Counseling for ADHD: When Does Therapy Help?

Counseling Attention Deficit Disorder - ADD ADHD

We are big believers that you should not just be giving an attention deficit child medication without therapy.

There are a lot of good, long-term studies from the days of Satterfield on, that show that medication by itself in long term is not a whole lot better than no treatment at all (Satterfield, et.al.). Medication for Attention Deficit Disorder - ADHD is far more effective when it is combined with counseling.

Family Therapy Can Be Helpful

The family needs to adjust to the ADHD child, and know how to adjust to him. Parents need to know what to expect from the Attention Deficit Disorder - ADHD child, and the siblings need to be filled in on what is going on as well.

In fact, often the focus of family therapy ought to be the siblings. There is often a lot of jealousy with the siblings focused at the ADHD patient. Why? Because the patient has been getting all kinds of attention from the parents, both good attention and bad, over the past several years.

Also because the ADHD child probably gets away with a lot more than his non-ADHD siblings do. So the jealousy needs to be addressed at some point.

Parent Training Classes are Great

Most parenting classes focus on getting kids with Attention Deficit Disorder to be more compliant.

It doesn’t matter if the ADHD child is noncompliance because he’s a space cadet and can’t remember what he’s supposed to do, or if he’s being defiant and refuses to do what he’s supposed to do. Either way there’s a problem that needs to be fixed.

A good parent training class will give parents the skills needed to teach their ADHD kids to be successful at being obedient.

Individual Counseling with ADHD Children: Skills Not Insight

What about individual counseling or therapy for Attention Deficit Disorder?

Individual therapy using cognitive-behavioral approaches can be very helpful in the treatment of Attention Deficit Disorder ADHD. Stop and think therapy, teaching the ADHD child how to solve problems, and teaching him how to decrease his impulsivity is great. Teaching the Attention Deficit Disorder - ADHD child how to monitor his own behaviors is important as well.

I really have a tough time with people doing regular psychotherapy with these kids, as in, “Well, how does that make you feel? Here, come play with this doll.”

Sorry, I have a tough time with that. If the problem is Attention Deficit Disorder - ADHD, then the child has a neurological problem.

Attention Deficit Disorder is an impulse-control disorder, or dis-inhibition disorder, and ADHD children need to be taught how to control themselves, how to decrease their impulsivity, how to solve problems, and how to stop and think before they act. They need to be taught skills to help them be more successful.

I rarely ask ADHD kids, “How do you feel?” simply because I rarely care how they feel.

Now, that may sound cold to you, but it’s really not.

I don’t try to help ADD ADHD kids to “feel good” about themselves, or have “good self-esteem.” There are too many people who feel good about themselves, but do wrong things, things that keep them from being successful, or things that get them into trouble, or things that hurt other people.

This may shock you, but Self-Esteem is highly overrated.

Some of you may find this opinion offensive. I'm sorry, but I know in my heart that I'm right.

Self-Esteem, without Self-Control and Respect for others, leads to selfish behaviors at best, and to criminal behaviors at worst.

Every criminal behind bars has good Self-Esteem, so much so that they believed that the laws of our society did not apply to them.

For those of you who want to argue, first consider this: one study published in 1997 reported that the "average" criminal locked up in prison had committed 116 crimes for which he was not arrested, or convicted, for each crime for which he was arrested and convicted! 116 to 1!

Every sociopath in the world has inflated self-esteem. We have to stop pushing self-esteem and start pushing self-control and respect for others.

Self-esteem should come naturally as the result of hard work which leads to success, not from "Self-Esteem Classes" or "Workbooks." We've become a society that praises mediocre work so that we don't offend anyone, and as a result our national work ethic has eroded away and we get lots of mediocre efforts.

Less Self-esteem, and More Self-control

The Keys to making this work:
Teach SELF-CONTROL and RESPECT FOR OTHERS.

In order to be successful in life, which should be the goal of therapy, Attention Deficit Disorder - ADHD - kids need to learn what to DO to be successful.

The good “Feelings” will come as a result of the successful “Doing.”

Attention Deficit Disorder - ADHD individuals need to be taught how to be under control, how to wait their turn, how to be polite, how to finish their work, how to work fast and hard until they are finished, how to pay attention to the right thing, how to follow rules, and how to obey their parents and teachers.

The better they become at these skills and virtues, the more successful they will be at home, at school, and in life.

If your child's counselor will focus on these things - great! If not, find someone else.

EEG Biofeedback for ADHD

EEG Biofeedback for Attention Deficit Disorder - ADD ADHD

What is EEG Biofeedback or Neurofeedback Training?

In this form of treatment for attention deficit hyperactivity disorder - ADD ADHD- the subject learns to pay attention to his own brain wave activity, and then apparently learns to change and control his brain wave activity.

The subject is given immediate feedback on just what his brain's activity is like at any given moment through the use of high-speed computers which provide both auditory and visual feedback.

This is a very good technology when combined with a good clinician and a motivated subject.

The variety of people that we used to see in our office was amazing, from head injured people, to ADHD kids, to professional athletes and business executives (for peak performance training or stress management).

Lots of studies are being published even as we speak. The intervention has been around for about 30 years, but mostly in the “ivory towers” of the universities and labs until just the past fifteen years.

There are about 1000 providers in USA at present time. The intervention works for about 70%-75% of kids, depending on factors such as what exactly the cause of the problem is, the severity of their problem, their IQ, motivation levels, and the number of sessions given.

Double-blind studies vs. Clinical studies

There has been a lot of bad mouthing about the supposed “lack of research” from the medical community and from psychologists who receive their funding from pharmaceutical companies regarding EEG Biofeedback.

Yet, there really is quite a bit of published research out there. The critics just don’t like what’s out there because they are “clinical studies” rather than “double blind” studies.

Double blind studies are great for pills, where you can fool the subjects into thinking that they are taking some medication when they are really only taking a sugar pill placebo.

But there are a lot of things worth studying in life that you simply can’t do double blind studies with.

For example, weight lifting.

Could you do a study with a placebo in weight lifting? No.

What would you do if you wanted to know if weight lifting made people stronger? You would test them at the beginning of the study to see how strong they were, then you would have them lift for a couple of months, and then you would retest them. In simple, that’s what you’d do.

In the health field that type of study is called a “clinical study.”

Most of the studies on EEG biofeedback training want to know, “Is the patient better or worse after having done X number of EEG biofeedback sessions?” Three out of four times the subjects are better off having done the training.

We personally provided EEG biofeedback training in our practice for eight years. Most of our patients liked it very much. As we mentioned earlier, we have worked with a wide assortment of patients from head injured, autistic, Attention Deficit Disorder - ADD ADHD, up to professional athletes who wanted “peak performance training.” Just think of it as weight lifting for the brain.

Might EEG Biofeedback help your child?

EEG biofeedback training works best with subjects who have average to high IQ, are seven years old or older, can sit still for a few minutes if interested in what he’s doing, and are motivated people.

It works much less well for those with low IQ, or are very young, or who couldn’t sit still under any circumstances, or those who “don’t want to be here.” The worst results are with 14 to 17 year olds who have been dragged to treatment by their mothers and don't want to be there.

Biggest Problem with EEG Biofeedback Training

The "Down Side” of the intervention is the cost. Treatment sessions range from $50/session up to $150/session, depending on the provider and the part of the country you live in. The usual course of treatment is two to four treatment sessions per week, for a total of about 25 to 40 sessions. However, we have seen some people do very well in as few as five sessions.

Our experience is that 65% to 75% of Attention Deficit Disorder - ADHD individuals receive benefit from this intervention. Results are usually slow but steady. Realistically plan on needing about 30 to 40 sessions (30-40 minutes each session).

We believe that the results of EEG biofeedback training can be enhanced significantly by using the Nutraceutical ATTEND while undergoing the neurofeedback training. We cannot prove this with research, but that has been our experience.

More information may be found at these sites:

• EEG Spectrum has an excellent site with lots of information and research papers.
• Remote Neurofeedback has some good information and home training options.
• ADHD Links Project Pages with 500 links, many of them to EEG biofeedback providers.

NIMH Study: Improvement Following ADHD Treatment Sustained in Most Children

But Linked Problems Persist Into Adolescence - Major Follow-up Study

Most children treated in a variety of ways for attention deficit hyperactivity disorder (ADHD) showed sustained improvement after three years in a major follow-up study funded by the National Institutes of Health's (NIH) National Institute of Mental Health (NIMH). Yet increased risk for behavioral problems, including delinquency and substance use, remained higher than normal.

The study followed-up children who had participated in the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA).

Press Release: July 20, 2007 National Institute of Mental Health. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services.

Initial advantages of medication management alone or in combination with behavioral treatment over purely behavioral or routine community care waned in the years after 14 months of controlled treatment ended. However, Peter Jensen, M.D., Columbia University, and colleagues emphasized that "it would be incorrect to conclude from these results that treatment makes no difference or is not worth pursuing."

Their report is among four on the outcome of the MTA study published in the August, 2007 Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP).

"We were struck by the remarkable improvement in symptoms and functioning across all treatment groups," explained Jensen.

After three years, 45-71 percent of the youth in the original treatment groups were taking medication. However, continuing medication treatment was no longer associated with better outcomes by the third year.

"Our results suggest that medication can make a long-term difference for some children if it's continued with optimal intensity, and not started or added too late in a child's clinical course," added Jensen.

For the followup study, a multi-site research team evaluated, at ages 10-13, 485 children from the original MTA study, the first major randomized trial comparing different treatments for ADHD, published in l999. That study found that intensive medication management alone or in combination with behavioral therapy produced better outcomes than just behavioral therapy or usual community care.

Ratings from families and teachers favored the combination treatment, which allowed for somewhat lower medication doses. Also, the careful management of medication by MTA physicians produced better outcomes than medication provided through usual community care sources.

After the 14 months of assigned treatments ended, families were free to choose from treatments available in their communities.

To understand why the initial advantage of medication wore off, the researchers examined medication use patterns that emerged after formal treatment in the study ended. They found that children who had been assigned to intensive behavioral treatment were more likely to begin taking medication, while those who had been taking medication were more likely to stop. For example, among children originally in the behavioral treatment group, the incidence of high medication use increased from 14 to 45 percent.

In a secondary analysis of the data that searched for possible explanations for the findings, in the same issue of the JAACAP, researchers led by James Swanson, Ph.D., University of California at Irvine, reported finding substantial individual variability in responses to medication. They identified three groups of children with different patterns of response. One group, about a third of the children, showed a gradual, moderate improvement; a second group, about half of the children, showed larger initial improvement, which was sustained through the third year; a third group, about 14 percent of the children, responded well initially, but then deteriorated as symptoms returned during the second and third years. Swanson and colleagues suggested "trial withdrawals" for some children to determine if they still need to take medications.

Another report by Swanson and colleagues in the same issue of the JAACAP confirmed an earlier finding from the MTA study that taking medication slowed growth. A group of 65 children with ADHD who had never taken medication grew somewhat larger — about three-fourths of an inch and 6 pounds more, on average — than a group of 88 peers who stayed on medication over the three years. Growth rates normalized for the children on medication by the third year, but they had not made up for the earlier slowing in growth.

In a fourth article, Brooke Molina, Ph.D., University of Pittsburgh, and colleagues reported that, despite treatment, the children with ADHD showed significantly higher-than-normal rates of delinquency (27.1 percent vs. 7.4 percent) and substance use (17.4 percent vs. 7.8 percent) after three years. Earlier evidence of lower substance use rates among children who had received intensive behavioral therapy had lessened by the third year. "These findings underscore the point that ADHD treatment for one year does not prevent serious problems from emerging later," noted Molina.

The follow-up of the MTA sample will continue as the participating children go through adolescence and enter adulthood.

The following researchers participated in the studies:

Three-year Follow-up of the NIMH MTA Study. Peter S. Jensen, L. Eugene Arnold, James M. Swanson, Benedetto Vitiello, Howard B. Abikoff, Laurence L. Greenhill, Lily Hechtman, Stephen P. Hinshaw, William E. Pelham, Karen C. Wells, C. Keith Conners, Glen R. Elliott, Jeffery N. Epstein, Betsy Hoza, John S. March, Brooke S.G. Molina, Jeffrey H. Newcorn, Joanne B. Severe, Timothy Wigal, Robert D. Gibbons, Kwan Hur

Secondary Evaluations of MTA 36-Month Outcomes: Propensity Score and Growth Mixture Model Analyses. James M. Swanson, Stephen P. Hinshaw, L. Eugene Arnold, Robert D. Gibbons, Sue Marcus, Kwan Hur, Peter S. Jensen, Benedetto Vitiello, Howard B. Abikoff, Laurence L. Greenhill, Lily Hechtman, William E. Pelham, Karen C. Wells, C. Keith Conners, John S. March, Glen R. Elliott, Jeffery N. Epstein, Kimberly Hoagwood, Betsy Hoza, Brooke S.G. Molina, Jeffrey H. Newcorn, Joanne B. Severe, Timothy Wigal, and the MTA Cooperative Group

Effects of Stimulant Medication on Growth Rates Across 3 Years in the MTA Follow-up. James M. Swanson, Glen R. Elliott, Laurence L. Greenhill, Timothy Wigal, L. Eugene Arnold, Benedetto Vitiello, Lily Hechtman, Jeffery Epstein, William E. Pelham, Howard B. Abikoff, Jeffrey H. Newcorn, Brooke S.G. Molina, Stephen P. Hinshaw, Karen C.Wells, Betsy Hoza, Peter S. Jensen, Robert D. Gibbons, Kwan Hur, Annamarie Stehli, Mark Davies, John S. March, C. Keith Conners, Mark Caron, Nora D. Volkow, for the MTA Collaborative Group

Delinquent Behavior and Emerging Substance Use in the MTA at 36-Months: Prevalence, Course, and Treatment Effects. Brooke S. G. Molina, Kate Flory, Stephen P. Hinshaw, Andrew R. Greiner, L. Eugene Arnold, James M. Swanson, Lily Hechtman, Peter S. Jensen, Benedetto Vitiello, Betsy Hoza, William E. Pelham, Glen R. Elliott, Karen C. Wells, Howard B. Abikoff, Robert D. Gibbons, Sue Marcus, C. Keith Conners, Jeffery N. Epstein, Laurence L. Greenhill, John S. March, Jeffrey H. Newcorn, Joanne B. Severe, Timothy Wigal, and the MTA Cooperative Group. The Office of Special Education Programs of the U.S. Department of Education, the Office of Juvenile Justice and Delinquency Prevention of the Justice Department, and the National Institute on Drug Abuse (NIDA) also participated in funding this study.

The National Institute of Mental Health (NIMH) mission is to reduce the burden of mental and behavioral disorders through research on mind, brain, and behavior. More information is available at the NIMH website.

The National Institutes of Health (NIH) - The Nation's Medical Research Agency - includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website.