ADHD and Drugs

The Washington Post ran an article on treatment of ADHD.  They discuss several alternatives including medications and their limitations.  Interestingly enough, one of the illustrations they use to show how medications seem to work in the ADHD brain, actually makes the case for why neurofeedback is such a great way to treat ADD/ADHD.  They show which areas of the brain seem to be involved in regulating ADHD and how they interact.  Neurofeedback is premised on teaching these various areas of the brain to function appropriately.  Othmer method neurofeedback also works on strengthening the communication tracts between these brain centers.  Neurofeedback does not discriminate between neurotranmitter and receptor sites–it trains all.  Medicines can also have unintended effects in the brain, like sleep and appetite disturbances.  These side effects are virtually non-existent in neurofeedback.

I am happy that the article discuss behavioral therapy as a part of ADD/ADHD treatment.  Learning to focus, organize, and see tasks to completion takes practice.  Parents, teachers, and therapists need to make behavioral expectations clear and then guide the person with problems through the learning process.  It is a lot of work, but the rewards can be remarkable.

The Length of Neurofeedback Training

Many people are surprised by the recommendation that at least 40-60 sessions of neurofeedback are needed to obtain lasting positive changes in the brain. Are these same people surprised that it takes many hours of careful physical effort to build up a healthy, muscular physique? Would they also be shocked that it takes most people years of concentrated study to earn an advanced university degree?

I would argue that just the opposite is true—it is surprising that only 40-60 sessions of neurofeedback is adequate to achieve lasting positive changes for most people! After all, the brain is an extremely complex organ that is so intricate that we are still in the early stages of exploring its functions. Even though the 10,000 hours of practice “rule” to become truly expert at a skill has been debunked, there is no doubt that lots of high-quality and disciplined practice is necessary to acquire an ability (

Neurofeedback using the Othmer method guides the brain towards the ability of calm and well-ordered function. During each session, the patient is asked to make better and better approximations towards desired brain states. The therapist, acting as a coach or teacher, is an essential part of the process since she determines the areas of the brain to be trained, evaluates the response to training, and then adjusts the neurofeedback accordingly. The goal of neurofeedback is to create default brain functioning that is controlled and orderly.

Within an individual session of neurofeedback, the brain often shows changes in its electrical activity over seconds to minutes of effort. However, there is a marked difference between the short-termed “learning” that occurs over a session with the long-term expertise that happens with repeated sessions of neurofeedback. The brain redevelops its “physique” and functioning just like an athlete develops the proper musculoskeletal physique, muscle memory, and mental state over months to years of practice and being well coached to excellent performance. New neuron-to-neuron connections with appropriate neurotransmitters are made in response to repeated practice. As newer and better brain pathways are reinforced, old, poorly functioning pathways are weakened and pruned. Practice over extended periods of time enables these types of structural changes of the brain. Repetition of healthy brain tasks via neurofeedback complemented with excellent brain maintenance in everyday life confers long-term brain health and function. The website,, has explanations of memory formation that describe the formation of long-term changes such as those induced via neurofeedback.

Some brain conditions such as autism can be so complex that many more sessions than the average may be required to enable improved brain performance. Some patients benefit from occasional “touch up” sessions to maintain effective brain operation.

Complex Issues of the Brain Usually Have Complex Solutions. The Fallacy of using medication for the treatment of ADD/ADHD.

The brain is an extremely complex organ that functions in ways that we are just beginning to understand. Issues of focus and attention are the result of many potential causes that include:

Adverse effects from medication use

Allergic rhinitis


Food sensitivities




Lead toxicity


Sensory impairment, like vision or hearing

Brain injury

Developmental delays

Learning disability

Intellectual disability

Seizure disorder

Sleep disorders

Speech or language problems


Conduct disorder


Obsessive-compulsive disorder

Oppositional defiant disorder

Posttraumatic stress disorder

Substance abuse

Child neglect

Physical or sexual abuse

Parenting issues


Improper learning environment

Parental psychopathology or substance abuse

Social skills deficits

Sociocultural factors

So why are people with attention issues quickly labeled as ADD or ADHD and placed on medication in the USA? This is certainly not the case in most of the rest of the world. Many advanced countries report low or virtually no incidence of ADD/ADHD.

I would argue along with many other clinicians in the US that attention problems are being pathologized with little examination of potential underlying causes. Then those with attention problems are placed on medicine with the mistaken notion that doing something so simple is the solution for a condition that is usually the consequence of many influences on the brain.

 Evidence is mounting for ADD/ADHD drugs having positive effects only for a few weeks. These same short-term improvements of improved focus, memory, and energy levels are felt in almost anyone who takes medication, both “normal” and ADD/ADHD-diagnosed subjects.   As data from long-term studies is analyzed, no differences in behavior can be discerned in continuously medicated children versus non-medicated children at both 3 and 8 years. Medicated children have no advantage in academic performance, flexibility in thought for complex tasks, peer relationships, antisocial behavior, substance abuse, or arrests. In fact, medicated kids have a higher drop out rate from high school and worse relationships with their parents versus non-medicated kids. Medicated boys trend towards worse academic performance. Medicated girls tend to have more emotional problems.

 Problems with medication for ADD/ADHD are well known, and include:

 Decreased appetite

Sleep problems








Growth retardation

Cardiac arrhythmias, hypertension and other cardiovascular issues

Rebound symptoms as medications wear off

Withdrawal symptoms when attempts are made to discontinue medication

 So how have an estimated 15% or 6.5 million American children ended up diagnosed as being ADD/ADHD, and an estimated 3.5 million of them placed on medication? First of all our care system routes children with attention problems into the medical system where attention issues are generally perceived as a biological disorder of biological causes as opposed to a medical condition, psychosocial condition, a condition of differently paced brain maturation, or a mix of these. Our current medical models reward “efficiency”. This means a short, screening visit possibly followed by family and school questionnaires to confirm an attention problem. Then a prescription is written. A follow-up appointment in a few weeks might confirm that the medicated patient is quieter and more focused. However, almost anyone placed on ADD/ADHD medication will also be more focused in the short run, too. Thus begins years of medication, and neglect of identifying and remediating the underlying causes of the attention problem.

 Placing kids on drugs give a sense of “doing something” about the issue of attention. Medical providers, families, and schools are looking for a simple fix for a complex brain issue. The mistaken impression that popping a pill is going to solve the issues of someone with attention problems is passing the buck on meaningful treatment. This causes a great disservice to those with attention problems, their families, and society at large since many do not go on to get the attention in school, psychosocial treatment, and other treatments like EEG neurofeedback that have been proven to treat attention disorders as well as behavioral issues on a long term basis.

 I try to look at each person who comes into my practice with attention problems as their own unique case. It is important to tease out the important contributions to an inability to focus well and consistently. Then I try to help that person and their support system to prioritize and deal with the factors that seem to be driving the problems that they present with.

 EEG neurofeedback is an important component of this treatment. However, most patients benefit from a thorough re-evaluation of their psychosocial milieu. Circumstances that promote inattention need to be recognized. Just like neurofeedback does not change brain function and architecture overnight, psychosocial interventions take time and practice. Neurofeedback and behavioral therapies are time-consuming, but long-term outcomes justify the additional effort. Those who prescribe and use medications for ADD/ADHD are using a Band-Aid approach that can cause more harm than good.

ADD/ADHD Season–EEG Neurofeedback Can Help

I remember all too well the dread that I used to feel as the start of school drew near.

 I did not always have to drag my child from bed, but if he was already awake, there was no telling where he would be or what he would be doing first thing in the morning. Getting him through morning routines in time to get to the school bus stop was always a major challenge. Every step of getting dressed, eating breakfast, brushing teeth, packing the knapsack, and getting out the door had to be strictly supervised. Once he was at the bus stop, an adult had to make sure that he did not bound out into traffic on the street.

 Then there were a few hours of quiet while he was in the care of school personnel. At the end of the school day, he would arrive home declaring how much he hated school, his teachers, and most of his classmates. He would have no idea of whether he had any homework. Sometimes a list of spelling words or a blank worksheet would be jammed into the knapsack along with a note from the teacher saying that he did not turn in his homework for the last week. Of course, that homework that had been done under great duress, was wadded into the bottom of the knapsack. He had “forgotten” to turn it in. The homework battle would begin. Once something resembling a completed assignment is finished, he would shoot off to his video game where he spends several hours almost perfectly still and with rapt attention. When you call him for supper, he cannot break away from his “screen”. He is cranky, maybe even has a meltdown when a parent finally shuts down the video game. When bedtime comes around, he cannot wind down to get to sleep and he keeps the whole household up late.

 At some point, the teacher notes, emails, and conferences would come nearly every day. He is constant fidgeting and making inappropriate noises; he won’t stay in his classroom seat; he plays too roughly; he interrupts lessons by speaking out or talking with classmates; he does not finish his classwork; the schoolwork he does is poorly organized and difficult to read; he did not follow the directions; he does not follow school rules; he doesn’t wait his turn; he acts out and “shows off”; he is immature; he seems unable to make friends.

 The family is expending huge resources, mentally and physically, trying to help the child get through each day. As a parent, you hurt for him, but realize that he needs to learn to perform age appropriate activities even though progress seems to be small or even non-existent.

 “Have you had him evaluated for attention deficit disorder?”

 Here are the official DSM 5 criteria for ADD/ADHD:

 DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

  1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
    • Often has trouble holding attention on tasks or play activities.
    • Often does not seem to listen when spoken to directly.
    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
    • Often has trouble organizing tasks and activities.
    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
    • Is often easily distracted
    • Is often forgetful in daily activities.

  2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
    • Often fidgets with or taps hands or feet, or squirms in seat.
    • Often leaves seat in situations when remaining seated is expected.
    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
    • Often unable to play or take part in leisure activities quietly.
    • Is often “on the go” acting as if “driven by a motor”.
    • Often talks excessively.
    • Often blurts out an answer before a question has been completed.
    • Often has trouble waiting his/her turn.
    • Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

  • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
  • Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
  • The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.

 Unfortunately, many issues and conditions besides ADD/ADHD can be manifested by these or similar brain-based symptoms. Medical conditions like allergic rhinitis, asthma, thyroid problems, infections, lead toxicity, malnutrition, medication reactions, and visual or hearing impairment can appear to be an attention disorder. Environmental conditions can be implicated: improper learning environments, sociocultural factors, social skills issues, parenting issues, bullying, and child neglect or abuse. Neurological problems like seizures, brain injury, developmental delays, learning disabilities, language processing problems, intellectual disabilities, and sleep disorders can be implicated. Lastly, psychiatric problems such as anxiety, conduct disorder, depression, obsessive-compulsive disorder, posttraumatic stress disorder, and substance abuse can appear to be attention problems.

 To complicate things further, many of these conditions can coexist with ADD/ADHD. It is particularly common to find anxiety, conduct disorder, developmental disorder, mood disorder, oppositional defiant disorder, substance abuse, and tics with ADD/ADHD. Additionally, I usually find that the effects of ADD/ADHD extend deeply in a patient’s family and psychosocial milieu. This sets off a cascade of issues that need attention and remediation.

 In my practice, I try to identify as many concerns as possible with each patient and help to prioritize efforts to find remedies. One of my major tools is the use of EEG neurofeedback because of its potential to help on a global basis. Its effects in encouraging cooperation of brain networks not only help with the symptoms of ADD/ADHD, but EEG neurofeedback also helps with many of the other issues that complicate the patient’s ability to successfully navigate their environment. As their brain begins to work better for them, family, work, school, and social interactions improve. Relationships begin to normalize and become self-sustaining in healthier patterns.

 EEG neurofeedback has been approved by the American Academy of Pediatrics as having the Best Level of Support for efficacy for treating ADD/ADHD. Unfortunately, medication not only wears off in a few hours, and it has a long list of potential negative effects. Medication does not seem to affect most psychosocial issues associated with ADD/ADHD. Patients on medication tend to lapse into old behavior patterns once medication is stopped. EEG neurofeedback and behavioral therapies are individualized to each patient. They take time to be effective, but have truly significant and long-lasting positive effects.

Vitamin D and Brain Health

A study that looked at brain health and Vitamin D levels was published in the journal Neurology yesterday.  Over 1600 people aged 65 or older who were apparently healthy were followed for 6 years with testing for brain function.  This was correlated with blood Vitamin D levels.  Severe Vitamin D deficiency (less than 25 nanomoles/l) was correlated with more than 2 fold (125%) chance of acquiring a form of dementia in the study population.  Moderate deficiency was associated with an increased risk of 53% of acquiring dementia.  The study’s researchers concluded that a blood level of at least 50 nanomoles/l were likely to be necessary for good brain health.

It is difficult for many people in our society to get adequate levels of Vitamin D unless they are often outdoors without sunscreen, eat oily fish and fortified dairy products on a frequent basis, or take supplements.  Symptoms of Vitamin D deficiency may include fatigue, fibromyalgia, weakness, and mood disorders.  We already know that there are Vitamin D receptors on almost all human tissues and that it is important in the health of bones, the cardiovascular system, immunity, and the hormone system.  Inadequate levels of Vitamin D have been implicated in multiple sclerosis, a disease of the nervous system.  An estimated 70% of white Americans and 95% of African-Americans are vitamin D deficient.  Blood tests can easily establish blood levels of Vitamin D.  Supplements are readily available, and I usually recommend in the range of 1000-2000 IU of Vitamin D daily.  Vitamin D comes in the form of gel caps (Trader Joes makes a good product), tablets, or drops.  For most people it is a simple addition to their daily routine.

Excessive Vitamin D can cause poor appetite, nausea, vomiting, weakness, frequent urination, and kidney problems.  So supplementation of more than 2000 IU/day, should be supervised by a health professional, blood levels should stay in the 50-100 nanomoles/l range with the understanding that we now have of Vitamin D function and metabolism.

Biofeedback “Homework”


A topic that frequently comes up in my office involves ways that a patient can actively practice mind-body control between sessions of neurofeedback.


The EZ-Air Plus program helps pace breathing to facilitate slow, calm breathing. This, in turn, helps to calm the brain and body. It is most useful for those who have breathing issues like asthma and COPD, but helps anyone who tenses up and begins to breath in a shallow fashion when they are stressed. For further information and a free trial:


The Stress Thermometer teaches you to warm your hands by giving you temperature information from your fingers. This is particularly helpful in people with headache issues, Raynaud’s Syndrome, and temperature regulation issues (those who feel cold more often that not and do not have thyroid regulation problems). This link,, gives more information.


Lastly, the emWave device trains heart rate variability. The healthiest hearts have a rhythm that varies with breathing in and out. Stress and cardiovascular stiffening decrease this variability. The emWave can decrease stress and increase feelings of well-being and relaxation. I have found it to be a particularly good way to calm the body and mind to get to sleep. This product is well supported by its manufacturer with training videos and instructions at


Just about any exercise that increases body-mind awareness is potentially beneficial. Yoga and meditative techniques are good examples. Seeking out calm and pleasant surroundings and learning to appreciate them is a desirable goal.

DARPA SUBNETS (Systems-Based Neurotechnology for Emerging Therapies) Program

In the Science section of today’s Washington Post, an article describes a research program funded by the Defense Advanced Research Projects Agency (DARPA).  The intent of this program seems wonderful–“to develop brain interfaces, computational models of brain activity and clinical therapies for such illnesses as depression, chronic pain, anxiety and post-traumatic stress disorder.”  The article elaborates that researchers hope “to expand the understanding of brain function” and that these efforts will help to develop new tools for clinicians to use on patients who have not responded to other therapies.  Teams at the University of California at San Francisco and Massachusetts General Hospital will be developing implantable brain devices to treat intractable brain problems.

I applaud the effort to ethically expand our knowledge of the human brain.  However as a neurofeedback practitioner, I have reservations about this program.  EEG neurofeedback when practiced by an experienced clinician has a high efficacy for treating these same conditions without the expense and potential dangers of invasive brain procedures.  I strongly suspect that neurofeedback has not been adequately assessed as as alternative to brain implants.  This may be due to the general ignorance and misconceptions that the medical community harbors towards neurofeedback, or it may be an effort “to do something” to help those who have not responded favorably to the dominant medical treatment model of medications.  As well-meaning as DARPA and its researchers may be, connecting patients to well-trained neurofeedback practitioners for at least a 30-40 session trial of neurofeedback before subjecting them to neurosurgical procedures, may be the more ethical and cost effective way to proceed with patients with symptoms that are refractory to “regular” treatment.

Just yesterday, the Washington Post published an extensive article about medical errors.  One credible researcher estimated that up to 1/2 of all hospital deaths are due to medical errors.  Neurosurgical procedures are quite prone to complications that can lead to permanent disability or death.  I have treated patients who have had complications and bad side effects of neurosurgery with neurofeedback.  None of these patients had been informed that neurofeedback was an alternative therapy to neurosurgery.  Many of these patients felt that they had not been adequately counseled about potential complications or that their surgery could worsen or not affect their problem.  While there are many conditions for which neurosurgery is the best solution,  neurofeedback presents a safe and efficacious alternative for many neurological and mental health issues.  I hope that DARPA and its researchers take great care in offering their experimental treatments to scrupulously screened patients who have been fully informed of treatment alternatives and the potential consequences of their procedures.

White House Concussion Symposium

It is great to see that the problem of head trauma and subsequent brain injury is getting a lot of attention today. Increased awareness of prevention and treatment of concussion is vital towards decreasing its prevalence.

The brain is beautifully protected is some ways. We have a thick bone called the skull that surrounds it. The skull, in turn, is filled with fluid in which the brain surrounded by its meningeal membranes floats. However, the skull can also cause problems. When someone sustains a significant blow to their head (or sometimes other parts of their body), the brain can “slosh” around inside the skull. If this movement is great enough, the brain can make contact with the unyielding skull interior and sustain injuries as mild a brain “bruise” or as severe as blood vessel rupture or even death. We even know now that repeated mild to moderate jostling of the brain can cause damage that can include concussion. It has been well demonstrated that recurrent concussions and other brain trauma can contribute to many types of brain function issues. These can include memory problems, difficulties in problem solving, and focus maintenance. In the long term, concussion may contribute to earlier onset of dementia.

The obvious first step is prevention. Evaluate the activities that you and your loved ones take part in. Some sports are well know for having a high incidence of head trauma–boxing and football come immediately to mind. However, other sports like soccer have been demonstrated to cause head trauma from doing things such as “heading” a ball or through collisions with other players. Helmets and other head protection can help somewhat. But they do not entirely remove the movement of the brain inside the skull. Do not forget to evaluate home, work, and other recreational environments for potentially preventable causes of head injury.

Once a concussion occurs, healing must be promoting. Any activity that physically jostles the brain must be stopped. Both physical and mental stress should be minimized to allow the body to marshall and direct healing resources to the brain. Sleep is essential to the healing process and may be for many more hours a day than usual. Following simple daily routines can help ease the way into normal activities. A healthy diet rich in vegetables and essential fatty acids provides nutrients vital to the healing process.

Neurofeedback also seems to be of great help to many with concussions. In my practice, I have seen patients begin to see increased energy, clearer thinking, and fewer headaches within a few sessions of neurofeedback. Often patients are well on their way to their normal life in no more than 20 sessions.