Clinical Correlate: ADHD
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Figure 1: Yoga and meditation have both been shown to positively benefit ADHD.
Definition
Attention-deficit/hyperactivity disorder (ADHD) is a chronic condition affecting millions of American children, which sometimes persists into adulthood.
ADHD is characterized by difficulty sustaining attention, and significant hyperactivity and impulsive behavior patterns.
Children with ADHD may struggle with self-esteem issues, may have difficulty with relationships, and may demonstrate poor performance in school. Symptoms sometimes lessen with maturity, but many clients never completely outgrow their ADHD challenges. However, clients can and often do develop strategies to be successful in life despite their ADHD.
There is no one cure for ADHD, but some complementary protocols can support clients to be more effective in school, work, and relationships.
Etiology¹
The exact causes of ADHD remain unclear, but research efforts continue to expand our understanding of possible causes.
ADHD often occurs in successive generations of families, suggesting a genetic basis[2]. As genetic factors associated with ADHD include tendencies towards allergies and decreased ability to detoxify drugs and heavy metals, environmental factors and diet play a significant role in how and whether these genetic factors result in the development of ADHD.
Signs and Symptoms
This condition has historically been called attention-deficit disorder (ADD), but attention-deficit/hyperactivity disorder (ADHD) is now the preferred term because it describes both of the primary features of this condition—inattention and hyperactive-impulsive behavior patterns.
Signs of ADHD may be noticeable as early as two years of age, but in some children, the signs appear later, often during the elementary school years.
The Centers for Disease Control and Prevention[3] diagnose ADHD by a range of symptoms, which are divided into two categories:
InattentionHyperactivity and impulsivity
#1 Inattention
A child up to the age of 16 must exhibit six or more of the following symptoms over a six-month period; adolescents older than 16 and adults must exhibit at least five of these symptoms over the same amount of time. In both age groups the behavior must disrupt normal development.
Symptoms of inattention may include:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activitiesOften has trouble holding attention on tasks or play activitiesOften does not seem to listen when spoken to directlyOften does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked)Often has trouble organizing tasks and activitiesOften avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)Is often easily distracted often forgetful in daily activities
#2 Hyperactivity and Impulsivity
Children and adolescents also need to present with at least six and five symptoms respectively over a six-month period. The symptoms are further classified as being disruptive and inappropriate for the developmental level.
In this category the individual often:
Fidgets with or taps hands or feet, or squirms in seat leaves seat in situations when remaining seated is expected run about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)Is unable to play or take part in leisure activities quietl Is often "on the go" acting as if "driven by a motor"Talks excessivelyBlurts out an answer before a question has been completedHas trouble waiting his/her turnOften interrupts or intrudes on others (e.g., butts into conversations or games)
ADHD occurs significantly more often in males than in females, and the behaviors are often quite different in boys and girls. The most typical pattern here is that boys may tend to be more hyperactive while girls may tend to be more quietly inattentive.
Differential Analysis
The differential diagnosis of ADHD includes:
Anxiety Disorders
Anxiety disorders are a large group of disorders that include generalized anxiety disorder, panic disorder, and various phobias.
Anxiety disorders, and specifically generalized anxiety disorder, are the most common causes of mental, emotional, and behavioral problems during childhood and adolescence.
Anxiety disorders may get confused with ADHD due to the similarity in symptoms: Difficulty with concentration, focus, and self-control, and hyperactivity.
However, in the case of anxiety disorders, these symptoms are caused by excessive worry, fears, and tension.
Bipolar Affective Disorder
Bipolar affective disorder is a mood disorder that causes a person to experience marked mood swings, from an extremely elevated mood (manic stage) to an extremely depressive mood (depressive episode).
While many symptoms overlap, bipolar affective disorders can be distinguished from ADHD as they are cyclic in nature and are accompanied by significant changes in sleep patterns and levels of energy.
Holistic Protocols
Exercise Program
Yoga, which can be combined with meditation, is recommended for adults and children suffering from ADHD. Yoga practice can help to relieve stress, increase focus and self-awareness, and raise confidence—all things people with ADHD can benefit from. Yoga was shown to be effective both as a family protocol for children diagnosed with ADHD[4] and when applied in high school settings[5].
Holistic Nutrition
Higher exposure to pesticides, particularly organophosphate compounds, was linked to increased risk of developing ADHD[6].
While it may be challenging to limit the diet exclusively to organic foods, focusing on the 2015 Dirty Dozen list of fruits and vegetables identified by the Environmental Working Group (EWG) can significantly reduce pesticide exposure[7]. (For example, the 2015 Dirty Dozen list includes apples, peaches, nectarines, strawberries, grapes, celery, spinach, sweet bell peppers, cucumbers, cherry potatoes, snap peas, potatoes, and hot peppers; however, this list is re-evaluated annually, so it's important to keep up-to-date. For more information, visit the EWG website athttp://www.ewg.org/foodnews/dirty_dozen_list.php (Links to an external site.))
Feingold Diet
A popular hypothesis proposed by Benjamin Feingol, MD, links the development of ADHD with exposure to food additives, such as artificial food colors, flavors, and preservatives[8]. While this hypothesis is not accepted by all healthcare professionals, studies provided solid evidence that a restricted diet focused on reducing the consumption of products containing food colors can benefit children with ADHD[9].
The Feingold Diet Program suggests eliminating food products that contains colors (Red 3, Red 40, Blue 1, Blue 2, Yellow 5, Yellow 6, Green 3, and others like Yellow 10 or Red 30), artificial flavors (such as vanillin), artificial sweeteners (such as aspartame and sucralose), and three preservatives (butylated hydroxytolune (BHA), butylated hydroxyanisole (BHT), and tertiary butylhydroquinone (TBHQ))[10].
Supplements
Iron and Zinc
Iron and zinc deficiency were also associated with ADHD. Low zinc and iron levels were linked with higher hyperactivity symptoms. Low zinc level was also linked with anxiety and conduct problems[11]. Iron supplementation (ferrous sulfate, 80 milligrams per day) was shown to produce considerable behavioral improvements[12]. Zinc supplementation (zinc sulfate, 150 milligrams per day) also helped to reduce many symptoms, such as hyperactivity, impulsivity, and impaired social behavior[13].
Magnesium
Magnesium aids smooth transmission of communications through the central nervous system, calms the central nervous system, and is essential for serotonin synthesis. It was reported that magnesium deficiency is much more common for children with ADHD than for healthy children[14].
Low dietary intake of magnesium was also linked to increased anger, frustration, and anxiety.
Studies have shown that magnesium supplementation (200 milligrams per day) may help relieve hyperactivity in children[15].
Omega-3 Fatty Acids
Children with ADHD often have a lower level of omega-3 fatty acids, which are critical for the development, structure, and function of brain cells. Studies have shown that dietary supplementation with fish oil, omega-3 fatty acids, and, particularly, eicosapentaenoic acid, can be effective for the management of ADHD symptoms[16].
Theanine
Poor sleep quality is a widespread problem among people suffering from ADHD. Theanine (an amino acid) supplementation (400 milligrams per day) was demonstrated as effective in improving sleep quality and was recommended as an adjunctive therapy[17].
Botanicals
American Ginseng
American ginseng Panax ginseng (L.), which is usually used as an antidepressant, has been investigated for use with ADHD. A few small-scale studies have demonstrated that ginseng supplementation can reduce hyperactivity and increase attention[18].
Ginkgo
Ginkgo Ginkgo biloba (L.) extract (dosage of 60 to 120 milligrams twice daily) has shown promising preliminary results for the management of the core symptoms of ADHD[19].
A combination of ginkgo and American ginseng was shown to be particularly effective; it reduced hyperactivity and impulsive behavior and helped to eliminate many social problems[20].
St. John's Wort
St. John's wort Hypericum perforatum (L.) has also been shown to manage ADHD. However, the results were much less promising with one study reporting it to be only slightly effective[21] and another study identifying it as ineffective[22].
Aromatherapy
Aromatherapy is a useful intervention for the management of many symptoms associated with ADHD, such as lack of concentration, hyperactivity, and impulsive behavior. It can be also used to improve sleep quality.
The following essential oils are usually recommended: Cedarwood Cedrus spp., frankincense Boswellia spp.,lavender Lavandula angustifolia (Mill.), ylang ylang Cananga odorata (Lam.), patchouli Pogostemon cablin(Blanco), and vetiver Vetiveria zizanioides (L.) Nash. Note that according to Tisserand, children with ADD/ADHD often have salicylate sensitivity. Essential oils with high methyl salicylate content, such as sweet birch Betula lenta (L.) and wintergreen Gaultheria procumbens (L.), should be avoided. Of course, these oils would not be recommended for use with children at all[23].
Homeopathy
Homeopathy was demonstrated as an effective intervention for children with ADHD[24]. One of the studies reported significant improvements when Stramonium, Cina, and Hyoscyamus niger were used.
Veratrum album and Tarentula hispanica were also reported to be effective.
In particular, Stramonium was indicated for children who suffered from numerous fears (especially of the dark or of water) or symptoms of post-traumatic stress disorder, such as startle responses or intrusive thoughts of traumatic events.
Cina was indicated for children who were physically aggressive, and prone to frequent fighting and arguing.
Hyoscyamus niger was indicated for the children who exhibited sexualized symptoms of any type, exhibited typically manic sorts of symptoms (pressured speech, very high energy, and indiscriminate positive evaluations), and were described as "wild" or impossible to control[25].
Other recommended homeopathic remedies include Tuberculinum, Verta alb, and Arsen iod[26].
Biofeedback
Biofeedback is often recommended and has successfully been used to manage many ADHD symptoms, such as inattention and impulsivity[27]. Biofeedback utilizes electronic instrumentation to provide clients with real-time feedback of their brainwave activity. Clients are trained to increase the production of brainwave patterns that reduce or eliminate ADHD symptoms.
References
[1] Etiology is the cause(s) for a disease or condition.
[2] Mick, E., & Faraone, S. (2008). Genetics of Attention Deficit Hyperactivity Disorder. Child And Adolescent Psychiatric Clinics Of North America, 17(2):261-284. doi:10.1016/j.chc.2007.11.011
[3] Centers for Disease Control and Prevention. (2015, June 26). Attention-Deficit / Hyperactivity Disorder (ADHD): Symptoms and Diagnosis. CDC.gov. Retrieved from: http://www.cdc.gov/ncbddd/adhd/diagnosis.html
[4] Harrison, L. (2004). Sahaja Yoga Meditation as a Family Treatment Programme for Children with Attention Deficit-Hyperactivity Disorder. Clinical Child Psychology And Psychiatry, 9(4):479-497. doi:10.1177/1359104504046155
[5] Mehta, S., Mehta, V., Mehta, S., Shah, D., Motiwala, A., & Vardhan, J., et al. (2011). Multimodal Behavior Program for ADHD Incorporating Yoga and Implemented by High School Volunteers: A Pilot Study. ISRN Pediatrics, 2011:1-5. doi:10.5402/2011/780745
[6] Bouchard, M., Bellinger, D., Wright, R., & Weisskopf, M. (2010). Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides. Pediatrics, 125(6):e1270-e1277. doi:10.1542/peds.2009-3058
[7] Environmental Working Group. (2015). EWG's Shopper's Guide to Pesticides in Produce. Environmental Working Group. [Online] Retrieved from http://www.ewg.org/foodnews/dirty_dozen_list.php
[8] Feingold, B. (1975). Why Your Child Is Hyperactive. New York, NY: Random House.
[9] Nigg, J., Lewis, K., Edinger, T., & Falk, M. (2012). Meta-Analysis of Attention-Deficit/Hyperactivity Disorder or Attention-Deficit/Hyperactivity Disorder Symptoms, Restriction Diet, and Synthetic Food Color Additives. Journal Of The American Academy Of Child & Adolescent Psychiatry, 51(1):86-97.e8. doi:10.1016/j.jaac.2011.10.015
[10] Feingold Association of the United States. (2015). ADHD DIET: What is the Feingold Diet? Feingold Association of the United States. [Online]. Retrieved from https://www.feingold.org/what.php
[11] Oner, O., Oner, P., Bozkurt, O., Odabas, E., Keser, N., Karadag, H., et al. (2010). Effects of Zinc and Ferritin Levels on Parent and Teacher Reported Symptom Scores in Attention Deficit Hyperactivity Disorder. Child Psychiatry Hum Dev., 41(4):441-447. doi:10.1007/s10578-010-0178-1
[12] Konofal, E. (2005). Effectiveness of Iron Supplementation in a Young Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics, 116(5):e732-e734. doi:10.1542/peds.2005-0715
[13] Bilici, M., Yıldırım, F., Kandil, S., Bekaroğlu, M., Yıldırmış , S., & Değer, O., et al. (2004). Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Progress In Neuro-Psychopharmacology And Biological Psychiatry, 28(1):181-190. doi:10.1016/j.pnpbp.2003.09.034
[14] Kozielec, T., & Starobrat-Hermelin, B. (1997). Assessment of magnesium levels in children with attention deficit hyperactivity disorder (ADHD). Magnes Res., 10(2):143-8.
[15] Kozielec, T., & Starobrat-Hermelin, B. (1997). 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(2):149-156.
[16] Richardson, A. (2006). Omega-3 fatty acids in ADHD and related neurodevelopmental disorders. International Review Of Psychiatry, 18(2):155-172. doi:10.1080/09540260600583031; Bloch, M., & Qawasmi, A. (2011). Omega-3 Fatty Acid Supplementation for the Treatment of Children With Attention-Deficit/Hyperactivity Disorder Symptomatology: Systematic Review and Meta-Analysis. Journal Of The American Academy Of Child & Adolescent Psychiatry, 50(10):991-1000. doi:10.1016/j.jaac.2011.06.008; Assareh, M., Davari Ashtiani, R., Khademi, M., Jazayeri, S., Rai, A., & Nikoo, M. (2012). Efficacy of Polyunsaturated Fatty Acids (PUFA) in the Treatment of Attention Deficit Hyperactivity Disorder: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Journal Of Attention Disorders. J Atten Disord. 2012 Nov 15. [Epub ahead of print] doi:10.1177/1087054712463962; Hawkey, E., & Nigg, J. (2014). Omega−3 fatty acid and ADHD: Blood level analysis and meta-analytic extension of supplementation trials. Clinical Psychology Review, 34(6): 496-505. doi:10.1016/j.cpr.2014.05.005
[17] Lyon, M., Kapoor, M., & Juneja, L. (2011). The Effects of L-Theanine (Suntheanine) on Objective Sleep Quality in Boys with Attention Deficit Hyperactivity Disorder (ADHD): a Randomized, Double-blind, Placebo-controlled Clinical Trial. Alternative Medicine Review, 16(4):348-354.
[18] Niederhofer, H. (2009). Panax ginseng May Improve Some Symptoms of Attention-Deficit Hyperactivity Disorder. Journal Of Dietary Supplements, 6(1):22-27. doi:10.1080/19390210802687221; Lee, S., Park, W., & Lim, M. (2011). Clinical effects of Korean red ginseng on attention deficit hyperactivity disorder in children: an observational study. Journal Of Ginseng Research, 35(2):226-234. doi:10.5142/jgr.2011.35.2.226
[19] Salehi, B., Imani, R., Mohammadi, M., Fallah, J., Mohammadi, M., Ghanizadeh, A., et al. (2010). Ginkgo biloba for Attention-Deficit/Hyperactivity Disorder in children and adolescents: A double blind, randomized controlled trial.Progress In Neuro-Psychopharmacology And Biological Psychiatry, 34(1):76-80. doi:10.1016/j.pnpbp.2009.09.026; Uebel-von Sandersleben, H., Rothenberger, A., Albrecht, B., Rothenberger, L., Klement, S., & Bock, N. (2014). Ginkgo biloba Extract EGb 761 ® in Children with ADHD. Zeitschrift Für Kinder- Und Jugendpsychiatrie Und Psychotherapie, 42(5):337-347. doi:10.1024/1422-4917/a000309
[20] Lyon, M., Totosy de Zepetnek, J., Shan, J., Pang, P., & Benishin, C. (2001). Effect of the herbal extract combination Panax quinquefolium and Ginkgo biloba on attention-deficit hyperactivity disorder: a pilot study. J Psychiatry Neurosci., 26(3).
[21] Niederhofer, H. (2010). St. John's wort may improve some symptoms of attention-deficit hyperactivity disorder.Natural Product Research, 24(3):203-205. doi:10.1080/14786410802076259
[22] Weber, W., Vander Stoep, A., McCarty, R., Weiss, N., Biederman, J., & McClellan, J. (2008). Hypericum perforatum (St John's Wort) for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. JAMA, 299(22):2633. doi:10.1001/jama.299.22.2633
[23] Tisserand, R., & Young, R. (2014). Essential Oil Safety: A Guide for Health Care Professionals. (2nd Ed.). Elsevier Health Sciences, 660.
[24] Frei, H., & Thurneysen, A. (2001). Treatment for hyperactive children: homeopathy and methylphenidate compared in a family setting. British Homoeopathic Journal, 90(4):183-188. doi:10.1054/homp.1999.0506; Frei, H., Everts, R., von Ammon, K., Kaufmann, F., Walther, D., & Hsu-Schmitz, S., et al. (2005). Homeopathic treatment of children with attention deficit hyperactivity disorder: a randomized, double-blind, placebo-controlled crossover trial.European Journal Of Pediatrics, 164(12):758-767. doi:10.1007/s00431-005-1735-7
[25] Lamont, J. (1997). Homeopathic Treatment of Attention Deficit Hyperactivity Disorder: A Controlled Study.British Homoeopathic Journal, 86:196-200.
[26] Der-Ohanian, T. (2013). HOMEOPATHY FOR ADD/ADHD. Vitality Magazine. [Online]. Retrieved from| http://vitalitymagazine.com/article/homeopathy-for-add-adhd/ (Links to an external site.); Leckridge, B. (n.d.). British Homeopathic Association. Homeopathy for school children. Retrieved from http://www.britishhomeopathic.org/bha-charity/how-we-can-help/articles/homeopathy-for-school-children/ (Links to an external site.); Chase, B. (n.d.). 6 Homeopathic Remedies for ADHD. Progressive Health. [Online]. Retrieved from http://www.progressivehealth.com/adhd-homeo-remedies.htm
[27] Arns, M., de Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of Neurofeedback Treatment in ADHD: The Effects on Inattention, Impulsivity and Hyperactivity: A Meta-Analysis. Clinical EEG And Neuroscience, 40(3):180-189. doi:10.1177/155005940904000311
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