Addressing Attention

by Alan Brandis, Ph.D.

There are several categories of treatment for reducing attention-deficit symptoms and related issues of performance and behavior. This is not intended to be an exhaustive list, but it highlights the most common approaches.

Chemical Approaches: Traditionally, the stimulant medications have been used, stemming from the “Dark Ages” (1980’s and before) when ADD was still called “Minimal Brain Dysfunction.” The names of these medicines are Ritalin, Adderall, Dexedrine, Metadate, Concerta, Focalin, and others. They are available in “regular” and time-release versions. They work by increasing activity in the prefrontal cortex, the part of the brain that controls voluntary attention, planning, and connecting behavior with consequences. Unfortunately, these medicines also increase activity in other parts of the brain, and because of this they can (but certainly do not always) cause “side effects” such as loss of appetite as well as increased anxiety or anger.

A note about “bad experiences” with medications (not just the stimulants, but also antidepressants and others). We often hear parents and patients describe their bad medication experiences. Almost always, these have occurred because of inadequate diagnosis (that’s why we use several tests to make sure of what we are treating), failure to properly adjust dosages, and/or lack of physician-parent-patient communication to “fine-tune” the treatment.

Most of the psychoactive medications have main effects as well as other, subtle effects that are important to consider. Often, a patient may have two conditions that require treatment, but only one is being treated. Unfortunately, physicians often have only a few minutes to spend with each patient so the subtle issues never get brought up. We strongly recommend continuing to see your psychologist or counselor until everyone involved feels that the medication or other regimen is working well. This will help ensure that all of the approaches are working in concert and will help minimize the chance of a bad experience.

There are now a number of alternative ways to alter brain chemistry, which might work for you or your child and could reasonably be tried before resorting to a prescription. Of course, any herbal remedy that changes brain function is still a “drug,” and it is an illusion to believe that an herbal product is somehow not “using a drug.” That said, there are a number of herbal/vitamin/amino acid substances and combinations available at nutrition stores and on the Internet.

Some people claim that powerful antioxidants help with focus and attention. Examples are Pycnogenol, derived from the bark of a tree that grows in France, or extracts of grape seeds or pine bark. These are 25-50 times more powerful than vitamin E. Some vitamins and amino acids (dietary precursors of brain chemicals) seem to help with attention and focus issues, especially if there is an unknown deficiency of that vitamin or brain chemical which the supplement is correcting. Some people have had success using l-tyrosine, the amino acid that the body uses to make dopamine.

Nutritional changes can also help some people with attention and focus. We do not believe that the widely publicized “Feingold Diet” of the 1980’s that severely restricted processed foods, preservative and food additives helped many people. However, maintaining a steady level of blood sugar is a good idea, and the best way to do that is to eat several small meals throughout the day and eat protein more than carbohydrates. Avoid simple carbs (read: sugar) and emphasize whole grains, fruits and vegetables.

Brain Training: Recent research has shown that, even in elderly people, new learning can increase the number of connections between brain cells. In that sense, the brain is like a muscle that can be built up with training and repeated use. There are two approaches to building up brain functions that we recommend – Computer-Based Training and Brainwave Biofeedback.

Computer-Based Training uses a set of modules to help the subject practice specific cognitive abilities that underlie many academic and employment skills such as attention, sensory discrimination, filtering, memory, processing and decision-making. Such approaches have been adapted from programs originally developed for cognitive rehabilitation of brain-injured patients. For people with mild-to-moderate attention issues, this can be a very effective approach, especially when combined with vitamins and nutrition. We offer this service under the name “Beyond Tutoring” because, rather than practicing a specific subject, we practice underlying cognitive skills that will improve performance in all subjects.

Brainwave Biofeedback (“Neurofeedback”) uses a two-computer system to measure and track EEG data as well as reward the subject for increasing one frequency range of brainwaves and decreasing or suppressing two others. Brainwaves that are associated with attention and focus are called “Beta” and are in the 15-18 cycles per second (cps) range. Lower frequency brainwaves (8-14 cps) are called “Theta” and are associated with sleeping and drowsiness. Higher frequencies (18-25 cps) are associated with obsessive thinking and rigidity, and interfere with focus.

The subject looks at the second computer and “plays” one of 10 games, which go faster and reward the subject with points, sounds and special effects for continuously keeping Beta high and the other frequencies low. Over time, we observe significant and measurable improvement in performance, behavior and test scores.

There are a few PC-based attention training “games” that consumers can buy for their children to use. Some of them are quite helpful, but we have found them to be most useful as additional treatments when combined with other approaches.

Behavior Management: Even if attention is improved significantly with one or more of the above approaches, “habits of attention” still need to be developed and maintained. Often, especially with children, the patient does not know that they do not pay attention well because they have never developed the habit of doing so. Parents can work closely with the school to develop a reward system for attending, staying on task and completing work in the allotted time. This often takes the form of a sheet on which the teacher notes whether the child is staying focused during each school period, which the child brings home. Priveleges are earned based on how many periods the child stayed on task. This will, over time, help the child discern when he or she is attending or not, since attending is now more relevant (due to the rewards). In general, we favor approaches that reward with privileges rather than with money or gifts. (That is another entire discussion, available elsewhere.)

Diagnosis of Other Conditions: Patients often have more than one condition that can appear to be AD/HD, or may affect the severity of symptoms. It is essential to look for these possibilities as well.

Depression can cause not only poor concentration and distractibility, but also often results in a lack of motivation. Stimulants can temporarily appear to improve depression and the poor attention caused by it, so you may conclude that the child has AD/HD because of the positive response to stimulant medication. Increasing serotonin levels often helps – medications include Prozac, Zoloft, Lexapro, Paxil, and Wellbutrin; supplements include St. John’s Wort, Melatonin, and 5-HTP. Inositol, one of the B vitamins, has also been shown to reduce moodiness and depression.

Sensory Integration Dysfunction (SID) can cause distractibility and emotional outbursts. These children are overly sensitive to touch, texture and sound, and are easily overwhelmed in group settings. This is usually diagnosed and treated by a Pediatric Occupational Therapist who provides treatment and teaches the parent how to perform exercises and treatments at home.

Obsessive Thinking can help compensate for poor attention but will be made worse by stimulant meds. Many people with obsessive patterns have above-average IQ’s and this can also help compensate for poor attention. They are often rigid, stubborn, bossy, argumentative and prone to emotional outbursts when life does not conform to their expectations. Over-focusing can be as debilitating as a lack of focus. Increasing serotonin levels as for depression can be helpful.

Irlen Syndrome , a problem with eye-brain information processing, can cause problems with reading and writing. Symptoms include a preference for reading in dim light, headache, nausea or drowsiness when reading, losing one’s place on the page, sensitivity to bright light and/or glare, and problems with spatial orientation (can’t catch well, bump into things, etc.). A screening process and correction with colored overlays or tinting of lenses is the approach used with Irlen Syndrome (also called scotoptic sensitivity).

Impulse Control Issues can be present with or without AD/HD. This may be due to over-activation or over-sensitivity of certain parts of the brain. Strong emotional states such as frustration or anger can trigger a cascading effect in which the person loses control and acts in ways that gets them in trouble. Several approaches have proven successful with impulse control issues. Medications that can help include Clonidine (a medicine to reduce blood pressure), several anticonvulsant medications (Neurontin, Lamictal, Depakote) which are used to prevent seizures and for bipolar disorder, and the supplement GABA (Gamma-Amino-Butyric Acid), the neurotransmitter that runs some inhibitory circuits in the brain. Those circuits act like governors to keep other circuits from running too fast, and can help prevent a “chain-reaction” when strong emotions occur.