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

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The Integrative Approach to ADHDor 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

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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).

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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

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Ritalin Use in the United States
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Stimulant Use -Leveling Off Over the Last 5
Years, but Still Very High
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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 dont have ADHD, even by a loosened
  definition.

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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.

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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

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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

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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.

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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.

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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.

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Many conditions can be Misdiagnosed as ADHD,
including

• Depression or bipolar disease
• Anxiety Disorder
• Learning disabilities
• The Gifted Child
• Intense or difficult temperament
• Boredom

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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

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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

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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

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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.

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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.

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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

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An Integrative Approach - 2

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

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Basic Nutrition or When did Pop Tarts become
a breakfast food?

• Maintaining a normal blood sugar
• Sugar
• Processed Carbohydrates
• Protein
• And the Glycemic Index

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• 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

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• 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

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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.

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Appleton Central

• Very Striking Results
• Better academic performance
• Fewer Behavior problems
• Less fighting
• Less drug use

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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

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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

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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.

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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
  (P0.003)
• Annals of Allergy. 72(5)462-8, 1994 May

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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.

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How do You Test for Food Sensitivities?

• Single Food Elimination
• Multiple Food Elimination
• Oligoantigenic Diet
• Allergy Testing IgE or IgG

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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)
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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

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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.

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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 lt .004)

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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 lt .001).

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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).

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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.

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Zinc for ADHD
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Zinc for ADHD
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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

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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
  normal.

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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?

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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.

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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.

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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

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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
  studies.
• Disadvantage -30-40 sessions,50 or more per
  session

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Homeopathy

• Completely different from herbal medicine
• Very high dilutions of common substances
• like cures like
• Individualized, constitutional

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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

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Craniosacral Manipulation

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

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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)

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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.

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What happened to Julie

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

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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
  psychostimulants.