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 , , , botanical medicine, , and mind-body medicine. Often what we discover as “new” is just the resurfacing

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33607Sadiq.indd607Sadiq.indd 550808 77/26/2007/26/2007 1:36:221:36:22 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 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-

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33607Sadiq.indd607Sadiq.indd 550909 77/26/2007/26/2007 1:36:231:36:23 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

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33607Sadiq.indd607Sadiq.indd 551010 77/26/2007/26/2007 1:36:251:36:25 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 life, and old age. It ga-3 fatty acid concentrations.20 The co- in children with moderate elevations in has been postulated that the imbalance morbidity of learning disabilities is seen blood lead levels have demonstrated im- of essential fatty acids (EFA) in the brain in children with ADHD. It was shown provement in ADHD behaviors .12 plays a role in ADHD, because EFAs are that children who have diffi culties such The role of genetics and the environ- “essential for normal neuronal structure as dyslexia have lower levels of omega-3 ment with the particular interactions and and function, maintenance of membrane fatty acids than controls.21 Other studies conditions that may be underlying the fl uidity, impulse transmission, recep- showed the severity of these clinical signs manifestation of the symptom complex tor sensitivity, and maintenance of ad- of fatty acid defi ciency to be strongly cor- of ADHD is revisited. Some of the varied equate neurotransmitter pool.16 In fact, related with the severity of dyslexic signs hypotheses and paradigm shifts current in dopamine-producing nerve endings are and symptoms, not only in the visual do- the “alternative approaches” for the man- highly fl uid and are composed of ap- main, but also with respect to auditory, agement of ADHD are discussed as listed proximately 80% DHA. linguistic, and motor problems.22 in Sidebar 1 (see page 510).

DIET: DOES FOOD AFFECT MOOD? “Let food be thy medicine, and medi- Some studies have suggested cine be thy food” — Hippocrates (460- that children who were formula 377 BC) fed have an increased risk Foods and herbs long have been used as medicine in traditional healing prac- of having ADHD symptoms tices. Elimination diets as well as special- compared with those who ized ones involving both detoxifying and strengthening potions of botanicals and were breast fed. minerals are common in the varied an- cient tool bag of remedies. There is increasing research showing IS THERE A SPECTRUM OF DISORDERS Some studies have suggested that a link between the gastrointestinal system ASSOCIATED WITH DEFICIENCY/ children who were formula fed have an (GI), often called the “second brain,” and IMBALANCE OF OMEGA-3? increased risk of having ADHD symp- behavior.13 Much confl icting data have There is increasing evidence that ab- toms compared with those who were been published regarding the effects of normalities of fatty acid and membrane breast fed.23 Breast-fed children and sugars, food additives, colors, and preser- phospholipid metabolism play a part in those who had received milk with added vatives in children with ADHD. Impaired neurodevelopmental and psychiatric dis- polyunsaturated fatty acids appear to be catecholamine control of sugar was found orders. A positive response to treatment better at solving problems and learn- in children with ADHD and may be as- with a daily dose of 9 g of omega-3 in ing language, compared with children sociated with worsening of behavior fol- people diagnosed with bipolar disorder receiving milk that does not contain lowing a sucrose challenge.14 It may be was suggested.17 Benefi cial improve- polyunsaturated fatty acids.24 The World controversial that sucrose as a single agent ments were reported in small studies Health Organization (WHO) made the contributes to ADHD. However, recent involving treatment with omega-3 in recommendation in 1995 that baby for- studies repeatedly have shown improve- ADHD, dyslexia, developmental coordi- mulas provide 40 mg of DHA per kg of ment in both school performance and nation disorder, depression, and autistic infant body weight. In the United States, behavior in children who changed their spectrum disorders.18 DHA has been added to many infant for- diet from “junk foods” high in artifi cial Some studies found that children with mulas since 2002. Nutritionists recom- fl avors, preservatives, and sucrose to more ADHD have a measurable reduction in mend 2 to 3 servings of fi sh a week, or nutrient-dense foods.15 tissue levels of omega-3 fatty acids when 100 mg a day, to maintain DHA levels.

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33607Sadiq.indd607Sadiq.indd 551111 77/26/2007/26/2007 1:36:261:36:26 PMPM Children with ADHD were reported SIDEBAR 2. to treatment with amphetamines. Posi- to have an increased oxidation of omega- tive effects of supplementation with zinc 3 as well as an impaired ability to syn- Natural Treatments sulfate (150 mg/day) were demonstrated thesize DHA from vegetable precursors St. John’s wort in a large, randomized, controlled trial found in a regular diet.19,25 The omega-3 (Hypericum perforatum) of hyperactive children, with signifi cant to omega-6 ratio should be between 1:1 Glutamine improvement in impulsive behaviors and or 1:6 for maintaining membrane and re- Taurine socialization skills compared with place- ceptor sensitivity. It is also hypothesized Glycine bo.36 Small studies showed low levels of that an increase in omega-6 in the diet Dimethylglycine magnesium in serum and red blood cells adds to the imbalance of the membrane Gamma-aminobutyric acid of children with ADHD, and improve- ratio of omega-3 and omega-6. In addi- Dimethylaminoethanol ment in behavior was demonstrated in tion, diets high in trans-fats are associ- (DMAE/deanol) 30 of 52 children with ADHD who were ated with impaired fetal and childhood S-adenosylmethionine (SAMe) treated with 100 mg magnesium daily 37 brain development, and they are known Phosphatidylserine/inositol and B6 supplementation. Iron is in- to block the enzymatic conversion of the Tyrosine volved in the metabolism of dopamine vegetable derived omega-3 and omega- and its regulation. A preliminary report Tryptophan 6 fatty acids into the critical long chain demonstrated reduction of ADHD symp- Gingko biloba fatty acids of DHA.26 toms within a month of supplementation Ginseng with iron in non-anemic children diag- ADHD AND ALLERGY nosed with ADHD.38 There are known associations among There are no studies that validate the allergic disorders, food allergies with with normal species may be important in use of megavitamin doses. The two ran- recurrent otitis media, sleep problems, preserving the mucosal barrier of the gut. domized controlled studies using high and ADHD. Other data also suggest There is some increasing evidence that doses of vitamin C, niacin, and pyridox- that people with atopy and food aller- supplementation with probiotic like bifi - ine did not show benefi t; however, they gies may have an increased requirement dobacteria and lactobacilli can decrease involved small numbers of participants for EFA, the normalization of which has the effects of food allergy.31 More stud- and had only short-term follow-up. a benefi cial effect on atopic disorders.27 ies are needed to explore this hypothesis Children with ADHD also often mani- and the pro and cons of using probiotics “NATURAL REMEDIES” fest symptoms of EFA defi ciency such in children with symptoms of ADHD. “The scientists’ religious feeling as thirst, frequent urination, dry hair, and takes the form of a rapturous amazement skin.28 Many studies using “oligoanti- HOW VITAL ARE VITAMINS at the harmony of natural law, which re- genic” or allergy elimination diets have AND MINERALS? veals an intelligence of such superiority been shown to improve behavior in some Inadequate nutrients during fetal life that, compared with it, all the systematic children with ADHD.29,30 Several mecha- may also play a signifi cant role in the de- thinking and acting of human beings is nisms have been postulated involving the velopment of the neurological system and an utterly insignifi cant refl ection.” — Al- infl ammatory mediators and neuro-pep- may be of some importance in ADHD.32 bert Einstein (1879-1955) tides, which have been shown to be in- Several small studies showed blood lev- creased in the blood after exposure to a els of zinc,33 magnesium,34 iron, and the Botanical: Is there bounty sensitizing food. B vitamins35 (particularly B1, thiamine), in botanicals? to be lower in children with ADHD than On review of the Natural Medicine WHAT ARE THE PROS OF USING in controls. There is biological plausi- Comprehensive Database, more than PROBIOTICS? bility that restoring optimal levels may 25 “natural” remedies have been pro- Frequent episodes of otitis media provide some benefi t in behaviors that moted for the treatment of ADHD. and treatment with antibiotics are com- have been associated with defi ciencies. Some are mentioned in Sidebar 2. mon in children with ADHD. Apart from Zinc is important as a co-factor in the Fewer botanicals have been studied in food allergy, an increase in intestinal metabolism of neurotransmitters, dopa- children than in adults. This is simi- permeability has been proposed in some mine, melatonin, and fatty acids. A di- lar to conventional medications, which children with the symptom complex of rect linear correlation was found in one generally are fi rst researched in adults ADHD. Maintenance of normal gut fl ora study between zinc levels and response and then often used “off-label” in chil-

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33607Sadiq.indd607Sadiq.indd 551212 77/26/2007/26/2007 1:36:291:36:29 PMPM dren. Some small studies are emerging increased relaxation and both compu- hyperactivity, inattention, and impulsiv- that have demonstrated a measurable tational speed and accuracy. Rosemary ity.46 However, the need for weekly visits treatment response. Larger trials are acted as a mild stimulant and increased averaging 40 sessions of individualized warranted. computation speed without decreasing training and lack of insurance reimburse- Standardized extracts of Ginkgo bi- accuracy.41 Valerian has been studied in ment make this a costly treatment option. loba (50 mg) and Panax quinquefolius children with cognitive defi cits. Com- (200 mg) in combination in an open-label pared with baseline and placebo, treat- Massage trial were shown to improve both school ment with valerian led to signifi cant re- Massage in various forms is part of performance and behavior, as measured duction in sleep latencies and nocturnal many traditional healing systems. Massage by the Conners’ rating scales, in 74% of time awake, lengthened total sleep time, therapy enhances “a sense of well being,” 36 children with ADHD after 4 weeks and improved sleep quality.42 The treat- which supports the concept of activating of a twice-daily dose.39 A more recent ment was most effective in children with the “innate healing” ability of the body. It randomized, double blind, placebo-con- hyperactive behavior. has been hypothesized that the mechanism trolled study using L-theanine (an amino Other sedative herbs used in Europe involves release of endogenous endorphins acid found in green tea) in children with for “restlessness” include chamomile, in the body. A small study of massage as ADHD also showed signifi cant improve- lemon balm, and hops. Melatonin has therapy in students with ADHD showed ment in symptoms. L-theanine may im- also been used to help with the sleep dif- an improvement in short-term mood and prove central dopaminergic activity, stabi- fi culties seen in children with ADHD. In long-term classroom behavior.47 In another lize mood, increase concentration, reduce a randomized controlled trial, 25 chil- study of adolescents with ADHD, more anxiety, and improve quality of sleep. It dren with chronic insomnia and ADHD “on time and on task” behaviors as well has been consumed in large quantities for were treated with 5 mg of melatonin as lower hyperactivity scores were report- throughout the past 20 years in Japan and and showed signifi cant improvements in ed by teachers. The massage group rated some parts of Europe. sleep latency, onset, and total sleep time themselves as “happier.” Randomized con- In a small-randomized controlled as compared with controls.43 trolled trials in premature infants and de- trial, treatment with 1 mg/kg/day of pyc- pressed adolescents have also shown ben- nogenol (pine bark extract) for 4 weeks MIND-BODY-MEDICINE IS MANIFEST efi cial results.48 Chiropractic manipulation was linked to reduction of behaviors IN MULTIPLE MODALITIES BOTH reportedly increases body alignment and associated with ADHD, including in OLD AND NEW’ awareness; however, there are no studies visual-motor coordination. There was a that have demonstrated benefi cial effects notable “relapse” in symptoms a month Neurofeedback of this therapy in children with ADHD. after stopping use.40 Neurofeedback is based on theories that include the organic basis of ADHD Yoga, Meditation, and Music Therapy Aromatherapy: Are sweet-smelling and utilizes biofeedback to guide people Yoga, meditation, and music therapy solutions a solution? to regulate their brain activity. It relies on are forms of mind-body-spirit practice. Essential oils (EO) have been used research that has demonstrated that most Various forms of yoga, originally from from the time of the Egyptians and in people with ADHD, as compared with the Indian subcontinent, have gained many spiritual practices and religious matched peers, have excess (theta) slow popularity in the United States. Stud- traditions. According to a study by Tor- wave activity and reduced (beta) fast wave ies have shown the benefi ts of yoga for sons of London in 1993, EO molecules activity.44 It provides immediate feedback asthma, stress reduction, pain manage- interact with receptors on nerve and to the person about brain activity in the ment, depression, and ADHD.49 Both other tissues similar to drugs (and hor- form of a video game, as well as in some meditation and yoga practice for chil- mones). When inhaled, some believe cases auditory feedback. This self-regula- dren are now being offered in summer that EO directly access the limbic sys- tion of slow cortical potentials has been camps and after-school programs. Sub- tem. EO also act like hemoglobin mol- postulated to involve similar neuro-biolog- jective improvements in behavior were ecules in the blood stream. Relaxing and ic pathways as medication.45 Neurofeed- reported in a 6-week open trial of twice neuro-stimulating properties of lavender back used with meta-cognitive strategies weekly yoga lessons for child and parent and rosemary oils were studied in human has shown positive results in ADHD, with with daily practice at home.50 A recent subjects who were evaluated for mood decrease in use of medications. In some study of adolescent boys with ADHD and were given math computations be- cases, this was comparable to the use of using both instructional and improvisa- fore and after aromatherapy. Lavender stimulants in decreasing the symptoms of tional models of music therapy reported

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33607Sadiq.indd607Sadiq.indd 551313 77/26/2007/26/2007 1:36:291:36:29 PMPM a signifi cant reduction of symptoms in SIDEBAR 3. concerning ones should be considered the classroom in teacher’s assessments and discussed carefully with parents. using the Conners’-Diagnostic and Sta- Multi-modal Management Although the numbers and studies are tistical Manual for Mental Disorders, 1. Classroom accommodations relatively few, more research as well as fourth edition (DSM-IV), sub-scales.51 2. Trial of medication regulation and standardization of bo- 3. Coaching tanical products and supplements for HOMEOPATHY, THE OF 4. Social skills groups use in children is needed. In keeping LESS IS MORE 5. Parenting skills training and pace with the rising interest and use of Homeopathy was as developed by the support groups, etc., are often CAM, it is imperative that pediatricians German chemist Samuel Hahnemann needed and recommended. stay informed, support, and expand the (1755-1843) in the late 18th and early 19th research on modalities that have a viable century. Hahnemann identifi ed “vibra- hypothesis, a low adverse side-effect tional patterns” of disease. Homeopathy quate sleep and limiting television viewing profi le, and may show benefi t. is based on the principal that a substance (less than 2 hours a day as recommended producing the same cluster of symptoms by American Academy of Pediatrics) are REFERENCES can treat the symptoms of a patient. The important, because lack of sleep and over- 1. Chan E, Rappaport LA, Kemper KJ. Comple- original substance is repeatedly diluted stimulation are known to be associated with mentary and alternative therapies in childhood attention and hyperactivity problems. J Dev Be- and “agitated,” with the “medicinal ener- symptoms of inattention and hyperactivity, hav Pediatr. 2003;24(1):4-8. gy” remaining in the end product. Higher irritability, and aggression in children. 2. Mental health in the United States. Prevalence dilutions are used as constitutional rem- of diagnosis and medication treatment for at- tention-defi cit/hyperactivity disorder — United edies for chronic conditions, with lower CONCLUSIONS States, 2003. MMWR. Morb Mortal Wkly Rep. dilutions for acute symptoms. Homeopa- The conventional comprehensive ap- 2005;54(34):842-847. thy is taught in medical schools in Europe proach for evaluating and treating chil- 3. Green M, Wong M, Atkins D, et al. Diagnosis of and Asia and therefore is not considered dren who present with symptoms of Attention Defi cit/Hyperactivity Disorder: Tech- nical Review 3. U.S. Department of Health and “alternative.” Families that are acculturat- ADHD often includes assessment for Human Services. Agency for Health Care Policy ed to it and have experienced its benefi ts associated co-morbidities of learning and Research: Rockville, MD; 1999. for other ailments have used it as the fi rst- disabilities, anxiety, depression, motor 4. Pastor PN, Reuben CA. Attention defi cit disor- der and learning disability: United States, 1997- line treatment for ADHD. Two random- co-ordination disorders, etc. as war- 98. Vital Health Stat 10. 2002;(206):1-12. ized controlled trials have demonstrated ranted by each individual child. A multi- 5. Dougherty DD, Bonab AA, Spencer TJ, Rauch improvements in behaviors as measured disciplinary evaluation is followed by a SL, Madras BK, Fischman AJ. Dopamine trans- by the Conners’ Global Index.52,53 multi-modal treatment plan (see Sidebar porter density in patients with attention-defi cit hyperactivity disorder. Lancet. 1999;354(9196): 3), which includes a trial of medication, 2132-2133. LIFESTYLE MEDICINE AS A combined with educational accommoda- 6. Blum K, Sheridan P, Wood R, et al. The D2 TREATMENT OPTION? tions and behavior management strate- dopamine receptor gene as a determinant of Incorporating some of the principles gies. Many of the alternative approaches reward defi ciency syndrome. J R Soc Med. 1996;89(7):396-340. of lifestyle medicine include developing discussed here can be integrated into the 7. Hechtman L. Families of children with attention routines and rhythms that help with the multi-modal plan as well as used indi- defi cit hyperactivity disorder: a review. Can J regulatory disturbance that is described in vidually. Additional research into the Psychiatry. 1996;41(6): 350-60. 8. Cook EJ, Stein M, Krasowski M, et al. As- children with ADHD. A changing of the effects of these approaches is indicated, sociation of attention defi cit disorder and the environment for the child versus the child utilizing scientifi cally sound clinical dopamine transporter gene. Am J Hum Genet. for the environment is the approach. A trial methods. 1995;56:993-998. balance of both is actually needed as chil- As we continue to explore and offer 9. Volkow ND, Wang G; Fowler JS, et al. Thera- peutic doses of oral methylphenidate signifi cant- dren learn to internalize the structure and alternative treatment options to children ly increase extracellular dopamine in the human strategies that have been created for them with ADHD, it is important to remember brain. J Neurosci. 200;21(2):RC121 externally as part of self-regulation. Using the Hippocratic oath of “Primum Non 10. 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