An Integrative Approach to ADHD

Dr. Sandy NewmarkCenter for Pediatric Integrative Medicine

Program in Integrative Medicine University of Arizona

What is ADHD

ADHD is a syndrome consisting of some combination of Hyperactivity Problems with attention and concentration, Impulsivity

That is causing significant problems at both home and school.

A Syndrome Not a Disease

A Syndrome is a collection of symptoms or traits or characteristics that form a pattern. fails to finish things has a hard time sitting still daydreams a lot

Pneumonia is a Disease Chronic Fatigue is a syndrome ADHD is a very subjective diagnosis

Incidence of ADHD

In 2003, approximately 4.4 millionchildren 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 - 150,0001980 - Between 270,000 and 541,000;1990 - 900,000, 2003 - 2.5 million

Ritalin Use in the United States

Why the Explosion in ADHD?

Possible Explanations We are better at finding and helping children

and adults who really do have ADHD. There are more children now who actually

have ADHD We have loosened the definition so more kids

are being diagnosed We are actually diagnosing many children

who dont have ADHD, even by a loosened definition.

Why the Explosion in ADHD?

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?

There are more children now who actually have ADHD Toxins in the prenatal and early childhood

environment (over 200 contaminants found in umbilical cord blood)

Less effective parenting mother not in home, father working more. Everyone more stressed.

Higher demands on children

Why the Explosion in ADHD?

There are more children now who actually have ADHD Toxins in the prenatal and early childhood

environment A recent study found over 250 toxins in

umbilical cord blood, including mercury, pesticides, organochlorines.

Organochlorines and Child Development

Dichlorodiphenyl dichloroethylene (p,p'DDE) measured in umbilical cord blood.

Serum levels were negatively associated with both mental and psychomotor development.

The higher the serum level, the worse the child's development at 13 months old.

Why the Explosion in ADHD?

There are more children now who actually have ADHD

Less effective parenting mother not in home, father working more. Everyone more stressed.

Teachers are more stressed as well

Why the Explosion in ADHD?

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?

Increased pressure on High School and College Students

Ritalin has become the drug of choice for students who cram.

"All you have to do is read a book on ADHD and you know what to tell a doctor," Cafeo said. "Now a lot of kids get it by saying they have a problem studying.

Ritalin Use/Abuse in Colleges

In a Midwestern UniversityFindings revealed that 17% of 179 surveyed men and 11% of 202 women reported illicit use of prescribed stimulant medication.

"It's a miracle drug," (a student) told The Boston Globe. "It is unbelievable how my concentration boosts when I use Adderall.

Why the Explosion in ADHD?

We are actually diagnosing many children who dont have ADHD, even by a loosened definition. Inadequate evaluations Schools demanding treatment Discipline problems

How Do We Diagnosis ADHD?

History, History, History! From Parents, Child, Teachers,

Others Standardized Questionnaires

The ADHD Evaluation

Initial Interview is usually about 2-1/2 hours. (for me, usually 2 sessions)

Besides the standard Integrative 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

Problems that can mimic 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

Conventional Treatment of ADHD

Behavioral methods School support Psychostimulant medications

Ritalin, Concerta Dexedrine, Adderall Strattera

Other medications Clonidine, Tenex Mood Stabilizers Depakote, Risperdal

Psychostimulant Medications for ADHD

Are They Lifesavers for Children, Parents, Counselors, and Teachers?

or

A Horribly Destructive Drug Which is Destroying Our childrens Minds!

1. Although medications such as Ritalin can be helpful and are sometimes necessary, they should not be the first and only treatment approach.

2. There is lots of hysteria about these medications.

3. They are not as good or bad as some people make them out to be.

Stimulant Medications and Side-Effects

Decreased Appetite Trouble Sleeping Abdominal Pain Headaches Tics Bizarre Behavior Generally, all of these stop when the

medication is stopped

Dangers That Do Not Exist

Liver Damage Kidney Damage Brain Damage Increasing Potential for Addiction -doubtful It is NOT just like cocaine

More Subtle but WorrisomeEffects

Hes just not himself Hes lost his spark, or his joy Hes just not the same kid Loss of Creativity

An Integrative Approach

It is important to see the child in the context of his 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 healthful eating Nutrition food Sensitivities and

elimination diets Nutritional Supplements

Omega-3 Fatty Acids Zinc Multivitamins

Creative Behavioral Approaches

An Integrative Approach - 2

Alternative or Complementary Therapies Herbal or Botanical approaches Homeopathy Craniosacral Therapy EEG Neurofeedback Traditional Chinese Medicine-Acupuncture

Nutrition

Sugars Artificial additives and preservatives Processed flour (the glycemic index) Protein

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.

Great positive results in behavior, concentration. See Video

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

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.

Single Elimination vs multiple elimination diets

Feingold

Food Colorings and Preservatives

277 children had artificial food colorings and sodium benzoate preservatives removed from their diet

Hyperactivity decreased In a placebo-controlled study, those who had the

colorings and preservatives added back had a return of their hyperactive behavior.

Arch Dis Child. 2005 Aug;90(8):875

Omega-3 Fatty Acids

Types of fat necessary for normal neurological development -Lipil

Definitely at low levels in the blood of children with ADHD

Have been shown to be helpful in studies of children with learning disabilities and other behavioral disorders

Omega-3s and LD

41 Children with ADHD and LD given a supplement containing Omega-3s for 12 weeks or a placebo.

After 12 weeks, children in the treatment group had significant improvement in their ADHD scores compared to placebo.

Omega-3s and LD

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

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?

Praise in, Ritalin out for Tolson pupils

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.

Other Herbs and Dietary Supplements

Ginkgo Ginseng Pycnogenol Tyrosine Phosphatidylserine Glyconutrients St. Johns Wort Commercial Combinations Attend Quiet

mind

EEG Neurofeedback

Children with ADHD do have a different pattern of brain waves

They can change these using video game biofeedback.

Does it help ADHD? Does it last? Drawbacks-expensive and time-

consuming

Homeopathy

Completely different from herbal medicine Incredible dilutions of common substances like cures like Based on the whole person Sometimes it works!

Craniosacral Manipulation

Gentle Osteopathic type of manipulation Not much science behind it Sometimes it works!

Traditional Chinese Medicine

Acupuncture and Herbs Some claims that it can be helpful Havent seen it myself but no harm in

acupuncture Careful about the herbs.

The Bottom Line

Make sure the diagnosis of ADHD is correct

Find a doctor who is has experience, expertise, and is willing to look at a child as a whole person in the context of a family and community and not just as a kid with ADHD.

Explore other possibilities before jumping straight to medication.

THE KEY TO SUCCESFUL TREATMENT OF ADHD IS CAREFUL AND FREQUENT FOLLOW-UP.