Alternative Treatments for ADHD: The Scientific Status

At the 1998 National Institute of Health Consensus Conference, Dr. Eugene Arnold, an emeritus professor of psychiatry from the University of Ohio, presented a very interesting talk in which he summarized the current scientific evidence for a variety of alternative treatments for ADHD. This is an area that many people have interest in, so I wanted to present his paper in some detail.

Based on his review of the existing research literature, Dr. Arnold rated the alternative treatments presented on a 0-6 scale. It is important to understand this scale before presenting the treatments. (Note: this is one person's opinion based on the existing data; other experts could certainly disagree.) The scale he used is presented below:

• 0—No supporting evidence and not worth considering further.
• 1—Based on a reasonable idea but no data available; treatments not yet subjected to any real scientific study.
• 2—Promising pilot data but no careful trial. This includes treatments where very preliminary work appears promising, but where the treatment approach is in the very early stages of investigation.
• 3—There is supporting evidence beyond the pilot data stage but carefully controlled studies are lacking. This would apply to treatments where only open trials, and not double-blind controlled trials, have been done.

  Let me briefly review the difference between an open trial and a double-blind trial because this is a very important distinction. Say you are testing the effect of a new medication on ADHD. In an open trial, you would just give the medication to the child, and then collect data on whether the child improved from either parents or teachers. The child, the child's parents, and the child's teacher would all know that the child was trying a new medication. In a double-blind trial, the child would receive the new medicine for a period of time and a placebo for a period of time. None of the children, parents, or teachers would know when medication or placebo was being received. The same type of outcome data as above would be collected during both the medication period and the placebo period.

  The latter is considered to be a much more rigorous test of a new treatment because it enables researchers to determine whether any reported changes are above and beyond what can be attributed to a placebo effect. In an open trial, you cannot be certain that any changes reported are actually the result of the treatment, as opposed to placebo effects alone. It is also very hard for anyone to provide objective ratings of a child's behavior when they know that a new treatment is being used. Therefore, open trials, even if they yield very positive results, are considered only as preliminary evidence.

• 4—One significant double-blind, controlled trial that requires replication. (Note: replicating a favorable double-blind study is very important. The literature is full of initially promising reports that could not be replicated.)
• 5—There is convincing double-blind controlled evidence, but further refinement is needed for clinical application. This rating would be given to treatments where replicated double-blind trials are available, but where it is not completely clear who is best suited for the treatment. For example, a treatment may be known to help children with ADHD, but it may be effective for only a minority of the ADHD population and the specific subgroup it is effective for is not clearly defined.
• 6—A well established treatment for the appropriate subgroup. Of the numerous alternative treatments reviewed by Dr. Arnold, no treatments received a rating of 6.

Only one treatment reviewed received a rating of 5. Dr. Arnold concluded that there is convincing scientific evidence that some children who display symptoms of ADHD can derive significant benefits from appropriate dietary treatments that involve placing children on diets that eliminate their exposure to certain foods or food additives that may cause them to have allergic reactions. The important task, as he sees it, is to determine what percentage of the ADHD population dietary responders constitute, and to better identify the child who is likely to respond to dietary treatment. Preliminary evidence suggests that preschoolers with a history of prominent irritability and sleep disturbance are the most likely to respond. Dietary interventions are also more likely to be helpful if there is a family history of migraines, or if a parent can give a definite example of a food/behavior change connection.

There were two alternative treatments for which a rating of 4 was assigned. The first treatment involves relaxation training using a type of biofeedback procedure (EMG biofeedback). There is some preliminary evidence that relaxation training does result in reductions in ADHD symptoms and Dr. Arnold believes that this treatment approach warrants further investigation. Currently, the magnitude and duration of the benefits are not clear.

The second treatment is known as de-leading, which involves reducing lead levels in the bloodstream. Positive effects are restricted to those children who have elevated blood lead levels to begin with; for such children, Dr. Arnold argues that de-leading would be the treatment of choice. It is not currently known how low the lead level should be before this treatment is extended.

Several alternative treatments received ratings of 3. Numerous studies have found that essential fatty acids tend to be lower in children with ADHD, and some preliminary data suggests that supplementing fatty acids in children with ADHD who have been shown to have low levels of these substances may result in behavioral improvement. Controlled trials of fatty acid supplementation should be pursued, although one would expect any beneficial effect to be restricted to those children with ADHD who are first shown to be deficient in their levels of these substances.

Promising data from open trials of providing glyconutritional supplements (these supplements contain basic saccharides necessary for cell communication and formation of glycoproteins and lipids) have also been obtained. These results are from only 2 studies, however, each with small sample sizes. Once again, placebo-controlled trials are necessary.

Promising initial results using several types of mineral supplements have also been reported. Iron supplementation has been associated with improvements in parent behavior ratings for ADHD boys, although no comparable improvement in teacher ratings was found. Magnesium supplementation has also yielded some promising preliminary results for children with ADHD who were also found to be deficient in magnesium. No double-blind trials of either type of supplementation have been conducted.

What about herbal treatments, an approach that is frequently touted? Two open trial studies using a "Chinese herbal cocktail" have reported extremely positive results; including the complete disappearance of all symptoms in 23 of 80 subjects with no recurrence for 6 months, and overall improvement reported in 90% of participants. Careful, controlled trials of Chinese herbal treatments are certainly warranted. (Interestingly, Dr. Arnold could not find any systematic data for using pycnogenol for treating ADHD, even though this is widely marketed using the Internet and other vehicles.)

Other treatments for which encouraging preliminary support has been reported include biofeedback, meditation, and some forms of perceptual stimulation and training. Controlled trials of all of these approaches are lacking, however, and research on the latter two approaches has not been published in over 10 years.

A number of alternative treatments were assigned ratings of 0 by Dr. Arnold, indicating that he views them as unworthy of pursuit. Such treatments include: eliminating sugar from children's diets, vitamin supplementation, amino acid supplementation, and hypnosis.

Several general conclusions can be drawn from Dr. Arnold's excellent review of alternative treatments for ADHD. First, in contrast to the more standard treatments of stimulant medication and behavioral therapy, there are no alternative treatments for which comparable empirical support exists. Thus, there is no alternative treatment that one could responsibly recommend prior to trying more standard treatments (exceptions may be de-leading for children with high blood lead levels and thyroid treatment for children with known thyroid dysfunction).

Second, there are a number of promising alternative approaches that would be reasonable to consider if more standard treatments are not effective. Although the necessary data to support the more routine use of these alternatives does not yet exist, one hopes that the required double-blind studies that provide support for these approaches will soon be available. Given some of the encouraging initial results reported for several approaches, it is somewhat surprising that more work in these areas has not been conducted.

Finally, it should be noted that several alternative treatments reviewed, if they are clearly demonstrated to be effective, are likely to apply to only a subgroup of the ADHD population. For example, it would not make sense to provide nutritional or mineral supplementation to a child who is not deficient in either area.

Dr. David Rabiner is a child psychologist and Senior Research Scientist at Duke University.and produces a monthly online newsletter, Attention Research Update, that helps parents, professionals, and educators keep informed about new research on ADHD. To sign up for a free subscription, please visit http://www.helpforadd.com.

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