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The Integrative Approach to ADHD or Do 4 million children really need Ritalin


Incidence of ADHD ... Why the Explosion in ADHD? ... ADHD is relative to what is asked of children ... – PowerPoint PPT presentation

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Title: The Integrative Approach to ADHD or Do 4 million children really need Ritalin

The Integrative Approach to ADHDor Do 4
million children really need Ritalin?
  • Sanford C. Newmark M.D.
  • Center for Pediatric Integrative Medicine Tucson,
  • 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
  • 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
  • 3.We have loosened the definition so more kids
    are being diagnosed and treated.
  • 4.We are actually diagnosing and treating many
    children who dont have ADHD, even by a loosened

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 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
    dont 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
  • Review any previous psychoeducational evaluations
    or other professional consults.

Many conditions can be Misdiagnosed as ADHD,
  • 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,
  • Conners Positive- teachers and parents
  • Home life is OK, except for homework
  • Lots of friends happy
  • Asthma and allergies

Stimulant Medications and Side-Effects
  • Decreased Appetite
  • Trouble Sleeping
  • Abdominal Pain
  • Headaches
  • Tics
  • Bizarre Behavior
  • Hallucinations (at least 1100)
  • Potential for Addiction -controversial
  • Generally, all of these stop when the medication
    is stopped

More Subtle but Worrisome Effects
  • Hes just not himself
  • Shes lost her spark, or her joy
  • Hes just not the same kid
  • Shes teary, or sad a lot
  • Hes 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
  • 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 fat-free 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 Childrens
    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 Childrens
    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

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

(No Transcript)
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

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
  • 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-3s, ADHD, and LD
  • 41 Children with ADHD and LD given a 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.

Progress in Neuro-Psychopharmacology
Biological Psychiatry (2002)
(No Transcript)
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

  • 117 children (5-12 years old) 60 active, 57
  • 3 month trial of Omega 3 and 6 Fatty Acids,
  • Active treatment - 80 fish oil and 20 evening
    primrose oil.

  • Before treatment, mean achievement scores 1 year
    below chronologic age.
  • After 3 months, the mean increases in reading age
  • Active Treatment - 9.5 months
  • Placebo - 3.3 months
  • (z 2.87, P lt .004)

  • After 3 months the mean increases in spelling age
  • Active treatment - 6.6 months Placebo -1.2 months
  • Again, the group difference was highly
    significant (z 3.36, P lt .001).

ADHD Related Symptoms
  • Active treatment, scores decreased from a mean of
    74.7 to a mean of 58.1, a reduction of gt0.5 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 lt .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 lt .001),
  • Arch Pediatr Adolesc Med. 2004

ADHD and Iron Deficiency
  • Serum ferritin levels were abnormal (lt30 ng/mL)
    in 84 of children with ADHD and 18 of controls
    (P lt .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

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

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

Tolson School
  • Discipline problems dropped sharply
  • Special education dropped from 31 students to 7
  • Now 2 of 519 students on medication for ADHD
  • Performing Plus School - increasing test

EEG Neurofeedback
  • Children with ADHD have predictable brain wave
    abnormalities. This can be measured by
    Quantitative EEG.(QEEG)
  • They generally have more slow wave (Theta-low
    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 long-term or controlled
  • Disadvantage -30-40 sessions,50 or more per

  • 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
  • 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
  • Havent seen it myself but no harm in acupuncture
  • Careful about the herbs.

What happened to Julie
  • Cleaned up diet Less sugar and refined
  • Eliminated food additives
  • Found dairy exacerbated inattention and allergy
  • Began Omega-3s and Zinc
  • Developed a better behavioral approach with
  • Still has her difficulties, but happier at home
    and school

Take Home Message
  • We need to be careful not to over- diagnose 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
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