case report - clinical education

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Confidential & Proprietary All Rights Reserved File Code: Case Report - 7 year old with ADHD improves multiple symptoms with NT final 10/5/2016 of 10

T H E C A R E G U I D E L I N E S

C A S E R E P O R T T o e n c o u r a g e o t h e r p r a c t i t i o n e r s t o c o n s i d e r s u b m i t t i n g a c a s e r e p o r t f o r t h e E – N e w s , w e h a v e r e s t r u c t u r e d t h e f o r m a t i n l i n e w i t h r e c o m m e n d a t i o n s f r o m J u l y 2 0 1 4 a n d h a v e l e f t i n t h e k e y g u i d e s – s h o u l d y o u b e i n t e r e s t e d j u s t e m a i l i n f o @ n u t r i -l i n k l t d . c o . W e w i l l s e n d y o u t h e w o r d d o c . Case reports are profesional narratives that outline the diagnosis, treatment, and outcomes of the medical problems of one or more patients. Information from case reports can be shared for medical, scientific, or educational purposes. They provide a framework for early signals of effectiveness adverse events, and cost. Case reports and the systematically collected data from which they are written also provide feedback on clinical practice guidelines.

Case Report of a 7 year old boy with ADHD whose Motor Skills, Spatial Development, Concentration & Energy All Improve with a Change of Diet & Supplements

Abstract. Summarise the following information if relevant: (1) Rationale for this case report, (2) Presenting concerns (eg, chief complaints or symptoms, diagnoses), (3) Interventions (eg, diagnostic, preventive, prognostic, therapeutic exchange), (3) Outcomes, and (4) Main lesson(s) from this case report. This case explores a nutritional focused approach in a young boy, T.H., diagnosed with ADHD (Attention Deficit Hyperactive Disorder) in November 2014.

The NHS website informs us that in the UK, 2-5% of school-aged children and young people have ADHD. The disorder usually starts in early childhood. Children with ADHD tend to be overactive and impulsive, with a short attention span. They may seem restless, are easily distracted and often fidget constantly. The ADHD Institute state that although there is no global consensus on the prevalence of attention-deficit hyperactivity disorder (ADHD) in children, adolescents and/or adults, meta-regression analyses have estimated the worldwide prevalence at between 5.29% and 7.1% in children and adolescents, and at 3.4% (range 1.2–7.3%) in adults. The prevalence of ADHD in very young children (aged <6 years) or later in adult life (aged >44 years), is less well-studied. A higher prevalence of ADHD is often reported in males. Children with ADHD can face serious difficulties. They can have trouble with schoolwork, meaning they under-achieve academically. They can find it hard to avoid common hazards and can have problems forming positive relationships with both their friends and their family. During adult life, people with ADHD can suffer from additional, sometimes severe problems. They may become addicted to drugs or get involved in crime, they can find it difficult to hold down a job, and they can have wide-ranging emotional and social difficulties, as well as personality disorders. From a medical perspective, there is no known cure for ADHD, though both medical and psychological treatments can help control symptoms. Around one third of children seem to grow out of their disorder during adolescence, but the others find their ADHD persists into adult life.

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Key Words. Provide 3 to 8 key words that will help potential readers search for and find this case report. ADHD (Attention Deficit Hyperactive Disorder), developmental delay, concentration, brain function, motor skills, fatigue. Introduction. Briefly summarise the background and context of this case report. T.H. was small for his age and clearly had developed more slowly than his siblings and his peers. Alongside the developmental delay were a collection of functions that fit within the umbrella of ADHD, which had only recently been formally diagnosed, but the signs and symptoms of which had been present for the whole of his life. Specifically, T.H. manifested a lack of concentration at school which then had a knock on effect on his ability to perform physical tasks as poor motor skills and coordination. He had difficulty catching a tennis ball, for example, or hitting a ball with a bat. T.H. suffered from daily fatigue which did not appear to be proportionate to either effort expended or food eaten (he eats well) but could have been linked to disrupted sleep. T.H.’s mother was already very aware of the connection with food and health and its impact on the brain of her child, and the brains and well-being of all of her 3 children. However, she wanted to know what else could be done on a therapeutic level. In particular, she wanted to avoid a prescription being required for Ritalin, which she feared would be. T.H. engaged in a change in diet and took specific supplements over a period of time during which his mother witnessed positive changes in her son. Presenting Concerns. Describe the patient characteristics (eg, relevant demographics—age, gender, ethnicity, occupation) and their presenting concern(s) with relevant details of related past interventions.

T.H. had been a slow developer, and his growth had formally been termed ‘Delayed Development’, and as such he was taken care of more by his older brother and sister in perhaps a more loving way than might otherwise have been the case. The fact that T.H. was different to others and was different to his siblings had brought about a maturity in the brother and sister who were expressively caring for their ‘little’ brother, and tolerated his periodic outbursts.

Although T.H. makes and keeps friends easily, he had been prone to these sudden outbursts and had been known to hit and bite when he was angry, but this was rare. His mother told me about the conversations she had had with the Occupational Therapist (O.T.) who attended to T.H. and reported that in the opinion of the O.T., her son was much more balanced when it came to mood and behaviour than other kids she managed with a similar profile. T.H. had been having regular OT sessions at school for a year and he performed exercises regularly at home. When we met, T.H. made eye contact right away and smiled and seemed attentive. However, he soon wandered off and it was a challenge to engage him during the consultation.

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He loved healthy food such as fish and vegetables and this was one of the benefits of having older siblings since he wanted to eat what they ate. He eats a lot, his mother said, but he does not gain weight easily. He was very slim and small in height for a 7-year-old. He was 115 cm (3ft 7) tall and weighed 28 kg (63 pounds). T.H.’s sleep was problematic and had been for over a year. He became agitated very often at bedtime and this would then draw out the time it took for him to settle down. It happened most nights and was wearing his Mum down as she did not want to be too stern but at the same time she felt he was taking advantage. He also woke up in the night 3 to 5 nights a week, sometimes staying awake for an hour or more. This was one of the major goals of the appointment, to improve his sleep from the start of the night and all the way through the night. T.H. suffered from blocked sinuses and chesty coughs. He ate a lot of yogurt and drank quite a lot of milk, which his mother thought may be connected to the sinus and chest infections but she had yet to bring herself to eliminate these foods. She had wanted to make sure he kept his weight up and believed that the calcium in the dairy products was important for his physical development. Other than the dairy products, the other food which T.H. liked to eat every day was biscuits. Since he needed to gain weight, this had been permitted, and his mother chose what she felt were the best biscuits, although ultimately on examination they contained the exact same ingredients as all other biscuits, namely sugar, hydrogenated vegetable oil and refined flour. T.H. also became tired easily and so food intake was encouraged to help him feel better. Due to his light body weight, his Mum was keen for T.H. to consume food at every opportunity. T.H.’s parents believe that food is very important for health and the connectedness of the family. They also believed that it had a lot to do with T.H.’s ‘ADHD’. The relatively recent diagnosis had been helpful at school because it meant that T.H. now received the attention that he needed. Now they wanted to know how best to proceed in order to improve their son’s energy, concentration, motor skills and sleep and weight. Clinical Findings. Describe: (1) the medical, family, and psychosocial history including lifestyle and genetic information; (2) pertinent co-morbidities and relevant interventions (eg, self-care, other therapies); and (3) the physical examination (PE) focused on the pertinent findings including results from testing. T.H. is the youngest of 3 children, with an older brother aged 12 and sister aged 10. All the family are Caucasian and English as are their grandparents. There is no history of ADHD in the family, and no particular type of illness suffered either. T.H. had been assessed over a year earlier by an O.T. professional and had been receiving Occupational Therapy (O.T.) sessions regularly at school. He had needed to visit the family GP in order to treat his sinus and chest infections, for which he had taken antibiotics several times over the past year and in previous years. He had been taken to the paediatrician many times since birth to review his growth and weight, since he was the shortest and lightest boy in his year. Blood tests and physical checks assured T.H.’s parents that he was fine but clearly small for his age. I reviewed his diet diary and he did eat good quality food for each of his meals, and ate a good portion size. The yogurt, milk and biscuits were evident but he did not eat sweets, instead he ate fruit mostly in the form of

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bananas. He consumed fresh orange juice every day because it was believed that this might help support his immunity and reduce the risk of sinus or chest infections. It was not obvious as to why T.H. did not gain weight on the diet he consumed, but I did make a note that there could be some kind of maldigestion or malabsorption due to food intolerance of some kind (to dairy, wheat or gluten?) that did not necessarily manifest in digestive symptoms; T.H.’s bowels were fine and he did not complain of any abdominal problems. There was no association in time with the consumption of any food and any specific behaviour or lack of concentration or hyper-activity or agitation. However, after eating his energy would typically improve. No specific tests were recommended by me, but instead I did recommend a controlled elimination diet. Timeline. Create a timeline that includes specific dates and times (table, figure, or graphic). In 2008, T.H. was born a light-weight baby weighing 5 lb 4 oz. He had remained below the lowest percentile for the whole of his life. He was breast fed for 6 months, and then weaned onto solid foods. Every landmark of growth and development was delayed. He walked late, close to 2 years of age, and started talking late, and his reading was also later than his peers. In 2013, he went to school, as all 5 year olds do, and it was evident from the outset that he needed more support than the others in his class. However, unlike other children with ADHD who could be disruptive and anti-social, T.H. was well-liked and was considered a friend by all in his class. His mother joked that he must have been given a friendly gene along with the ADHD gene. When it came to motor skills, T.H. was very uncoordinated and he could not catch a ball nor engage meaningfully in team games or activities. It was probably the fact that he was popular and well-liked that meant he was not teased or bullied; it seemed that very quickly anyone who got to know him immediately understood that he was different and accepted him for who he was. He did not complain about anything and genuinely seemed to be happy and content. From 2012, T.H. had colds, chesty coughs and sinus issues. In late 2014, the formal diagnosis of ADHD was made and was welcomed by his parents since this meant that the school and others could accommodate his needs more appropriately then before. In 2015, T.H. had made little progress or advances in physical coordination and his spatial awareness was less than ideal when tested. He had ongoing difficulty with his concentration at school, and learned slowly and did not retain the information very well. His mother had a nagging feeling that there was more that could be done. Diagnostic Focus and Assessment. Provide an assessment of the (1) diagnostic methods (eg, PE, laboratory testing, imaging, questionnaires, referral); (2) diagnostic challenges (eg, financial, patient availability, cultural); (3) diagnostic reasoning including other diagnoses considered, and (4) prognostic characteristics (eg, staging) where applicable. T.H.’s case history had been read before we all met and it was reviewed at the first appointment. His mother showed me a report from the O.T. which was 6 months old but which captured the essence of what was going on for T.H. in terms of a comparison to a normal state.

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In the research, there are a number of nutritional associations with ADHD which include food reactivities, fatty acid imbalances (fish oil, flax oil), mineral imbalances (zinc, magnesium, iron), vitamin C & D status, value of broad-spectrum micro-nutrients, need for more protein and so on. This literature has been growing and I had been familiarising myself with some of this every year since 1990.

Therapeutic Focus and Assessment. Describe: (1) the type(s) of intervention (eg, preventive, pharmacologic, surgical, lifestyle, self-care) and (2) the administration and intensity of the intervention (eg, dosage, strength, duration, frequency). The nature of the nutritional intervention involved an exclusion diet combined with the taking of specific, targeted supplements. Three food groups were recommended to be avoided and replaced with alternatives. The replacements were particularly important because of T.H.’s low body weight. These foods were wheat, cow’s products and orange juice (& oranges). Wheat-free or gluten free biscuits were found, GF oats for breakfast was an immediate and useful alternative, and coconut yogurt and coconut butter, on wheat-free toast, were chosen as the prime alternatives. We established a plan for a wheat-free, dairy-free and orange juice free diet. Before they left the consulting room, we had prepared examples of what could be eaten for breakfast for the next week, which option at school he could choose and what to have for dinner. The snacks were the most important since his Mum told me that without the snack as soon as school had finished, T.H. would be unmanageable, very tired and sometimes very stubborn and naughty. The alternative and replacement foods were to be bought before any foods were stopped. I also recommended specific supplements, and as with all patients and children, these needed to be suitable to be swallowed and taken, and not too numerous. I incorporated a human strain probiotic bacteria due to the history of antibiotics, a digestive enzyme to support this process, an active B vitamin formula for his energy and nervous system and neurotransmitter metabolism, as well as the NT Factor phospholipids to support his CNS.

First Supplement Programme – June 2015 Dose

ATP Lipids Powder (ARG) 1 scoop with breakfast & dinner

Bio-3B-G (BRC) 1 with each meal & 1 at bedtime

Gluten-Gest (ARG) 1 caps with each meal (supported by school)

Lactobacillus GG Culturelle (ARG) 1 caps with dinner

I met T.H. and his mother after 5 weeks on the first programme. He. Had managed to take the supplements and follow the dietary advice all except for two instances when he had some wheat one day and some milk on another. The replacement foods had worked well.

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It was interesting and not the first time that I have seen this, but T.H. had been the one to tell his Mum that he should not be eating wheat and dairy products on a number of occasions. He was the one directing the nutritional programme much of the time. I find that children of a certain age, even with a label of “ADHD” it seems, are able to take on what is good for them and stick to it with strict adherence and be responsible for what they are doing. It must be said that T.H. is less extreme case of ADHD than many, in terms of behaviours, food cravings and temper tantrums, for example. T.H. had not lost any weight and had gained a few pounds, but not that you could tell. He had eaten well. His first question was whether he still needed to avoid wheat, to which I responded I did not know but I would know more once I had found out what had happened in his health. As he had improved so noticeably, I did recommend he continue to avoid wheat. T.H.s energy had improved, so had his concentration much of the time, his focus was definitely more switched on, and his spatial awareness and skills in PE were also definitely improved. His Mum told me that she thought the latter was because he was able to pay attention and focus on the ball or whatever skill he was engaged in. All of his teachers noticed a difference. His Mum said that there had been a big change in her son. However, not everything was better. T.H.’s sinus mucus was the same, and you could tell when he spoke that he was blocked, and his sleep issues remained as they had been. T.H. had also received some cranial osteopathy, which his Mum thought had been good for him. As a result of the improvements, the programme and the food exclusions were kept as they were and I added a mucolytic supplement, called Mucolyxir®, to attempt to reduce the mucus in his sinuses. In spite of avoiding all dairy products the mucus was no different, and I wondered if the coconut replacement may be mucus forming. In discussion with his Mum, it seemed that the mucus remained impacted in his sinus and he did not blow his nose or need to suggesting that there was not an ongoing mucus production issue. T.H. really liked the ATP Lipids Powder (ARG) and so he was able to take all of the supplements as directed. The next programme of supplements, five weeks later, was very similar but included an additional item to help thin and so reduce the mucus in his sinuses.

Second Supplement Programme – July 2015 Dose

ATP Lipids Powder (ARG) 1 scoop with breakfast & dinner

Bio-3B-G (BRC) 1 with each meal, 1 right after school & 1 at bedtime

Gluten-Gest (ARG) 1 caps with each meal (supported by school)

Lactobacillus GG Culturelle (ARG) 1 caps with dinner

Mucolyxir® (ARG) 4 drops under / on tongue 2-3 times a day

We then met 6 weeks after T.H. had started the second programme.

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T.H. was able to maintain his concentration in this third consultation noticeably better than the first, and he sat in his chair for half of the appointment whereas previously he had lasted less than 5 minutes before he was up and exploring the room. Mum reported that his mucus was definitely improved and his sleep had also improved too, so we connected the two things together. He had not had any infections over the time period either. T.H. had broken the strict dietary avoidances on a few occasions but there were no adverse symptoms as a result. He had gained another few pounds now and he did not look so skinny as he had done when we first met. I explained that this may be due to a number of reasons including improved digestion and the avoidance of foods which impeded digestion and absorption in some way. The whole of his family had witnessed the difference in him and were very supportive of him. His teachers confirmed the ongoing improvement and he was now enjoying sports a lot more, now that he could play them and be a member of the team. T.H. continued to love taking the NT Factor powder and takes a higher dose now and is doing very well on it. T.H. has experienced a noticeable improvement in his energy, concentration, ability to focus, ability to respond to others asking him to focus, gained weight, improved his physical and sports skills and improved his sleep. T.H. followed this second programme for 6 weeks and then revisited me and the programme was slightly revised again. The NT Factor powder was increased, the probiotic stopped for this period of time, and the digestive enzyme was reduced to two meals a day, and the Mucolyxir® was also reduced in frequency.

Third Supplement Programme – September 2015 Dose

ATP Lipids Powder (ARG) 2 scoops with breakfast & dinner

Bio-3B-G (BRC) 1 with each meal, 1 right after school & 1 at bedtime

Gluten-Gest (ARG) 1 caps with breakfast & dinner

Mucolyxir® (ARG) 4 drops under / on tongue 1-2 times a day

T.H. has followed this nutrition programme for a total of over 6 months whilst making visits for follow up appointments. Since then I have had email contact with T.H.’s mother. He continues with the third supplement programme and abides by the dietary recommendations of the no wheat, no dairy & no orange. In January 2016, I had further email exchange with T.H.’s Mum who wondered if we needed to meet again, so I asked about how T.H. was getting on. She reported that the benefits that T.H. had experienced were still very much there and he was doing well in all areas that had been issues in the past. T.H. had also gained more weight. The O.T. was really surprised to see the changes that had occurred and naturally T.H.’s Mum explained all that they had been doing and the therapist was very supportive and expressed the wish that all parents would do the same thing for all the kids he looked after.

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We did not meet in January 2016, but rather I recommended that T.H. continue with the same dietary measures and the same supplements and asked her to report back in another 6 weeks’ time. Supplement Information ATP Lipids Powder (ARG) – http://tinyurl.com/9x4lctq This provides the NT Factor phospholipids only. This has been shown to improve mitochondrial membrane quality and so increase energy production. It provides material required for membrane replacement – Membrane Replacement Therapy (MRT), in which damaged lipids in cell and mitochondrial membranes are replaced by healthy and balanced phospholipids. Bio-3B-G (BRC) This is a low dose B vitamin formula in which 3 of them are in their active form. The pills are small and therefore easy to swallow. This formula has helped many patients improve their energy and sleep when taken at night. B vitamins are also required for the co-factors in the metabolism of neurotransmitters, and they support the nervous system. Gluten-Gest (ARG) – http://tinyurl.com/34kbbdx This is a broad-spectrum vegetarian enzyme formula which supports the digestion of gluten. Wheat and not gluten was suspected as a potential culprit food. Given his lack of weight gain in spite of good volumes of food, this digestive aid was recommended. Lactobacillus GG Culturelle (ARG) – http://tinyurl.com/66yuha6 The world’s most researched probiotic providing 30 billion live lactobacillus rhamnosus GG cells (even though the packet says 10 billion – which is the minimum present at expiry date). This was particularly recommended because of the antibiotics. Mucolyxir® (ARG) – http://tinyurl.com/3w4nr6e Mucolyxir® is a liquid food supplement, formulated from double-stranded deoxyribonucleic acid (DNA) derived from wild Pacific salmon. The small amount of DNA in Mucolyxir® may balance mucus levels via a regulatory mechanism. It has proven very successful in reducing levels of mucus in my patients whenever it has been used, no matter what the cause of the mucus. Discussion. Please describe (1) the strengths and limitations of this case report including case management, (2) the literature relevant to this case report (the scientific and clinical context), (3) the rationale for your conclusions (eg, potential causal links and generalizability), and (4) the main findings of this case report: What are the take-away messages? Strengths and limitations of this case report including case management The belief of T.H.’s parents that the food and drink that T.H. consumed had a real role to play in his health issues has been validated. Their joint support, and that of the other two children, has most definitely been a real advantage for T.H. since he had a whole support group.

http://tinyurl.com/9x4lctq

http://tinyurl.com/34kbbdx

http://tinyurl.com/66yuha6

http://tinyurl.com/3w4nr6e

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The early improvements also enabled the school teachers to be on side swiftly which also helped in T.H. being in a position to abide by the food exclusions at school and to take the B vitamin at lunchtime in the first two programmes. A possible limitation in this case, was the fact that fatty acids were not provided in supplement form. T.H. was not recommended EPA nor DHA nor GLA. However, he did eat fish already, so perhaps he had less of a need as a result. It is not known if this would or could have a benefit. The literature relevant to this case report As indicated in the introduction, there is mounting evidence that nutritional changes and nutrients and micro-nutrients can have a meaningful role to play in the functioning brain of youngsters with conditions that have hitherto been believed to be ‘genetic’ or non-modifiable except with pharmaceutical agents.

The rationale for your conclusions The mounting literature in support of nutritional factors improving outcomes in those with ADHD combined with clinical experience led to relatively straightforward decision-making in this case. For T.H. there were the classic foods that needed to be avoided; that of wheat and cow’s products. He also did better away from orange juice but we do not know if it was the juice or the orange specifically that was an irritant, since he did not replace it with any other juice. The supplements were also relatively straightforward to choose, but again relied on clinical experience and knowledge of a wide array of supplements. The main findings of this case report: What are the take-away messages? T.H. is yet another example for NTs of a child whose life has been changed for the better by changing the diet, and taking of appropriate supplements. Food and nutrients can affect the brain in a positive way, as well as a negative way, and a subtle negative way at that; it was not obvious that wheat or gluten were having an adverse effect on T.H. but their removal resulted in improvements. The NT Factor phospholipids have played a positive role, in my opinion, but because they are one of a number of variables it is not possible to determine how much. It was a definite bonus that T.H. liked the taste of the powder. In the patients I see, I am finding that the NT Factor powder is very commonly a helpful addition to the nutrition programmes, and for children where there is a need to support the CNS, it is an extremely valuable addition to the products that we NTs have available to us.

The belief of T.H.’s parents that the food and drink that T.H. consumed had a real role to play in his health issues has been validated. Their joint support, and that of the other two children, has most definitely been a real advantage for T.H. since he had a whole support group. T.H.’s Mum is naturally delighted to have seen the impact on T.H. and has loved the positive feedback from all of those who know him. Whilst it should not necessarily be this way, because T.H. is such a likable boy, the comments and feedback have been all the more easy-flowing and generous and complimentary.

Patient Perspective. The patient should share his or her experience or perspective of the care in a

narrative that accompanies the case report whenever appropriate.

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Informed Consent. Did the patient give the author of this case report informed consent? Provide if requested. The patient is not aware his case history is being used, and all identifiable data has been removed. T.H. are not the boy’s real initials.

C a s e R e p o r t S u bmi s s i o n R eq ui r e m en t s f o r A u th o r s

None Known

This case was not presented to an ethics committee.

All patient data has been re-identified

Antony Haynes, RNT, practices from his clinic in London W1.

1. Competing interests. Are there any competing interests?

2. Ethics Approval. Did an ethics committee or Institutional Review Board give approval? If yes, please provide if

requested.

3. De-Identification. Has all patient related data been de-identified?

4. Author. Name of Author and practice

case report - clinical education

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