Attention Deficit Hyperactivity Disorder: Clinical Review

What is ADHD?

• Most commonly diagnosed behavior disorder in children, affecting 3–5% of all American children
• Child can be inattentive, impulsive, and hyperactive-also restless and fidgety, talking too much and interrupting conversations, easily distracted
• In school, has trouble completing assignments, does not listen well, disorganized, disruptive in class
• Feels isolated from peers
• Behavoir can persist into adolescence and adulthood; these individuals may be antisocial, impulsive and have problems in school
• Symptoms must persist for at least 6 months to a significant degree that is maladaptive for the diagnosis to be made

Etiology

• Not completely known, but strongly suspected to be related to a neurochemical imbalance in the brain
• Dietary factors such as amino acid deficiency, vitamin deficiency, blood sugar swings from too much simple sugars, food allergy, exposure to dyes and other food additives are often associated with ADHD, and studies are suggestive (Kaplan et al, 1989), but not conclusive; data and studies are controversial and contradictory; Feingold diet is not now widely accepted as valid
• Hyperkinetic boys showed markedly different protein metaboism than normal boys—weight and height inversely proportional to hyperactivity
• Some children have lower essential fatty acid concentrations in blood (Stevens et al, 1995)
• Food allergies remain a popular assumption with practitioners, but data is inconclusive
• The central nervous system is almost entirely regulated by amino acids and peptides-protein deficiency is possible with junk food diet high in fats and sugar
• Studies show lower that normal levels of dopamine in animal models
• Effective medications influence levels of several brain neurotransmitters
• Low metabolic levels in regions of the brain controlling attention, social judgement, using PET imaging
• Risk factors include low birth weight, hypoxia at birth, exposure to alcohol, cocaine, and nicotine

Modern Medical Treatment

• A high success rate with comprehensive program of drugs, counseling, increased attention from parents, dietary intervention (up to 67%); most practitioners, researchers agree that treatment should not focus on drugs alone, yet counseling time is often limited
• Pharmaceutical drug therapy includes methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert), along with antidepressants like imipramine (tricyclic); inhibits reuptake of serotonin, norepinephrine, has sedative action
• Drugs can improve attention, reduce restlessness, impulsiveness, improve performance in school, decrease aggression
• Behavioral therapy includes work with psychologist and in groups; behavior modification is one method (rewards and incentives for changing behavior)
• Parent education is important

Outcome/Prognosis

• Children seldom completely outgrow the behavior, but they can either adapt or even turn the emotional and mental predisposition to their advantage-adults are often passionate, emotional, intense, highly energetic

Ritalin is the most commonly-prescribed medication. Its affects on children with attention and other behavioral problems were first mentioned in 1937, first published study was in 1948 by Meier. Many psychiatrists agree with more multifaceted approach in theory, but most tend to only prescribe Ritalin.

Adverse Effects (Short and Long Term) of Ritalin and Methedrine

Organic System Affected

• Cardiovascular

  • Palpitation
  • Tachycardia
  • Increased blood pressure

• Central nervous system

  • Excessive CNS stimulation
  • Psychosis
  • Dizziness
  • Headache
  • Insomnia
  • Nervousness
  • Irritability
  • Attacks of Gilles de la Tourette or other tic syndromes

• Gastrointestinal

  • Anorexia
  • Nausea
  • Vomiting
  • Stomach pain
  • Dry mouth

• Endocrine/metabolic

  • Weight loss
  • Growth suppression

• Other

  • Leukopenia
  • Hypersensitivity reaction
  • Anemia
  • Blurred vision

Summary of Studies on Ritalin

Study Type	Patient No./Age	Outcome	Reference
Randomized double-blind placebo-controlled	234 children, 5–15 years old	insomnia, decreased appetite, stomachache, headache, dizziness increased during therapy even at low doses (0.3 mg/kg); consistent with other studies; irritability and sadness reported in up to 22% of children receiving stimulant meds	Ahmann et al, 1993
Open trial	—	Up to 9% of children studied developed tics which worsened on stimulant medication	Stevenson & Wolraich, 1989; Lipkin et al, 1994
Open trial	—	Growth retardation; can be more severe with longer treatment; drug “holidays” in summer and on weekends may compensate	Safer et al, 1972
15 separate controlled studies	—	significant elevation of resting heart rate was found in previously unmedicated children; reduced with continued tx	Safer, 1992
Open trial	—	May reduce cerebral blood flow; shown when delivered i.v.	Wang et al, 1994
Literature review	—	No evidence to suggest stimulant medication increases likelihood of drug or alcohol use in adolescents	Hechtman, 1985
New studies	—	Ritalin may be a risk factor for substance abuse; 17–45% of ADHD adults had alcohol abuse problems; increases cocaine use in rats; needs further study	Stevenson & Wolraich, 1989; Lipkin et al, 1994

Risks of Abuse of Stimulant Medications with Aging Treatment Population

• Internationally, Ritalin is considered to have a high potential for abuse
• Sharp increase of availability for children and their parents; production has increased from 1,361 kg in 1985 to 10,410 kg in 1995, most in last 5 years; 85–90% of prescriptions written for children and adolescents
• The United States now consumes more than 80 percent of the total world supply of methylphenidate or five times more that the rest of the world combined; United Nations Narcotics Control Division has written letters to U.S. officials expressing concern about increased use of Ritalin
• More patients are staying on the medications longer-even into adulthood
• More accessibility for older adults

“In addition, ADHD adults have a high incidence of substance abuse disorders. With three to five percent or more of today’s youth being administered methylphenidate on a chronic basis, these issues are of great concern.” “Methylphenidate is available (as Ritalin and in the generic form) in 5, 10 and 20 mg tablets for oral consumption. Ritalin SR and a generic version are available as sustained release tablets of 20 mg for oral use.”

Contraindications

• Glaucoma
• Motor tics
• Family history or diagnosis of Tourette’s Syndrome
• Under six years of age
• Cardiovascular problems
• Emotional instability?

Natural Medicine Protocols: TCM and Phytotherapy

Most Important Risk factors

• Diet
• Parent-child interaction (success of other relationships start here)
• Electromagnetic radiation

Treatment Can Focus On:

• Diet
• Parent Counseling (to encourage more attention to children, more touching, positive feedback); up to 50–70% may be psychogenic in origin
• Herbal treatment

Diet

Foods to Check, Eliminate from the Diet on a Trial Basis:

(Parents can adopt diet for best effect)

• Dairy, especially factory-farmed cow dairy products (growth hormones, steroids, antibiotics)
• Wheat
• Processed foods (dyes, preservatives, other additives)
• Refined sugar products (including fruit juice, rice milks, honey, dried fruits); fresh fruit in season ideal sweet
• Red meat, except organic or wild meat 1–2 times a week in small amounts
• Experimental Diet: In one study, artificial flavors, colors, chocolate, monosodium glutamate, preservatives, caffeine, specific problem foods for individual child, simple sugars, dairy was all eliminated; more than half of the subjects exhibited a marked improvement in behavoir; bad breath, night awakenings and trouble falling asleep was also helped (Kaplan et al, 1989)
• Double blind cross-over study showed relationship of food color intake in 220 children to extreme irritability, restlessness and sleep disturbance (Rowe, 1988) [children were given Feingold diet-food additive-free]
• A review of several well-designed studies refute a causal relationship between food additives and ADHD [Feingold diet] (Wender, 1986)
• Sugar intake was related to hyperactivity in one study-researchers said it was likely idiosyncratic, based on genetic presdisposition (Kaplan et al, 1989)

Foods to Consider Adding

• More fresh fruits, vegetables
• More soy products (unless allergic)
• Almond milk (high in L-tryptophan)
• More fish, turkey* (high in L-tryptophan)
• Amino acid supplements, especially L-tryptophan, GABA, taurine, glycine *Glycine (wheat germ, turkey, wild game) *Taurine (MSG can reduce levels; fish) [ *GABA (lysine may potentiate, in wheat germ, oats, egg; B6 is necessary for production of; manganese, taurine and lysine increases synthesis of) [therapeutic dose: up to 200 mg, t.i.d. to q.i.d.] *Tryptophan is often deficient in vegetable foods, except almonds, wheat germ, soy (corn and rice are especially so) [therapeutic dose: 200-1000 mg]
• B-vitamin supplements, especially vitamin pyridoxine (B6, most important vitamin for amino acid metabolism), riboflavin, niacin (can spare tryptophan);
• Note: blood plasma test is most accurate for amino acid status**

Nutrient	Affect	Food	References
Phosphatidyl choline	supports nerve function	soy, lecithin supplements	—
GLA, linolenic, linoleic acids	insures proper essential fatty acid status	borage seed oil, evening primrose oil, flax seeds	1 study showed significantly lower essential fatty acid levels in 54 children with ADHD (Stevens et al, 1995)
Pycnogenol, catechins, leucoanthocyanidins	antioxidant	grape seeds, extract	—
Calcium, magnesium supplements	“sedates heart fire” promotes nerve function	oyster shell flour; supplements	—

Herbal Strategies

Treating the Branch (Phytotherapy)

Summary

• Calmatives (relax CNS, promote sleep, reduce hyperactivity)
• Antispasmodics (reduce tics, intestinal spasms, promote digestion, relax muscles)
• Aperient/Bitters (reduce food allergies; more complete digestion, eliminate mucus)
• Regulate hormones (thyroid, adrenals, sexual hormones)

Action Type	Herb	Prep- aration	Dose	Energy	Contra	Notes
Calmatives	Eschscholtzia rx	1:3 tincture	2–4 ml q.i.d.	cool, bitter	yin xu wi/o yin tonics	weak benzodiazepine activity but non-addictive; commonly prescribed in Europe; generally safe
	Passiflora hb	1:4 tincture	3–5 ml q.i.d.	cool	none known	mild calmative for worriers, paranoia
	Humulus fl	infusion; 1:5 tincture	2–4 ml q.i.d.	warm	diuretic; not just before bed; drying	phytoestrogenic
	Valeriana rz	1:3 fresh tincture	2–4 ml t.i.d.	spicy warm	yin xu; drying, can stimulate children who are very yin and blood deficient	sedates, central nervous system
	Lactucca	dried juice	1–2 grams b.i.d.	cool, bitter	stomach fire	juice whole fresh plant, dry in food dehydrator; official in U.S.P as “lactucarium”
	Scutellaria hb	1:4 tincture	2–4 ml t.i.d.	cool, bitter	none known	especially calming to tics, twitches, “restless leg syndrome,” or “happy legs”
	Nepeta hb	infusion	_ to 1 cup b.i.d. or before bed	spicy-cool	dislike of cats	mild sleep-inducing herb
	Tilia hb	infusion	_ to 1 cup b.i.d.	cool	none known	tastes good, mildly relaxing
Anti- spasmodics	Piper meth. rx	1:2 tincture, commercial extract	1–3 ml t.i.d.; 100-300 mg of powdered extract	warm	alcohol potentiates; bradychardia	only significant western herbal skeletal muscle relaxant; can interfere with muscle coordination; mildly euphoric
	Chamomilla	1:4 tincture; infusion	1–3 ml t.i.d.; _ to 1 cup t.i.d.	cool	none known	mildly calming, good before bed, relaxes intestinal spasms (colic)
	Dioscorea vil.	1:2 tincture	2–4 ml t.i.d.	neutral	none known	relaxes bowels
	Eschscholtzia	1:3 tincture	2–4 ml t.i.d.	cool, dry	yin xu-use yin tonics
Cool liver fire	Gentiana	1:3 tincture	1–2 ml t.i.d.	cool	stomach fire
	Taraxacum	1:3 tincture	3–5 ml t.i.d.	cool	none known
Regulate brain metabolism	Ginkgo	1:4 tincture, standard extr.	2–5 ml t.i.d. 40 mg t.i.d.	cool	caution with 24% SE	also reduces action of PAF
Support adrenals	adaptogens: eleuthero, Panax q., Ligustrum l.	1:3 tincture	various	cool; various	Panax q.-not with yang xu
Regulate hormones: Calm thyroid	Lycopus (calm thyroid) bladderwrack	1:5 tincture	2–4 ml t.i.d.	cool blwrk neutral	not with hypothyroidism	bladderwrack regulates hormones
	Vitex (regulate sex hormones)	1:4 tincture, capsules PH	1–2 ml b.i.d.	warm	not with birth control pills
Strengthen digestion, eliminate phlegm	Artemisia abs.	1:5 tincture	1-2 ml t.i.d.	Cool	stomach fire
	Centaurium	1:4 tincture	2–3 ml t.i.d.	cool	stomach fire
Support liver	Silybum	standard extr.	120 mg b.i.d.	cool	none known	protects liver with pharmaceutical drugs
Action Type	Herb	Prep- aration	Dose	Energy	Contra	Notes

TCM

• Spleen tonics (Panax g.-sometimes paradoxical effect, calms hyperactive kids), jujube, Glycyrrhiza, etc.)
• Remove food stagnation (Crataegus, sprouted barley, rice, wild radish seed)
• KI yin tonics (Ligustrum, rehmannia, Panax q.)
• Liver yang rising: liver yin tonics (Ligustrum l., anemarrhena), also calm liver yang
• Drain liver fire: xia ku cao (Prunella); huand qin (Scute); Long dan cao (Gentian); Mi Meng hua (Buddleia flowers); Zhi zi (gardenia fr.)

Calming formulas in TCM

• Nourish Yin, clear heart heat (Tian Wang Bu Xin Dan) [Sedative Cinnabar bolus (flaring up of pathogenic fire of the heart due to insufficiency of vital essence of the heart-calms nerves, clears pathogenic heat, nourishes blood] Decoction of Glycyrrhizae, wheat and jujube (for yin xu with visceral disturbance, Nourishing the heart and claming nerves-fidgeting, anxiety)
• Calm Liver Wind; Nourish Liver, Calm Spirit Tian Ma Mi Huan Su (Gastrodia and Honey mushroom extract) [mention Armilariella extract] Decoction of Ziziphi Spinosae (calms restlessness and insomnia due to insufficient liver blood, giving rise to endogenous pathogenic heat)

Where can I find more information?

These articles, available from a medical library, may provide more in-depth information on ADD:

• “Attention-Deficit Hyperactivity Disorder: Recent Literature.” Hospital and Community Psychiatry, 40:7; 699–707 (July 1989).
• “Attention Deficit Disorder: Current Perspectives.” Pediatric Neurology, 3:3; 129–135 (1987).
• “Attention-Deficit Disorder in Adults.” Clinical Therapeutics, 14:2; 138–147 (1992).
• “Attention Deficit Hyperactivity Disorder—Residual Type.” Journal of Child Neurology, 6; S44–S50 (1991).
• “Diagnosis and Management of Attention Deficit Disorder: A Pediatric Perspective.” Pediatric Clinics of North America, 31:2; 429–457 (April 1984).

Information may also be available from the following organizations:

• Children with Attention Deficit Disorder (CHADD) 499 NW 70th Avenue Suite 109 Plantation, FL 33317 (305) 587-3700
• Challenge, Inc. P.O. Box 488 West Newbury, MA 01985 (508) 462 -0495
• National Center for Learning Disabilities, Inc. 281 Park Avenue South Suite 1420 New York, NY 10016 (212) 545-7510
• Learning Disabilites Association of America 4156 Library Road Pittsburgh, PA 15234 (412) 341-1515 (412) 341-8077
• National Institute of Child Health and Human Development Building 31, Room 2A32 Bethesda, MD 20892-2425 (301) 496-5133
• National Institute of Mental Health Parklawn Bldg, Room 7C02 5600 Fishers Lane Rockville, MD 20857-8030 (301) 443-4515

Further Reading

• “Attention-Deficit Hyperactivity Disorder: Recent Literature.” Hospital and Community Psychiatry, 40:7; 699-707 (July 1989).
• “Attention Deficit Disorder: Current Perspectives.” Pediatric Neurology, 3:3; 129–135 (1987).
• “Attention-Deficit Disorder in Adults.” Clinical Therapeutics, 14:2; 138–147 (1992).
• “Attention Deficit Hyperactivity Disorder–Residual Type.” Journal of Child Neurology, 6; S44–S50 (1991).
• “Diagnosis and Management of Attention Deficit Disorder: A Pediatric Perspective.” Pediatric Clinics of North America, 31:2; 429–457 (April 1984).

Information drawn from:

• National Alliance for the Mentally Ill Helpline Fact Sheet: Attention Deficit Disorder
• National Institute of Neurological Disorders and Stroke/NIH: Attention Deficit Disorder

References

• Burgess JR. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. American Journal of Clinical Nutrition, 1995 Oct, 62(4):761–8. [Food additives and hyperactive behavior in children (letter)].
• Nederlands Tijdschrift voor Geneeskunde, 1991 Apr 20, 135(16):725–6.
• Kaplan B.J. et al. 1989a. Dietary replacement in preschool-aged hyperactive boys. Pediatrics 83(1):7–17.
• Kaplan, B.J. et al. 1989b. Overall nutrient intake of preschool hyperactive and normal boys. Journal of Abnormal Child Psychology 17(2):127–32.
• Rowe KS. 1989. Synthetic food colourings and ‘hyperactivity’: a double-blind crossover study. Australian Paediatric Journal, 1988 Apr, 24(2):143–7.
• Wender EH. 1986. The food additive-free diet in the treatment of behavior disorders: a review. Journal of Developmental and Behavioral Pediatrics, 1986 Feb, 7(1):35–42.
• Stein TP; Sammaritano AM. Nitrogen metabolism in normal and hyperkinetic boys. American Journal of Clinical Nutrition, 1984 Apr, 39(4):520–4.

© 2000 Christopher Hobbs