1. 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

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)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

6. Vanderbilt:

7. ADHD Symptoms Inattention 1.Easily distracted 2.Forgetful 3.Loses things 4.Difficulty sustaining attention 5.Avoid/dislike difficult tasks 6.Difficulty organizing 7.Careless mistakes 8.Doesn’t listen 9.Difficulty following instructions 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

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 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 Wissow and Gadomski, 2008

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 Pediatrics 2008 Feb;121:266-75.

20. Crude 6-month change in child clinical measures as a function of change in provider’s patient-centeredness Change in symptom scoreChange in impact score p<.0001 adjusted for baseline symptomsp=.015 adjusted for baseline function

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 1. Identify the goal; prioritize among several 2. Consider various strategies 3. Pick a strategy 4. Identify a small, achievable step that the patient and family can support 5. Explore pros and cons of change 6. Anticipate barriers; identify resources 7. Plan rewards/celebrations! 8. 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 Food Fitness Manage Stress Relationships

28. 5 Fundamentals: 5Fs 1. Fitness and Sleep: more exercise, more sleep (sleep hygiene) 2. Food – “Eat food. Mostly plants. Not too much.” Consider supplements to avoid deficiencies and meet unique metabolic or drug-induced needs. 3. Friendship with self: emotional, mental, spiritual attention, frustration, and stress management 4. Friendship with others –participate; develop social skills; taking turns 5. 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. FOOD – or “When did Pop Tarts become breakfast?” 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 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

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 Akhondzadah S BMC Psychiatry 2004

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 MMousain-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 Stumbling blockStepping 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.

56. Manage Mistakes Constructively DoDon ’ t Recognize the mistakeIgnore or cover up an error. See it as a learning opportunityEngage 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 resourcesDwell on deficiencies Pick one small, concrete, measurable achievable behavior to improve. Be overly ambitious or vague. Plan to celebrate your successesTake success for granted.

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 moreB. 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 CHANGEPros (reasons to do it) Cons (reasons against it) Making a changeMore physically fit Better performance and attention span More time with fit friends Takes time Equipment expense Not changingNo 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

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 ActivityMTuWTF.SatSunTOTAL SUCCESSES Week 1:√ bike √ run √ walk √ bike √ walk 5! Week 2: Week 3: Week 4: Week 5: CELEBRATE; REFLECT, REVISE, REPEAT

65. Resources Web –www.aap.org/sections/CHIMwww.aap.org/sections/CHIM –www.wfubmc.edu/cimwww.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 monthtsalus@aap.org 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