You may wonder if there’s something besides medicine or behavior therapy you can do to help your child with ADHD . Can unconventional treatments work?
Can Changes to Diet Treat ADHD?
There’s a lot of controversy about sugar and ADHD symptoms. Does it lead to hyperactivity?
There is no proof that sugar causes ADHD.
Then why do kids seem so hyper if they eat a lot of sugar? Research does show that refined sugar and carbohydrates can affect your child’s activity level. Kids can feel a rush because refined sugar quickly enters the bloodstream. That boosts blood sugar fast. When blood sugar spikes, your child may become much more active. The burst of energy is from an adrenaline rush caused by the rise in blood sugar.
So what can you do? Nutritionists say to add more fiber to your child’s diet to help keep blood sugar levels even. High-fiber foods include berries and other fruits, whole grains, and oatmeal.
Premiere Date: October 20, 2019
Expiration Date: April 20, 2021
This activity offers CE credits for:
1. Physicians (CME)
2. Other
All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.
ACTIVITY GOAL
The goal of this activity is to provide an understanding of the evidence for the use of complementary and alternative (CAM) treatments for ADHD.
LEARNING OBJECTIVES
At the end of this CE activity, participants should be able to:
• Discuss the limitations of conventional treatment and how CAM therapies are used as adjuncts to stimulants;
• Describe the effects of certain food products and how they might affect ADHD symptoms as well as the evidence for the use of the oligoantigenic diet;
• Explain EEG biofeedback protocols and the strategies to address various symptoms of ADHD;
• Identify which nutritional and herbal supplements have the best evidence for treating symptoms of ADHD.
TARGET AUDIENCE
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
CREDIT INFORMATION
CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the
Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.
CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™.
DISCLOSURE DECLARATION
It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.
The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.
James Lake, MD, has received received travel support from Blackmores Institute Visiting Fellowship and royalty payments from Norton, American Psychiatric Publishing, Thieme Medical, and Blue Poppy Press.
Professor Sarris has received either presentation honoraria, travel support, clinical trial grants, book royalties, or independent consultancy payments from Integria Healthcare & MediHerb, Pfizer, Scius Health, Key Pharmaceuticals, Taki Mai, FIT-BioCeuticals, Blackmores, Soho-Flordis, Healthworld, HealthEd, HealthMasters, Grunbiotics, Australian Natural Therapies Group, Kantar Consulting, Research Reviews, Elsevier, Chaminade University, International Society for Affective Disorders, Complementary Medicines Australia, SPRIM, Terry White Chemists, ANS, Society for Medicinal Plant and Natural Product Research, Sanofi-Aventis, Omega-3 Centre, the National Health and Medical Research Council, CR Roper Fellowship. He also receives support from a NHMRC Clinical Research Fellowship (APP1125000).
Patricia Gerbarg, MD, (peer/content reviewer) has no disclosures to report.
Applicable Psychiatric Times staff and CME Outfitters staff have no disclosures to report.
UNLABELED USE DISCLOSURE
Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.
For content-related questions email [email protected]; for CME credit questions call 877.CME.PROS (877.263.7767) Call us at 877.CME.PROS (877.263.7767)
Recent surveys suggest that 7% to 8% of children and 4% to 5% of adults meet ADHD criteria.1,2 The rate at which ADHD is diagnosed and treated has increased dramatically since the syndrome was recognized by DSM as a specific disorder in the 1970s. It is estimated that fewer than 20% of adults with ADHD have had a correct diagnosis and have thus incurred significant social and occupational risk. Almost half of those who have ADHD never graduate from high school and fewer than 5% complete a 4-year university degree program.3 A diagnosis of ADHD has been associated with 35 days of lost work on average per year, which suggests US$19 billion in lost productivity and 120 million lost work days annually.4
Limitations of conventional treatment
Because stimulants are usually classified as scheduled or restricted medications (depending on the country), prescriptions are often limited to a small supply, which results in treatment interruptions and transient worsening of when refills are not obtained on timely basis. Adverse effects of stimulants include insomnia, decreased appetite, abdominal pain as well as occasional stimulant-induced psychosis; chronic use can increase the risk for slow growth. Moreover, stimulants and other pharmacologic treatments for adult ADHD may be only half as effective as they are in children.
Controlled-release stimulants, bupropion, and the SSRI antidepressants are being increasingly used in the adult ADHD population, however these medications may not be as efficacious as stimulants. Although atomoxetine is FDA-approved for the treatment of childhood ADHD, there are growing concerns about its adverse effects, including hypertension, tachycardia, nausea and vomiting, liver toxicity, and possibly increased risk of suicide.
CAM therapies are widely used to treat ADHD
Growing concerns about inappropriate prescribing or over-prescribing of stimulant medications and the incomplete understanding of risks associated with their long-term use have led to increasing acceptance of complementary or alternative medicine (CAM) therapies. CAM therapies in children with ADHD are used largely out of parental concerns over prescription drug safety. CAM therapies, including vitamins/minerals, dietary changes, and expressive therapies, are used although parents rarely disclose this to the child’s doctor. Although there is limited evidence to support most CAM therapies for treating ADHD, it is highly regarded by many patients’ parents.
Dietary modification
Early studies suggested that artificial food colors were associated with ADHD; however, a meta-analysis of studies spanning a 35-year period failed to confirm this relationship.5 One such diet, the oligoantigenic diet (OAD), is a highly restrictive multiple elimination diet that excludes food colors and additives, in addition to dairy products, sugar, wheat, corn, citrus, eggs, soy, yeast, nuts, and chocolate. The diet permits a limited number of hypoallergenic foods like lamb, chicken, potatoes, rice, bananas, apples, cabbages, broccoli, brussels sprouts, carrots, peas, pears, and cucumber, as well as salt, pepper, calcium, and some vitamins. Reductions in hyperactivity were seen in children who were on the OAD regimen when specific food items were eliminated from the diet.6 Behavioral symptoms improved during the elimination and placebo phases and recurred when children were subsequently challenged with the eliminated food item.
Roughly one-third of hyperactive children may benefit from some form of an elimination diet.5 Although these findings are promising, they cannot be used to develop general ADHD treatment protocols because of study design flaws, including heterogeneity of patient populations, absence of standardized outcome measures, high dropout rates and, in some studies, non-blinded researchers.
The American Academy of Pediatrics does not endorse elimination diets because of inconsistent efficacy findings as well as concerns that highly restrictive diets do not provide balanced nutrition . Parents who are considering restrictive diets should consult with a qualified nutritionist. Highly restrictive diets should not be continued for longer than two weeks in the absence of noticeable improvements in ADHD symptoms.
EEG biofeedback
Many individuals with ADHD have abnormal patterns of brain electrical activity, including under-arousal in the frontal and midline cortical regions. Electroencephalogram (EEG) biofeedback is aimed at normalizing EEG activity to correct the brain’s state of relative under-arousal and improve cognitive and behavioral functioning. Two EEG biofeedback protocols have been extensively evaluated as treatments of ADHD.
Sensorimotor rhythm (SMR) training reinforces EEG activity in the faster beta frequency range (16-20 Hz) in the midline cortical regions, with the goal of reducing symptoms of impulsivity and hyperactivity. Theta suppression reduces EEG activity in the slower theta frequency range (4 to 8 Hz) and is primarily used to treat symptoms of inattention. An EEG biofeedback protocol directed at suppressing theta activity (4 to 8 Hz) over the midline regions is probably the most effective strategy when treating primarily symptoms of distractibility and inattention.
Controlled studies that compared EEG biofeedback with a stimulant medication versus a waitlist showed positive clinical effects and EEG normalization; however, it is not yet established whether improved alertness is associated with increased or decreased alpha activity (12 to 18 Hz).7,8 A review of 14 randomized neurofeedback trials in children with ADHD consistently showed beneficial outcomes.9 Findings of neurofeedback research are limited by small study sizes, heterogeneous populations, absence of a control group, inconsistent outcome measures, and limited or absent follow-up. The potential benefits of neurofeedback are limited by expensive treatments that are seldom covered by insurance.
Nutritional supplements
Children with ADHD have lower plasma concentrations of certain essential fatty acids (EFAs). However, findings from controlled trials of supplemented EFAs in ADHD are inconsistent. One study found no differential benefit of EFAs compared with stimulants.10 In another study, parents of children in the EFA-treatment group (n = 104) reported more improvement than parents of children who received a palm oil placebo.11 This study has been criticized because a high dropout rate confounds findings in a positive direction. A meta-analysis (including studies from 1965 to 2010) confirmed positive effects of adjunctive EFAs in childhood ADHD; however, therapeutic benefits were significantly less compared with conventional pharmacological treatments.12
The use of olive oil as a placebo in certain studies may mask the beneficial clinical effects of EFAs because an active constituent of olive oil is converted into oleamide, which is known to affect brain function. Furthermore, the short durations and low doses of EFAs used in most studies may not be adequate to result in the long-term changes in neuronal membrane structure required for clinical improvement.
Some children with ADHD have abnormally low plasma zinc levels, which may interfere with optimal information processing and thereby result in difficulties maintaining attention. However, findings on zinc supplementation are inconsistent. In a large 12-week prospective controlled trial, children and adolescents randomized to zinc (150 mg/d) experienced significant improvements in hyperactivity and impulsivity over placebo but not inattention.13 However, a high dropout rate limited the significance of these findings. In contrast to these findings a more recent placebo-controlled study failed to show efficacy.14
Abnormally low serum ferritin levels may be associated with hyperactivity in children with non-anemic ADHD, but not with deficits in cognitive performance. A 2012 systematic review of studies on iron in children with ADHD found mixed results in the relationship between serum iron levels and symptom severity as well as inconsistent responses of ADHD symptoms to iron supplementation.
