Download Alternative treatments for ADHD

Non-pharmacologic
Alternatives in the Treatment
of Attention Deficit
Hyperactivity Disorder
Kelsey Brown
Advisor – 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 parentteacher 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 attention
and 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.