Introduction

As naturopathic doctors, we have worked with a numerous children with a number of different conditions that are along the behavior disorder continuum. In many cases, we have witnessed first-hand how diet, family and lifestyle changes along with appropriate nutrient supplementation will help avoid medicines and create optimal health. Our hope is this article will inform parents of the well-researched effective natural choices available and that medication can often be reserved as either a back up plan if these are not successful or for cases of true urgency. Our experience is that in most cases, more natural means can achieve positive results, address the underlying factors, and avoid side effects that can come with stimulant medications.

Statistics

Attention-Deficit/ Hyperactivity Disorder (ADHD) is an increasingly pervasive condition in our pediatric community. Although the National Institute of Mental Health reports an incidence of 3 to 5 percent, the most recent pediatric investigation shows almost 10 percent of children are now diagnosed.[i] As a result, this illness is now considered the most common childhood behavior disorder with a six-fold increase in boys over girls. The United States claims the greatest prevalence of ADHD over other nations. 

Symptoms and Causes

ADHD is considered a neurobiological disorder which inhibits a child’s ability to balance activity, perform tasks, and regulate behavior. Children with this disorder can have functional difficulties in the school environment, at home, and with peer relationships. Typical symptoms include a child’s inability to sit still for a reasonable period of time, act without thinking, and not finishing tasks. Children with this condition become at advanced risk for gambling, depression, anxiety and eating disorders.
 
ADHD is thought to have a genetic component. Some emerging research suggests medicated hospital birthing procedures may promote ADHD.[ii] Other studies have drawn relationships between simultaneous prenatal toxic exposures to lead and tobacco.[iii] Health difficulties in the mother, including ADHD, seem to predispose a child to this illness.[iv] Finally, parental marital difficulty and tumultuous environments also seem to increase predisposition to ADHD.[v]

Conventional Treatments

Conventional treatments medications and behavioral work. Stimulant medications like Ritalin, Adderall and Dexedrine increase dopamine, a brain chemical known to balance motivation, attention, movement and pleasure. Non-stimulant medications such as atomoxetine (Strattera) increase the level of norepinephrine, but is not found as effective as the stimulants.
 
In the United States, these drugs are used a greater percentage of time to treat ADHD over any other part of the world. Stimulant medications may prevent certain children to go on to have other mood disorders such as depression later in life,[vi] and thus may be appropriate if other natural treatments are not effective. However, it is in our opinion that these medications should be used more judiciously than currently prescribed. We know that nearly one-third of children on these medications experience worrisome side effects.[vii] There is an association with sudden unexplained deaths in pediatric patients, [viii] suicide risk,[ix] liver toxicity,[x] adolescent medications abuse,[xi] as well as increases in blood pressure and heart rates.[xii]

Naturopathic Medicine Can Help Parents Make a Plan

In many cases, there are wonderful natural, non-drug treatments that can help a child balance, focus and calm. Naturopathic medicine focuses on using various natural therapies together to allow the body to heal itself. Naturopathic physicians are trained to clarify the multiple factors usually involved in the clinical presentation of this challenging condition and create a cohesive individualized plan for health.
 
Unless there is a dire situation or question of safety, a typical naturopathic plan will attempt to avoid medications, and instead prescribe psychotherapy (not covered in this article) as well as diet, lifestyle, nutrient and herbal suggestions. Although much research is still needed, there is growing evidence regarding the effective use of individual natural therapies for this condition.
 
In many cases, any one recommendation alone will not necessarily create behavioral change. As a result, it is best to work with a naturopathic physician who will ask the right questions and design a recommendation plan to include the aspects that will help your child the most. Here are some recommendations which collectively we have found most helpful with our young patients:

1 - Foods: Sugar Balance, Additives and Protein

Naturopathic diet recommendations usually revolve around stabilization of blood sugar by avoiding high glycemic foods (foods that can quickly raise blood sugar) and replacing these with more complex carbohydrates, while assuring adequate intake of protein and fats to slow sugar absorption. Academic investigations out of Yale University as well as the University of South Carolina both corroborate the role of sugar intake contributing to changes in behavior and restlessness in ADHD children.[xiii],[xiv] Despite this data, other studies on sugar avoidance have not shown a clear link.[xv] It is possible in these negative studies, other factors (as outlined in this article below) also needed to be addressed simultaneously in order to effect a positive behavioral changes.
 
Interestingly, some research suggests that a link between sugar and hyperactivity may involve parental perception: mothers who were told the child received sugar reported more hyperactive behavior, even when aspartame-sweetened foods devoid of sugar were actually used. Mothers who were told the child received a low-sugar snack were less likely to report worse behavior.[xvi] It is possible in this study, the artificial sweetner used may have confounded these results.
 
Meal timing is crucial. Even in non-ADHD kids (and many of us adults) when there are large gaps of time between meals, the result can be irritability and mood change. In patients with susceptibility to ADHD, this likely triggers impulsivity, poor concentration or behavior difficulty. A remedy for this is assuring regular small meals, snacking, and increases in protein intake. These will prevent extreme vacillations in blood glucose. Research has found that hyperactive children who consumed a high-protein meal performed equal or better than non-hyperactive kids who didn't eat as much protein.  As such, it is important to have healthy protein snacks available for regular treats, such as natural protein bars, or apples with natural peanut butter before a child’s behavior changes.
 
Food sensitivities may play a role in some kids. Published in the 1970’s, the Feingold diet main tenet teaches that chemicals found in food additives can trigger abnormal brain response. Feingold also considered salicylates (aspirin- like compounds in certain foods) to also be a culprit.[xvii] These sensitivities are worth expoloring when other diet changes alone are not helping. The British journal Lancet reported in 1985 that almost 80% of children with hyperactivity improved behavior when sugary foods and foods with artificial colors were removed from the diet.[xviii] A follow up six-week study from 2007 revealed that kids with additives in their diet had clearly higher hyperactive behaviors over children with additive-free diets.[xix]

2- Sleep and Melatonin

It is estimated that up to one-third of children in the United States suffer from inadequate sleep. Inadequate sleep appears to be an independent risk factor for ADHD. In a cross-sectional study of 7 to 8 year-olds, researchers found that kids with less than 7.7 hours of sleep each night were significantly more prone to hyperactivity or inattentiveness, compared with children who were moderate or longer sleepers.[xx] Also important is consistency of bedtimes. Melatonin is a natural hormone made in the brain to help induce sleep. Used as a natural supplement, a presentation at the American Academy of Child and Adolescent Psychiatry showed that melatonin was helpful for treating delayed sleep onset in children with ADHD, according to the results of a double-blind, crossover-design pilot. The side effect profile of melatonin is minimal and is quite safe in children.[xxi]

3 - Exercise / Yoga

The neurotransmitter dopamine and norepinephrine help the brain stay attentive. It is well known that exercise increases the concentration of both dopamine and norepinephrine, as well as other brain chemicals. One expert in the field, Dr. J. Ratey is quoted as saying:
 
            “exercise is like taking a bit of methylphenidate (Ritalin) or amphetamine/dextroamphetamine (Adderall); it's similar to taking a stimulant.[xxii]
 
Given this knowledge, it makes sense to add significant exercise and movement that a child enjoys to their everyday life. Getting outdoors in nature as often as possible helps raise vitamin D levels and is known to be calming.
 
Two small trials also looked to yoga as a method to improve symptoms of young patients who were already stabilized on medication. Both studies showed improvement trends, but were not large enough to be definite.[xxiii],[xxiv] Given the positive research about yoga in other mood disorders, it is certainly worth a try.

4 - Home Environment

The home should be evaluated regarding calmness, consistency and sense of security for the child.. Recent evidence shows that children who watch television for 1.5hrs or more have higher blood pressure.[xxv] Early TV watching has been definitively linked to attention problems by age 7.[xxvi] Possibly, less time watching TV and using video games, and more time in nature would be balancing for the ADHD brain. In our clinical experience, we have also found replacing TV time with special parent-child time where one parent spends time doing an activity with the child for at least 15 minutes a day can help calm and focus a child’s challenging behavior. In many cases, we have seen ADHD behaviors linked to marital conflict and general strife[xxvii] within the household, which can contribute to ‘mixed messages’ and lack of consistency. Working on these, and having the guardians involved assure consistency in regards to the children have had major breakthroughs in a few cases.

 
Clinical Case: Joshua
 
Joshua was a 8 year-old who came to our diagnosed with ADHD about one year prior and was placed on Ritalin . Unlike some kids with ADHD, Joshua did well academically, but acted very restless in school which was getting him in trouble with the teachers. He also struggled with being a bit recluse from peer relationships, suffered from insomnia, had frequent colds, and had some digestive problems. The Ritalin had helped his symptoms, but when his mother discontinued the medication about four months prior, Joshua’s moody symptoms returned.
 
Joshua lived at home with his parents. There had been some strife in the house since the father lost his job at the onset of the recession. From that point, there was increased arguing, mostly over money issues, which spilled over into how the parents cared for their son. His mother brought Joshua in due to the Ritalin side effect of low appetite, and she was concerned about some long-term consequences to the heart that she read about. Joshua was already doing cognitive therapy work and was put on a low sugar diet, although juices were consumed liberally.
 
After a one-hour first visit with Joshua and his mom and learning their story, we recommended a regular schedule of protein-based small frequent meals as opposed to less-frequent larger meals to help increase food intake and balance blood sugar and avoidance of juice and milk products. We recommended he continued his behavioral therapy. We also recommended counseling for the parents to help them learn how to work together when addressing Joshua care for best consistency. We stressed the need for consistent ritual around bedtime, which the parents were able to agree upon. Joshua was placed on essential fatty acids, a multiple vitamin, Bacopa, melatonin in the evening, and recommended child-specific probiotics for his digestive issues. Joshua’s lab tests unearthed low B12 status, which was then supplemented accordingly.
 
In one month, Joshua’s digestive symptoms and colds had cleared. In four months, we began to work with his prescribing doctor to wean off his medications, at which point we increased his bacopa. Joshua remained off the medication for two months with no regression in his symptoms, so we began the process of decreasing the bacopa, and continued monitoring of his diet, food schedule, environment and other nutrients status.
 
 

5 - Essential Fatty Acids

About 10% of the brain is composed of fat (and the rest is water). As such, children need healthy fat ingestion in order to build healthy and functioning brains. These fats are called ‘essential fatty acids’ because these cannot be made by the body, and must be derived from the diet. Commonly, children’s diets are low in the foods that possess these. Foods with significant amounts include coldwater fishes, raw nuts and seeds, and flax meal. Recently, published work by researchers at Harvard’s Massachusetts General Hospital recommends a high omega-3 fatty acid supplement to be the a first choice in treatment for children with ADHD, as well as those with other mood disorders and behavioral problems. In this evaluation, omega-3 fats were tested for 8 weeks in 6 to 17 years olds. Half of these participants experienced a rapid 30 percent reduction in symptoms with no side effects. [xxviii]

6 - Zinc and Iron

Similar to fish oil intake, ADHD children are typically at risk for low trace mineral status, including deficiencies in zinc. One study revealed that serum zinc below laboratory norms was present in 77% of children aged 6 to 9 years and 67% of children aged 10 to 12 years.[xxix] Minerals like zinc may aid in producing dopamine, which is a neurotransmitter raised by stimulant medications. A second study of ADHD treatment with zinc sulfate as a supplement to medication has also shown beneficial effects and further confirmed the role of inadequate zinc.[xxx] Although these studies have shown help with zinc supplementation alone, other studies have not shown clear efficacy. Long term zinc supplementation may lower copper status and should be supplemented accordingly.
 
Iron is also an important nutrient for healthy mood. Pediatric investigators found that serum ferritin levels (which is the storage form of iron in the body) were significantly lower in children with ADHD and likely contribute to kids who are“inattentive and distractable and suffer from learning disabilities” according to the study authors. "Iron supplementation could be considered a first-line treatment for children with ADHD and iron deficiency…and decrease the need for psychostimulants" the authors concluded.[xxxi]
 
Given the association with mood disorders[xxxii], other vitamin and nutrient levels such as vitamin B12, vitamin D, and carnitine may be useful to look at with the pediatric patient.

7 - Herbal Remedies: St. John’s wort and Bacopa

Botanical remedies, known as herbs, have been used in children’s care for hundreds of years, if not millennia. One study of St. John’s wort found this herb, traditionally used in depression, as safe, but ineffective for symptoms of ADHD in children.[xxxiii] This study was an eight-week trial, which may not have been enough time to truly allow St. John’s wort to fully take effect. With other natural recommendations, St. John’s wort may still be a reasonable addition, but longer term stuy is needed. Another double blind study at a medical school in India revealed benefit after 12 weeks of using the botanical medicine Bacopa monnieri in regards to sentence repetition, logical memory and learning tasks. The children were still found improved four weeks after the herb had been discontinued. Bacopa did not show any side effects.[xxxiv]

8 - Other nutrients and herbs

Other nutrients that have been studied with some preliminary positive results include the amino acid L-carnitine, pycnogenol, and the herb ginkgo.[xxxv] Other herbs can be used for symptomatic help commonly associated with ADHD, such as California poppy for anxiety, or chamomile for digestive issues. Given their safety profile, these may be considered if other recommendations are not sufficient, but much more study is needed.

9 - Homeopathy

Used extensively in Europe and India, homeopathy is an energetic medicine that uses the law of ‘like cures like’ by using infinitesimal dilutions of various compounds. In children, homeopathy seems to be effective for many conditions, as a child’s energy is usually quite strong and responsive to this modality. We have used homeopathy quite effectively for a range of conditions, include infant colic and sleeping issues, pediatric fevers and colds, as well as mood balancing. At least three randomized controlled trials have evaluated the efficacy of homeopathy for the treatment of ADHD with mixed results, not allowing any research to show a clear advantage for using homeopathic medicines.[xxxvi] In our clinical experience, choosing a remedy is very individual, and may help when used in conjunction with the above recommendations. Since homeopathy quite non-toxic, and will not interfere with medications, it is worth pursuing for children with ADHD and needs further study.

10 - Psychotherapy

Not covered in this article - however every parent should include some type of group and individual psychologic work, behavorial and or cognitive therapy to learn more about how the child perceives the world, and to offer tools which may help the child enhance self-esteem, organize his or her day, and reduce anxieties.

Summary of Naturopathic Therapies for ADHD
 
 
1 - Diet: low sugar, higher protein, chemical-free, consider food sensitivities and salicylate free foods, assure adequate water intake
 
2 - Sleep: consistent early bedtimes, melatonin if indicated
 
3 - Exercise: every day
 
4 - Environment: identify home-life conflict, limit TV and video
 
5 – Essential Fatty Acids
 
6 – Zinc and Iron
 
7 – Herbal Remedies: Bacopa
 
8 - Other Nutrients: for extra help, see above
 
9 - Homeopathy: individualized to the child
 
10 - Psychotherapy
 

Conclusion

Although a challenging condition, we have found that children respond well to naturopathic approaches treatments for attention deficit and can prevent the need for medication. The key is to work with a practitioner like a naturopathic doctor who will to take the time a sort out which factors are most needed for each child to create an effective plan utilizing some of the above recommendations as appropriate for the best results and a healthy child.
 
About the NYANP: The New York Association of Naturopathic Physicians (NYANP) current mission is to keep New Yorker healthy, and pass legislation for licensure of naturopathic physicians in the State of New York. They can be contacted by visiting: www.NYANP.org.
 
Dr. Pina LoGiudice and Dr. Peter Bongiorno are a husband and wife, naturopathic doctor and acupuncturist team. Both were pre-doctoral fellows at the National Institute of Mental Health before their medical school and acupuncture training . They also served as past and current vice-president (respectively) of the NYANP, and have private practices in New York (New York City and Long Island). They can be reached by visiting www.InnerSourceHealth.com.


[i] Stein RE, Horwitz SM, Storfer-Isser A, et al Pediatrics. 2009;123:248-255
[ii] Wahl RU. Could oxytocin administration during labor contribute to autism and related behavioral disorders? A look at the literature. Med Hypotheses. 2004;63:456-460.
[iii] Anderson P. Pediatrics. Published online November 23, 2009.
[iv] Ray GT. Med Care. 2009;47:105-114
[vi] Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV Do Stimulants Protect Against Psychiatric Disorders in Youth With ADHD? A 10-Year Follow-up Study. Pediatrics. 2009;124:71-78
[vii] Pope TP. NY Times WELL; Weighing Nondrug Options for A.D.H.D.June 17, 2008.
[viii] Gould MS, Walsh BT, Munfakh JL, et al. Sudden death and use of stimulant medications in youths. Am J Psychiatry. 2009 Jun 15.
[ix] Med Watch. The U.S. Food and Drug Administration (FDA). http://www.fda.gov/medwatch
[x] Med Watch. The U.S. Food and Drug Administration (FDA). http://www.fda.gov/medwatch/safety/3500.pdf
[xi] Brauser D. Prescription ADHD Medication Abuse by Adolescents on the Rise
Pediatrics. Published online August 24, 2009.
[xii] Boggs W. J Pediatr 2009;155:84-89.
[xiii] Girardi NL Blunted catecholamine responses after glucose ingestion in children with attention deficit disorder.Pediatr Res. 1995 Oct;38(4):539-42.
[xiv] Wolraich M, Milich R, Stumbo P, Schultz F. The effects of sucrose ingestion on the behavior of hyperactive boys. Pediatrics, 1985; 106; 657-682.
[xv] R. Schnoll, D. Burshteyn and J. Cea-Aravena, Nutrition in the treatment of attention-deficit hyperactivity disorder: a neglected but important aspect, Appl Psychophysiol Biofeedback 28 (1) (2003), pp. 63–75.
[xvi] Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interaction. Journal of Abnormal Child Psychology, 1994; 22; 501-515.
[xvii] B. Feingold, Why your child is hyperactive, Random House, New York (1975).
[xviii] Egger J, et al. Controlled trial of oligoantigenic treatment in the hyperkinetic syndrome. Lancet. 1985;1:540-545.
[xix] Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomized, double-blinded, placebo-controlled trial", Lancet, Sept 2007
[xx] Paavonen J. Pediatrics. Published online April 27, 2009.
[xxi] AACAP 50th Annual Meeting: Abstract E16. Presented Oct. 14-19, 2003.
[xxii] Wysong P. Exercise and ADD: An Expert Interview With John J. Ratey, MD
Medscape Psychiatry & Mental Health 10/08/2009
[xxiii] P.S. Jensen and D.T. Kenny, The effects of yoga on the attention and behavior of boys with Attention-Deficit/hyperactivity Disorder (ADHD), J Atten Disord 7 (4) (2004), pp. 205–216.
[xxiv] S. Khilnani, T. Field and M. Hernandez-Reif et al., Massage therapy improves mood and behavior of students with attention-deficit/hyperactivity disorder, Adolescence 38 (152) (2003), pp. 623–638.
[xxv] Eisenmann J. Archives of Pediatrics and Adolescent Medicine. August 2009
[xxvi] Christakis DA. Early Television Exposure and Subsequent Attentional Problems in Children PEDIATRICS Vol. 113 No. 4 April 2004, pp. 708-713
[xxvii] Kitzmann KM. Effects of marital conflict on subsequent triadic family interactions and parenting. Dev Psychol. 2000 Jan;36(1):3-13.
[xxviii] Locke C. Eur Neuropsychopharmacol. 2007. Jan 25
[xxix] Weiss M. American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract 17.3. Presented October 31, 2009.
[xxx] Dodig-Curković K et al. The role of zinc in the treatment of hyperactivity disorder in children. Acta Med Croatica. 2009 Oct;63(4):307-13.
[xxxi] Konofal E. Arch Pediatr Adolesc Med. 2004;158:1113-1115
[xxxii] Bongiorno P. Naturopathic and Conventional Medicine for Depression. CCNM Press. 2010.
[xxxiii] Weber W, Vander Stoep A, McCarty RL, et al. Hypericum perforatum (St. John's Wort) for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. JAMA. 2008;299(22):2633–2641.
[xxxiv] Negi KS, Singh YD, Kushwaha KP, Rastogi CK, Rathi AK, Srivastava JS, Asthana OP, Gupta RC, Lucknow G. "Clinical evaluation of memory enhancing properties of Memory Plus in children with Attention Deficit Hyperactivity Disorder." Indian Journal of Psychiatry, 2000 Apr; 42(2) Supplement
[xxxv] Weber W, Newmark S. Complementary and Alternative Medical Therapies for Attention-Deficit/Hyperactivity Disorder and Autism Pediatric Clinics of North America, Volume 54, Issue 6, 2007:983-1006