Non-pharmacologic%20Alternatives%20in%20the%20Treatment%20of%20Attention%20Deficit%20Hyperactivity%20Disorder

1
Non-pharmacologic Alternatives in the
Treatmentof Attention Deficit Hyperactivity
Disorder

• Kelsey Brown
• Advisor Professor Fahringer

2
Hippocrates first describes ADHD

• The physician-scientist described his patient
  as having quickened responses to sensory
  experience, but also less tenaciousness because
  the soul moves on quickly to the next
  impression, and attributed the symptoms to an
  overbalance of fire over water.

3
Hippocrates first describes ADHD

• As a treatment, he suggested barley rather than
  wheat bread, fish rather than meat, watery
  drinks, and many natural and diverse physical
  activities (Baumgaertel, 1999).
• Hippocrates therapy plan consisted of what we
  currently consider to be alternative treatments.
  His dietary prescription anticipated modern
  theories of the benefit of gluten-free diet and
  essential fatty acids in brain-behavior
  functioning.

4
stimulants as the gold standard in the treatment
of ADHD

• Common stimulants include methylphenidate
  (Ritalin), mixed amphetamine salts (Adderall) and
  dextroamphetamine (Dexedrine)
• Side effects occur in 20-50 of individuals
  taking pyschostimulant medications
• The most common are headaches, anxiety,
  irritability, stomach aches, decreased appetite,
  and insomnia

5
why non-pharmacologic alternatives are sought

• stimulants may be ineffective
• stimulants may produce unacceptable adverse
  effects
• stimulants may be contraindicated because of a
  co-morbid condition
• parents seek a more natural approach to treatment
  
• parents wish to be more active in the therapeutic
  process
• negative publicity may exist in the media
  regarding stimulants

6
Dietary Interventions

• The Feingold Diet
• The Conners Sugar Challenge
• Crooks Antifungal Agents
• Linus Paulings Megavitamin Therapy
• Magnesium Supplementation
• Omega-3 Supplementation

7
The Feingold Diet

• Dr. Feingold stated that artificial coloring and
  flavors, preservatives and naturally occurring
  salicylates contained in fruits and vegetables
  were the primary cause of hyperactivity and
  learning disorders in children.

8
The Feingold Diet

• Challenges are individualized to include specific
  foods and additives that parents believe to
  produce symptoms.
• Children are first placed on a basic elimination
  diet that excludes standard food allergens,
  including milk, soy, wheat, corn, citrus,
  peanuts, artificial additives and foods believed
  to cause symptoms for that particular child.

9
The Feingold Diet

• If the child responds to the elimination diet
  with behavioral improvement in 2 to 4 weeks,
  individual open challenges with several of the
  offending agents are performed, allowing several
  days between challenges.
• If behavioral deterioration results from any of
  the challenges, a specific double blind, placebo
  controlled, food challenge is initiated with the
  offending agents disguised within food vehicles
  that mask smell, flavor and texture.

10
is there a link between sugar and ADHD?

• The research on sugar seems to be clear in
  disproving its having any role in ADHD.
• The preference for the taste of sugar is
  hardwired into the brain, and depends completely
  on glucose as a metabolic substrate.
• This is apparently reinforced by the social role
  of sugar as treats and rewards.
• Children with ADHD often have conspicuous sugar
  cravings, which contributes to the perception
  that sugar intake can cause hyperactivity,
  despite evidence to the contrary.

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the sugar elimination diet

• Food researcher Dr. C. Keith Conners observed
  that the category of food consumed with a sugar
  challenge seemed to affect cognitive responses.
• A sugar challenge given with a protein-rich
  breakfast improved attention, but not behavior,
  in hyperactive children, whereas a sugar
  challenge with a carbohydrate-rich breakfast
  decreased attention in both normal and
  hyperactive children (Conners, 1989).
• This data suggests that a popular breakfast of
  sweetened cereal may be problematic in terms of
  inattentiveness, but that it is more likely
  related to sedation rather than hyperactivity.
• At this time, there is no research or physiologic
  explanation that supports that sugar
  independently causes or enhances ADHD therefore,
  there is no justification for promoting a strict
  sugar elimination diet.

12
combining antifungal agents with the sugar
elimination diet

• Dr. William Crook, an allergist and pediatrician,
  reported a 75 success rate in reducing
  hyperactive behavior in his ADHD patients using
  individualized elimination diets.
• Crook maintained that prolonged or frequent
  antibiotic treatment results in chronic
  candidiasis and candida toxin production, which
  are responsible for a variety of metabolic and
  behavioral disturbances, including hyperactivity,
  irritability and learning disorders (Crook,
  1986).

13
combining antifungal agents with the sugar
elimination diet

• Crooks treatment includes the use of antifungal
  agents such as nystatin or ketonazole, along with
  a diet strictly eliminating any sources of sugar
  due to its promotion of yeast growth and any
  foods made with or contaminated by molds and
  yeast including breads, processed foods, cheeses
  and dried fruits.
• His dietary plan has a large lay following, but
  his claims are based on experience rather than on
  scientifically derived data.

14
Megavitamin Therapy

• based on Linus Paulings theory that a highly
  complex and individualized biochemical balance is
  the foundation of optimal mental functioning
• described as using at least 10 times the
  recommended daily allowance of a particular
  vitamin

15
Megavitamin Therapy

• In 1992, a double blind, placebo controlled,
  crossover study of megavitamin treatment in
  children with ADHD using a combination of B6,
  niacinamide, ascorbic acid and calcium
  panthotenate was conducted.
• Children who initially were seen to have improved
  classroom attention while on megavitamins in an
  open trial did not show any behavioral
  improvement in the double blind, placebo
  controlled, crossover phase.
• In fact, the children studied demonstrated 25
  more disruptive behavior while taking
  megavitamins than with placebo.
• 42 showed liver enzyme elevations (Haslam,
  1992).
• This supported an early concern of the toxic
  effects of prolonged multivitamin use. Haslams
  findings suggest that megavitamins are of little
  benefit in the treatment of ADHD and may actually
  cause harm.

16
Magnesium Supplementation

• Naturally occurring magnesium is often lost
  during food processing.
• Magnesium deficiency frequently manifests as
  neuromuscular hyperactivity and irritability.
• A recent study of a cohort of children with ADHD
  and relative magnesium deficiency showed
  behavioral improvement after a 6 month
  supplementation with magnesium (200mg/day),
  whereas an unsupplemented group with the same
  characteristics showed no change
  (Starobrat-Hermelin Kozielec, 1997).

17
Omega-3 Supplementation

• Investigations have confirmed that physical signs
  of fatty acid deficiency are more common in ADHD
  children than controls.
• In clinical trials, active treatment of dosing
  300-700mg of omega-3 eicosapentaenoic acid (EPA)
  daily, led to highly significant improvements in
  reading and spelling progress in children, in
  addition to significant improvements in their
  ADHD symptoms when compared with placebo
  (Richardson, 2006).
• Benefits of active treatment over placebo were
  also found for teacher-rated attention and parent
  rated conduct.

18
Behavior Modifications

• token economies
• positive attention for appropriate behaviors and
  punishment for non-compliance
• charting of antecedent behavior
• yoga
• massage

19
Neurofeedback

• Mechanism to help the ADHD patient modify
  brainwave activity to improve attention, reduce
  impulsivity, control hyperactive behaviors and
  produce long term change.
• Patients with ADHD exhibit characteristic surface
  EEG disturbances.
• 85-90 display signs of cortical hypo-arousal
  typically observed over frontal and central
  midline brain regions.
• A smaller subgroup patients exhibit an EEG
  pattern of hyper-arousal distributed diffusely
  across multiple cortical recording sites.
• The hyper-aroused group tends to respond poorly
  to stimulant medications (Friel, 2007).
• EEG biofeedback protocols are developed to
  inhibit cortical slowing and reward higher
  frequencies in hypo-aroused patients, with the
  goal of normalizing EEG activity in regions
  thought to be responsible for attention and
  behavioral control

20
Neurofeedback

• Multiple studies have demonstrated that 80 of
  ADHD patients treated with neurofeedback showed
  significant improvements in IQ scores,
  standardized tests of achievement, and
  parent-teacher ratings of behavior, and the
  effects were maintained at long-term follow-up
  (Fox, Tharp Fox, 2005).
• It was also reported that those who received EEG
  biofeedback showed greater attention and less
  hyperactive/impulse behaviors at home and in
  school settings when compared to those treated
  with stimulant medications.

21
CAM as treatment for ADHD

• Both CAM users and nonusers give high importance
  ratings for physician recommendations and
  scientifically proven therapies.
• Parents expect physicians to be familiar with CAM
  therapies and to recommend them when appropriate.
  
• According to the Ambulatory Care Quality
  Improvement Program assessment exercise, 93 of
  pediatricians reported that parents ask them
  about alternative treatments for ADHD (Chan,
  Rappaport Kemper, 2003).

22
References

• Baumgaertel, A., Alternative and controversial
  treatments for attention-deficit/hyperactivity
  disorder.
• Pediatr Clin North Am., 46(5)977-992, 1999.
• Chan, E., Rappaport, L.A., Kenmper, K.J.,
  Complementary and alternative therapies in
  childhood attention
• and hyperactivity problems. J Dev Behav,
  24(1)4-8, 2003.
• Conners, CK., Feeding the Brain. New York, Plenum
  Press, 1989.
• Crook, W.G., The Yeast Connection, New York,
  Vintage Books, 1986.
• Cumyn, L., Kolar, D., Keller, A., Hechtman, L.,
  Current issues and trends in the diagnosis and
  treatment
• of adults with ADHD. Expert Rev Neurother.,
  7(10)1375-1390, 2007.
• Doggett, A.M., ADHD and drug therapy is it still
  a valid treatment? J Child Health Care,
  8(1)69-81, 2004.
• Friel, P.N., EEG biofeedback in the treatment of
  attention deficit/hyperactivity disorder.
  Alternative Medicine
• Review, 12(2)146-151, 2007.
• Fox, D.J., Tharp, D.F., Fox, L.C.,
  Neurofeedback an alternative and efficacious
  treatment for attention deficit
• hyperactivity disorder. Applied
  Psychophysiology and Biofeedback, 30(4)365-373,
  2005.
• Haslam, R., Is there a role for megavitamin
  therapy in the treatment of attention deficit
  hyperactivity disorder?
• Adv Neurol, 58303-310, 1992.
• Richardson, A.J., Omega-3 fatty acids in ADHD and
  related neurodevelopmental disorders.
  International Review
• of Psychiatry, 18(2)155-172, 2006.
• Rojas, N.L. Chan, E., Old and new controversies
  in the alternative treatment of attention-deficit
  hyperactivity
• disorder. Mental Retardation and Developmental
  Disabilities Research Reviews, 11116-130, 2005.