Evidence Based Treatments for ADHD

Hey there everybody, and welcome to this video on ADHD treatment evidence based practices. I'm your host, Dr. Donnelly Snipes. In this video, we're very simply going to review current evidence based practices for adhd. Now remember, evidence based practices are those that have been researched and shown to to be effective for some people. It doesn't mean that it's going to be effective for every person and it also doesn't mean it's one of those, quote, best practices. Best practices are generally voted on by a group like the APA or something to identify what they think is the first line treatment. Evidence based practices, as I use them in these videos are studies that have looked at multiple studies. So they're meta analyses or systematic reviews that have a significant sample size to them. So it's not just one study here or there. There are a lot of other treatments out there that only have a couple of studies that have been done on them. But that doesn't give me enough evidence to really put it in here as an evidence based port practice. Let's start out with the physical interventions. Sleep. Helping people who have ADHD regulate their circadian rhythms and get good quality sleep and address obstructive sleep apnea is very important. Sleep impacts neurocognition and daytime functioning and may contribute to worsened symptom severity and persistence of ADHD into adulthood. This is one of those that's sort of an indirect treatment. But think about yourself, think about your kids or kids, you know, when they're not getting enough good quality sleep. It does have an impact on impulsivity, on attention, on memory, on organization. Nutritionally, foods can be very important. Now a lot of the research on dietary interventions is somewhat poor in quality, so there weren't any really good meta analyses to take a look at. However, there were a few little tidbits that I was able to pull out of some of the research that indicated that people with ADHD are often low in iron, zinc, magnesium and or vitamin D. Now that is not a license to go out and just start supplementing these things. The only way that it's effective is if the person has a deficiency. So that means, guess what, go to the doctor, get your blood tested. An anti inflammatory diet has been shown to be helpful for a lot of people with adhd, partly because they've shown an association between inflammation and neurocognitive symptoms. So if inflammation is kept under control, then theoretically neurocognitive symptoms won't be as bad. What does that mean? That in general means eating a diet that's low in highly processed sugars and low in trans fats. Low in processed meats, are high in nitrates and nitrites like sandwich meat and hot dogs, and low in red meat. Those are the things that you really want to look at. But you can research an anti inflammatory diet. It's helpful for a lot of things. It's recommended as a best practice for people with depression. It's probably not going to be harmful to to consider reducing some of the inflammatory foods in your diet. Additionally, they did find that the gut microbiome in people with ADHD had a different balance of bacteria. And one of the bacteria that it tends to be low on is a bacteria that is associated with reducing inflammation. So since it is low, the researchers speculate that it's possible that people with ADHD have a higher level of systemic inflammation. And they have done some studies that have shown higher levels of inflammatory cytokines in people with adhd. Which again goes back to the anti inflammatory diet. There is right now no great way to modulate the specific bacteria in the gut microbiome. There are probiotics and prebiotics that people can take, but alteration of those can alter your neurotransmitter balance because a lot of your hormones and neurotransmitters, if they're not made in the gut, they're made from things that are broken down by the gut and, and those microbes are what breaks down the food you eat. That being said, it's important to recognize that Goldilocks principle. Too little is bad, too much is bad. We need to find what is just right for that person. Exercise. Interestingly, a lot of times when we talk about exercise for mood disorders, we talk about gentle exercise to reduce cortisol. And in adhd, they found that moderate to intense aerobic activity actually helped reduce symptoms. Why might that be? Well, moderate to intense aerobic activity is more likely to release endorphins and it may increase dopamine and norepinephrine because of the intensity and focus required to do it. When your body releases endorphins, that means that it's a pleasurable activity in some way. So your brain registers that and dopamine, which is your. I want to do that again. Neurochemical is going to say, hey, let's do that again. Let's do that some more. So we do think that there may be a connection. But there were significant improvements in ADHD symptoms in children and adolescents who engaged in that moderate to intense aerobic activity, repetitive transcranial magnetic stimulation, RTMS is currently under investigation, but it is not an evidence based practice. There are a few very low number studies, very low low number of participants. So there we really can't draw any general conclusions. But it is exciting that it is on the forefront because right now when you look at the research, when you go to pubmed and type in ADHD treatment, you get page after page after page of pharmacology and there are very few articles unless you specifically look for them on anything other than pharmacological interventions. Pharmacological interventions are not tolerable to approximately 20% of people and an additional percent, I'm not sure what the percent is but an additional percent do not respond well to or get achieve full symptom remission from pharmacological interventions. So we do need to be looking at what are some other things that people can do either in addition to medication or instead of medication. Neurofeedback has been found to be especially helpful with inattentiveness and moderately helpful for impulsivity. They are coming out with some at home neurofeedback devices. I'm interested to learn more about those. Right now neurofeedback largely has to be done in a doctor's office where they can manage or monitor the activity of the neurons in your brain. It's not the same as biofeedback where you are monitoring your heart rate or your blood pressure or your breathing. Neurofeedback looks at brain waves Medicinal Like I said, the majority of the first line interventions are psychopharmacological at this point. They suspect that ADHD symptoms are often due to low dopamine and norepinephrine and there is some involvement, although they're unclear as to what it is of serotonin which is 5ht and glutamatergic or glutamate systems. Sorry. Stimulants that are used include methylphenidate and dexmethylphenidate. Those are your common first line interventions for a lot of people with adhd. Non stimulant medications. This tends to be used in people who can't tolerate stimulants because of other underlying health conditions or because they are in recovery. Atomoxetine, which is brand name Strattera or Clonidine have both been used for for adhd. I'm not as familiar with Strattera, but Clonidine is very frequently used in detox units when people are coming off of alcohol to control the spike in blood pressure. Blood pressure spikes when the HPA axis kicks off and there is a dump of cortisol and glutamate and those sorts of things. So clonidine actually acts to reduce that to a certain extent, but they have found it is helpful for some people. Other medications that have been shown to impact ADHD symptoms, they're not. And they're still exploring this. They don't have specific medications that they're really recommending at this point. They're exploring medications that impact your histamine levels. Think about your allergies. Antihistamines reduce inflammation caused by substances that trigger a histamine reaction. So they're looking at that. So that's that inflammatory system, glutamate, that is one of your main excitatory neurotransmitters. They're looking at the impact of glutamate on adhd, norepinephrine, acetylcholine. Acetylcholine is another stimulant stimulating neurotransmitter. It's your second most abundant stimulating neurotransmitter after glutamate. And then, interestingly enough, we talk about ADHD and stimulants a lot. They seem to go hand in hand. But another system that is implicated is actually your GABA system. And GABA is your natural anti anxiety neurochemical, your natural relaxant neurochemical. So I thought that was interesting that some of the medications they're exploring actually increase GABA as well as dopamine levels. Remember, when you alter one of your neurotransmitters, serotonin, norepinephrine, gaba, dopamine, glutamate, acetylcholine, when you alter one of those, it affects the levels of all the others. So some of these drugs may be indirectly working to alter other neurotransmitters. So by increasing gaba, it may increase dopamine. And dopamine is actually what the target is. It's kind of hard sometimes to know exactly which neurotransmitters are the ones that are responsible. The key is helping the person get a neurochemical environment that is best for them, that is balanced for them. And I've said this in every other video on neurochemicals. It is impossible at this point to do a blood test or a urine test to identify the levels of neurotransmitters in your brain. You have neurotransmitter receptors throughout your body. So if you do a test for your, quote, dopamine levels, that's telling you how much dopamine you've got circulating throughout your entire body. It doesn't say how much is in your brain. Additionally, neurochemicals, when we talk about deficiencies, that is really oversimplified. It could be that there's not enough dopamine being made. It could be that the system that triggers the release of dopamine is not working. It could be that the dopamine is removed from the synaptic space too quickly before it has a chance to do its job. It could be that the neurons on the other end aren't working correctly to transmit that signal out. So it's not necessarily just a lack of particular neurochemical. You may have plenty of it. But if the system that transmits that signal with the receptors are not working well, then you could. It could seem like you've got a deficiency in that particular neurochemical. So there are a lot of things that we need to consider and not oversimplify what's going on in the brain. Cognitive interventions Mindfulness intervention showed improvement of ADHD symptoms, including some aspects of executive function and emotional dysregulation. When the person was encouraged and trained to be more mindful, to stop, to slow down, it was helpful. A lot of the mindfulness interventions involve also adding environmental triggers for the person to remind them to check in and be mindful of what they're doing. Mindfulness also interventions also involve the environment and knowing or recognizing environments that were conducive to work versus not conducive to work. My son, for example, when he goes to study, he knows that he needs to be in an environment in which there are not a lot of extraneous stimuli because he has a lot of inattentiveness, and he is mindful of that. When he goes about trying to study or doing something that requires intense concentration, he's mindful of when his energy levels are best because that also means his norepinephrine levels are. Are higher. And he pays attention to those things he's mindful of. When his attention starts declining, he has, you know, certain windows. He can focus for, you know, X number of minutes, and then he needs to take a break for a second or he starts getting more easily distracted. So there are a lot of mindfulness interventions that can be helpful. What's important is to work with each individual and identify what are your symptoms, what mitigates it, what helps improve it, what makes it worse, what works right now and what doesn't work, and build from there. Build on strengths, build on what works, and don't expect the same treatment plan or the same interventions to work for every Single person, everybody's unique. Cognitive behavioral therapy in an individual setting has been shown to be useful for ADHD symptoms and associated mood disturbances. Cognitive behavioral therapy is great, however, when you're talking about somebody who has difficulty with impulse control and attentiveness. Cognition and cognitive restructuring can be very difficult, especially if in a group setting or in a situation where there's a lot of distractions. CBT needs to be tailored to the person to promote success, not to create an environment in which they get more frustrated. So the interventions chosen need to be chosen very carefully and that the person can implement that don't require too much sustained concentration, etc. Organizational skills led to moderate effects in ADHD symptoms. Well, this makes sense if you're working with a person who has difficulty following through with completing things, has difficulty losing things or remembering things, or attention to detail. A lot of these things can be modified with good organizational skills. Having a particular place for everything, and I mentioned in the video on diagnosing adhd, having an environment like a mud room that somebody comes into the house where they're not immediately bombarded with people and activities and dogs and whatever else where they can put their stuff that can help them be more organized and know remember the next morning where they put their stuff. Having checklists in their book bag, in their briefcase, in whatever that identifies what they need to remember can also be very, very helpful for anybody, not just people with adhd. But that's another one of those organizational skills that can be super empowering so the person doesn't get frustrated and think, you know, I can never remember everything I need to Going to the grocery, make a grocery list. Going to the gym, make a list of what you need in your gym bag. If you're going to shower there, going to school, what do you need to make sure is in your book bag and just go through it. Whether you want to call that organizational or mindful or whatever, it's very, very helpful for a lot of people for assignments, assignment, organization, creating a checklist of things that need to be included in the assignment or a rubric of sorts can also be very helpful. Whether it's an English assignment in high school or it's a project that you've got to do at work. Having a list of what needs to be in it so you can go through and check the blocks to make sure you remembered everything can be very, very helpful for the person who has difficulty organizing especially complex tasks noted in meta analyses but not currently in evidence based practice is essential oils, bergamot, lavender and Lemon essential oils boost dopamine, which has been shown to indirectly boost norepinephrine. Now remember, it's boosting those levels throughout the body when we don't necessarily know that it's boosting those levels in the brain. But it is another one of those environmental interventions that's non pharmacological that somebody could experiment with to see if any of those essential oils were helpful at increasing their attention, increasing their focus. Finally, relational parent training has been found to be very effective for preschool children to reduce parent reported but not objectively assessed ADHD symptoms. So you may be saying, well, if it's not reducing objectively assessed ADHD symptoms, what's the point? Oh, there's a big point. If it reduces parent reported ADHD symptoms, it's also likely going to reduce family discord and tension within the family. If parents are happier, kids are happier and vice versa. So it can create a more supportive environment for that child and lay the groundwork for more detailed interventions later on. Social skills training, interestingly enough, did not demonstrate notable improvements. And that's important because a lot of times, because one of the main symptoms for a lot of people with ADHD is social intrusion. Blurting, not taking their turn, finishing people's sentences. Many times the thought is, well, if you can just train the person to hold their tongue or have better social skills, then they won't have this problem. And that's just not true. They found in the research that is really difficult for people with ADHD to manage some of these symptoms. There are situations where it can be done. However, it's important to work slowly and not expect 180 degree turn. With teaching somebody a social skill, it requires a lot of practice, a lot of training, a lot of distress tolerance. For example, when you feel like you're going to blurt something, counting to 10 in your head, that can be something that people can do. What's the drawback? Well, if I'm counting to 10 in my head, I'm not paying attention to what's being said. That happens to be one technique that one of my clients found to be very helpful for reducing blurting in group. Remember I said in substance abuse treatment, a lot of substance abuse interventions are in a group format. And that can be really, really challenging for people who have adhd, not only waiting their turn, but also sitting still and being in an environment where there are constantly distractions going on around them, whether somebody's switching, crossing their leg in a different way, or fidgeting with their hands or something else. A person with ADHD may be distracted by all of those things and have more difficulty focusing in group. If you're working in a setting in which group treatment is the expectation, it's going to be important to work with people who have concurrent ADHD and identify what can be done to help you focus and in this environment, some things that have been helpful. Note taking can be helpful for some people who have adhd, creating a situation in which the room is arranged such that the person with ADHD can stand up periodically because sitting for an hour and a half can feel oppressive. It requires some creativity and again requires attention to what that particular person's symptoms are. But recognize ADHD is not a willful disregard for people's feelings or for social mores. It is a clinical diagnosis that we need to help people figure out how to mitigate. Since the causes of ADHD are still being explored, new treatments are regularly emerging. Medication is often the first line treatment, although up to 20% of people cannot tolerate the medication. Exploring core symptoms and helping the person learn how to develop individualized strategies to mitigate negative impacts is still central to the treatment. Notice I said helping the person learn how to develop individualized strategies. I didn't say we're doing it for them. Why? Because counseling is designed to provide people tools to empower them to, to learn how to live their highest quality of life. We're not going to be with them every day. We're not going to be with them for the next 15 years. So it's important that they learn how to identify, okay, this is a problem situation. These are ways I've handled similar situations. What's going to work now? We want to help each person feel empowered to manage their symptoms and their condition in a variety of environments.