Transcript Managing ADHD Naturally Kathi J Kemper, MD, MPH Center for Integrative Medicine WFUBMC Thanks to Drs.

Managing ADHD Naturally
Kathi J Kemper, MD, MPH
Center for Integrative Medicine
WFUBMC
Thanks to Drs. Scott Shannon, Sandy Newmark and
Wendy Weber for sharing slides
Disclaimer
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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.
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 – [email protected])
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”.
Attention Deficit Hyperactivity
Disorder AD(H)D: criteria
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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
Vanderbilt:
ADHD Symptoms
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Inattention
1.
2.
3.
4.
5.
6.
7.
8.
9.
Easily distracted
Forgetful
Loses things
Difficulty sustaining
attention
Avoid/dislike difficult
tasks
Difficulty organizing
Careless mistakes
Doesn’t listen
Difficulty following
instructions
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Hyperactive/Impulsive
1. Fidgety
2. Difficulty staying in seat
3. Runs or climbs
excessively Hyper
feeling
4. Acts on the go/ driven
by a motor
5. Difficulty doing things
quietly
6. Talks excessively
7. Difficulty waiting turn
8. Blurts out answers
9. Interrupts/intrudes
Differential Diagnosis
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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)
ADHD: Comorbidity
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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%
Epidemiology:
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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
What’s wrong
with his brain?
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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
NIH Consensus Conclusions
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“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
Placebo Effects
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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
Usual vs. Integrative Approach
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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
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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
Assessment
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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-IntegrativeMedicine/Specialty-Services/Pediatric-Second-Opinion-Clinic.htm
Standard (TAU) challenges
• Making a diagnosis; what if they don’t meet
criteria?
• Mastering medications, side effects etc.
• Managing resistance to treatment/referral
Wissow and Gadomski, 2008
Medication Challenges
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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
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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
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
Pediatrics 2008 Feb;121:266-75.
Crude 6-month change in child clinical measures as a
function of change in provider’s patient-centeredness
Change in symptom score
p<.0001 adjusted for baseline symptoms
Change in impact score
p=.015 adjusted for baseline function
Strengths-based approach
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Build on strengths; great for sales,
entertainment, the arts
–
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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
Health Care Steps
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Health promotion
Disease prevention
Early detection
Early, safe, effective,
evidence-based,
culturally sensitive
care
Tertiary care
Rehabilitation
Treatment Strategies
How: Behavioral Pediatrics
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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
Which is a specific goal?
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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
Which is a specific goal?
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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
Healthy Habits, Healthy Habitat
Relationships
Manage Stress
Food
Fitness
5 Fundamentals: 5Fs
1.
2.
3.
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5.
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
Activity/Sports
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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)
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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)
Sleep and ADHD
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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
Sleep Hygiene
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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, 5HTP, tryptophan
FOOD – or “When did Pop Tarts
become breakfast?”
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Eat Breakfast, Lunch,
Dinner, snacks
Maintain a normal blood
(glycemic index)
Whole Foods 
Avoid sensitizers
Get essential nutrients
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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).
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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
Appleton Central HS
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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.
Appleton Central HS
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Very Striking Improvements
– Better academic performance
– Fewer Behavior problems
– Less fighting
– Less drug use
Dietary Controversies
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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
Artificial Colors, Flavors,
and Preservatives
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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
Food allergies?
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Allergic shiners
Hx of colic
Hx of ezcema
Hx of reflux
Long bone pain (vit
D insufficiency?)
Belly pain, IBS
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Bad breath
Foot odor
Hx of antibiotics
Family hx atopy
Runny nose
Insomnia
ADHD and Food Allergy
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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
ADHD and Food Allergy
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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
Dietary Trial
1. Remove potentially sensitive food(s)
for 2 weeks; NOT FOREVER
2. Challenge eliminated foods one at a
time
3. Keep diary
4. Must be highly motivated and nutrition
educated
Supplements
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Correct deficits
– Iron
– Zinc
– Magnesium
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Omega 3 fatty acids
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NOTE: Most MV contain
very little of these three.
Diet is best source.
Iron in ADHD
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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)
Zinc in ADHD
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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)
Zinc in ADHD
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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.
Zinc for ADHD
Akhondzadah S BMC Psychiatry 2004
Magnesium?
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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
Flax oil and vitamin C
supplements improve ADHD
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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
Essential fatty acid DS
for ADHD
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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.
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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
Omega-3’s, ADHD, and LD
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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
TV and ADHD
TV and Attention
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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
TV and ADHD in Adolescence
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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
TV and Attention
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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)
Behavioral Reframes
Stumbling block
Stepping stone
What’s wrong?
What do you want?
What caused it?
How can we fix it?
Who is to blame?
What can we do about it?
What if it fails?
How will we celebrate mastery?
Will I fail?
What will it take to succeed?
I’m a failure.
I’ve identified important areas of strength
and challenge areas to improve.
Share with parents. Try them yourself. Role play with
family members, staff, or each other during breaks.
Manage Mistakes Constructively
Do
Don’t
Recognize the mistake
Ignore or cover up an error.
See it as a learning opportunity
Engage in name-calling (idiot,
moron, loser, terrible person,
awful parent, etc.) or fault
finding
Remember that all human beings
have needs, values and goals
Tell yourself what you “should”
have done
Reflect on your resources
Dwell on deficiencies
Pick one small, concrete,
measurable achievable
behavior to improve.
Be overly ambitious or vague.
Plan to celebrate your successes
Take success for granted.
SMART PLAN
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Specific
Measurable
Achievable
Reasonable and Relevant
Time-specific and Trackable
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.
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.
Explore Resources/Barriers
(e.g. Exercise)
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Resources
Motivation
Family Support
Have dog to walk
Have sidewalks
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Barriers
Time; reschedule
No friends doing it;
shy
Need better shoes
Pros and Cons
CHANGE
Pros
(reasons to do it)
Cons
(reasons against it)
Making a change
More physically fit
Better performance and
attention span
More time with fit friends
Takes time
Equipment expense
Not changing
No need for new clothes or
shoes
No gym membership expense
Feel guilty for not doing
what I know is right.
Risk of obesity, heart
disease, cancer
Continued inattention
See Mental Health Naturally for blank forms and more examples
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.
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.
TRACK PROGRESS
Activity
M
Tu
Week 1:
√
bike
√
run
W
T
F.
Sat
Sun
TOTAL
SUCCESSES
√
walk
√
bike
√
walk
5!
Week 2:
Week 3:
Week 4:
Week 5:
CELEBRATE; REFLECT, REVISE, REPEAT
Resources
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Web
– www.aap.org/sections/CHIM
– www.wfubmc.edu/cim
Books
– Kemper K. Mental Health, Naturally
– Culbert and Olness. Integrative Pediatrics
Suggested Practice Changes
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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 ([email protected] 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.
EXTRA INFO
Melatonin in ADHD
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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
American ginseng and Ginkgo
for ADHD
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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