Download Complementary Therapies in ADHD April 19th, 2016, 12

Management and Diagnosis of ADHD
Learning Collaborative
Webinar #2
Title:
Complementary Therapies in
ADHD
April 19th, 2016, 12:15pm -1:00pm
Malinda Horton, CPNP
• Malinda has been a practicing NP for 25 years in
various settings from general pediatrics to bone
marrow transplant. She has completed a fellowship
in Integrative Medicine at the University of Arizona
and has specific training in aromatherapy as well as
herbalism. She works in the Pediatric Integrative
Medicine Program located at Primary Children’s
Hospital and has a private practice as well.
• Clinical interests are in the use of natural therapies
to address behavior and mood disorders, postconcussive syndrome as well as chronic pain.
[email protected]
Disclosures
• Funding from: nothing to disclose
• Institutional support from: nothing to disclose
CME Credit
Accreditation: This activity has been planned and implemented
in accordance with the essential areas and policies of the
Accreditation Council for Continuing Medical Education through the
joint providership of Primary Children’s Hospital, the Department of
Pediatrics at the University of Utah School of Medicine, and UPIQ.
Primary Children’s Hospital is accredited by the ACCME to provide
continuing medical education for physicians.
AMA Credit: Primary Children’s Hospital Designates this live
activity for a maximum of 8 AMA PRA Category
• 1 Credit(s)™. Physicians should only claim the credit that
commensurate with the extent of their participation in the
activity.
Objectives
1. Describe the most popular and most often used
complementary therapies in ADHD.
2. Become aware of the evidence for use of natural
ADHD therapies.
3. Identify modalities available in the community
which caregivers may be referred to.
Background
WHAT - Integrative medicine focuses on treating
the source of symptoms and utilizes all therapies
that have evidence and/or a low risk of harm.
WHO - 2012 National Health Survey: about 12 % of
children use complementary or alternative
medicine (CAM). Of that, about 2% used CAM for
ADHD
WHY - Parents report discomfort with long-term
stimulant medication and fear of side-effects as the
most common reason for seeking alternative care.
(Sinha, 2005)
Sinha D. et al, Complementary and alternative medicine use in children with attention deficit hyperactivity disorder. J Paediatr Child Health.
2005 Jan-Feb ;41(1-2):23-6.
Integrative Medicine Approach
“…address the genetic, biologic, environmental and
psychosocial factors while viewing each child as
unique.” Sandy Newmark, MD- Director of Pediatric Integrative
Neurodevelopmental Program UCSF
• Diet
• Dietary and herbal supplements
• Mind/Body – Yoga, Mindfulness, Biofeedback,
Neurofeedback
• Behavioral therapies
• Energy work
• Aromatherapy
Does Diet Affect Behavior?
• Parents have reported for many years that
eliminating food dyes, preservatives and artificial
ingredients have made a difference in behavior.
• Remains controversial but studies over the last 30
years demonstrate a connection between artificial
food colors and behavioral changes. (Arnold, 2012)
• Since 2010 the European Union has required
mandatory labeling on foods that contain 6 specific
artificial colorings. The label must state:
“…dyes may have an adverse effect on activity
and attention in children.”
Arnold, L. Artificial Food Colors and Attention-Deficit/Hyperactivity Symptoms: Conclusions to Dye for. Neurotherapeutics 2012,
9:599-609
The Appleton Central High School story:
A charter, alternative school in Wisconsin for children
with significant psychological and emotional problems.
In 1998 healthy meals began being served at breakfast
and lunch and junk food removed from vending
machines.
Principal concluded: “I can say without hesitation that
it’s changed my job.” “… we’ve had zero weapons on
campus, zero expulsions from the school….“Students are
on task, attentive and can concentrate for longer periods
of time.”
Gluten free ? Dairy free? Paleo? Elimination?
• Gluten breaks down to glutamate in the body- can contribute to
anxiousness and difficulty focusing in susceptible people.
• If food sensitivities are suspected, may be helpful to try elimination diet
in order to support gut health which in turn supports healthy serotonin
levels.
• Encourage a whole foods anti-inflammatory diet including protein for
breakfast. i.e. Pop-tarts are not breakfast!
- plant heavy
- low sugar
- healthy fats
- lean protein
- avoid or limit processed grains
Dietary Supplements
Omega-3s - Children with ADHD have lower RBC levels of omega-3s. (Colter,
2008)
• Mechanism may be related to neuronal cell membrane function and
phospholipid composition effecting dopaminergic and serotonergic activity.
• 2011 meta-analysis demonstrated Omega-3s to be “modestly effective” and
cumulative evidence supports this.
• Best dose is unknown however appears that higher EPA:DHA is better.
Generally, 500 - 2000mg daily.
Phosphatidylserine- most common phospholipid in the brain.
• Felt to increase production of dopamine and improve neuronal cell signaling.
Known to modulate cortisol effect.
• 2014 Hirayama et al. investigated PS at 200mg daily x 6 months in 36 children.
Significant improvements in inattention, auditory memory and impulsivity.
Subjects had never had medication treatment.
Hirayama, S. et al. The effect of phosphatidylserine administration on memory and symptoms of attention-deficit hyperactivity disorder: a
randomized, double-blind, placebo-controlled clinical trial. J Hum Nutr Diet 2014 Apr;27 Suppl 2:284-91.
Minerals
Zinc
• Two older studies suggest that when used with methylphenidate, medication
dosing could be reduced. (Arnold, 2011)
• High copper levels result in anxiousness and irritability. Zinc is usually low
when copper is high.
• Zinc picolinate 15-30mg daily taken with food.
Magnesium
• Cofactor in neurotransmitter synthesis and glutamate antagonist, producing
calming effect.
• Some studies have shown magnesium deficiencies (RBC) in children with
ADHD and improvement with supplementation, however there have been no
RCTs using magnesium as monotherapy.
• Magnesium aspartate or other chelated form best for crossing the blood brain
barrier. 100 – 200mg daily
1. Arnold L. Zinc for attention-deficit/hyperactivity disorder: placebo-controlled double-blind pilot trial alone and combined with amphetamine.
J Child Adolesc Psychopharmacol. 2011 Feb;21(1):1-19.
2. Russo, A. Decreased zinc and increased copper in individuals with anxiety. Nutr.Metab. Insights. 2011 Feb7;4:1-5
Iron
• Cofactor in synthesis of norepinephrine and dopamine.
• Low ferritin levels but not necessarily associated with anemia,
are proportional to more ADHD symptoms. (Oner, 2012)
• Anecdotally, most integrative practitioners recommend treating
for ferritin < 30.
Oner P. et al, Ferritin and Hyperactivity Ratings in Attention Deficit Hyperactivity Disorder. Pediatr Int. 2012 October ; 54(5): 688–692.
Herbal Supplements
Lemon balm – acts on GABA receptors
• especially helpful in younger children to promote calming and alertness.
• Most often combined with other herbs.
Bacopa – neuroprotective, regulates dopamine and inhibits cholinesterase
•
•
Used for centuries to aid memory, concentration and learning.
2014 open-label study over 6 months with 61 children – 85% of
participants had reduction in several ADHD behaviors.
Pycnogenol– believed to modulate elevated catecholamine levels in ADHD
• In a one month RCT there was reduction in teacher-rated hyperactivity and
inattention.
• After stopping the supplement, the behaviors returned to baseline.
• Significant improvement in anti-oxidant status 1 month after termination of
supplement.
1 .Dave, U. et al. An open-label study to elucidate the effects of standardized Bacopa monnieri in the management of symptoms of ADHD in
children. Advances in Mind-Body Medicine, vol. 28, no.2, pp. 10-15, 2014.
2. Trebaticka, J. et al. Treatment of ADHD with French maritime pine bark extract, Pycnogenol. European child and adolescent psychiatry.
Sep; 2006 15(6):329-335.
Choosing an herbal supplement
1. First choice is a professional level brand – only
available to practitioners and pharmacies.
2. Label should state that product complies with GMP
and or EU certification.
3. Choose organic herbal products when available and
should be a standardized extract.
4. Caution on Chinese and Indian herbs due to lead
contamination.
5. Parents should investigate company websites to look
for declaration of contamination testing.
Mind/Body – Stress Management
•
Yoga – studies have shown a mild benefit by reducing sympathetic
nervous system activity and learning to focus on breathing.
•
Mindfulness – 2016 meta-analysis of 9 small studies highlighted
possible benefits in reducing ADHD behavior (Cairncross, 2016).
•
Biofeedback/neurofeedback – involves feeding back
information to the brain to teach patients to alter their brain wave
pattern.
2014 review of 5 controlled studies on neurofeedback
demonstrated positive effect on inattention.
*30 -50 sessions at a total cost of $4-$5,000.
1. Cairncross, A., Miller, CJ. The Effectiveness of Mindfulness-Based Therapies for ADHD: A Meta-Analytic Review. J Atten Disord. 2016 Feb 2.
2. Micoulaud-Franchi, J. EEG neurofeedback treatments in children with ADHD: an updated meta-analysis of randomized controlled trials.
Front Hum Neurosci. 2014 Nov 13;8:906.
Massage – Few studies but demonstrate some shortterm benefit in mood and behavior.
Acupuncture – 2015 review of 13 controlled clinical
trials revealed that acupuncture with pharmacotherapy or
behavioral therapy is more effective than either the latter
two therapies alone based on the Connors’ index.
Energy work – No research to support this modality
but some patients report benefit.
Frequency Specific Microcurrent – Use of
physiological currents to modulate neurotransmitter
transmission. Only case study reports in ADHD.
Ni XQ, A. Meta-analysis on Acupuncture Treatment of Attention Deficit/Hyperactivity Disorder. Zhen Ci Yan Jiu 2015
Aug;40(4):319-25.
Referral Resources
Acupuncture and Massage
Primary Children’s Hospital Integrative Medicine Clinic
Alyssa Johnson L.Ac
Wendy Rolfe-Cook LMT
801-662-1602
Neurofeedback – University of Utah
Psychologytoday.com listings
Biofeedback
Numerous apps can be found for relaxation and attention
training.
See reference handout.
Comments/Questions
Malinda Horton, APRN, CPNP
Primary Children’s Hospital Pediatric Integrative Medicine
[email protected]
801-662-3680
Cornerstone Integrative Healthcare
[email protected]
801-599-4334
Reminder: 3rd Webinar, Tuesday, June 21st @12:15pm