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Treating ADD Naturally with David F. Velkoff, M.D.

In recent years the widespread use of Ritalin to combat ADD has been the cause of much controversy. Dr. Velkoff believes in treating Attention Deficit Disorder naturally, with biofeedback, instead of with drugs. He has successfully weaned a great deal of children off Ritalin. He will be discussing his different approaches to ADD treatment when he chats on WebMD Live.

Tuesday, January 11, 2000 10:00 p.m. EST

By David Velkoff , M D

Chat Transcript

Event_Moderator Welcome to WebMD Live. Today we are discussing Treating ADD Naturally, with David Velkoff, M.D.

David F. Velkoff, M.D., is currently the medical director of the Drake Institute of Behavioral Medicine in California. He received his medical degree from the Emory University School of Medicine and a Master's Degree in Psychology from California State University, Los Angeles. After practicing preventative medicine from 1977-1980, Dr. Velkoff co-founded the Drake Institute of Behavioral Medicine. With the Menninger Foundation he has received training for treatment of hypertension and cancer and studied EEG neurofeedback and its applications for addictions. He had conducted clinical research studies on the effects of stress and psychophysiological treatment on the immune system. Dr Velkoff's pioneering efforts in medicine have been featured in Physician's Weekly, Life Magazine, Wall Street Journal, Los Angeles Time, CNN, Dan Rather's 48 Hours, and Eye-To-Eye with Connie Chung.

Dr. Velkoff, Welcome to WebMD Live.

Velkoff_Speaker

I'm pleased to be here, thank you.

Event_Moderator

When did doctors first begin diagnosing kids with ADD?

Velkoff_Speaker

The disorder has been diagnosed since the early 1900s, but it hasn't always been called ADD. Organic Brain Syndrome, Hyperkinetic Reaction of Childhood, Hyperkenesis, Minimal Brain Dysfunction, and more recently, Attention Deficit Disorder. It's been reported in medical literature for the past 100 years, but its had different names.

Event_Moderator

How is ADD diagnosed? Has this changed at all in recent years?

Velkoff_Speaker

The assessment process has been unchanged; clinical interview is probably the most important information. Behavioral questionnaires are also very important; then you can do continuous performance tests that measure the capacity of the brain, and its necessary to do more in-depth testing through neurophysicological testing, and QEEG testing, depending upon the complexity of the symptoms. Not every clinic has the ability to do this kind of testing. It's often poorly evaluated and often misdiagnosed.

Event_Moderator

Is taking history the most important thing?

Velkoff_Speaker

The most important, it's first.

Event_Moderator

Do you think that the majority of ADD diagnoses are valid? Was there ever a time that ADD was over-diagnosed?

Velkoff_Speaker

I think that the majority of the people who've been diagnosed with ADD probably do have ADD, but there may be more going on than ADD in contributing to inattention. It can come from a variety of different causes, and sometimes it is misdiagnosed. Undiagnosed seizure disorders can produce inattention during the day that's not due to ADD. Not infrequently, children and adults can have neurological-based learning disorders that attribute to attention. Inattention, actually. The diagnoses may be accurate, but may be incomplete. If they're not properly evaluated, they can't be fully treated and cared for.

Event_Moderator

Does that include depression?

Velkoff_Speaker

Depression certainly can cause inattention. It gets complicated because many people with ADD are depressed, and I think that it's an appropriate reaction to feel depressed if you have ADD and not properly treated because your life is so frustrating, filled with disappointment. You can also be very bright and not be able to fill your potential. Depression is a normal reaction to having ADD, but people can be depressed and not have ADD. It's through a careful clinical history you can start to sort out whether it's ADD with depression, or if it's depression as the primary disorder. For adults to have ADD, they must have a childhood history of difficulty focusing, concentrating. You don't develop ADD when you're 22-years-old. There has to be a history going back to childhood. It has nothing to do with intelligence; you can be highly intelligent but not be able to concentrate if it's not interesting to you.

Event_Moderator

How long has Ritalin been used to treat ADD?

Velkoff_Speaker

It's been used for over 40 years.

Event_Moderator

What exactly does Ritalin do? What parts of the body does it affect?

Velkoff_Speaker

I don't think anyone understands exactly the mechanism of how it works. It increases the arousal level of the brain, and causes the brain to become more stimulated. It also stimulates the cardiovascular system, may affect the level, and may interfere with growth hormone cycles. It can improve short-term improvement in ADD, but no long term improvements. I'm uncomfortable in using powerful stimulant drugs in children if we can avoid it.

Event_Moderator

Do you feel Biofeedback offers long-term improvements?

Velkoff_Speaker

Which we frequently can in our treatment process program. Yes, used properly in a comprehensive treatment program. Biofeedback is not a standalone treatment; it needs to be combined with other therapeutic intervention. Used properly, we've seen long-term improvements in many patients we've helped, where years later they're still symptom-free of ADD or their initial improvement is sustained. Once the brain is working at a fuller level, all you need is time to catch up with your life, where you literally re-integrate back into your life with full usage of your brain.

It's similar to physical therapy, in building-up an undeveloped muscle. If you have an undeveloped calf muscle a nd unable to develop physical skills through physical therapy, you build up the muscle. If you stop, the muscles' normal development will always stay strong if you continue to use it. We find the same results in our neurofeedback program, where the child reintegrates back into the world with a higher level of brain functioning. Those new successes can complete the healing. You need to treat it with psychosocial support. We may have to do testing for neurological learning disorders and some kind of education remediation, but neurofeedback is at the core of the treatment because it strengthens the brain. Many people we treat no longer have to be dependent on using drugs to manage their symptoms.

Event Moderator

Can you characterize the general behavior of children with ADD?

Velkoff_Speaker

Inattentive, if it's not interesting to them. They will get easily sidetracked. A half hour of homework can take two hours, with the parent there to oversee them. They could play video games for hours with perfect concentration. If they're into legos or Pokemon, they can hyperfocus. But routine academic tasks are very difficult for them to stay focused with. They may have problems with impulsivity, and do things spontaneously; almost too spontaneously without considering consequences. About 50% of children with ADD will be hyperactive; they'll get fidgety, get out of their seat inappropriately in class, may have difficulties sitting through dinner, and they will have difficulties in their lives irrespective of how good their parents were or how bright they are. The more bright they are, the more frustrated they may get as they get older, because they can't express their full potential. Many people don't understand they have a neurobiological disorder that makes their lives so difficult.

Before we start treatment, we have the patients come to a seminar first where I can educate them about the neurobiology of the disorder, so we can help explain to the parents how we can help them overcome them. It takes blame and guilt off the child and adult patient, which makes the therapeutic intervention later on so much easier. On an unconscious level, parents blame themselves for the children's problems with ADD, when it's not the parent's fault.

Event_Moderator

Is ADD considered a life-long condition, or do some kids "out-grow" it?

Velkoff_Speaker

In majority of kids, it's considered a life-long disorder if not properly treated. Using neurofeedback in a comprehensive program, we've helped many patients who no longed have symptoms of ADD. As a physician, I'd conclude they no longer have the disorder. That runs contrary to physicians who use drugs to suppress the disorder. In my clinical experience, it's been possible to help patients help solve the disorder by using neurofeedback.

Event_Moderator

How successful have your alternative treatments been?

Velkoff_Speaker

Our alternative treatment is neurofeedback in a comprehensive program. I think it should be the primary treatment for ADD. If neurofeedback is not successful, then you can try a more drastic treatment, that has side effects like medication. Treatment should always begin with the most benign treatment, and neurofeedback is the safest.

Event_Moderator

Do you think the prevalence of TV's and computers has any correlation with or effect on ADD?

Velkoff_Speaker

Not that I'm aware of. Kids with ADD can hyperfocus on computers, video games, and TV because it's more interesting to them. Because their brain is underactivated, it takes something very stimulating to hold their attention. Kids with ADD will do better in classes of art, music or drama, because it's more creative and stimulating. Unfortunately, they have difficulty with everyday tasks. I've knew a physician with ADD, he could not work in a regular medical office. He could only work in the emergency room, where he was under such high stimulation it kept his brain revved up. We've created police officers with ADD, and before we helped them. The only time they could focus was in life-threatening situations, because they require that adrenaline rush to help focus. All the adrenaline focus puts stimulation on their digestive system, and we'd have to treat them first with biofeedback before we can address the ADD.

I might add that thirty years ago, if someone had ADD, they could get by with it much easier than kids can today. 30 years ago, they could compensate around it, work around it. Today, kids with ADD can't get by anymore without having the disorder properly helped. Life is more challenging for kids today, and life has become more competitive today with kids in school. Without full usage of their brain, they're going to suffer more readily than 20 years ago. That's one of the reasons we're seeing more ADD cases today than years ago.

Event_Moderator

When should a parent begin to worry that their child has ADD?

Velkoff_Speaker

By five or six years of age. Hyperactivity in a 3-year-old can be normal behavior. In a 4-year-old, it still can be relatively normal. By 5, it can start being inappropriate. I've heard of kids put on Ritalin when they're 3, and they shouldn't. There are isolated cases of hyperactivity by the age of 3, but the earliest case of hyperactivity I've ever experienced was a young girl, six years ago, that as a fetus, she actually broke 2 ribs in her mother during pregnancy. That's the easiest case I've ever heard, and we were able to help this girl dramatically.

Event_Moderator

How do you recognize children with ADD who are NOT hyperactive?

Velkoff_Speaker

It's more difficult, because they're not going to have behavioral control problems. They're more like to be daydream, be inattentive, and have problems following directions. Most girls with ADD are primarily inattentive, and they don't get diagnosed nearly as easily. I think there's still a gender prejudice that operates in our school system, where if a boy has difficulty academically, they're more likely to overact, where if a girl is having problems, I've seen them frequently dismissed as "she's a sweet child, just not a good student." They don't show the same concern to the inattentivity in a girl tha n in a boy. Girls with ADD might get missed, and it doesn't become symptomatic until junior high or middle school when they get overwhelmed.

Event_Moderator

Do most children displaying behavioral problems at an early age have ADD?

Velkoff_Speaker

I don't know the answer to that. It's the most common psychiatric disorder in childhood. The most damaging part of untreating ADD properly, is that it damages self-esteem. It gets damaged at a very early age; their view of themselves get shaped by their day- to-day experiences and they'll criticize themselves as stupid or dumb. They have a neurologic dysfunction they can't control. It sets them up for failure, underachievement and sometimes their parents get unfairly blamed. It places an enormous strain on family dynamics. That's why again, I have patients come to my seminar first before we even evaluate them to be treated, to see if there's enough indication for the child to be treated. I want parents to understand that in most cases, it's not their fault. The child came into the world with a disorder that they didn't want to have, and it makes their life so difficult until it's properly handled.

Event_Moderator

Do we know yet if ADD is hereditary?

Velkoff_Speaker

There's a lot of research that suggest a hereditary predisposition to ADD. It's not the only possible cause, but it's an important cause. Sometimes it's multiple causes; premature births, complications during birth, fetal distress, or elevated bilirubin during childbirth. Sometimes traumatic delivery may accidentally cause a brain injury leading to ADD. Frequent and severe ear infections at early ages can increase the likelihood. So can high fevers, head injuries, and meningitis. We recently evaluated a 7-year-old girl with ADD and multiple learning disorders. When her mother was in her seventh month of pregnancy, the baby stopped moving for 2 days. They did a emergency ultrasound and found the fetus was straining her own umbilical cord. They did emergency maneuvers and she released hold of her umbilical cord. There are a lot of things that happen during pregnancy. If you smoke a pack or more cigarettes during pregnancy, that can cause ADD or neurological lear ning disorders. One of the reasons we're seeing higher ADD today is the advancement of neonatology. 30 years ago, low birth weight infants wouldn't survive. The probability of their survival today is much higher, but we'll find that by the time they're 10, 11-years-old, 2/3 of them will have significant learning problems.

MTSTREETDOC_WebMD

Is there any evidence of the success of non-prescriptive treatment for ADED/ADHD, i.e., bee pollen, ginko biloba, or ginseng?

Velkoff_Speaker

If there is, I'm not aware of it. Most children will not show significant improvement with dietary change alone; there are always isolated cases. The research may say otherwise. Over and over sugar will produce more tension and hyperactivity. Using neurofeedback, we've seen that sugar makes the disorder worse. There may be research out there, but I'm not aware of it. We use the patient's own empowerment of their brain... and it's exciting when the child can be in the driver's seat of improving their own dysfunction. You can train neurons to do the job that they weren't able to do before. That's one of the aspects so exciting about neurofeedback.

jfishburn_WebMD

What affect, if any, does diet have in the management of ADD?

Velkoff_Speaker

I think that there are a small percent of ADD symptoms that have food allergies. It's a real small percent I've seen rarely. When it is present, it's significant. I think it's greatly over-reported, and I've not seen it frequently at all.

Velkoff_Speaker

Other than healthy food, taking daily vitamins, supplements, and minimize sugar; that's about all we do with nutrition, and we've found that to be adequate. Patients have come to us first that have tried nutritional programs to help ADD, b ut there has been minimal improvement, until we helped them with neurofeedback. I'm very supportive of vitamins, but in my experience it's not going to reverse a neurological disorder like ADD if the diagnoses is accurate.

CinJon_WebMD

Is biofeedback effective in treating adults that have been diagnosed with ADD later in life?

Velkoff_Speaker

Yes, it is. We usually will add biofeedback treatment for stress also to our adult patients because most adults come to us with more than ADD; they've developed secondary anxiety and/or depression. The longer you live with ADD, you're going to develop secondary problems. By using biofeedback treatment for stress first, our patients improved. Then we go onto neurofeedback for ADD. I've had patients with ADD that improved just with the stress treatment. If you have ADD, you're going to have more stress because it takes you much longer to complete things, and knowing that things will be harder for you, your adult relationships are going to be impaired. If you're impulsive you can get into difficulty for being "brutally honest" and overly spontaneous without awareness of the impact that your actions can have on people close to you. We are very successful in helping adult patients, but we want to help patients as easily as we can so we can prevent secondary problems if you have untreated ADD.

joey01_WebMD

You mentioned that neurofeedback is only one part of your treatment- What else do you offer?

Velkoff_Speaker

If it's a child, we work with the parents and give out support, guidance, and family counseling when necessary. We work with the child in being sure they learn what we call self-regulation with biofeedback, so what they experience in the treatment sessions is integrated into their life all the time. We may also provide educational support, do testing for learning disabilities, and some learning disabilities we're able to help. We address whatever deficits the child has. If it's an adult patient, we'll also treat their stress symptoms. Neurofeedback shouldn't be a standalone treatment for most patients; it needs to be used in a comprehensive program, because the symptoms for ADD don't exist in a vacuum.

You need to work with the family, because what's going on in the child's brain can affect family dynamics, where the best of parents can get burned out. It takes extraordinary parenting skills, and we help our parents learn that. We will not treat a child today unless the parents are involved with us. Fortunately, many parents are motivated and appreciate it because it makes their lives easier as well.

Event_Moderator

How has the rest of the scientific community responded to Biofeedback?

Velkoff_Speaker

It has been mixed. Whenever there's major medical breakthroughs, the existing establishment will resist it for awhile. In the breakthrough of biofeedback, it's history repeating itself all over again. The scientific community at first resisted, but we're treating more and more children today of physicians. We get more referrals from doctors than ever before; there's been extensive clinical research showing how effective neurofeedback is for ADD. It's not at the level of acceptance is needs to be, but I think we're moving in that direction very promptly right now.

Event_Moderator

Is this process (biofeedback) affordable?

Velkoff_Speaker

It's affordable for many families. The time it takes and 40 treatments, costs somewhere in the range of $4,000. We try to help patients as best as we're able to, and work out payment plans, but we can't accommodate everyone. You need to see this as more than a non-drug medical treatment; it's a foundation for the rest of the patient's life. If not properly treated, the expenses to this patient are going to be enormous in the years to come, with tutors, psychotherapy, mental complications, missed opportunities, etc. So, it's a highly cost effective treatment in the middle and long run. If you think about the cost of maintaining someone on medication for years, periodic blood tests, EKGs, the cost of chronic medication builds up significantly over the years. This is a much shorter treatment in a shorter time period with very significant long-term e ffects in people.

Event_Moderator

How long does it take?

Velkoff_Speaker

The treatments are generally a hour. If they live in Southern California, we do most of the treatments over 4 to 5 months. We have patients come here from all parts of the country and they will do the treatment in 8 weeks. You can do the treatment intensively, but patients in Southern California usually spread it out over 4 to 5 months.

Event_Moderator

Do you get much opposition from psychiatrists who believe in the use of Ritalin?

Velkoff_Speaker

Yes.

Event_Moderator

How long should a child, in your opinion, take Ritalin to deal with ADD? Are there serious negative effects of long-term use?

Velkoff_Speaker

We try to treat our patients without using drugs. I'm very uncomfortable with having children on stimulant drugs, because we don't know what the long-term effects are. In animals, they'll result in brain and heart damage. We don't know if that can be happening in children. So if someone is on stimulant medication for years as a child, 40 years down the road are they going to be at more risk for hea rt disease, high blood pressure? We don't know. I made a choice years ago as a physician to use this preferred non-drug treatment, because of how clinically effective it is, it doesn't have side effects, and the carry-over effect is much greater than you'll ever see with stimulant drugs. I do believe there's a small percent of kids that need to be medicated, but that's a very small percent.

Event_Moderator

How is Ritalin similar to other psychiatric drugs, such as Prozac?

Velkoff_Speaker

Ritalin is purely a stimulant drug; Prozac is an anti-depressant drug. Welbutrin may sometimes have a stimulant effect.

von-1027_WebMD

Is one of the symptoms of ADD not being able to sit still?

Velkoff_Speaker

Yes, in about 50% of children. There are degrees of hyperactivity. You can stay in your chair, but you're moving around. Some patients outgrow hyperactivity. They generally will outgrow the inattention, but some kids don't. By the time they're adults, even if they don't look hyperactive, they'll report a feeling of restlessness inside themselves that they can't turn off. They can have racing thoughts, or a motor inside them that they can't turn off. They have this excess energy that they need to get up and do something.

Event_Moderator

How fragile are the brain's neurotransmitters?

Velkoff_Speaker

I'm not an expert on neurotransmitters, so I can't answer that.

CinJon_WebMD

Do you see any co-relation between OCD and ADD?

Velkoff_Speaker

They can co-exist.

Velkoff_Speaker

They will coexist more commonly in patients who suffer with Tourette's syndrome. We have helped patients with OCD and ADD, but it is more complex. Sometimes they will over focus on something they can't shift their attention off of. They get so locked into something that it gets stressful for them to shift their attention. They don't have flexibility of their attention system.

Event_Moderator

Do you think Biofeedback helps that?

Velkoff_Speaker

Yes, it can.

joey01_WebMD

If a child or an adult has been on medication for ADD and want to try neurofeedback, would they have to stop the medication before starting neurofeedback?

Velkoff_Speaker

Absolutely not. You don't want to take a patient off stimulant medication if it's temporarily stabilizing them. If we add our treatment to the medication, generally you will see more improvement than you saw from the medication alone. Once that improvement is stable for 3 weeks and I get gradually start treating patients off medication, I usually start at 15 to 20 treatments. I want them to go right on medication after our evaluation, and don't want to adjust it until they've improved. If you're going to take them off medication, you have to have something to take its place that's better, otherwise you'll leave them unprotected.

CinJon_WebMD

Is this treatment method (biofeedback) available elsewhere in the country?

Velkoff_Speaker

It's available all over the country, but it's just a technology. How effective it is, is going to be influenced by the training and expertise of the professional that's using it. The results can be very variable and the durability will be variable, depending on the doctors using it. It can be misused by people treating ADD that are really not qualified to be treating neurological disorders. You're working with the brain, and inattention can come from a variety of different causes, and it's not always simple ADD. If someone were to inquire about treatment, they should inquire about professional education and training and qualifications of the individual. How are they qualified to be treating a neurological-based disorder with neurofeedback?

chaka1_WebMD

What advice do you have for adults who were diagnosed with ADD as children and still may have difficulties concentrating?

Velkoff_Speaker

The same advice I give patients that come to us for care; that they don't have to live with this degree of symptoms for the rest of their life. They can change their life at any age. We've helped patients in their sixties. The brain has enormous plasticity to it and we have more plasticity as children. The brain can learn new and more healthy patterns and be productive at any age. Unfortunately, because adults have lived with the disorder for a longer period of time, their feeling of hopelessness may be more ingrained than as a child. They may have tried medications, and nothing really produced permanent improvement, and many adults feel hopeless about trying again. I try to get them to come to our seminar first so I can give them information about enlightening them. I have a toll-free number -- 1-866-606-4ADD. They can e-mail me at help@drakeinstitute.com ... and they can contact me on our web page at www.drakeinstitute.com.