THE ROLE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE IN THE TREATMENT OF ATTENTION DEFICIT DISORDER By George Thomas Attention Deficit Disorder and Attention Deficit-Hyperactivity Disorder (AD/HD) is a condition that affects a person's cognitive, behavioral, emotional, social, and academic life. This condition presents in childhood with the symptoms of inattention, impulsivity, and hyperactivity. If left untreated, this condition can possibly result in causing a low self-esteem, criminal behavior, and a failure to reach one's true potential. The prevalence of AD/HD is between 8 to 10 percent of school aged children, making it one of the most common disorders of childhood. However, the condition of AD/HD isn't limited to children. As many as 70% of children who have been diagnosed with AD/HD were shown to have persistent symptoms of the disorder well into adulthood. Another interesting aspect of AD/HD is that it isn't spread equally among the sexes. AD/HD occurs 4 times more commonly in boys than in girls in terms of the hyperactivity type of the disease and 2 times more frequently in boys in respect to inattentive type. Although there are several theories as to the pathogenesis of Attention Deficit Disorder and Hyperactivity Disorder, it is now thought to be due to an imbalance in catecholamine metabolism within the cerebral cortex. This hypothesis of catecholamine imbalance in patients with AD/HD is based on brain imagining, animal studies, and the potency of noradrenergic medications, such as methylphenidate, in the treatment of AD/HD. There also appears to be a genetic component in the pathogenesis of AD/HD. Based on twin studies, there appears to be 92% concordance rate among monozygotic twins and 33% concordance rate amongst dizygotic twins. The diagnostic criteria by which AD/HD is based is important in the forming the eventual goals in treating this disorder. The American Psychiatric Association's DSM-IV addresses several features of AD/HD diagnosis. These include symptoms presenting in more than one setting (eg. home and school), symptoms that impair academic, social, and occupational activities, symptoms that are present before seven years of age, and symptoms that persist for greater than six months. If a child or adult shows symptoms that are consistent with the above recommendations the physician must not only diagnose AD/HD but also set target goals for treatment of this disorder. Examples of target goals of treatment include: improving relationships with parents, siblings, peers, and teachers, improving the ability to follow rules, and improving academic performance. It is in hopes to reach such final outcomes that conventional as well as alternative treatments for AD/HD have been used. Conventional treatments of AD/HD are centered primarily around two modalities: pharmacotherapy and behavioral/psychological intervention. Pharmacotherapy for AD/HD include: 1) stimulants, such as methylphenidate (Ritalin), dextroamphetamine, and amphetamine (Adderall); 2) antidepressants such as bupropion (Wellbutrin), imipramine and desipramine; 3) selective norepinephrine reuptake inhibitor like atomoxetine (Strattera); and 4) alpha-2 adrenergic agonists such as clonidine. It goes without saying that such medications are likely to have several and sometimes serious side effects. For instance, adverse effects of stimulant medications such as methylphenidate and dextroamphetamine include anorexia, appetite disturbances (in as
many as 80%), sleep disturbances, and weight loss. Antidepressants such as buproprion, a dopamine reuptake inhibitor, can cause side effects such as motor tics and decreased seizure threshold. Tricyclic antidepressants (imipramine, desipramine, and nortryptyline) have been shown to cause arrhythmias, dry mouth, constipation, and lowering the threshold for seizures. The newest medication used in the treatment of AD/HD is atomoxetine (Strattera) which was approved by the Food and Drug Administration in November 2002 is the first AD/HD pharmacotherapy approved for use in adults. However, Strattera also has many accompanying side effects such as weight loss, abdominal pain, decreased appetite, vomiting, nausea, dyspepsia, and sleep disturbances. Clonidine, the alpha-2 adrenergic agonist, has been shown to cause sedation, depression, headache, and hypotensive episodes. Although there is a large arsenal of pharmacological treatments for Attention Deficit/ Hyperactivity Disorder, based on investigations by the American Medical Association, they have not shown to improve long term outcomes in behavioral, cognitive, emotional, academic and social functioning. The second modality that has been used commonly as a conventional treatment for AD/HD is behavioral and psychological interventions. Behavioral interventions, for example, deal with changing the social and physical environment in which the child or adult with AD/HD surrounds themselves and then consequently change the patient’s behavior. For instance, children with AD/HD are asked to make checklists for tasks that need to be completed, maintain a daily schedule and rewarded for good behavior. Psychological interventions deal with the patients thought patterns and emotional health and is often used together with behavioral therapies. Such treatments are limited based on willingness to participate and compliance to such therapies that require a significant amount of discipline from not only the patient but the patient's school, family, work place, etc. It is for such reason that behavioral therapies have not been shown to reduce the core symptoms of AD/HD in children not undergoing pharmacologic therapy. Such evidence has shown that conventional treatments have many significant drawbacks that need to be addressed in the treatment of patients with AD/HD. The concerns with the conventional treatments stated above are one that causes alarm to both physicians and parents alike. Parents are often concerned about giving their children "mind-altering" drugs, as they are unsure of their long term side effects and the duration there child will undergo treatment. Physicians also share such reservations to the use of certain drugs on patients with AD/HD. For instance, many physicians avoid the use of stimulants on very young children unless it is the very last option. Due to such reasons parents and physicians have begun to search out and consider more "natural" treatment options. Two ways such therapies can be implemented. First, one could use a complementary medical treatment option which could lessen the need adjunctive stimulant therapy or other pharmacologic treatment. Another option is an alternative medical treatment which would result in avoiding stimulant medications or other pharmacologic treatment altogether. Therefore, such treatment modalities, which are usually outside the realms of the dominant health care system, are generally referred to as Complementary and Alternative Medicine (CAM). In order to clearly demonstrate what CAM therapies are available for the treatment of AD/HD it may be useful to consider a conceptual model devised by Kemper in The Pediatric Review in 1996. Kemper's model of CAM is based on 4 general categories wherein specific therapies for AD/HD can be grouped. The four categories are
biochemical, lifestyle/mind body, biomechanical, and bioenergentic. The most commonly used methods in the treatment of AD/HD come from the biochemical and lifestyle/mind body groups. The biochemical therapies, as the name suggests, work on a biochemical level. This method is possibly the best understood and readily used treatment by physicians. This method involves not only medications, such as those described previously, but also herbal remedies, nutritional supplements, and vitamins. The use of herbs in the treatment of AD/HD is usually just an extension of their traditional uses. Herbs used in the management of AD/HD tend to reply on their sedative properties. For example herbs with sedative actions such as kava kava, valerian and chamomile may be useful in treating those with sleep disturbances (as seen in AD/HD), restlessness, and decreased/impaired abilities to concentrate. However, such herbal treatments aren't without possible side effects and toxicities. For example, although chamomile is on the FDA's Generally Recognized as Safe List, it can in rare instances cause in hypersensitivity reactions in those who are allergic to ragweed. High doses of chamomile can also cause vomiting. Kava Kava, an anxiolytic, shown in animals to act as an anticonvulsant, antispasmodic, and central muscle relaxant, can rarely cause allergic reactions, dry skin, and muscle weakness. Twenty percent of heavy users have also developed a puffy face, scaly rashes, and decreased platelet counts. Kava Kava is also contraindicated for those who are pregnant or nursing, and should not be taken for longer than 3 months without physician supervision. Velerian, another sedative herb used for those with sleep disturbances, can rarely cause gastrointestinal upset, headaches, restlessness, and cardiac dysfunction. Nutritional supplements, such as blue green algae, evening primrose oil, and ginkobiloba, have been shown to be of benefit in the treatment of AD/HD. Blue green algae, known to have antitumor effects and a rich source of proteins and B vitamins, can rarely nausea and diarrhea. Evening primrose oil, an essential fatty acid supplement is often used in anti-inflammatory disorders, eczema, and premenstrual syndrome and has been shown to cause diarrhea and headaches when taken in high doses. Ginko biloba, which is used in dementia and peripheral vascular disease due its effects in improving microcirculation have been rarely associated with GI upset, dizziness, headaches and allergic skin reactions. Chronic use of ginko have shown to be associated with sporadic reports of spontaneous subdural hematomas. The use of vitamins as a biochemical treatment modality for AD/HD has been suggested based on the theory that defiency in certain vitamins have been attributed to cause hyperactivity and impulsivity. Vitamin supplements of iron, pyridoxine, zinc, magnesium, coenzyme Q, and other vitamins have been used for the treatment of AD/HD. However, there has been little evidence to suggest the use of suggest supplemental vitamins in patients who already have adequate healthy diets is effective in the treatment of AD/HD. In fact "megadose" therapies (taking vitamins several times more than the recommended daily allowance), have actually shown to cause more disruptive behaviors in 25% of children with AD/HD at school. Lifestyle and Mind Body therapies for AD/HD are the second category of treatments used frequently in CAM. Such interventions include exercise, environmental changes, and mind-body techniques such as neuro feedback, hypnosis, and psychotherapy. Exercises have been shown to be of considerable benefit for children with AD/HD. Such benefits include improving overall well being and to release excess
energy in a constructive way such that the patient may "tire out". Additionally, participating in group sports can help improve one's social skills. One important lifestyle therapy is that of nutrition and diet. One method of diet manipulation for the treatment of AD/HD is the Feingold/Feingold diet. The Feingold/Feingold diet require elimination of artificial and natural salicylates found in aspirin, Pepto Bismol, grapes, berries, cucumbers, tomatoes, tea, and other food sources. By doing this Feingold saw 50% behavioral improvement in children with AD/HD. However, subsequent trials of the Feingold diet have shown no evidence for such measures. Another important CAM treatment for AD/HD is environmental interventions such as music therapy. In one study, it was shown that fast tempo music lead to greater mistakes made by boys with AD/HD, whereas slow tempo music caused boys with AD/HD to perform equally well as those without AD/HD. Mind-body therapies are particularly useful in the treatment of AD/HD, as they focused on the mind's ability to influence body function. Children with AD/HD can use mind body therapies to help reduce autonomic hyper arousal caused by stress by the use of relaxation techniques. These techniques include progressive muscle relaxation, mediation, deep breathing, hypnosis, and biofeedback. Two forms of biofeedback have been studied as treatments in patients with AD/HD: Electromyogram (EMG) biofeedback which helps the patient learn how to reduce ones muscle tension, and Electroencephlalogram (EEG) biofeedback, which teaches patients to decrease theta waves and increase beta waves in their EEG pattern in order to normalize cortical function. One study has shown a correlation improved AD/HD behavior, intelligence and visual attention with decreasing excessive theta waves seen in patients with AD/HD. One drawback of such procedures is that therapy often requires 35-50 training sessions, though results are usually seen after 15-20 sessions. The final two treatment groups which are much less frequently used in CAM approaches to AD/HD are Biomechanical and Bioenergetic therapies. Biomechanical therapies refer to those practices that serve to align, stimulate, move, or remove larger tissues or organs. These include therapies such as surgery, chiropractic spinal manipulation, and massage therapy. Very few studies have been used to evaluate effectiveness of biomechanical modalities in patients with AD/HD. Massage therapy, which induces relaxing effects, was shown to improve mood and decrease hyperactivity in male students with AD/HD. Unfortunately, this has been the only study on the use of massage therapy for the treatment of AD/HD. Bioengertic modalities, including acupuncture, therapeutic touch, prayer, and homeopathy, deal with restoring the harmonious balance of the bodies energy and spirit. Such therapies are usually not based on scientific laws and studies using such treatments are either ongoing or inconclusive. By the use of such therapeutic modalities it is clear that the integration of CAM is possible in the treatment of AD/HD. By incorporating the benefits CAM has to offer a patient with AD/HD, the physician begins to consider the patient's mind, body, emotions and spirit in treatment. Studies have shown that patient's have a general interest in complementary and alternative therapies, and that as many as one third of patients discuss the use of CAM with their physician. Additionally, the same survey revealed that as many as 64% of patients had or were currently using alternatives to medication in treating AD/HD. For these reasons it is important that the physician not only have the resources to learn about CAM practices but they ask patients about them so that an open dialogue is established. In her article in "The Journal for Developmental and Behavioral Pediatrics"
Eugina Chan advises physicians to have 3 main goals when attempting to integrate CAM in the treatment of AD/HD. First, the physician needs to learn what the patient and possibly the patient’s family already know about CAM and if they've already tried any such measures. Such a goal will set the background by which further discussions about CAM can take place. The second goal is to understand what the patients and parents expectations are with treatment. This response will vary from family to family based on cultural values and attitudes toward AD/HD. Some may want permanent resolution of their symptoms whereas others may be satisfied with decreasing the symptoms. The third goal the psyching must have in integrating CAM in the treatment of AD/HD is that of patient education. The physician should be a valuable source of information to patients, warning them about possible toxicities and adverse side effects that CAM therapies may cause. Additionally, the physician should also educate the patient in how to discern and critically assesses the value of various CAM therapy advertisements. For instance, patients should be warned about Internet advertisements claiming miracle cures that may sound rational to a lay person. By such measures the physician serves to become an ally to the patient interested in CAM treatments for AD/HD. Due to concerns by patients, parents, and physicians who prefer to avoid pharmaceuticals in the treatment of AD/HD the use of CAM modalities have been more common. CAM treatments such as nuerofeedback, essential fatty acids supplements (such as evening primrose) and diet and exercise, in some form, offer the most promise in CAM for the treatment of AD/HD due to their relatively little and rare side effects. It is for such reasons that CAM therapies for AD/HD have become very attractive to patients and their families. Therefore, it is imperative that physicians who treat AD/HD not only understand the different treatment options out there but also guide patients toward the most appropriate treatments for them personally. Such incorporation of CAM modalities into the treatment of AD/HD can be of significant benefit to those who suffer from attention deficit disorder or attention deficit hyperactivity disorder. References: 1) Biederman, J. "Attention-deficit/hyperactivity disorder: a life-span perspective". Journal of Clinical Psychiatry 1998; Volume 59, Suppl 7:4. 2) Brue AW, Oakland TD. "Alternative treatments for attention-deficit/hyperactivity disorder: does evidence support their use?". Alternative Therapies in Health and Medicine. 2002 Jan-Feb; Volume 8(1):pgs. 68-70, 72-4. 3) Bussing, R, Zima, BT, Gary, FA, Garvan, CW. "Use of complementary and alternative medicine for symptoms of attention-deficit hyperactivity disorder". Psychiatric Services 2002; Volume 53, page 1096. 4) Chan E, Rappaport LA, Kemper KJ. "Complementary and alternative therapies in childhood attention and hyperactivity problems". Journal of Developmental and Behavioral Pediatrics. 2003 Feb;24(1):4-8.
5) Chan E. "The role of complementary and alternative medicine in attention-deficit hyperactivity disorder". Journal of Developmental and Behavioral Pediatrics. 2002 Feb;23(1 Suppl):S37-45. 6) Goldman, LS, Genel, M, Bezman, RJ, Slanetz, PJ. "Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents". Council on Scientific Affairs, American Medical Association. JAMA 1998; Volume 279: pg. 1100. 7) Kratochvil, CJ, Heiligenstein, JH, Dittmann, R, Spencer, TJ. "Atomoxetine and methylphenidate treatment in children with ADHD: a prospective, randomized, openlabel trial". Journal of the American Academy of Child and Adolescent Psychiatry; Volume 41: pg. 776, 2002 8) Kemper, K. "Seperation or synthesis: A holistic approach to therapeutics". Pediatric Review. Volume 17, pgs. 279-283; 1996. 9) Merrell, C, Tymms, PB. Inattention, hyperactivity and impulsiveness: their impact on academic achievement and progress. British Journal of Educational Psychology 2001; 71:43. 10) Popper, CW. "Antidepressants in the treatment of attention-deficit/hyperactivity disorder". Journal of Clinical Psychiatry 1997; volume 58, pg. 14 11) Spencer T., Biederman J, "Pharmacotherapy of attention deficit hyperactivity disorder". Child and Adolescent Physciatry; Volume 9 pgs. 77-97; 2000. 12) Stubberfield T, Parry T. "Utilization of alternative therapies in attention deficit hyperactivity disorder". Journal of Pediatric Child Health; Volume 35: pgs. 450-453, 1999. 13) Wender, PH. "Attention-Deficit Hyperactivity Disorder in Adults". New York, Oxford University Press, 1995. pgs. 36-38.