The Integrative Approach to ADHD or Do 4 million children really need Ritalin? Sanford C. Newmark M.D. Center for Pediatric Integrative Medicine Tucson, Arizona Program in Integrative Medicine, University of Arizona, Tucson, Arizona Incidence of ADHD • In 2003, approximately 4.4 million children aged 4--17 years were reported to have a history of ADHD diagnosis; of these, 2.5 million (56%) were reported to be taking medication for the disorder. • CDC - from the 2003 National Survey of Children's Health (NSCH). Ritalin Use in the United States Estimated Number of Children Taking Ritalin 1970 - 150,000 1980 - Between 270,000 and 541,000; 1990 - 900,000, 2003 - 2.5 million Ritalin Use in the United States Stimulant Use -Leveling Off Over the Last 5 Years, but Still Very High Why the Explosion in ADHD? Possible Explanations 1. We are better at finding and helping children and adults who really do have ADHD. 2.There are more children now who actually have ADHD 3.We have loosened the definition so more kids are being diagnosed and treated. 4.We are actually diagnosing and treating many children who don’t have ADHD, even by a loosened definition. Why the Explosion in ADHD? 1.We are better at finding and helping children and adults who really do have ADHD. – Kids previously termed lazy or stupid. – Kids who dropped out early. – ―Behavior problems‖. Why the Explosion in ADHD? 2.There are more children now who actually have ADHD ADHD is relative to what is asked of children • Less effective parenting – mother not in home, father working more. Everyone more stressed. • Higher demands on children Toxins in Umbilical Cord Blood • 10 newborns –an average 200 industrial chemicals and pollutants • Of the 287 chemicals detected, 180 cause cancer in humans or animals, 217 are toxic to the brain and nervous system, and 208 cause birth defects or abnormal development in animal tests • Environmental Working Group 2005 Why the Explosion in ADHD? 3. We have loosened the definition so more kids are being diagnosed Years ago it was only the extremely hyperactive child being treated. Now: • • • • The inattentive child The difficult or intense child The rambunctious 3 year-old The child of demanding parents. Why the Explosion in ADHD? 4. We are actually diagnosing many children who don’t have ADHD, even by a loosened definition. – Inadequate evaluations – Schools demanding treatment – Parents unable to provide appropriate parenting because they are not there. The ADHD Evaluation • Initial Interview is usually about 2-1/2 hours. (for me, usually 2 sessions) • Besides the Standard Consult: – Need to speak to the parents alone, the child alone, and the family together. – Use some type of standardized questionnaire. – Also speak to teachers, counselors, school psychologists. – Review any previous psychoeducational evaluations or other professional consults. Many conditions can be Misdiagnosed as ADHD, including: • • • • • • Depression or bipolar disease Anxiety Disorder Learning disabilities The Gifted Child Intense or difficult temperament Boredom Problems that can mimic or worsen or coexist with ADHD • Oppositional Defiant Disorder • Misfits between the child and school, or even the child and teacher. • Sleep Apnea or Upper Airway Obstruction • Iron Deficiency • Lead toxicity • Poor Nutrition • Food Sensitivities Julie -10 Years Old – 4th Grade • Trouble in school, off and on, since K, but some years were good. • Poor attention, fidgetiness, not completing work, etc. • Conners Positive- teachers and parents • Home life is OK, except for homework • Lots of friends – happy • Asthma and allergies Stimulant Medications and SideEffects • • • • • • • • • Decreased Appetite Trouble Sleeping Abdominal Pain Headaches Tics Bizarre Behavior Hallucinations (at least 1:100) Potential for Addiction -controversial Generally, all of these stop when the medication is stopped More Subtle but ―Worrisome‖ Effects • • • • • ―He’s just not himself‖ ―She’s lost her spark, or her joy‖ ―He’s just not the same kid‖ She’s teary, or sad a lot He’s not as enthusiastic or creative. An Integrative Approach It is important to see the child in the context of his or her family, friends, school, and community, and not just as someone with a set of symptoms one is trying to fix. Sometimes a change in the home environment, school or teacher is more important than any medicine or herb. An Integrative Approach -1 • Nutrition – Basic principles • Nutrition – food Sensitivities and elimination diets • Nutritional Supplements – Omega-3 Fatty Acids – Zinc – Magnesium – Multivitamins • Creative Behavioral Approaches An Integrative Approach - 2 • Alternative or Complementary Therapies – EEG Neurofeedback – Herbal or Botanical approaches – Homeopathy – Craniosacral Therapy – Traditional Chinese Medicine-Acupuncture Basic Nutrition – or ―When did Pop Tarts become a breakfast food?‖ • Maintaining a normal blood sugar – Sugar – Processed Carbohydrates – Protein • And the Glycemic Index • Here's what happens: A child eats a breakfast that has no fat, no protein, and a high glycemic index — let's say a bagel with fatfree cream cheese. His blood sugar goes up, but pretty soon it crashes, which triggers the release of stress hormones like adrenaline. • What you're left with, at around 10 a.m., is a kid with low blood sugar and lots of adrenaline circulating in his bloodstream. David Ludwig, M.D., Ph.D., director of the Optimal Weight for Life program at Children’s Hospital Boston • He's jittery and fidgety and not paying attention. That's going to look an awful lot like ADHD to his teacher. • The possibility exists that in children predisposed to ADHD, quality of diet may have additional impact. • David Ludwig, M.D., Ph.D., director of the Optimal Weight for Life program at Children’s Hospital Boston Appleton Central • Appleton Central Alternative Charter High School –kids ―struggling in conventional settings • ―Natural Ovens‖ began a healthful meal program for breakfast and lunch • Vending machines selling candy, soda, and chips removed. Appleton Central • Very Striking Results – Better academic performance – Fewer Behavior problems – Less fighting – Less drug use Appleton – Typical Weekly Menu • Monday: Tacos, fresh fruit, salad bar, energy drink, whole grain breads • Tuesday: Scalloped potatoes and ham, corn, Texas toast, fresh fruit, salad bar, energy drink, whole grain breads • Wednesday: Chicken Noodle Soup, Turkey Sandwiches, Ham or Egg Salad, fresh fruit, salad bar, energy drink, whole grain breads. • Thursday: Chicken Patty on a Bun, Roasted Vegetables and Pasta, Fresh Fruit, salad bar, energy drink, whole grain breads. • Friday: Baked Omelets, Sausages, fresh fruit, salad bar, energy drink, whole grain breads Artificial Colors, Flavors, and Preservatives • 273 three year olds with hyperactivity enrolled in DBPC • Given a diet free of food coloring and preservatives, then a daily drink with colorings and sodium benzoate. • Significant increases in hyperactivity when getting the active mixture. • Arch Dis Child. 2004 Jun Food Allergies • A number of good scientific studies have shown that some children with ADHD will have significant improvement in their symptoms if taken off foods or additives they are sensitive to. ADHD and Food Allergy • 19 children responded favorably to a multiple food elimination diet. • 16 then completed a DBPC Food Challenge. • Symptoms improved significantly on days given placebo rather than foods they were sensitive to (P=0.003) • Annals of Allergy. 72(5):462-8, 1994 May ADHD and Food Allergy • 76 children were treated with an Oligoantigenic diet, 62 improved. • 28 who improved completed a DBPCFT foods thought to provoke symptoms were reintroduced. Symptoms worse on active foods than placebo. 48 foods were incriminated. • Artificial colorants and preservatives were the commonest provoking substances. • Lancet. 1985 Mar 9. How do You Test for Food Sensitivities? • • • • Single Food Elimination Multiple Food Elimination Oligoantigenic Diet Allergy Testing – IgE or IgG Omega-3’s, ADHD, and LD • 41 Children with ADHD and LD given a Omega-3’s for 12 weeks or a placebo. • After 12 weeks, children in the treatment group had significant improvement in their ADHD scores compared to placebo. Progress in Neuro-Psychopharmacology & Biological Psychiatry (2002) Developmental Coordination Disorder • Performance in Daily Activities that Require Motor Coordination is substantially below that expected given age and intelligence. • Motor delays, clumsiness, poor handwriting • Substantial overlap with ADHD, Learning Disabilities, Autism, and Sensory Integration Disorder Methods • 117 children (5-12 years old) – 60 active, 57 placebo • 3 month trial of Omega 3 and 6 Fatty Acids, • Active treatment - 80% fish oil and 20% evening primrose oil. Reading Before treatment, mean achievement scores 1 year below chronologic age. After 3 months, the mean increases in reading age were: Active Treatment - 9.5 months Placebo - 3.3 months (z = 2.87, P < .004) Spelling • After 3 months the mean increases in spelling age were: • Active treatment - 6.6 months Placebo -1.2 months • Again, the group difference was highly significant (z = 3.36, P < .001). ADHD Related Symptoms • Active treatment, scores decreased from a mean of 74.7 to a mean of 58.1, a reduction of >0.5 SD. • In contrast, almost no change was seen in the placebo group (pretreatment mean: 69.5; post treatment mean: 67.9; • This group difference was highly significant (z = 5.48, P < .0001). Zinc for ADHD • 40 Patients with ADHD between 5 and 11 • 20 given Ritalin and Zinc • 20 given Ritalin and Placebo • Teacher and parent rating scales done at day 1 and after 6 weeks. Zinc for ADHD Zinc for ADHD ADHD and Iron Deficiency • Fifty-three children with ADHD and 27 controls. • The mean serum ferritin levels, were lower in the children with ADHD (mean ± SD, 23 ± 13 ng/mL) than in the controls (mean ± SD, 44 ± 22 ng/mL; P < .001), • Arch Pediatr Adolesc Med. 2004 ADHD and Iron Deficiency • Serum ferritin levels were abnormal (<30 ng/mL) in 84% of children with ADHD and 18% of controls (P < .001). • In addition, low serum ferritin levels were correlated with more severe general ADHD symptoms and greater cognitive deficits • Serum iron, Hemoglobin, and hematocrit were normal. Behavioral Approaches • Can be effective, with or without medication • Often history is good year-bad year, good-year-bad year. Why? Great teachers! • Kids with ADHD need structure, firm limits, and lots of positive reinforcement. • What if an entire school could have that kind of approach? Tolson School-the Nurtured Heart • 75% school from low income families. • Four years ago entire school began to apply Nurtured Heart approach • Behavioral management system based on increased positive feedback, clear rules, and well defined consequences. Tolson School • Discipline problems dropped sharply • Special education dropped from 31 students to 7 students • Now 2 of 519 students on medication for ADHD (0.3%) • ―Performing Plus School‖ - increasing test scores. EEG Neurofeedback • Children with ADHD have predictable brain wave abnormalities. This can be measured by Quantitative EEG.(QEEG) • They generally have more slow wave (Thetalow arousal) activity and less Fast Wave (Beta-high arousal) activity than controls • One study –QEEG had 86% sensitivity and 98% specificity for Dx of ADHD • Neuropsychology 1999 EEG Neurofeedback • Children can be trained to alter these brain waves by biofeedback techniques • A few small studies indicate effects comparable to stimulants, but no longterm or controlled studies. • Disadvantage -30-40 sessions,$50 or more per session Homeopathy • Completely different from herbal medicine • Very high dilutions of common substances • ―like cures like‖ • Individualized, ―constitutional‖ Homeopathy and ADHD • Open Study Followed by Randomized Double Blind Crossover Study -62 patients • In open study 80% showed significant improvement (Conners) • Blinded Crossover study showed improvement decreased with placebo and increased with homeopathic treatment. • European Journal of Pediatrics 2005 Craniosacral Manipulation • Gentle Osteopathic type of manipulation • Not much science behind it • Sometimes it works! Common Herbs Used for ADHD Echinacea Siberian ginseng Brahmi (Bacopa monnieri) Blue-green algae Ginkgo (Ginkgo biloba) Oligomeric proanthocyanidin (OPCs, Pycnogenol) Valerian (Valeriana officinalis) Lemon balm (Melissa officinalis) Kava (Piper methysticum) Chamomile (Matricaria recutita) Passion flower (Passiflora incarnata) Hops (Humulus lupulus) Traditional Chinese Medicine • Acupuncture and Herbs • Some claims that it can be helpful • Haven’t seen it myself but no harm in acupuncture • Careful about the herbs. What happened to Julie • Cleaned up diet – Less sugar and refined carbohydrates • Eliminated food additives • Found dairy exacerbated inattention and allergy symptoms • Began Omega-3’s and Zinc • Developed a better behavioral approach with teacher • Still has her difficulties, but happier at home and school Take Home Message • We need to be careful not to overdiagnose ADHD. • When we do make the diagnosis, I believe we should seriously consider at least exploring non-pharmaceutical options which are certainly safe, and may be effective, before beginning psychostimulants.
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