scale studies have tried to determine the impact of social and family influences on ADHD. Researchers at the Karolinska Institute in Stockholm, Sweden assessed data on 1.16 million school children and examined the health histories of nearly 8,000 Swedish-born kids, aged six to 19, who had taken ADHD medication.

"We tracked their record through other registers … to determine a number of other factors," said lead author Anders Hjern.

Here’s what the researchers found:

  • Living in a single parent family increased the chances of being on ADHD medication by more than 50 percent.
  • A family on welfare upped the odds of medication use by 135%.
  • Boys were three times more likely to be on medication than girls.
  • Social dynamics affected both sexes equally.

"Almost half of the cases could be explained by the socioeconomic factors included in our analysis, clearly demonstrating that these are potent predictors of ADHD-medication in Swedish school children," Hjern said.

It’s clear that this study found a link between socioeconomic factors and ADHD medication use/diagnosis. Other US studies have found that minority children and children of low socioeconomic status were more likely to receive ADHD medication.

Factors like low income and diminished quality time are more common in single-parent families. These typically lead to stressors like family conflict and a lack of social support, Hjern said.

While more research must be done, one has to ask, is medication the answer to social stressors like lack of time and money? Sounds too silly to ask, but it seems that our answer, ridiculously, is a resounding, YES!

We are the masters of our lives. We can make significant personal changes, but we must have the tools to do so. That’s why I began Play Attention (support.playattention.net) years ago.

Summer ADHD brain drain

Research tells us that during the summer, the average student loses one to three month’s math and reading gains made over the prior year. Academic losses are so common among students that educators have given the phenomena a name: Summer Brain Drain.

Summer Brain Drain may even be worse for ADHD students already having trouble at school.

Going to school daily provides schedules and routines. The summer break means those routines aren’t there. Expectations are lowered or relaxed. Even sleep schedules are often totally abandoned.

Unfortunately, exercise is often replaced with computer time, watching movies, or playing video games with friends. That’s a bad idea. While there’s nothing wrong with playing video games or watching movies, sedentary activity must always be balanced with exercise. This is especially important for an ADHD student. 

I’ve included some specific articles that approach this topic from varying perspectives. Enjoy and gain the benefits this summer!

Children with ADHD benefit from time outdoors enjoying nature

(http://www.news.uiuc.edu/NEWS/04/0827adhd.html)

News Bureau at the University of Illinois at Urbana-Champaign from May 15 through June 8. — Kids with attention deficit hyperactive disorder (ADHD) should spend some quality after-school hours and weekend time outdoors enjoying nature, say researchers at the University of Illinois at Urbana-Champaign.

The payoff for this “treatment” of children 5 to 18 years old, who participated in a nationwide study, was a significant reduction of symptoms. The study appears in the September issue of the American Journal of Public Health.

“The advantage for green outdoor activities was observed among children living in different regions of the United States and among children living in a range of settings, from rural to large city environments,” wrote co-authors Frances E. Kuo and Andrea Faber Taylor. “Overall, our findings indicate that exposure to ordinary natural settings in the course of common after-school and weekend activities may be widely effective in reducing attention deficit symptoms in children.”

ADHD is a neurological disorder that affects some 2 million school-aged children, as well as up to 2 to 4 percent of adults, in the United States. Those with ADHD often face serious consequences, such as problems in school and relationships, depression, substance abuse and on-the-job difficulties.

“These findings are exciting,” said Kuo, a professor in the departments of natural resources and environmental sciences and of psychology at Illinois.

“I think we’re on the track of something really important, something that could affect a lot of lives in a substantial way,” she said. “We’re on the trail of a potential treatment for a disorder that afflicts one of every 14 children – that’s one or two kids in every classroom.”

If clinical trials and additional research confirm the value of exposure to nature for ameliorating ADHD, daily doses of “green time” might supplement medications and behavioral approaches to ADHD, the authors suggest in their conclusion.

Kuo and Faber Taylor, a postdoctoral researcher who specializes in children’s environments and behavior, recruited the parents of 322 boys and 84 girls, all diagnosed with ADHD, through ads in major newspapers and the Web site of Children and Adults with Attention Deficit/Hyperactivity Disorder. Parents were interviewed by means of the Web and asked to report how their children performed after participating in a wide range of activities. Some activities were conducted inside, others in outdoor places without much greenery, such as parking lots and downtown areas, and others in relatively natural outdoor settings such as a tree-lined street, back yard or park.

The researchers found that symptoms were reduced most in green outdoor settings, even when the same activities were compared across different settings.

“In each of 56 different comparisons, green outdoor activities received more positive ratings than did activities taking place in other settings, and this difference was significant or marginally significant in 54 of the 56 analyses,” Kuo said. “The findings are very consistent.”

The two researchers have been pursuing the ADHD issue as an extension of a long line of previous research they’ve conducted on the nature-attention connection among the general population in mostly urban settings.

“The medications for ADHD that are currently available work for most kids, but not all,” Kuo said. “They often have serious side effects. Who wants to give their growing child a drug that kills their appetite day after day and, night after night, makes it hard for them to get a decent night’s rest? Not to mention the stigma and expense of medication.”

Simply using nature, Kuo said, “may offer a way to help manage ADHD symptoms that is readily available, doesn’t have any stigma associated with it, doesn’t cost anything, and doesn’t have any side effects – except maybe splinters!”

There are a number of exciting possible ways in which “nature treatments” could supplement current treatments, she said.

Spending time in ordinary “urban nature” – a tree-lined street, a green yard or neighborhood park – may offer additional relief from ADHD symptoms when medications aren’t quite enough. Some kids might be able to substitute a “green dose” for their afternoon medication, allowing them to get a good night’s sleep.

“A green dose could be a lifesaver for the 10 percent of children whose symptoms don’t respond to medication, who are just stuck with the symptoms,” Kuo said. As Kuo and Faber Taylor wrote, a dose could be as simple as “a greener route for the walk to school, doing classwork or homework at a window with a relatively green view, or playing in a green yard or ball field at recess and after school.”

The National Urban and Community Forestry Advisory Council, U.S. Forest Service, and the U.S. Department of Agriculture’s Cooperative State Research, Education, and Extension Service supported the project.

Exercise Improves Learning and Memory
Chalk up another benefit for regular exercise. Investigators from the Howard Hughes Medical Institute (HHMI) have found that voluntary running boosts the growth of new nerve cells and improves learning and memory in adult mice.
"Until recently it was thought that the growth of new neurons, or neurogenesis, did not occur in the adult mammalian brain," said Terrence Sejnowski, an HHMI investigator at The Salk Institute for Biological Studies. "But we now have evidence for it, and it appears that exercise helps this happen."
USA Today (http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm)

ADHD treatment is getting a workout

http://www.usatoday.com/news/health/2006-03-26-adhd-treatment_x.htm
Doctors haven’t done many definitive studies about exercise and ADHD, says David Goodman, an assistant professor of psychiatry at the Johns Hopkins University School of Medicine. But Goodman says it makes sense that working out would help people cope with the condition. Studies show that exercise increases levels of two key brain chemicals — dopamine and norepinephrine — that help people focus.

"Your cognitive function is probably better for one to three hours after exercise," Goodman says. "The difficulty is that by the next day, the effect has worn off."

If kids could exercise strenuously three to five times a day, they might not need medications at all, says John Ratey, an associate clinical professor of psychiatry at Harvard Medical School. Ratey is so intrigued by the question that he’s writing a book about how exercise can reduce symptoms of ADHD or at least help patients cope.

Team sports might help children with ADHD in several ways, says James Perrin, a professor of pediatrics at Boston’s MassGeneral Hospital for Children. Children with the condition benefit from following a regular schedule. Coaches who lead kids through structured exercises also might help build concentration and organizational skills.

Immediate rewards and the ADHD brain

A Nottingham University research team in the United Kingdom found that the brains of children with ADHD appear to respond to immediate rewards in the same way as they do to medication. Their research was published in the journal Biological Psychiatry.

“Our study suggests that both types of intervention [medicine and immediate reward/reinforcement] may have much in common in terms of their effect on the brain,” said Professor Chris Hollis, the lead investigator of  the study.

The research team used an EEG (electroencephalograph) to measure the brain activity of children as they played a computer game that provided extra points for less impulsive behavior.

The researchers devised a computer space game which rewarded the ADHD children when they caught aliens of specific colors  while avoiding aliens of designated colors. The game design actually tested the children’s ability to resist the impulse to grab the wrong colored aliens.

To test whether immediate reward/reinforcement made a difference, one iteration of the game rewarded the children fivefold for catching the right alien and penalized them fivefold for catching the wrong one.  All of this was done while activity in different parts of their brains was monitored with an EEG.

Hollis found that the immediate rewards helped the children perform better at the game. This was verified by the EEG which  revealed that both medication and immediate reward/reinforcement were "normalizing" brain activity in the same regions.

Many parents of ADHD children are aware that giving a reward to an ADHD child a week after their good behavior is insignificant to that child. ADHD children respond better to immediate reward, not delayed reward.

"Although medication and behavior therapy appear to be two very different approaches of treating ADHD, our study suggests that both types of intervention may have much in common in terms of their effect on the brain. Both help normalize similar components of brain function and improve performance,"  said Hollis.

"We know that children with ADHD respond disproportionately less well to delayed rewards – this could mean that in the ‘real world’ of the classroom or home, the neural effects of behavioral approaches using reinforcement and rewards may be less effective."

It’s obvious that providing immediate rewards/reinforcement 24 hours a day and 7 days a week would be impractical and impossible. But what does this research tell us? It tells us that if we are to train an ADHD student, feedback, reward, and reinforcement need to be immediate if we are to get their brain to rewire.

We at Play Attention have known this for many years. This is why we integrated immediate feedback/reinforcement for attention training, cognitive training, memory training, and behavioral shaping by using feedback technology. We patented this method years ago because of its inherent strength. While we knew this was the best way to achieve success, we feel research like this rather reinforces our approach. It’s about time the world caught up!

What Lurks Below the ADHD Iceberg?

Virtually anyone that knows, teaches, counsels, or works with an ADHD person is aware that ADHD is not a simple matter of attention deficit. That’s just the tip of a very large iceberg.

As a matter of fact, the term ‘attention deficit’ is actually a misnomer of sorts. ADHD people have diffused attention, not a deficit or lack of attention. Ask them. I often asked ADHD students what was happening in my classroom. They could tell me about the bird outside the window, the cobwebs in the corner of the room, a little about my lesson, a little about the whispering around them, and a little about when the air conditioner was turning on and off. That’s actually a great amount of attention. It’s just scattered or diffused over a wide area all day long.

A true hallmark of ADHD is the brain’s inability to direct attention for long periods without becoming distracted. So, it’s not a deficit at all; ADHD is an inability to direct attention. But there’s more.

ADHD is also a matter of difficulty in multiple domains of cognition. These domains are also labeled “Executive Functions.” Aside from diffused attention, ADHD also encompasses difficulty in organization of thought and tasks; sustaining effort while filtering out distractions; memory (both short-term and working memory); managing behavior/emotion; and visually directing attention and actions.

How does one cope with all these areas? It seems a monumental task. Of course, the primary medical intervention is medication. Does medication actually address all of these cognitive domains? No, it does not. Medication has limitations. That’s a fact. That’s why many parents do not see academic, behavioral, or social improvements [see the MTA study] over time. Another fact is that many of these cognitive domains can be strengthened by direct instruction.

Several small and large software companies have introduced themselves recently into the brain fitness category. Each company tends to address a specific domain like memory or focus. So, to satisfy the cognitive and behavioral needs of an ADHD person, one would need to purchase many of these games.

As the original pioneer and developer back in the late 1980s,  I saw that there was a vast gap in the needs of the ADHD person and what was being delivered. By 1994, I developed Play Attention to teach sustained attention, visual tracking with attention (like watching a teacher move about the classroom), organizing and finishing tasks, memory, filtering out distractions, and motor skills. I even included behavioral shaping. Later this year we’ll deliver social skills, more working memory & short-term memory modules, and more.  We’ve received 3 patents for this pioneering effort.

Play Attention is a careful collaboration between you, the Play Attention software, and the Play Attention professional support staff. It’s provided us with a 92% satisfaction rating.

Of course, to get results, you need to use it. Next week I’ll address how Play Attention transcends being useful to being compelling.

Meditation & ADHD

Sunset & Sky 098 Researchers, Dr. Zylowska, et al from the University of California-Los Angeles conducted a feasibility study of an 8-week mindfulness training program for adults and adolescents with ADHD. Their report was published in The Journal of Attention Disorders (2008 May;11(6):737-46. Epub 2007 Nov 19).

The researchers sought to inquire whether mindfulness meditation could improve attention, reduce stress, and improve mood. The researchers recruited 34 adults and 8 adolescents. Study participants were given a weekly training session. They were also required to practice daily starting with 5 minutes of meditation per day and gradually increasing to 15 minutes per day.

The majority of participants (after dropouts) reported improvements in self-reported ADHD symptoms. Independent tests on tasks measuring attention and cognitive inhibition also indicated improved symptom outcomes. Improvements in anxiety and depressive symptoms were also observed.

In yet another pilot study conducted by Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist, a group of middle school students with ADHD were required to meditate twice a day in school. After three months, researchers found over 50 percent reduction in stress and anxiety and improvements in ADHD symptoms.

"The effect was much greater than we expected," said Sarina J. Grosswald, Ed.D., a George Washington University-trained cognitive learning specialist and lead researcher on the study. "The children also showed improvements in attention, working memory, organization, and behavior regulation."

Due to the neuroplasticity of the brain, better attention can be attained through meditation. Buddhist monks have been doing it for centuries. This seems to be true of ADHD persons as well. However, it is quite apparent that attention difficulties are just the tip of the ADHD iceberg. Other skills including organization, filtering out distractions, memory, time on-task, motor skills, visual tracking, etc, are typically diminished in ADHD persons. A complete program like Play Attention is required to teach these skills.

As for meditation, it is likely a good supplement to training in the aforementioned skill areas, but given the nature of the cited studies, a controlled clinical study is warranted.

Neurofeedback, ADHD and Medication

In his Attention Research Update, September 2007, David Rabiner, Ph.D. Senior Research Scientist, Duke University, entitled his article, How Strong is the Research Support for Neurofeedback Treatment? The report is rather perfunctory and the staid course he’s followed for years. A fresh, candid review must be performed regarding research on multi-modal treatments, neurofeedback, and medication.

Therefore, my intent here is to examine multi-modal treatments, neurofeedback, medication, their accompanying controversy and myth, and research support. I’m certain you’ll find this examination both enlightening and substantially different perceptively.

I will use some of Dr. Rabiner’s statements and also attempt to make sense of the misinformation that is propagated intentionally or unintentionally through CHADD (Children and Adults with Attention Deficit /Hyperactivity Disorder).

For the purpose of full disclosure when writing this entry:

Play Attention

I should disclose that I developed Play Attention, a device that monitors brain activity. It is used educationally to teach cognitive skills, improve attention, and shape behavior. It is not clinical neurofeedback. To be candid, I’m not a proponent of clinical neurofeedback for reasons I’ll describe below.

Dr. David Rabiner

Furthermore, it should also be disclosed that the Dr. Rabiner’s newsletter is funded by CogMed, a group that sells memory games to address ADHD, and Shire pharmaceuticals, the makers of Adderall and other ADHD medications.

Play Attention has paid Dr. Rabiner in the past to advertise in his newsletter. Dr. Rabiner also sat on the advisory board for Play Attention for several years. Play Attention can no longer advertise in Dr. Rabiner’s newsletter due to his contractual obligations with CogMed. CogMed will no longer allow Dr. Rabiner to sit on Play Attention’s advisory board either.

CHADD & Neurofeedback

CHADD is listed as a nonprofit organization, but still receives significant financial support from the pharmaceutical industry. Historically, it has done little else other than offer tips and strategies and support the use of medicine as a primary treatment.

According to Dr. Rabiner’s newsletter, CHADD’s stance on neurofeedback is summarized in their fact sheet on alternative and complementary interventions, which includes the following statement about neurofeedback:

It is important to emphasize, however, that although several studies of neurofeedback have yielded promising results, this treatment has not yet been tested in the rigorous manner that is required to make a clear conclusion about its effectiveness for AD/HD. The aforementioned studies can not be considered to have produced persuasive scientific evidence concerning the effectiveness of EEG biofeedback for ADHD.”

Well, if we hold EEG biofeedback (neurofeedback) to this “rigorous manner that is required to make a clear conclusion about its effectiveness for AD/HD,” it is only fair to hold every intervention including medication and multi-modal interventions to it as well.

Quite frankly, you’ll be surprised that they do not live up to this standard either. The actual research about medication is really no stronger than that for neurofeedback. It seems we have double talk here by an organization that receives funding from the pharmaceutical industry. Perhaps, given the benefit of the doubt, they just aren’t aware of it.

ADHD Medication Research
While it received little press in 2005, the Drug Effectiveness Review Project, based at Oregon State University released a 731-page report which thoroughly analyzed 2,287 studies – virtually every investigation ever done on ADHD drugs anywhere in the world – to reach its conclusions. To date, it is the most thorough and comprehensive evaluation of all research performed on ADHD drugs.

The American Association of Retired Persons (AARP) and Consumers Union, the publisher of Consumer Reports report the data to their respective audiences. Fourteen states other than Oregon are the principal financiers the Drug Effectiveness Review Project.

The prestigious Oregon Evidence-based Practice Center, Oregon Health & Science University Drug Effectiveness Review Project’s primary purpose is to provide consumers and state insurance plans trustworthy information about pharmaceuticals. The Drug Effectiveness Review Project’s physicians and pharmacists don’t just analyze ADHD medications, so this was not an attempt to subvert or smear that industry. They analyze virtually every study on a given class of pharmaceuticals to determine the best drugs in that class and present their findings to the public and insurance industry. The Project examined 27 drugs which included Adderall, Concerta, Cylert, Focalin, Provigil, Ritalin, Strattera, and others.

In its analysis of published and unpublished research data produced by six prominent ADHD medication producers, the group found that 2,107 studies were unreliable and were subsequently rejected. Now, this is telling in itself. Finding 2,107 funded yet critically poor or fundamentally flawed studies performed by universities and the pharmaceutical industry itself speaks volumes to the nature of that research and those people responsible for it.

The Project began its review of the remaining 180 studies which demonstrated good controls and methods. Its conclusions regarding ADHD medication were quite astounding.

Here, bulleted, are some incredible results with comments:

• “No evidence on long-term safety of drugs used to treat ADHD in young children” or adolescents. Now, if you ask any physician, or the pharmaceutical industry, they will tell you the drugs are completely safe for long-term use based on research. That research doesn’t exist.

• The research providing any evidence of safety is of “poor quality.” This includes research regarding the possibility that some ADHD drugs could cause heart or liver conditions, tics, or stunt growth.

• “Good quality evidence … is lacking” that ADHD drugs demonstrate improvement in “global academic performance, consequences of risky behaviors, social achievements,” and other measures. The common perception is that ADHD drugs do improve academic performance and social skills. Many drug makers use ads depicting this. However, evidence for long-term improvement in academics, social skills, or behavior is virtually non-existent.

• Drug makers have found that they can expand their market by inducing adults into the ADHD experience. However, the Project found that evidence “is not compelling” demonstrating that ADHD drugs actually help adults, nor is there evidence that one drug “is more tolerable than another.”

Furthermore, the Project found that the U.S. Food and Drug Administration doesn’t require pharmaceutical manufacturers to compare newly developed medications with medications currently on the shelf. Most companies simply use a placebo or sugar pill given instead of their medication as a control. Therefore the Project found that “good quality” studies are lacking that pit one drug against another to provide evidence of effectiveness. It also could not find comparative data which might help determine which ADHD medications are less likely to produce detrimental side effects like heart and liver problems, depression, decreased appetite, tics, or seizures.

The Project could not find research that clearly provided an understanding of way that ADHD drugs work. It is not well understood for most ADHD drugs.

Even the research on ADHD performed by the respected Dr. Russell Barkley, a critic of neurofeedback studies, ranked only “fair” in the Project’s analysis of research and he’s had significant funding from the pharmaceutical industry, federal government, and universities. Noting that he’s cited most neurofeedback research as lacking, wouldn’t we expect at least a “good” or even a “superior” on his report card?

So, if one chooses ADHD medication, how does one know which drug is safer? Works better? Has fewer side effects? The research isn’t there, so we don’t know. In light of this, the Project suggested that one may do just as well on methylphenidate (generic Ritalin) which is far less expensive than newer options such as Concerta or Adderall. Incidentally, when the Project reviewed research on Concerta, it concluded that Concerta “did not show overall difference in outcomes” compared to generic good old cheap generic methylphenidate. Is Adderall any better? The Project found evidence to be “lacking.”

Do ADHD drugs provide long-term improvement for academic performance? Social interaction? Better behavior? The research just isn’t there.

The Project made clear that its findings do not mean ADHD drugs are unsafe. They may be safe and sometimes useful, but the Project found scientific proof is lacking.

While I’m not a clinical neurofeedback proponent, I think it’s clear that if pundits like Dr. Rabiner and organizations like CHADD are going to talk about good research, then let’s level the playing field and have the same requirements for everyone.

Standards of Research, Dr. Rabiner, & CHADD

Let’s go back to CHADD for a moment and its warnings about neurofeedback.

“Controlled randomized trials are required before conclusions can be reached. Until then, buyers should beware of the limitations in the published science. Parents are advised to proceed cautiously as it can be expensive – a typical course of neurofeedback treatment may require 40 or more sessions – and because other AD/HD treatments (i.e., multi-modal treatment) currently enjoy substantially greater research support.

Now, let’s examine the 3-Year Follow-up of the NIMH MTA (multi-modal treatment) Study. CHADD states studies such as this most recent one and most thorough one “enjoy substantially greater research support.” :

According to Dr. Rabiner, neurofeedback studies, while often producing good results, often lack random assignment. Here’s what he states in his current newsletter:

    Random Assignment

    Imagine that you are testing a new medication treatment for ADHD with 50 children who have been carefully diagnosed. In a random assignment study, whether each child is assigned to the treatment or control condition is determined by chance – you could flip a coin and give the medicine to the ‘heads’ and nothing to the ‘tails’. This insures that any differences that might exist between children who get the medication and those who don’t are purely chance differences. At the end of the study, if those who received the medicine are doing better, you could feel confident that this is probably due to the medicine itself, and not to differences that may have been there before the treatment even started.

    What if you didn’t use random assignment, but let each child’s parents choose whether their child is in the treatment or control group? In this case, it is possible that children in the 2 groups differed in important ways before the treatment began. If children who received the medication were doing better at the end of the study, it might be because of differences that were there to start with.

    For example, parents who chose the medicine might be more willing to pursue other ways to help their child than those who didn’t. The fact that children who received the medication were doing better at the end of the study might thus have nothing to do with the medicine itself, but reflect other things their parents were doing to help them. No matter how hard you might try to rule out these other possible explanations – and I’m sure you can think of many others – you could never do this with certainty. Thus, I might reasonably doubt that your new medication is really effective.

National Institutes of Mental Health Multi-Modal Treatment Study

But if Dr. Rabiner is correct that research without random assignment is ambiguous, possibly not valid, then let’s try to evaluate data from the 3-Year Follow-up of the NIMH MTA (Multi-Modal Treatment) Study. Let’s look at the researchers said about the 14th month:

    Indeed, once the delivery of randomly assigned treatments by MTA staff stopped at 14 months, the MTA became an observational study in which subjects and families were free to choose their own treatment but in the context of availability and barriers to care existing in their communities.

So what are we to gain from the long-term evaluation done in the MTA study? Does it enjoy substantially greater research support? According to Dr. Rabiner’s standards, not if it became an observational study.

CHADD also warns that neurofeedback is expensive. How expensive is it compared to ongoing medication for a lifetime? We’ll that’s relative isn’t it? How expensive is medication to a single mom with no insurance? Heck, to any parent with or without insurance? To grandparents raising their grandchild in mom’s absence? And by taking medication, which is expensive (Concerta, AdderallXR), etc, are we guaranteed anything more than what neurofeedback might offer? According to available research, No. CHADD’s arguments lack substance but have been their common response for a long time. I am asking that this nonsense ends.

Neurofeedback

Back to neurofeedback…The primary purpose of neurofeedback is to alter brainwave patterns that are presented in real-time feedback to clients. Clients [Rabiner] “…are trained to alter their brainwave activity and taught to alter their typical EEG pattern to one that is consistent with a focused and attentive state. According to neurofeedback proponents, when this occurs, improved attention and reduced hyperactive/impulsive behavior will result.”

Thus, the fundamental premise behind neurofeedback is that brainwaves are dysregulated, especially in certain areas of the brain, and training can regulate them. Furthermore, it is proposed that this regulation improves attention and behaviors. I find this to be rather facile. Neurofeedback’s premise is surprisingly similar to medication in essence; fix these brainwaves and the person is fixed whereas proponents of drug intervention insist that if one takes a pill ADHD is fixed! Unfortunately, neither of these therapies adequately fully addresses core issues of ADHD. Neither medication or neurofeedback, by themselves teach the skills one needs to survive and thrive in the workplace or classroom. Skills like organization, improved memory, discriminatory processing, auditory processing, time-on-task, etc. are not trained through either of these interventions. The only way to attain them is to train and learn them.

I’m not saying that neurofeedback doesn’t work. It’s been field tested as has been medication for years. Could it be a worthwhile tool to be used in a multi-modal plan? Yes. Again, let’s level the playing field.

Current Neuroscience & Neuroplasticity vs. Current ADHD Interventions

The reality about neurobehavioral problems is that they exist in a context, i.e. they exist because of the brain and because of that brain’s environment. The brain is directly affected by its environment. The brain is neuroplastic; it will and does adapt according to the stimulation it receives. That is conclusive fact. No doubt about it. So, if we are speaking about a human being, then attention problems are not just brain based. They may take root there, but they are also directly related to and affected by one’s environment. Therefore, appropriate environmental factors play a great role in the treatment of ADHD including behavior shaping, consistent reward/consequences, structure, etc.

The fact that our current system doesn’t address this fact is where we fall far short of correctly treating ADHD.

Let’s say that little Jimmy demonstrates some fidgeting and inattention at school. His teacher writes a note home telling Jimmy’s parents she suspects Jimmy may have ADHD. Jimmy’s parents take heed and bring him to the pediatrician where Jimmy gets a prescription for medication within 20 minutes. This is the norm.

What’s sorely missing is where Jimmy’s parents or Jimmy’s pediatrician write a note back asking to speak to the teacher to develop a plan of action regarding Jimmy’s behavior before beginning medication. This should be our standard practice regarding ADHD. We need to change the way we view ADHD and the way we address ADHD according to current neuroscience, not how we addressed it in 1980.

Unfortunately, most pediatricians or general practitioners are quite overwhelmed and not well equipped educationally to provide a full battery of tests taking up to four or five hours for an accurate diagnosis. So, a reverse diagnosis is made; the MD writes the prescription for medication and if it works, it was ADHD!

The problem is that stimulant medication works for everyone. If we have two groups of children, one group diagnosed with ADHD and one group of average children, both given boring tasks, both medicated, who will do better on the boring tasks? The answer is: Both! Medication is a shotgun approach that teaches nothing. Virtually no research demonstrates long-term efficacy in social improvement, academic improvement, or behavioral improvement.

Attention is a skill like any other skill. It can be considered a cognitive skill that is measured by behavioral or performance analysis. Should strategies, known to work to improve performance on ADHD students be attempted before medication or neurofeedback? Yes. Resoundingly yes! Should Jimmy’s parents adopt a structured, consistent schedule at home? Yes. Should Jimmy’s parents develop a behavioral plan for school and home working together with Jimmy’s teacher? Yes. Should all of this be employed before neurofeedback and medication? Yes. Could it be employed while using either medication or neurofeedback? Yes. Is it far less expensive than these other interventions? Yes.

Why don’t we do this first then? While a variety of factors relate to the answer, one of the most significant ones is: It is easier to take a pill or to ask someone else to solve your problem than it is to do the work to solve it yourself. Granted, many parents are not trained to work with ADHD children, but they can learn and need to – it’s part of being a parent.

I’ll quote the respected psychologist, Dr. Abraham Maslow –

If the only tool you have is a hammer, you tend to see every problem as a nail.

Here’s how this quote relates to our current dilemma: Many parents rely on their Doctor’s opinion alone believing the physician is almost all knowing. Doctors, pediatricians included, are sparsely trained to instruct parents or educators on how to facilitate a multi-modal management plan. Instead, as they are instructed from medical school and because medicals schools rely heavily on pharmaceutical money, they are given the only answer: drugs. It is only natural that parents believe this. Unfortunately, neither the medical industry, pundits, or CHADD are familiar with research regarding medication or either choose to ignore it.

Neurofeedback Controversy

Back to Dr. Rabiner’s newsletter, this segment entitled, Controversy Surrounding Neurofeedback Research.

Neurofeedback treatment for ADHD has been a source of substantial controversy in the field for many years and remains so today. Although there are a number of published studies in which positive results have been reported, many prominent ADHD researchers feel that given significant limitations to the design and implementation of these studies, neurofeedback should be considered a promising, but unproven treatment.

I think it’s quite reasonable to say that the ‘controversy’ surrounding neurofeedback is constantly stirred up by articles such as Dr. Rabiner’s. He also says that neurofeedback studies sometimes suffer from smaller populations, etc. It does make good press, but given significant limitations to the design and implementation of studies on multi-modal treatments and pharmaceuticals, they should all be considered promising, but unproven treatments. Neurofeedback research seems to suffer the same dilemma as that of multi-modal and pharmaceutical interventions – all could be far stronger. All have considerable weaknesses. All have some strengths because they’ve been field tested for many years. So, either they are all controversial, or none of them is controversial. It’s far past time to stop double talking.

Summary

Neither medication nor neurofeedback are solutions unto themselves.

Without hidden agendas or profit motives they are on the same playing field. Now, let’s play fair and develop strategies based on our knowledge of the ADHD problem. It’s in the best interest of our children and their outcomes to find workable, manageable solutions.

Obviously, no one intervention is best, proven, or more reliable even if marketing people would like to make it seem so. It takes a whole village to raise a child. It takes a group of interventions to raise an ADHD child. Let’s find the best interventions, based on honest available research, use them in concert, and see if it works. And understand this caveat clearly, just because research, no matter how high a grade it’s given, demonstrates efficacy, it doesn’t mean that it will work successfully for you or your child. That’s just because we’re human. We learn differently, respond differently, and are wired differently based on our years of exposure to the world and our genetic makeup. That’s not theory. That’s fact.

Given that no intervention is sufficient by itself, it will always be a matter of trail and error to determine what course of actions will succeed for the long-term. Even though we desire or wish it, none are guaranteed, but that’s life, isn’t it?