An Integrative Approach to

ADHD
Dr. Sandy Newmark
Center for Pediatric Integrative Medicine
Program in Integrative Medicine
University of Arizona

What is ADHD
ADHD is a syndrome consisting of some
combination of
Hyperactivity
Problems with attention and concentration,
Impulsivity

That is causing significant problems at

both home and school.

A Syndrome Not a Disease

A Syndrome is a collection of symptoms or
traits or characteristics that form a pattern.
fails to finish things
has a hard time sitting still
daydreams a lot

Pneumonia is a Disease
Chronic Fatigue is a syndrome
ADHD is a very subjective diagnosis

Incidence of ADHD
In 2003, approximately 4.4 million
children aged 4--17 years were reported to
have a history of ADHD diagnosis; of
these, 2.5 million (56%) were reported to
be taking medication for the disorder.

CDC - from the 2003 National Survey of

Children's Health (NSCH).

Ritalin Use in the United States

Estimated Number of Children Taking
Ritalin
1970 - 150,000
1980 - Between 270,000 and 541,000;
1990 - 900,000,
2003 - 2.5 million

Ritalin Use in the United States

Why the Explosion in ADHD?

Possible Explanations
We are better at finding and helping children
and adults who really do have ADHD.
There are more children now who actually
have ADHD
We have loosened the definition so more kids
are being diagnosed
We are actually diagnosing many children
who dont have ADHD, even by a loosened
definition.

Why the Explosion in ADHD?

We are better at finding and helping
children and adults who really do have
ADHD.
Kids previously termed lazy or stupid.
Kids who dropped out early.
Behavior problems.

Why the Explosion in ADHD?

There are more children now who actually
have ADHD
Toxins in the prenatal and early childhood
environment (over 200 contaminants found in
umbilical cord blood)
Less effective parenting mother not in
home, father working more. Everyone more
stressed.
Higher demands on children

Why the Explosion in ADHD?

There are more children now who actually
have ADHD
Toxins in the prenatal and early childhood
environment
A recent study found over 250 toxins in
umbilical cord blood, including mercury,
pesticides, organochlorines.

Organochlorines and Child

Development
Dichlorodiphenyl dichloroethylene
(p,p'DDE) measured in umbilical cord
blood.
Serum levels were negatively associated
with both mental and psychomotor
development.
The higher the serum level, the worse the
child's development at 13 months old.

Why the Explosion in ADHD?

There are more children now who actually
have ADHD
Less effective parenting mother not in
home, father working more. Everyone
more stressed.
Teachers are more stressed as well

Why the Explosion in ADHD?

We have loosened the definition so more
kids are being diagnosed
Years ago it was only the extremely
hyperactive child being treated, now,

The inattentive child

The difficult or intense child
The rambunctious 3 year-old
The child of demanding parents.

Why the Explosion in ADHD?

Increased pressure on High School and
College Students
Ritalin has become the drug of choice for
students who cram.
"All you have to do is read a book on
ADHD and you know what to tell a doctor,"
Cafeo said. "Now a lot of kids get it by
saying they have a problem studying.

Ritalin Use/Abuse in Colleges

In a Midwestern UniversityFindings
revealed that 17% of 179 surveyed men
and 11% of 202 women reported illicit use
of prescribed stimulant medication.
"It's a miracle drug," (a student) told The
Boston Globe. "It is unbelievable how my
concentration boosts when I use Adderall.

Why the Explosion in ADHD?

We are actually diagnosing many children
who dont have ADHD, even by a
loosened definition.
Inadequate evaluations
Schools demanding treatment
Discipline problems

How Do We Diagnosis ADHD?

History, History, History!
From Parents, Child, Teachers,
Others
Standardized Questionnaires

The ADHD Evaluation

Initial Interview is usually about 2-1/2 hours. (for
me, usually 2 sessions)
Besides the standard Integrative Consult:
Need to speak to the parents alone, the child alone,
and the family together.
Use some type of standardized questionnaire.
Also speak to teachers, counselors, school
psychologists.
Review any previous psychoeducational evaluations
or other professional consults.

Many conditions can be

Misdiagnosed as ADHD, including:

Depression or bipolar disease

Anxiety Disorder
Learning disabilities
The Gifted Child
Intense or difficult temperament

Problems that can mimic or coexist

with ADHD
Oppositional Defiant Disorder
Misfits between the child and school, or
even the child and teacher.
Sleep Apnea or Upper Airway Obstruction
Iron Deficiency
Lead toxicity

Conventional Treatment of ADHD

Behavioral methods
School support
Psychostimulant medications
Ritalin, Concerta
Dexedrine, Adderall
Strattera

Other medications
Clonidine, Tenex
Mood Stabilizers Depakote, Risperdal

Psychostimulant Medications for

ADHD
Are They Lifesavers for
Children, Parents, Counselors,
and Teachers?
or

A Horribly
Destructive Drug
Which is Destroying
Our childrens Minds!

1. Although medications such as Ritalin can

be helpful and are sometimes necessary,
they should not be the first and only
treatment approach.
2. There is lots of hysteria about these
medications.
3. They are not as good or bad as some
people make them out to be.

Stimulant Medications and SideEffects

Decreased Appetite
Trouble Sleeping
Abdominal Pain
Headaches
Tics
Bizarre Behavior
Generally, all of these stop when the
medication is stopped

Dangers That Do Not Exist

Liver Damage
Kidney Damage
Brain Damage
Increasing Potential for Addiction -doubtful
It is NOT just like cocaine

More Subtle but Worrisome

Effects

Hes just not himself

Hes lost his spark, or his joy
Hes just not the same kid
Loss of Creativity

An Integrative Approach
It is important to see the child in the
context of his family, friends, school, and
community, and not just as someone with
a set of symptoms one is trying to fix.
Sometimes a change in the home
environment, school or teacher is more
important than any medicine or herb.

An Integrative Approach -1
Nutrition Basic healthful eating
Nutrition food Sensitivities and
elimination diets
Nutritional Supplements
Omega-3 Fatty Acids
Zinc
Multivitamins

Creative Behavioral Approaches

An Integrative Approach - 2
Alternative or Complementary Therapies
Herbal or Botanical approaches
Homeopathy
Craniosacral Therapy
EEG Neurofeedback
Traditional Chinese Medicine-Acupuncture

Nutrition

Sugars
Artificial additives and preservatives
Processed flour (the glycemic index)
Protein

Appleton Central
Appleton Central Alternative Charter High
School kids struggling in conventional
settings
Natural Ovens began a healthful meal
program for breakfast and lunch
Vending machines selling candy, soda,
and chips removed.
Great positive results in behavior,
concentration. See Video

Appleton Typical Weekly Menu

Monday: Tacos, fresh fruit, salad bar, energy drink,
whole grain breads
Tuesday: Scalloped potatoes and ham, corn, Texas
toast, fresh fruit, salad bar, energy drink, whole grain
breads
Wednesday: Chicken Noodle Soup, Turkey
Sandwiches, Ham or Egg Salad, fresh fruit, salad bar,
energy drink, whole grain breads.
Thursday: Chicken Patty on a Bun, Roasted
Vegetables and Pasta, Fresh Fruit, salad bar, energy
drink, whole grain breads.
Friday: Baked Omelets, Sausages, fresh fruit, salad
bar, energy drink, whole grain breads

Food Allergies
A number of good scientific studies have
shown that some children with ADHD will
have significant improvement in their
symptoms if taken off foods or additives
they are sensitive to.
Single Elimination vs multiple elimination
diets
Feingold

Food Colorings and Preservatives

277 children had artificial food colorings and
sodium benzoate preservatives removed from
their diet
Hyperactivity decreased
In a placebo-controlled study, those who had the
colorings and preservatives added back had a
return of their hyperactive behavior.

Arch Dis Child. 2005 Aug;90(8):875

Omega-3 Fatty Acids

Types of fat necessary for normal
neurological development -Lipil
Definitely at low levels in the blood of
children with ADHD
Have been shown to be helpful in studies
of children with learning disabilities and
other behavioral disorders

Omega-3s and LD
41 Children with ADHD and LD given a
supplement containing Omega-3s for 12
weeks or a placebo.
After 12 weeks, children in the treatment
group had significant improvement in their
ADHD scores compared to placebo.

Omega-3s and LD

Developmental Coordination
Disorder
Performance in Daily Activities that Require
Motor Coordination is substantially below that
expected given age and intelligence.
Motor delays, clumsiness, poor handwriting
Substantial overlap with ADHD, Learning
Disabilities, Autism, and Sensory Integration
Disorder

Methods
117 children (5-12 years old) 60 active,
57 placebo
3 month trial of Omega 3 and 6 Fatty
Acids,
Active treatment - 80% fish oil and 20%
evening primrose oil.

Reading
Before treatment, mean achievement
scores 1 year below chronologic age.
After 3 months, the mean increases in
reading age were:
Active Treatment - 9.5 months
Placebo - 3.3 months

(z = 2.87, P < .004)

Spelling
After 3 months the mean increases in
spelling age were:
Active treatment - 6.6 months Placebo 1.2 months
Again, the group difference was highly
significant (z = 3.36, P < .001).

ADHD Related Symptoms

Active treatment, scores decreased from a mean
of 74.7 to a mean of 58.1, a reduction of >0.5
SD.
In contrast, almost no change was seen in the
placebo group (pretreatment mean: 69.5; post
treatment mean: 67.9;
This group difference was highly significant (z =
5.48, P < .0001).

Zinc for ADHD

40 Patients with ADHD between 5 and 11

20 given Ritalin and Zinc
20 given Ritalin and Placebo
Teacher and parent rating scales done at
day 1 and after 6 weeks.

Zinc for ADHD

Zinc for ADHD

Behavioral Approaches
Can be effective, with or without
medication
Often history is good year-bad year, goodyear-bad year. Why? Great teachers!
Kids with ADHD need structure, firm limits,
and lots of positive reinforcement.
What if an entire school could have that
kind of approach?

Praise in, Ritalin out for Tolson

pupils

Tolson School-the Nurtured Heart

75% school from low income families.
Four years ago entire school began to
apply Nurtured Heart approach
Behavioral management system based on
increased positive feedback, clear rules,
and well defined consequences.

Tolson School
Discipline problems dropped sharply
Special education dropped from 31
students to 7 students
Now 2 of 519 students on medication for
ADHD (0.3%)
Performing Plus School - increasing test
scores.

Other Herbs and Dietary

Supplements

Ginkgo
Ginseng
Pycnogenol
Tyrosine
Phosphatidylserine
Glyconutrients
St. Johns Wort
Commercial Combinations Attend Quiet
mind

EEG Neurofeedback
Children with ADHD do have a different
pattern of brain waves
They can change these using video game
biofeedback.
Does it help ADHD?
Does it last?
Drawbacks-expensive and timeconsuming

Homeopathy

Completely different from herbal medicine

Incredible dilutions of common substances
like cures like
Based on the whole person
Sometimes it works!

Craniosacral Manipulation
Gentle Osteopathic type of manipulation
Not much science behind it
Sometimes it works!

Traditional Chinese Medicine

Acupuncture and Herbs
Some claims that it can be helpful
Havent seen it myself but no harm in
acupuncture
Careful about the herbs.

The Bottom Line

Make sure the diagnosis of ADHD is
correct
Find a doctor who is has experience,
expertise, and is willing to look at a child
as a whole person in the context of a
family and community and not just as a
kid with ADHD.
Explore other possibilities before jumping
straight to medication.

THE KEY TO SUCCESFUL

TREATMENT OF ADHD IS
CAREFUL AND FREQUENT
FOLLOW-UP.