Helping distractible, hyperactive kids.
Scott Shannon, M.D., a child psychiatrist at the McKee Center for Holistic Medicine in Loveland, Colorado, sees a lot of children suffering from problems with attention and hyperactivity. He described three children, two of whom have attention-deficit hyperactivity disorder (ADHD) and one who doesn’t. See if you can tell which is which.
“Rob,” Shannon says, “is spacey, off in another world. Testing shows he’s highly intelligent.” But 12-year-old Rob would, as the expression goes, lose his own head were it not attached. If he remembers to bring home assignments, he usually does them (with a little parental reminding). Unfortunately, he often neglects to turn in homework, which leads to Cs and Ds.
Mickey, on the other hand, is “a human top.” Unless he’s asleep, he’s constantly in motion. He runs rather than walks, shouts rather than speaks. He ransacks the toy box, playing with one toy for a few seconds, before tossing it and moving on to the next. When his kindergarten teacher insists he sit still, he soon becomes frustrated, sometimes to the point of throwing things and hitting his classmates.
Teachers didn’t complain about Amanda until she was 13. Before then, she had gotten Bs and Cs in school, had a good group of friends and played lacrosse. Her seventh-grade teacher observed that, during class, Amanda fidgeted, chewed her nails, stared out the window and wrote on her arm. Her grades plummeted. When a teacher commented on this diminished academic performance, Amanda became defensive, then burst into tears, saying, “I just can’t concentrate.”
Rob and Mickey both have ADHD. Amanda’s father lost his job and her parents have been arguing a lot lately. She suffers from anxiety, which makes it difficult for her to concentrate.
ADHD affects 3 percent to 5 percent of school-age children — perhaps as many as 2 million American kids, or about one child per classroom. Boys are three to five times more likely to be diagnosed with ADHD than girls. Symptoms begin before the age of 7 and often continue into adolescence and adulthood. The condition disrupts school performance, relationships with friends, family dynamics and psychological development. It has nothing to do with intelligence or talent. Leonardo da Vinci is thought to have had ADHD.
Although the exact cause hasn’t been pinpointed, most experts believe ADHD arises from a complex interaction of genetic, biological and environmental factors, a theory that fits with the fact that symptoms vary from child to child. And because many factors can generate symptoms, treatment needs to address those factors. Many experts believe ADHD is under-recognized, with less than half of affected kids receiving appropriate diagnoses. Moreover, few kids who do get a diagnosis receive appropriate treatment. However, some practitioners, such as Shannon, believe the condition is overdiagnosed.
Most psychiatric disorders interfere with a person’s ability to pay attention to the world around them. Anxiety and mood disorders (depression) are the most common disorders misdiagnosed as ADHD. Substance abuse and psychosocial stress also disrupt attention and, depending upon the situation, can make a child or adolescent hyperactive. Adults’ unrealistic expectations about child behavior also can lead to a misperception of ADHD. Because no single objective test identifies ADHD or any other psychiatric problem, arriving at a correct diagnosis can challenge the most astute and experienced. Vision and hearing problems, which can make a child appear inattentive, easily can be ruled out with appropriate testing. The same holds for head trauma and petit mal seizures.
An oft-cited 1999 study published in Clinical Pediatrics revealed that physician office visits for the treatment of ADHD more than doubled between 1990 and 1995. A 2002 update by the same authors found that the rate of doctors’ visits documenting a diagnosis of ADHD increased threefold in the United States between 1990 and 1998. During the same time period, prescriptions for stimulant drugs increased 2.8-fold for girls and 2.2-fold for boys. Another study, published in the American Journal of Public Health in 2002, found that in one North Carolina town, 15 percent of boys in first through fifth grade had been diagnosed with ADHD, triple the estimated prevalence of 3 to 5 percent. The 1999 Clinical Pediatrics study also found that prescriptions for the stimulant drugs that treat ADHD nearly tripled among children 5 to 18 years old.
Here’s the rub: For kids who really do have the condition, the consequences of inadequate treatment can include academic and social failure, low self-esteem, drug addiction and trouble with the law.
Some kids are naturally rowdier and more easily distracted than others. How, then, is a parent to know whether her child might have ADHD? Children usually are given the ADHD label when they’re significantly more rambunctious, impulsive and unfocused than their peers, and the symptoms impair schoolwork and social relationships.
Depending upon the nature of the symptoms, ADHD is split into three subtypes: (1) inattentive without much hyperactive or impulsive behavior; (2) hyperactive and impulsive but without a problem with attention; (3) both inattentive and hyperactive/impulsive. The combined type is the most frequent. Symptoms of inattention include having trouble with planning and with staying organized and on task. Easily distracted, these children bounce from one activity to the next, sometimes juggling several projects, rarely completing any of them. They also can become hyperfocused on something that interests them and have trouble switching gears. Hyperactive kids always seem to be moving or talking. Loud and impatient, they interrupt constantly and when asked to sit still, they fidget and bother their classmates.
But even in dealing with these recognizable behaviors, there is no objective test for ADHD. “Diagnosis hinges upon the child’s history and rating scales, both of which are notoriously subjective,” Shannon says. “A health professional judges whether a constellation of symptoms reaches a threshold for the criteria in the psychiatric handbook.” Because diagnosis takes time and expertise, Shannon urges parents to seek an evaluation from an experienced clinician — ideally a child psychologist or psychiatrist.
For argument’s sake, let’s say that some percentage of children who meet the criteria for ADHD simply don’t fit current cultural norms. A friend once remarked that his son would have thrived in this country a century ago. He would have been successful scouting, hunting, building railways and prospecting for gold. Instead, this energetic boy suffered in the confinement of the modern classroom.
Think about how our educational system has changed. Children are expected to begin reading at younger ages, classroom sizes have swelled (increasing the number of distractions and reducing the teacher’s ability to interact with students individually), and outdoor time and physical education have dwindled. Then add the cookie-cutter approach to education, where “No Child Left Behind” does precisely that when a child doesn’t fit the mold.
Now add dietary changes. The diet of a typical American child typically is low in brain-friendly nutrients (C and B vitamins, calcium, magnesium and long-chain fatty acids) and abundant in junk foods, which contain preservatives, simple sugars, caffeine, and saturated and hydrogenated fats. The nutrients the brain needs to function well are also the ones stress depletes. Shannon believes that a genetic vulnerability toward psychiatric maladies may further increase the brain’s demand for critical nutrients.
Adding insult to injury, most youngsters don’t get enough sleep. Sleep deficits in teens can erode academic performance. Specifically, fatigue can diminish learning, memory, attention, abstract thinking and grades, according to a 2004 study published in Child Development. Young children don’t yawn or otherwise look obviously sleepy; instead they become irritable, show low tolerance for frustration, display a short attention span and develop hyperactivity. Do those symptoms ring a bell?
Furthermore, tired children can’t handle stress very well. And American children are generally stressed. Stress disrupts concentration, makes people twitchy and interferes with learning and memory. Serious stress can cause a child to be inattentive, easily distracted, impulsive and restless. Many of the symptoms of stress in kids overlap with the symptoms of ADHD. Shannon often sees children who have been labeled ADHD but who are actually overstressed or downright anxious. Amanda is a case in point.
Conventional treatment for ADHD centers on the use of stimulants (Ritalin, Adderall and others), as well as giving children, teachers and family members skills to help with focus, attention and planning, and to counter unruly behavior. In mainstream American medicine, therapy plus drugs is thought to be the ideal treatment.
According to a 2004 study published in Psychiatry and Clinical Neurosciences, the medications can improve grades and behavior at home and at school. Side effects for the first few days include nausea, dizziness, abdominal pain and headaches. Reduced appetite with accompanying weight loss may persist. Contrary to popular myth, prescription stimulants in childhood do not raise the risk of later substance abuse, according to a 2003 study from the Journal of Child and Adolescent Psychopharmacology. However, children with untreated ADHD are at an increased risk for substance abuse.
In his practice, when Shannon believes medications are necessary, he starts with the lowest dose and works up, only as needed. He also employs a host of other treatment modalities to help his young patients.
A recent survey published in the Journal of Developmental and Behavioral Pediatrics found that 54 percent of parents used complementary and alternative therapies, including vitamins and dietary changes, for their children with attention and hyperactivity problems. So far, supporting research into these modalities ranges from preliminary to nonexistent. Nevertheless, there’s hope that many simple, inexpensive methods can, at the very least, augment conventional treatment.
A calm, orderly, predictable home environment helps children stay sane and organized. Diet, sleep and exercise influence brain function. Kids who chronically get insufficient sleep can appear to have ADHD, only to recover once their parents make sure they get to bed at a good hour.
Other habits can make a difference, too. Television is a major culprit. A child who watches TV to the exclusion of other more brain-friendly activities will wire his or her brain in a different way. Some experts believe that TV overstimulates the brain. A 2004 study published in Pediatrics found that the amount of television viewing in children aged 1 to 3 correlated with the chance of developing attention problems by age 7.
Exercise increases growth factors important in learning and memory. It facilitates the creation of new nerve cells and counteracts the negative effects of stress. Exercise also boosts serotonin and dopamine, brain chemicals associated with mood, learning and a sense of reward. Excessive stress lowers dopamine — evidence enough that we need to do what we can to minimize the stress in our children’s lives. People with ADHD have deficits in dopamine and also norepinephrine; stimulant medications help increase these neurotransmitters.
Sports can give ADHD-diagnosed children a way to blow off steam, build self-confidence, focus concentration and make friends. Although some case reports have not linked exercise with improved attention or behavior, others (published in Complementary Therapies in Nursing & Midwifery) attest that movement therapy can produce positive changes in attention span, concentration, coordination, dexterity and social behavior. Shannon recommends exercise as part of an integrated program for children diagnosed with ADHD.
Diet has a profound influence on behavior and concentration. For a while, many people believed sugar contributed to ADHD. Most research has found no such correlation. However, in a study published in Pediatrics, one group of researchers found that sugar in the absence of protein (in this case, a high-sugar, high-carbohydrate breakfast) did result in more hyperkinetic behavior. The researchers concluded that the combination of sugar with other carbohydrates might create the extra activity.
Shannon finds that children with ADHD symptoms do better on high-protein diets. He also has them steer clear of sweets, caffeine and artificial flavors, colors and preservatives. Furthermore, because heavy metals and other environmental toxins are considered risk factors for ADHD, it makes sense to feed children — and the rest of the family — organic foods whenever possible.
For years, holistic health practitioners like Shannon have believed that artificial food colorings and preservatives aggravate ADHD, despite the fact that most research failed to support that claim. However, a large, well-designed study published in the June 2004 issue of Archives of Diseases in Childhood did show such a link. The researchers used a group of more than 1,800 3-year-olds and took away foods with food colorings and the preservative sodium benzoate for one week. The following week, the children were given either a placebo or a drink containing artificial colorings and sodium benzoate additives. The results? According to parents’ reports, removal of colorings and sodium benzoate improved symptoms of hyperactivity; subsequent reintroduction was associated with ADHD symptoms. Children who had preexisting hyperactivity or allergies were no more vulnerable than those who didn’t.
Food allergies can contribute to ADHD symptoms. One small study found that children with ADHD were seven times more likely to have food allergies than their peers. At least six published studies suggest that eliminating problem foods can lessen symptoms. (Common dietary culprits include dairy, wheat, corn, citrus fruits, strawberries, eggs, chocolate and peanuts.) In a recent Dutch trial, 40 children diagnosed with ADHD followed their usual diet for two weeks, then switched to an elimination diet (a hypoallergenic diet of rice, turkey, pears and lettuce) for two weeks. According to parents’ ratings, 62 percent of kids improved 50 percent in behavior. Nine children (23 percent) dropped out of the study because the parents were unable to stick to the diet or because the child became ill.
Signs that your child might have a food intolerance include a recurring skin rash, a runny nose, throat clearing, coughing, dark circles under the eyes, gas, cramps, diarrhea and headaches. Identifying and eliminating food allergens is a huge undertaking but one with big payoffs. Jesse Lynn Handley, M.D., author of the handbook Attention Deficit Disorder (IMPAKT, 1999), says she’s seen many children improve after food allergens and excessive dietary sugar have been eliminated from their diets and they’ve been switched to balanced diets featuring whole foods. She adds that, for a child to happily comply with dietary changes, the whole family needs to adopt the healthier diet.
Although little research exists on herbal treatment for ADHD, a recent survey published in Pharmacotherapy found that 20 percent of adult caregivers of children with ADHD or depression gave their kids herbs. Most adults did not tell health practitioners about using herbs, and some were combining herbs with medications. Because of the potential for herbs to interact with drugs (in either a positive or negative fashion), it’s important to tell your child’s doctor about such supplements.
Commercial herbal formulations marketed toward kids with symptoms of ADHD typically combine herbs that enhance mental functioning (for example, ginkgo, ginseng, bacopa and gotu kola) with herbal sedatives (such as valerian, lemon balm and oats).
Ginkgo (Ginkgo biloba) increases circulation to the brain and has nerve-protective properties. Most of the research has investigated this herb’s ability to delay the course of dementia. Ginkgo also has been shown to significantly improve memory and other cognitive functions in healthy adults.
Asian ginseng (Panax ginseng) and American ginseng (P. quinquefolius) are adaptogens, meaning they improve the body’s ability to cope with stress. Research suggests ginseng can enhance both mental and physical functions under stress. Ginseng extracts have been shown to improve memory and attention in healthy adults. In lab studies, active ingredients called ginsenosides have been shown to increase brain levels of dopamine and norepinephrine.
Ginkgo and ginseng combined. In an open trial (the herb was not compared to a placebo) published in the Journal of Psychiatry & Neuroscience, a proprietary herbal formula (AD-FX) containing American ginseng and ginkgo was given to children between the ages of 3 and 17 who were already on medication for ADHD. The dosage of the herbs was 200 mg of American ginseng extract and 50 mg of ginkgo extract, twice a day at least 30 minutes before meals. Four weeks later, 74 percent of the children had improved. German researchers also have shown a ginseng/ginkgo combo to enhance memory in healthy adults.
Preliminary studies have shown the Indian herb bacopa (Bacopa monnieri) to enhance memory and learning in adults and children. Another Indian herb, gotu kola (Centella asiatica), improves memory and concentration, although the research so far involves rats. A preliminary study from the Journal of Clinical Psychopharmacology suggests this herb is also effective at reducing anxiety in humans.
Valerian (Valeriana officinalis). Whether or not they are on stimulant medications, children with ADHD tend to have trouble sleeping, which exacerbates problems of attention, learning and behavior. A small 2002 study published in Phytomedicine investigated the use of an extract of Mexican valerian (Valeriana edulis) in another group that often has disordered sleep, children with “intellectual deficits.” Some of the five learning-disabled boys in the study also had ADHD. The boys took a placebo for two weeks, nothing for seven days, then 500 mg of dried valerian root for two weeks. Valerian improved sleep and was particularly helpful for the boys with hyperactive behavior.
Lemon balm (Melissa offici-nalis) is one of herbalist Sunny Mavor’s personal favorites for soothing agitated, hyperactive children. Mavor, coauthor of Kids, Herbs, & Health (Interweave, 1998), says, “A cup of regular-strength tea — one teaspoon of dried herb infused in one cup of water — has a calming effect on kids during the day. A double-strength tea at bedtime can help kids get to sleep.” The pleasant-tasting herb also can be given as a glycerin extract.
Oats (Avena sativa) have a subtle, calming effect on the nervous system. Whole oat groats are better than cut oats. Children can eat oatmeal for breakfast (sweetened with fruit and/or honey). Adding nuts will boost the protein content, and the whole family will benefit from the cholesterol-lowering, colon-cleansing properties of oats. You also can use tinctures and teas made from oatstraw and oat seed.
Fatty acids. The brain is 60 percent fat. Getting the right kind of dietary fat is important. The fats the brain likes best are the omega-3 fatty acids, specifically docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). These fats influence cell membrane fluidity, neurotransmitter function and several aspects of brain development.
Animal studies link diets low in omega-3s with abnormal behavior, decreased stress tolerance and learning capacity, and increased anxiety and depression. Kids with ADHD may be deficient in these essential fatty acids.
In a 1995 study from the American Journal of Clinical Nutrition, researchers compared 52 boys suffering from ADHD with 42 normally active boys. The researchers found that a significant number of the hyperactive boys had signs of essential fatty acid deficiency, such as excessive thirst and dry skin and hair. A subgroup of 21 ADHD boys also had significantly lower blood levels of various fatty acids. The authors speculated that either low dietary intake or poor metabolic conversion might be to blame. Later, the same researchers found that, compared to youngsters with normal levels, children with lower omega-3 fatty acids had significantly more temper tantrums and problems with behavior, learning, health and sleep.
Try feeding your child fish twice a week. Cold-water fish contain both DHA and EPA. Salmon, tuna, sardines and herring are rich in omega-3s and lower in mercury than some deep-sea fish (the Food and Drug Administration now recommends that children eat no more than 12 ounces of canned light tuna or 6 ounces of albacore tuna weekly). Eggs, depending upon what the chickens eat, contain varying amounts of DHA. Although the conversion is not terribly efficient, the body also can create EPA and DHA from the alpha-linolenic acid found in green leafy vegetables, flaxseed, chia seeds, canola oil, pumpkin seeds, Brazil nuts and walnuts.
Shannon recommends giving children an omega-3 blend of EPA and DHA at a dose of 250 mg for children 3 to 6; 500 mg for children 7 to 11; and 1,000 mg for children 12 and older.
Magnesium may play a role in ADHD. Children with ADHD symptoms often have low blood levels of this mineral. Signs of magnesium deficiency include irritability, decreased attention span and mental confusion. Magnesium Research recently published a study of 50 children with ADHD and a documented magnesium deficiency, showing that the supplementation of drug treatment with 200 mg per day of magnesium for six months improved behavior more than standard therapy alone.
Dietary sources of magnesium include legumes, tofu, seeds, nuts, whole grains and green leafy vegetables. In addition, Shannon puts his patients aged 5 to 11 on supplements of 200 mg per day, and older children on 300 to 400 mg per day. He recommends taking magnesium as magnesium citrate, with an equal amount of calcium citrate.
Zinc helps regulate the activity of fatty acids and neurotransmitters, including dopamine. Levels of this mineral seem to be low in children with ADHD. According to a 2000 study published in the Journal of Child and Adolescent Psychopharmacology, low zinc can reduce the response to stimulant medication. Two 2004 studies suggest zinc supplementation has a therapeutic effect. In the first study, 400 children with ADHD either took a placebo or a supplement of zinc sulfate (150 mg a day — about 45 mg elemental zinc, which is a hefty dose) for 12 weeks. Zinc significantly reduced hyperactive and impulsive behavior but not inattention. In the second study, 44 children with ADHD took Ritalin plus either a placebo or zinc sulfate (55 mg daily, or about 15 mg of elemental zinc) for six weeks. The addition of zinc resulted in significant improvement.
The recommended dietary allowance for zinc is 10 mg for children aged 1 to 10; 15 mg for kids 11 and up. Food sources include meat, fish, shellfish, poultry, dairy products, whole grains, legumes and nuts. Caution: High doses of zinc (150 mg daily of elemental zinc) can cause nausea, vomiting, copper-deficiency anemia and depressed immune function.
Recently, a group of researchers set out to try to correct ADHD in a single nutritional supplement. This supplement included essential fatty acids, amino acids (precursors of neurotransmitters), phospholipids (fatty substances concentrated in the brain and essential for proper brain function), B vitamins (critical to neurotransmitter production), other vitamins and minerals involved in proper brain function (vitamins C and E, magnesium, calcium and zinc), plant-derived antioxidants (citrus bioflavonoids and grape seed proanthocyanidins), silymarin (the active complex in the herb milk thistle, which supports liver function and helps rid the body of toxins), and Lactobacillus acidophilus and bifidus (healthful intestinal bacteria that improve digestive function and immunity, correct antibiotic-induced disturbances in gut bacteria, and offset food allergies).
The researchers compared Ritalin to this nutritional supplement in 20 children with ADHD. The two treatments produced equivalent improvement in a performance test often used in the diagnosis of ADHD. The results were published in the August 2003 issue of Alternative Medicine Review.
Denver-based health practitioner Hongfei Lin, M.D., believes Traditional Chinese Medicine can help children with ADHD. She says parents often will bring children to her to treat physical complaints, and discover that her treatments relieve not only the physical problems but also the inattention and hyperactivity.
Lin customizes herbal formulas to treat each child’s particular imbalances. In children under the age of 7, she uses Tui Na (pronounced twee-nah), which involves techniques such as massage, acupressure and manipulation of tendons, ligaments and joints. She also teaches parents to use Tui Na at home.
In older children, Lin uses acupuncture. (She stresses that the extremely thin needles don’t cause pain.) She also may tape seeds or magnetic pellets over acupuncture points in the ears and tell the child to stimulate them during the day. Lin adds, “I also encourage the parents to get TCM treatment, since well-balanced and calm parents will help to speed up and stabilize the recovery of their children.”
One of Handley’s first steps when working with kids with ADHD is to teach them how to breathe deeply and slowly. She instructs the parents, too. Handley explains, “If someone sitting next to you starts breathing deeply, you start breathing deeply and relaxing.” Studies have shown that other modalities, such as meditation, massage, yoga, biofeedback-assisted relaxation and progressive muscle relaxation, can help calm and center children’s ADHD symptoms.
When it comes to problems of inattention and hyperactivity, no silver bullet exists. Kids need help controlling emotions, making and keeping friends, and finding strategies to accomplish schoolwork. Therapy for the child and his frazzled family members is usually recommended. Medication might be necessary to help a child be successful in school. For milder cases, alternative therapies may be enough to control symptoms. In more severe cases, they can augment conventional treatment. Whenever our children are struggling, they deserve help. As parents, it’s our responsibility to make sure they get it.
Linda B. White, M.D., is the coauthor of Kids, Herbs, & Health (Interweave, 1998) and The Herbal Drugstore (Rodale, 2000).
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