Transcript The Integrative Approach to ADHD

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:
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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:
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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
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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
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“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.
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Lancet. 1985 Mar 9.
How do You Test for Food
Sensitivities?
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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.