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Attention-Deficit/Hyperactivity Disorder and Integrative Approaches Attention-defi cit/Hyperactivity Disorder and Integrative Approaches Asma J. Sadiq, MD A Brief History of Medicine “I have an earache.” 2000 B.C. “Here, eat this root.” 1000 A.D. “That root is heathen, say a prayer.” 1850 A.D. “That prayer is superstition, drink this potion.” 1940 A.D “That potion is snake oil, swallow this pill.” 1985 A.D. “That pill is ineffective, take this antibiotic.” 2000 A.D. “That antibiotic is artifi cial, here, take this root.” —Anonymous ncreasing numbers of Americans are turning to complemen- tary and alternative medical therapies (CAM) for themselves Iand their children. A host of explanations for this increase has been surveyed and researched. A recent study reported 54% of parents using CAM therapies for their children, but only 11% ever discussing them with their pediatricians. The most impor- tant attraction of CAM therapies for parents is the belief that they are “a more natural therapy” and that they have greater control over treatments. Dissatisfaction with the process or the results of conventional care was noted in a small but increasing number within the population studied.1 Concerns regarding side effects and long-term use of medications are also factors fueling this quest, particularly in the case of children diagnosed with attention-defi cit/hyperactivity disorder (ADHD). Is this trend toward holistic care a “fad” or just a rebalancing of the medical pendulum, as it equilibrates itself with a new dynamic tension? We see the increasing use of naturopathy, homeopathy, acupuncture, botanical medicine, chiropractic, and mind-body medicine. Often what we discover as “new” is just the resurfacing 508 PEDIATRIC ANNALS 36:8 | AUGUST 2007 33607Sadiq.indd607Sadiq.indd 550808 77/26/2007/26/2007 11:36:22:36:22 PMPM of old truths in a different time and context. diagnosed as having ADHD. A review of and possibly harmful alternatives to the The process of integrating the conventional both the conventional and alternative the- conventional “proven” ones also need to with the traditional, the synthetic with the ories and treatments of ADHD will be dis- be addressed with an awareness of the “natural,” the part with the whole, and the cussed. A focus on some of the evidence- relative risks of either modality. old with the new is an ongoing challenge based studies that explore the hypothesis Traditional medicine carries with it for us, as we play our part in the history of and rationale of the CAM modalities is the validity inherent in the longevity and medicine. reviewed, with acknowledgement of the diversity of its use. We often see similar fact that what is considered “alternative” approaches and herbs being used in vari- “Teach thy tongue to say I do not at one time may become integrated into ous complex medical systems such as know and thou shalt progress” — Moses the mainstream as evidence and experi- Chinese medicine, Ayurvedic, Hikmat, Maimonides (1135-1204) ence support the outcomes. A call for and Native American medicine. more research involving CAM therapies A current defi nition of complemen- Pediatric healthcare providers should for children with the symptom complex of tary therapies is “those that are used understand the paradigm shifts and theo- hyperactivity, impulsivity, and inattention in conjunction with mainstream, con- ries behind the CAM therapies that are is warranted. Concerns by the medical ventional medical therapies.” Alterna- currently being sought out for children community regarding the use of unproven tive medicine often refers to those ap- PEDIATRIC ANNALS 36:8 | AUGUST 2007 509 33607Sadiq.indd607Sadiq.indd 550909 77/26/2007/26/2007 11:36:23:36:23 PMPM proaches that are not taught in medical SIDEBAR 1. ADHD suggests a genetic basis for some school and not covered by insurance. forms of this disorder.7 Studies have iden- This defi nition is very fl uid and chang- Alternative Treatments tifi ed differences in the genes encoding ing as more medical institutions are of- for Attention-defi cit/ for both the D2 and D4 dopamine recep- fering courses in CAM and developing Hyperactivity Disorder tors in people with ADHD. Other genetic departments of Integrative Medicine. Diet polymorphisms have been associated Also, more third-party payers are re- Omega-3 (DHA/EPA) with increased activity of the pre-synap- imbursing for CAM services or have Probiotics tic dopamine transporter, which would 8 providers on their panels. Vitamins cause increased uptake of dopamine. This supports the hypothesis of a “hypo- Botanicals “Integrative Medicine is a healing dopaminergic state” or relative dopamine Aromatherapy oriented medicine that takes account of insensitivity in the affected areas of the Mind-body medicine the whole person (body, mind, and spir- brain. An imbalance in dopamine and nor- it), including all aspects of lifestyle. It Neurofeedback epinephrine in the pre-frontal cortex with emphasizes the therapeutic relationship Massage/chiropractic increased stimulatory activity of norepi- manipulation and makes use of all appropriate thera- nephrine and decreased inhibitory activity pies, both conventional and alternative.” Yoga, meditation, and of dopamine contributes to the pathogen- music therapy The Program in Integrative Medicine, esis of the symptom complex of ADHD. Homeopathy University of Arizona Atypical functioning of the fronto-striatal Lifestyle complex and reduced local activation of WHAT DO WE KNOW ABOUT ADHD? the basal ganglia and right anterior frontal ADHD is a neurodevelopmental dis- There is increasing scientifi c aware- lobe have also been studied in association order characterized by impulsivity, dis- ness that ADHD is a heterogeneous dis- with ADHD. The stimulant medications tractibility, and hyperactivity that mani- order that continues from childhood and inhibit the reuptake of dopamine at the fests in early childhood. The symptoms adolescence into adulthood and in many pre-synaptic level, thereby increasing do- affect cognitive, academic, behavioral, cases carries a high risk of co-morbidi- pamine at the synaptic terminals as well emotional, and social functioning. It is a ties, such as mood disorders and learning as causing some striatal stimulation.9 common disorder of childhood, with re- disabilities.4 Morphologic and metabolic Other genetic factors that contribute to ported prevalence rates varying from 2% differences in the brains of people with the symptom complex of ADHD may be and 16%, depending on diagnostic crite- symptoms of ADHD have been suggested the inherited tendencies toward allergic ria and population studied.2 The preva- by studies using magnetic resonance im- states, immune dysfunction, and various lence of ADHD in school-aged children aging (MRI), positron emission tomogra- genetic polymorphisms that result in an in the United States is 8% to 10% across phy (PET) scans, and EEGs. altered capacity to detoxify heavy metals all socioeconomic levels.3 The male to ADHD is often described as a “hypo- and xenobiotics. female ratio is 4:1 for the predominantly dopaminergic disorder” or a disorder of Exposure to environmental toxins hyperactive type, and 2:1 for the pre- self-regulation, often called an “executive possibly associated with the development dominantly inattentive type. It may be function dysfunction.” The most accepted of ADHD in some cases may begin at or underidentifi ed in girls. hypothesis is that the cognitive and behav- even before conception. Maternal tobac- ioral symptoms of ADHD are the result co and other drug use have also been as- Asma J. Sadiq, MD, is Director, Division of of diminished function of polysynaptic sociated with an increased risk of ADHD. Developmental and Behavioral Pediatrics, dopaminergic circuits of the pre-fron- In one study up to 25% of all behavioral Beth Israel Medical Center, and Assistant Pro- tal executive centers of the brain cortex, disorders in children were associated fessor of Pediatrics, Albert Einstein College of which are responsible for impulse control with smoking in pregnancy.10 Children Medicine, New York, NY. and sustained attention.5 Decreased activ- with fetal alcohol syndrome may have Address correspondence to: Asma J. Sadiq, ity of dopamine has been associated with cognitive and behavioral features con- MD, Albert Einstein College of Medicine, 10 increased risk for addiction, as the D2 re- sistent with the diagnosis of ADHD. The Union Square East, New York, NY 10003; fax ceptor has been implicated in the reward Centers for Disease Control and Preven- 212-844-8338; [email protected]. mechanisms in the brain.6 tion estimated that about 2% of American Dr. Sadiq disclosed no relevant fi nancial The etiology of ADHD is unknown, children younger than 6 years met the cri- relationships although evidence from family studies of teria for lead toxicity at levels that have 510 PEDIATRIC ANNALS 36:8 | AUGUST 2007 33607Sadiq.indd607Sadiq.indd 551010 77/26/2007/26/2007 11:36:25:36:25 PMPM been associated with cognitive defi cits ESSENTIAL FATTY ACIDS: compared with age-matched controls.19 A and behavioral disturbances (> 10 µg/ FROM WOMB TO TOMB greater number of behavior problems as- dL). Low-level lead intoxication has been Essential fatty acids, particularly sessed by the Conners’ Rating Scale, tem- associated with hyperactivity, impulsiv- docosahexaenoic acid (DHA), play a per tantrums, and sleep problems were ity, and addictive behavior.11 Pilot studies critical role during pregnancy and infant reported in subjects with lower total ome- of chelation therapy with calcium EDTA development, adult
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