What do you recommend for a child that has a short attention span? My son goes to mainstream 2 hours a day and they would like to increase his time but his ability to pay attention for longer periods of time is an issue. Some teachers are recommending medication to increase his attention, which they have seen work for other children with autism that have already been fully mainstreamed but I don’t really want to put him on any meds.
Dr. Jerry’s Answer:
I often see Attention Deficit (AD) with or without hyperactivity in my clinic. Parents tell me that their child simply cannot stay focused on anything. There seems to be a great issue with the child’s ability to concentrate and in the classroom, this can look like:
• Child requires many prompts to stay on task
• Very little toy play, moves from object to object
• Constant fidgeting
• Easily frustrated
• Poor recall of information already learned
• Slow processing speed
• Poor social function
Here are several interventions that may help with ADD/ADHD. I have also written individual blogs discussing some of these interventions in much greater detail.
Genetically speaking, it is very common to find a family history of Attention Deficit disorder, depression, bipolar disease, and anxiety. This family history points to what is known as a methylation defect and can be improved with Vitamin B12, Di- or Tri- methyl glycine, folinic acid, cysteine, and glutathione.
Thyroid disorders can manifest as ADD/ADHD and need to be addressed and corrected.
Allergies can definitely hamper ones ability to stay tuned in and focused. Thus, these have to be addressed and treated.
Any chronic inflammation must be addressed and treated.
The diet can have a HUGE influence of focus, concentration and behaviors. I cannot stress enough how much this has to be evaluated and managed. Food sensitivities must be addressed and eliminated, removal of sugar and food additives, and each meal must be properly balanced and contain a protein, a carbohydrate, and a fat. Omega oils are essential! Good vitamin and mineral supplementation may help as well.
Theanine is derived from the leaves of Camellia sinesis which is a green tea, as well as 2 other Camellia species. Studies from Japan confirm this has a generalized calming effect on the brain, which in turn, helps with focus and concentration. Dosing in our clinic usually starts with 100mg capsules take 1-4 caps twice daily.
Phosphatidylserine is the amino acid attached to a phosphatidyl fatty acid molecule. These are derived from soy bean. Research has been weak demonstrating effectiveness, but use in my clinic seems to be calming, especially when combined with omega 3 fatty acids. These are thought to help by incorporating themselves into neuron cell membrane and helping with overall normalization of this membrane. It may really be beneficial for those children who have had severe self-limited diets like cookies or French fries and have an overall nutritional deficit. These may be used cautiously in those children with soy allergies. Dosing is usually 100mg capsules, 1-4 caps twice daily.
Hyperbaric Oxygen Therapy (HBOT)
Many studies looking at attention disorder have focused on brain imaging and oxygen utilization/glucose utilization. Many of these studies note that there are definite areas of the “AD” brain that consistently show decreased oxygen utilization, or what is commonly termed “hypoperfusion.” Please note, that there are some other areas that have INCREASED perfusion as well. The rationale of using HBOT in children with autism and AD would then to increase the oxygen supply to these areas of hypoperfusion. We generally recommend starting at very modest pressures (this is measured in “atmospheres of pressure”), with 100% oxygen for 60 minutes, once daily. In about 20-40 sessions, we can generally see if this therapy is helpful. I will discuss hyperbaric therapy more extensively in a later blog.
Neurofeedback ultimately attempts to train the brain to have the most effective brain wave pattern for focus and concentration. There have been many pioneers in this research who have published impressive clinical results demonstrating marked improvement in the attention deficit. Briefly, a child’s brainwave pattern is determined by a qEEG (quantitative electroencephalography). After the therapist has evaluated this qEEG, a program is put into place where a child is usually allowed to play a video game or watch a video on computer. The trick is that the game or movie only plays if the child brain wave pattern conforms to the protocol set up by the therapist. Overtime, the brain “learns” what patterns are required to continue the play of the game/movie. What this translates into, eventually, is the minimizing of attention deficit.
Sometimes medications may be required to induce focus and concentration. Of course, prior to using medications, it is important to try the natural options first. If the natural options are unsatisfactory, then prescription medications may be considered.
The goal is to find medications that work to help with inattentiveness, impulsivity, and hyperactivity. In addition, when you find a medication that addresses these problems, you often also find improvement in social skills, improvements with language - both expressive and receptive, and the general ability to learn improves as well.
Medications used in treating attention deficit are designed to stimulate receptor sites in the brain. Now it can get a bit confusing here. There are different classes of attention deficit medications and each class works on different receptor sites in the brain. The question is if we “tickle” the right receptor site in the brain, do we get more focus and concentration?
Many of us have used coffee as a “drug” to stimulate focus and concentration. Actually, it is the caffeine in coffee that stimulates caffeine receptors in the brain, and for some of us, it is just what we need to stay on task. Some use cigarettes. It is actually the nicotine that stimulates the nicotinic receptor sites in the brain, and that, for some, can stimulate focus and concentration.
A general rule of thumb when prescribing these medications is to start with a low dose and quickly work up the dose until it is working, or until side effects occur. Attention deficit medications work “today” and you do not have to wait more than 2-3 days before deciding on a dose adjustment.
Classes of attention deficit medications:
Dextroamphetamine: Adderall and Vyvanse
Methylphenidate: Ritalin and its long acting forms, Ritalin-SR, Metadate ER, Metadate CD, Methylin ER, Concerta
Tricyclic Antidepressants: include Anafranil and Tofranil
Side effects: Each class has its own potential side effects that must be reviewed individually as these medications can interact with other medications your child might be on, or, even conditions your child might have, such as epilepsy. As always, with everything we do in medicine, the benefits of a particular medication must outweigh the potential risks. With the children I see in my practice, when all the natural ways of inducing focus and concentration have failed to produce significant results, I do prescribe attention deficit medications.
The attention deficit medications, that I have found to have the fewest side effects in my patient population, are Strattera and Intuniv, so I usually start with one of these. Strattera can be compounded into a transdermal cream, which is great for those children unwilling to swallow capsules and have a hard time taking supplements in general. These medications dosages depend on the weight of the child. I always tend to start at a lower dose and work my way upward. It is important to be on the lookout for the side effects, I cannot stress that enough.
Several medications may have to be tried, and remember, we are stimulating different receptor sites in the brain. What works for one child may not for another child. Though I would prefer not to have to use any of these medications, some children will cease to progress academically without these medications, and for some, if not most parents I work with, that is intolerable. Benefits of learning and growing socially may then outweigh the risks of having to take some of these medications. This truly is a case by case intervention and definitely tailored to each child and their family.
Dr. Jerry Kartzinel is Board Certified pediatrician and a Fellow in the American Academy of Pediatrics. He specializes in the recovery of neurodevelopmental, chronic neuro-inflammatory diseases, and hormonal dysfunctions. Dr. Jerry co-authored Healing and Preventing Autism with Jenny McCarthy.