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Disclaimer. I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:
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1. Managing ADHD Naturally Kathi J Kemper, MD, MPH
Center for Integrative Medicine
WFUBMC
2. Disclaimer I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:
American Academy of Pediatrics, “Mental Health, Naturally "Author. Royalties anticipated.
The presentation will include no description of any proprietary items for screening, diagnosis, or treatments.
I do not intend to discuss an unapproved or investigative use of a commercial product in my presentation.
3. Objectives By the end of this session, participants will be able to
Describe the epidemiology of ADHD and use screening instruments to identify, monitor progress, and use in N of 1 trials (ask me!)
Counsel patients on dietary modifications to improve attentiveness
Use effective behavioral strategies and provide advice about behavior management
Use and recommend evidence-based resources (See AAP Section for Complementary and Integrative Medicine; join the listserv – tsalus@aap.org)
4. Case You are referred an 11 year old boy by a family nurse practitioner for management of ADHD because he did not respond to Ritalin.
The mother says she stopped giving the Ritalin after two weeks, because she didn’t like the idea of “drugging him up.” Instead, she has been giving him ginseng and ginkgo.
She doesn’t know if he’s any better, but “at least it’s natural”.
5. Attention Deficit Hyperactivity Disorder AD(H)D: criteria Core symptoms of:
Impulsivity (or Hyperactivity)
Inattention
Impairing home, school, social and self-concept (at least 2 settings)
By age 6 years
Chronic condition (at least 6 months)
Use standard screen, Vanderbilt www.brightfutures.org/mentalhealth/pdf/professionals/.../adhd.pdf Core symptoms are in 3 areas of hyperactivity, inattention, and impulsivity
The most commonly-diagnosed behavioral disorder in children
estimates of prevalence 3-11%
However, prevalence may rise with the use of DSM-IV criteria, since it better characterizes the heterogeneity of ADHD in terms of its 3 subtypes: inattentive, hyperactive-impulsive, and combined.
Wolraich study in school-children K-5 in Tennessee county:
ADHD all types: 16.1% (6.8% if impairment considered)
ADHD inattentive type 8.8% (3.2%)
ADHD hyperactive/impulsive type 2.6% (.06%)
ADHD combined 4.7% (2.9%)
Increasing recognition of ADHD as a chronic condition persisting into adulthood and requiring
long-term therapy
on-going monitoring
periodic assessment for consequences and complications
Core symptoms are in 3 areas of hyperactivity, inattention, and impulsivity
The most commonly-diagnosed behavioral disorder in children
estimates of prevalence 3-11%
However, prevalence may rise with the use of DSM-IV criteria, since it better characterizes the heterogeneity of ADHD in terms of its 3 subtypes: inattentive, hyperactive-impulsive, and combined.
Wolraich study in school-children K-5 in Tennessee county:
ADHD all types: 16.1% (6.8% if impairment considered)
ADHD inattentive type 8.8% (3.2%)
ADHD hyperactive/impulsive type 2.6% (.06%)
ADHD combined 4.7% (2.9%)
Increasing recognition of ADHD as a chronic condition persisting into adulthood and requiring
long-term therapy
on-going monitoring
periodic assessment for consequences and complications
6. Vanderbilt:
7. ADHD Symptoms Inattention
Easily distracted
Forgetful
Loses things
Difficulty sustaining attention
Avoid/dislike difficult tasks
Difficulty organizing
Careless mistakes
Doesn’t listen
Difficulty following instructions Hyperactive/Impulsive
Fidgety
Difficulty staying in seat
Runs or climbs excessively Hyper feeling
Acts on the go/ driven by a motor
Difficulty doing things quietly
Talks excessively
Difficulty waiting turn
Blurts out answers
Interrupts/intrudes
8. Differential Diagnosis Vision and hearing problems
Chronic illness with itch; breathing impairment, e.g., sleep apnea; sleep problems
Developmental or learning problems; language deficits
Absence seizures
Acute change in living situation, grief, family conflict, recent trauma
Substance abuse; side effect of medications
Stress
FREQUENT CO-MORBIDITIES (Other mood or anxiety disorder; psychotic disorder; adjustment disorder) fixing them can solve most of the problem (next slide)
9. ADHD: Comorbidity Learning Disability: 37-50%
Anxiety: 20 to 33%
Depression: 10 to 20%
Bipolar: 63 to 92% of Pediatric BPD also meets criteria for ADHD
ODD: 40%
Conduct Disorder: 20%
Tourettes/Tics:7%
10. Epidemiology: Prevalence: 4-11% in US
Boys: Girls, 3:1
Etiology: multifactorial
Genetic – family history of ADHD, alcoholism, sociopathy, LD, mood and anxiety disorders
Medical (maternal smoking and alcohol use during pregnancy; gestational diabetes; head injury; seizures; CNS infection; OSAS), and
Environmental risks (lead, CO, Cd, TV) and protective factors (high IQ, supportive, structured family environment)
Cultural – much lower prevalence estimates in Europe and Japan than US
many unknowns
11. What’s wrong with his brain? 446 kids with and without ADHD scanned repeatedly over years
ADHD kids lag 3 yrs in cortical growth
ADHD: motor cortex matures earlier
Brain imaging not clinical tool
No evidence of abnormality, only delay
Shaw P. National Academy of Science. 2007
12. NIH Consensus Conclusions “Unclear if ADHD is at the far end of the spectrum of normal behavior or if it reflects a qualitatively different behavioral syndrome.”
“Remarkable lack of research on the etiology or prevention of ADHD. We know little about this. ”
NIH Consensus Panel, JAACAP, 2000
13. Placebo Effects Placebo effects well documented in psychiatry
Parents and teachers tend to evaluate kids more positively if they think they are medicated
Parents and teachers tend to attribute positive changes to medications even when no meds are given
Waschbusch, DA J Dev Behav Pediatr 2009
14. Usual vs. Integrative Approach Treatment as Usual (TAU)
Diagnose, using standard scale
Rule out anemia, vision, hearing probs.
Start stimulants
Monitor sleep and growth
Revise or refill as needed Integrative Care
Identify goals, strengths, resources, lifestyle
Assess of attention, impulsivity, hyperactivity with standard scale
Identify specific target behavior (SMART plan)
Brainstorm behavioral, lifestyle, natural and medical treatment options; focus on fundamentals
Prioritize plan, anticipate difficulties
Monitor
Revise, follow-up
15. Assessment History (age of onset); other conditions
Family History
Diet: allergies, sensitivities, artificial colors/flavors/sweeteners?
Activity (sports), sleep; TV, nature
Stress management; Social and Organizational skills; Managing Misbehaviors
Interview: mood, trauma, anxiety
Standardized: Vanderbilt; vision, hearing, PE (allergies, rashes, heart murmurs, neurologic)
Lab studies: freeT4, ferritin, Vit D; consider lead level
ALL CURRENT TREATMENTS and others tried
Intake form: http://www.wfubmc.edu/Center-for-Integrative-Medicine/Specialty-Services/Pediatric-Second-Opinion-Clinic.htm
16. Standard (TAU) challenges Making a diagnosis; what if they don’t meet criteria?
Mastering medications, side effects etc.
Managing resistance to treatment/referral
18. Medication Challenges Poor response
Poor response in 35% (no behavioral improvement)
Side effects >50%: nausea, weight loss, insomnia, tics, irritability, not himself; arryhthmias, liver dysfunction
Increase in calls to Poison Control Centers
Failure to take them; stigma; dependence
Lack of attention to other aspects of lifestyle that improve overall health and esteem
Parents seek other options (30% - 40%)
Chan E. J Dev Beh Ped, 2003
Psychopharm Bull 2008; 41:37-47
Setlick, J Pediatrics 2009; 124: 875-80
19. Evidence-based skills Agenda setting
Engaging both child and parent
Prioritizing specific concerns; goals; define success
Problem formulation and solving
Finding reasons to hope and first steps to solutions
Framework: health promotion and stress management
Time management
Managing rambling and interruptions
Promoting hope and confidence
Advice giving
Avoiding and managing resistance
21. Strengths-based approach Build on strengths; great for sales, entertainment, the arts
Creativity, imagination, innovation
Energy, exuberance, enthusiasm
Desire to please; Sociability
Flexible; notices subtle details in environment
NOT a character flaw or willfully bad
Improvement in specific skills (attention, diligence, self-discipline) is possible
22. Health Care Steps Health promotion
Disease prevention
Early detection
Early, safe, effective, evidence-based, culturally sensitive care
Tertiary care
Rehabilitation
23. Treatment Strategies
24. How: Behavioral Pediatrics Identify the goal; prioritize among several
Consider various strategies
Pick a strategy
Identify a small, achievable step that the patient and family can support
Explore pros and cons of change
Anticipate barriers; identify resources
Plan rewards/celebrations!
Re-evaluate; take the next step
25. Which is a specific goal? Do better in school.
Stop being such a pest.
Behave better.
Complete math homework in 30 minutes at least 3 days per week and turn it in the next day.
Be more respectful.
At least once a day, when I (parent) give directions, listen and repeat what I say before acting.
Be neater
26. Which is a specific goal? Do better in school.
Stop being such a pest.
Behave better.
Complete math homework in 30 minutes at least 3 days per week and turn it in the next day.
Be more respectful.
At least once a day, when I (parent) give directions, listen and repeat what I say before acting.
Be neater
SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT, TIME-SPECIFIC
27. Healthy Habits, Healthy Habitat
28. 5 Fundamentals: 5Fs Fitness and Sleep: more exercise, more sleep (sleep hygiene)
Food – “Eat food. Mostly plants. Not too much.” Consider supplements to avoid deficiencies and meet unique metabolic or drug-induced needs.
Friendship with self: emotional, mental, spiritual attention, frustration, and stress management
Friendship with others –participate; develop social skills; taking turns
Fields/Environment: More nature; mindful music; Less TV and toxins
29. Activity/Sports Yoga? 2X/week for 6 weeks lessons for parents and child, + daily home practice. Parents and children felt it was beneficial (Harrison. Clin Child Psychiatr, 2004; Jensen. J Atten Discord, 2004)
Therapeutic Eurythmy – movement therapy developed by Rudolph Steiner; positive case reports
TaeKwonDo; Karate; TaiChi (discipline)
DOSE: 60 minutes daily
SAFETY EQUIPMENT; SUPERVISION
ABCs (Activity Bursts in Classroom)
30. Sleep and ADHD Children with ADHD have much higher rates of sleep problems, parasomnias, and sleep disordered breathing.
Polysomnography in 33 (3-16 yo) with ADHD: 24% had obstructive sleep apnea; 30% had periodic limb movements;Compared with ADHD as whole= more obese
Goroya JS. Pediatric Neurology, 2009
Li S, 2008
Mayes SD, 2008
31. Sleep Hygiene Regular time; Routine
Hot bath; cool, dark room
Massage/back rub
Consider snack (protein + CHO)
Music (quiet or boring, not dance); chamomile/lavender fragrance
Read, draw, or journal something reassuring, uplifting; gratitude
NO TV IN BEDROOM
NO stimulants after 4pm
NO vigorous exercise right before bed
GET MORE!
Second level: melatonin, valerian, chamomile, 5-HTP, tryptophan
32. Eat Breakfast, Lunch, Dinner, snacks
Maintain a normal blood (glycemic index)
Whole Foods ?
Avoid sensitizers
Get essential nutrients
33. Case
Janey eats a breakfast that has no fat, no protein, and a high glycemic index — e.g., a bagel with fat-free cream cheese. Her blood sugar goes up, then crashes, triggering the release of stress hormones (adrenaline).
What you're left with, at around 10 a.m., is Janey with low blood sugar and lots of adrenaline circulating in her bloodstream. She is jittery and inattentive. Teacher thinks: ADHD.
David Ludwig, M.D., Ph.D.,
Director, Optimal Weight for Life
Children’s Hospital Boston
34. Appleton Central HS Charter School for kids “struggling in conventional settings
Removed vending machines selling candy, soda, and chips.
“Natural Ovens” began a healthful meal program for breakfast and lunch
Serving salad bars, fresh fruits, whole grain breads and cereals, vegetables, meats, etc.
35. Appleton Central HS Very Striking Improvements
Better academic performance
Fewer Behavior problems
Less fighting
Less drug use
36. Dietary Controversies 12 negative RCTs of sugar
Some artificial colors, flavors, preservatives do trigger hyperactivity in both toddlers and school age children
Supplements – megavitamins bad; magnesium, zinc, iron may be helpful
37. 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.
Batteman B. Arch Dis Child. 2004
38. Food allergies? Allergic shiners
Hx of colic
Hx of ezcema
Hx of reflux
Long bone pain (vit D insufficiency?)
Belly pain, IBS
Bad breath
Foot odor
Hx of antibiotics
Family hx atopy
Runny nose
Insomnia
39. ADHD and Food Allergy 19 children responded favorably to a multiple food elimination diet.
16 completed a DBPC Food Challenge.
Symptoms improved significantly on days given placebo rather than foods they were sensitive to (P=0.003)
Boris M. Annals of Allergy, 1994
40. ADHD and Food Allergy 62/76 children treated with an Oligoantigenic diet improved.
28/62 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 most common provoking substances.
Egger J. Lancet. 1985
41. Dietary Trial Remove potentially sensitive food(s) for 2 weeks; NOT FOREVER
Challenge eliminated foods one at a time
Keep diary
Must be highly motivated and nutrition educated
42. Supplements Correct deficits
Iron
Zinc
Magnesium
Omega 3 fatty acids
NOTE: Most MV contain very little of these three. Diet is best source.
43. Iron in ADHD Iron plays a key role in dopamine metabolism
Low ferritin levels associated with more hyperactivity in ADHD patients (Oner, 2008)
84% of ADHD pts had abnormally low ferritin levels (Konofal et al, Arch. Pediatr. Adolesc. Med. 2004)
Iron improved Connor’s ratings (Sever, 1997)
Iron treatment for ADHD reduced ADHD rating scale and CGI at 12 weeks (Konofal, 2008)
44. Zinc in ADHD Zinc levels predict stimulant response(Arnold, 1990)
Serum zinc levels low in ADHD (Bekaroglu, 1996)
Zinc effective as supplement to stimulant (Akhondzadeh, 2004)
Zinc effective in reducing hyperactive and impulsive behavior (Bilici, 2005)
45. Zinc in ADHD RCT of Zinc supplements for 209 7th graders
Dose: 0, 10 or 20 mg Zinc 5x/wk for 10 Weeks
Statistical improvement in 20mg group (no improvement with lower doses)
Study presented at Experimental Biology meeting April 4, 2005 at San Diego, CA by James Penland, Ph. D.
46. Zinc for ADHD
47. Magnesium? French study evaluated magnesium and B6 in 52 ADHD kids and relatives
30 / 52 hyperactive children had low ERC-Mg values
Open label supplementation with 100 mg daily of Mg and B6 for 3-24 weeks
“In all patients, symptoms of hyperexcitability (physical aggressivity, instability, scholar attention, hypertony, spasm, myoclony) were reduced after 1 to 6 months treatment. Other family members shared similar symptoms, had low ERC-Mg values, and also responded clinically to increased Mg(2+)/vitamin B6 intakes. “
MORE STUDIES NEEDED; May help anxiety
Mousain-Bosc M, Am J Clin Nutr, 2004
48. Flax oil and vitamin C supplements improve ADHD 30 kids with ADHD, compared with 30 normal kids in clinic in India
Supplement with 200 mg ALA + 25 mg Vitamin C twice a day, for 3 months
All kids had more EFA in RBC cell membranes after 3 months
ADHD kids had (P<0.01) improvements in total hyperactivity score, self-control, psychosomatic, restlessness, inattention, impulsivity, social problems, learning problems
Joshi K. Prostaglandins Leukot Essent Fatty Acids. 2006
49. Essential fatty acid DS for ADHD 41 kids, RCT to EPA 186 mg + DHA 480 mg + GLA 96 mg + cis-linoleic acid 864 vs. placebo mg daily for 12 weeks; EFA lowered Conners scores.
Richardson. 2002.
Oxford-Durham RCT of fatty acids suppl’s for 117 children with developmental coordination disorder: “significant improvements for active treatment vs placebo were found in reading, spelling, and behavior over 3 months of treatment in parallel groups. After the crossover, similar changes were seen in the placebo-active group.”
Richardson. Pediatrics, 2005
50. Omega-3’s, ADHD, and LD Lower omega-3 FA levels in children with ADHD
Omega 3’s are important in brain development
RCT: 41 Children with ADHD and LD given a Omega-3’s vs. placebo for 12 weeks. Significant improvement in ADHD scores for active vs. placebo.
More studies needed.
May help with anxiety/depression.
Progress in Neuro-Psychopharmacology
& Biological Psychiatry, 2002
51. TV and ADHD
52. TV and Attention National Longitudinal Survey of Youth
Follows 1300 kids
Surveyed kids at 1.5 and 3 years
Best predictor of ADHD at 7: early TV time
Christakas D et al Pediatrics 2004
53. TV and ADHD in Adolescence 1037 kids followed from 5 to 15 yrs
TV viewing assessed at 5, 7, 9 and 11
Self, parent and teacher forms: 13 & 15
Mean hours of TV earlier assoc with ADHD symptoms later, independent of gender, SES, IQ
Lanhuis C Pediatrics 2007
54. TV and Attention TV viewing accounted for significant portion of the variation in ratings of ADHD s/s (Miller CJ, 2007)
Frequent television viewing associated with subsequent attention and school problems (Johnson JG, 2007)
No evidence of bidirectionality between TV time and Attention/Learning issues (Johnson JG, 2007)
55. Behavioral Reframes
56. Manage Mistakes Constructively
57. SMART PLAN Specific
Measurable
Achievable
Reasonable and Relevant
Time-specific and Trackable
58. Which is SMARTER? A. Don’t watch so much TV. B. Turn off the TV at 9pm at least 5 nights in the next 7 days.
59. Which is SMARTER? A. Exercise more B. Sign up for a weekly Tai Chi class and practice at home at least 15 minutes at least 4 days per week for the next 4 weeks.
60. Explore Resources/Barriers (e.g. Exercise) Resources
Motivation
Family Support
Have dog to walk
Have sidewalks Barriers
Time; reschedule
No friends doing it; shy
Need better shoes
61. Pros and Cons
62. Which is SMARTER? A. Eat breakfast that contains some protein at least 4/5 school days each week for the next 2 weeks. B. Eat better, cut down on junk food.
63. Which is SMARTER? A. Turn off TV at 8pm. Take a bath, read a book together, back rub. Lights out at 9pm. Sticker for every night this is complete for next week. Earning 5 stickers means you get to pick a movie next weekend. B. Get more sleep.
64. TRACK PROGRESS
65. Resources Web
www.aap.org/sections/CHIM
www.wfubmc.edu/cim
Books
Kemper K. Mental Health, Naturally
Culbert and Olness. Integrative Pediatrics
66. Suggested Practice Changes Design a parent-completed standard intake form for ADHD visits within the next 6 months.
Test for ferritin and T4 in at least 50% of ADHD evaluations
Use SMART goal and behavioral strategies with at least one family in the next week.
Recommend breakfast, sleep hygiene, and at least 60 minutes of exercise daily for at least three patients in the first week home
Join the AAP SOCIM (tsalus@aap.org or www.aap.org/sections/chim/ within the next month
Read Mental Health, Naturally or Integrative Pediatrics chapters on ADHD within the next 2 weeks
Track one of YOUR behaviors using a behavior diary
Practice a reframe with a colleague or family member later today.
68. EXTRA INFO
69. Melatonin in ADHD RCT in 25 children with ADHD and chronic sleep onset insomnia; melatonin 5 mg daily at 6pm vs. placebo
Melatonin significantly improved sleep onset; decreased sleep latency and increased total sleep time
No change in ADHD behavior over 4 weeks, but all kids kept using it for one year
Smits. J Neurology, Neurosurg, Psychiatry, 1999
70. American ginseng and Ginkgo for ADHD Open trial among 36 children, 3-17 yo
Panax quinquefolium (200 mg) + Ginkgo biloba (50 mg) BID X 4 weeks
Connors parents scale
2 weeks: 31% improved on anxious/shy; 67% improved on psychosomatic
4 weeks: 74% improved on Conners’ ADHD Index
Lyon, et al. J Psychiatry Neurosci, 2001