Treatment alternatives for Attention-Deficit/Hyperactivity Disorder (ADHD)

Objective: To review alternate treatments (Tx) of Attention-Deficit/Hyperactivity Disorder (ADHD)—those other than psychoactive medication and behavioral/psychosocial Tx—for the November, 1998 National Institute of Health (NIH) Consensus Development Conference on ADHD. Method: The literature was searched on Medline and Psychlnfo 1963-1998 and investigators known to be interested in alternate Tx were contacted for unpublished data. Results: Twenty-three alternate Tx were identified, ranging in scientific documentation from discrediting controlled studies through mere hypotheses to positive controlled double-blind clinical trials. Many of them are applicable only to a restricted etiological subgroup. The oligoantigenic or few-foods diet has convincing double-blind evidence of efficacy in multiple trials for a properly selected subgroup. Enzyme-potentiated desensitization to foods, relaxation/EMG biofeedback, and deleading also have controlled evidence of efficacy. Glyconutritional supplementation, iron supplementation, magnesium supplementation, Chinese herbals, EEG biofeedback, meditation, mirror feedback, channel-specific perceptual training, and vestibular stimulation all have promising prospective pilot data. Single-vitamin megadosage has some intriguing pilot trial data. Zinc supplementation is hypothetically supported by systematic case-control data but has no systematic clinical trial. Laser acupuncture has promising unpublished pilot data. Essential fatty acid supplementation has promising systematic case-control data but clinical trials are equivocal. Recommended-Daily-Allowance vitamin supplementation, nonChinese herbals, homeopathic remedies, and antifungal therapy have no systematic data in ADHD. Megadose multivitamin combinations are probably ineffective for most patients and possibly dangerous. Simple sugar restriction and hypnosis seem ineffective. Amino acid supplementation, though mildly effective in the short term, is not effective beyond a few weeks. Thyroid Tx is effective in the presence of documented thyroid abnormality, but not otherwise. Conclusion: Some alternate Tx of ADHD are effective or probably effective, but mainly for restricted etiologic subgroups. In some cases they are the Tx of choice, and initial evaluation should consider the relevant etiologies. A few have failed to prove effective in controlled trials. Most need research to determine whether they are effective and/or to define the applicable subgroup. Some of them, though not safer than standard Tx, may be preferable for an etiologic subgroup

The Art of Medicating Hyperkinetic Children: A Number of Practical Suggestions

The psychologic aspects of the prescribing, giving, and taking of medicines are especially important when trying to modify the emotion-laden behavior of hyperkinetic children. The physician should start by cultivating positive expectations in child, parents, and teacher. This is necessary in order to break up existing complex vicious cycles of negative expectations, low self-esteem, discouragement, resentment, misbehavior, and poor achievement. One promotes the child's cooperation by building rapport from the first contact and by negotiating a medication contract directly with him. The child needs to know not only that his past misbehavior or failures are not being held against him but also that better is expected of him now that he has medical help. Parents deserve unhurried clarification of questions and should be warned about side effects. The time taken to talk directly with the teacher is most valuable. Direct communication can help set up positive expectations in school and elicit objective information about the child's day-to-day performance

Beta Blockers in Mental Retardation and Developmental Disorders

β-Adrenergic blockers appear to be effective in the management of verbal aggression, physical aggression, or self-injurious behavior associated with mental retardation and other developmental disorders. However, methodological limitations of the available studies make it difficult to judge the value of these treatments. Optimal doses for treating patients with mental retardation or developmental disorders appear lower than described in the general psychiatric literature, so low doses of β-blockers may be preferred in such patients with abnormal brain development. Children and adolescents with mental retardation or developmental disorders appear to respond to particularly low doses (e.g., below propranolol 150 mg daily). Propranolol is recommended for central blockade, and nadolol is recommended for peripheral blockade. Most β receptors in the brain (except cerebellum) seem to be β1 (cardiac type), but it is not clear that central blockade is required for psychotropic effects. Interim suggestions for empirical trials are offered, and rating scales and other measurement approaches are discussed. Since evidence supporting the efficacy of β-blockers in mental retardation or developmental disorders in children and adolescents is not definitive, the clinician is advised to consider designing an empirical trial for each patient, utilizing pre- and postmedication measures, when conventional treatments have been unsuccessful

Limbic Regression with Derepression of Oedipal Feelings

Most knowledge of the normal preschool oedipal feelings for a parent of the opposite sex come from reconstructive analysis of neurologically normal adults or from observation of phallic stage children. We have discovered in the symptoms of a severely brain-damaged adolescent evidence of a slightly different and interesting type. It seems to result from a biological unmasking of repressed material by post-encephalitic age regression

Does Zinc Moderate Essential Fatty Acid and Amphetamine Treatment of Attention-Deficit/Hyperactivity Disorder?

Zinc is an important co-factor for metabolism relevant to neurotransmitters, fatty acids, prostaglandins, and melatonin, and indirectly affects dopamine metabolism, believed intimately involved in attention-deficit/hyperactivity disorder (ADHD). To explore the relationship of zinc nutrition to essential fatty acid supplement and stimulant effects in treatment of ADHD, we re-analyzed data from an 18-subject double-blind, placebo-controlled crossover treatment comparison of d-amphetamine and Efamol (evening primrose oil, rich in gamma-linolenic acid). Subjects were categorized as zinc-adequate (n = 5), borderline zinc (n = 5), and zinc-deficient (n = 8) by hair, red cell, and urine zinc levels; for each category, placebo-active difference means were calculated on teachers' ratings. Placebo-controlled d-amphetamine response appeared linear with zinc nutrition, but the relationship of Efamol response to zinc appeared U-shaped; Efamol benefit was evident only with borderline zinc. Placebo-controlled effect size (Cohen's d) for both treatments ranged up to 1.5 for borderline zinc and dropped to 0.3-0.7 with mild zinc deficiency. If upheld by prospective research, this post-hoc exploration suggests that zinc nutrition may be important for treatment of ADHD even by pharmacotherapy, and if Efamol benefits ADHD, it likely does so by improving or compensating for borderline zinc nutrition

Caffeine Versus Methylphenidate and d-Amphetamine in Minimal Brain Dysfunction: A Double-Blind Comparison

The authors compared the efficacy of caffeine, methylphenidate, and d-amphetamine in children with minimal brain dysfunction using a double-blind crossover design. The slight improvement with caffeine was not significantly better than placebo. Both prescription drugs resulted in significant improvement and were significantly superior to caffeine. The authors suggest that the discrepancy between these results and an earlier, more optimistic report may stem from the use in this study of pure caffeine rather than whole coffee