Non-pharmacologic Alternatives in the Treatment of Attention Deficit Hyperactivity Disorder Kelsey Brown Advisor – Professor Fahringer.

Non-pharmacologic Alternatives in the Treatment

of Attention Deficit Hyperactivity Disorder

Kelsey BrownAdvisor – Professor Fahringer

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.”

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.

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

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

Dietary Interventions

• The Feingold Diet

• The Conners Sugar Challenge

• Crook’s Antifungal Agents

• Linus Pauling’s Megavitamin Therapy

• Magnesium Supplementation

• Omega-3 Supplementation

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.

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.

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.

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.

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.

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).

combining antifungal agents with the sugar elimination diet

• Crook’s 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.

Megavitamin Therapy

• based on Linus Pauling’s 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

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. Haslam’s findings suggest that megavitamins are of little benefit in the treatment of ADHD and may actually cause harm.

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).

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.

Behavior Modifications

• token economies

• positive attention for appropriate behaviors and punishment for non-compliance

• charting of antecedent behavior

• yoga

• massage

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

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.

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).

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 attentionand 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, 58:303-310, 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, 11:116-130, 2005.Starobrat-Hermelin, B. & Kozielec, T., The effects of magnesium physiological supplementation on hyperactivity

in children with attention deficit hyperactivity disorder (ADHD): Positive response to magnesium oral loading test. Magnes Res, 10:149-156, 1997.