Updates in ADHD Bradley Siu, Psy.D. Kaiser SSF Child Psychiatry - - PowerPoint PPT Presentation

Updates in ADHD

Bradley Siu, Psy.D.

Kaiser SSF Child Psychiatry

Please sign the attendance sheet in the room to claim your credit.

1

Pediatric Grand Rounds: 8/23/2017

Epidemiological Data

❖ ADHD prevalence rates for youth have increased considerably in the past 25

• years. Growth rates were about 4.5% annually from 26.2 per1000 office visits in

2008 to 107 per 1000 in 2013.

❖ A history of ADHD diagnosis by a health care provider increased by 42%

between 2003 and 2011:

❖ 7.8% had ever had a diagnosis in 2003 ❖ 9.5% had ever had a diagnosis in 2007 ❖ 11.0% had ever had a diagnosis in 2011 ❖ The percentage of US children 4-17 years of age with an ADHD diagnosis by a

health care provider, as reported by parents, continues to increase. Since then the growth has been about 2.9% annually

❖ For Adults there was an eightfold increase in ADHD

Epidemiological Data

❖ 2012-2013 visits made by African American youths were 24% more

likely to include an ADHD diagnosis and 19% more likely to include a diagnosis and drug prescription than were visits made by White youths.

❖ The youth of other races predominantly Asian/Pacific Islander, were

less likely than White youths to receive an ADHD diagnosis or drug prescription.

❖ For adults and children interaction of a mood or anxiety disorder with

FEMALES increased the odds of ADHD diagnosis and treatment by a factor between 1.7 to 2.5x.

❖ This fulfills the AB 1195 requirement for incorporation of CLC into

CME.

The Prefrontal Cortex

❖ Consist of a collection of cortical areas. Collectively these

have important ties to other brain areas that together manage Executive Functions, cognitive control, and self regulation.

❖ Also has interconnections with brain areas responsible for

processing of external information: sensory systems, motor systems, and internal information. It is connected to the motor system, Basal Ganglia, and Limbic system.

Executive Functions

❖ Executive Functions is a widely used term in the

Neuropsychological literature, and is now broadly used in general psychology, clinical psychology, and in education.

❖ Executive Functioning is a meta construct or an umbrella term

that describes a set of cognitive functions, or group of tools necessary in goal directed action, behavior towards the future, and self regulation.

ADHD = Executive Functioning Deficit Disorder

❖ Executive Functions are skills and task that are managed by the prefrontal cortex

and corresponding neuropathways:

– Organizing – Planning – Inhibition – Activation – Emotional Self Control – Time Management – Attention and Focus

❖ ADHD can be seen as a disorder of the neuropathways that involve the PFC’s

connection to the other areas of the brain.

ADHD = Executive Functioning Deficit Disorder

Devolving Attention?

❖ Non Biological ADHD - Lifestyle Disorder? ❖ Digital Dementia ❖ Distracted Lifestyle ❖ Gut Health: Nutrition ❖ Non-Omega 3 FA (inflammatory oils) ❖ Sleep ❖ Addiction

Addiction

❖ All Addiction looks the same under FMRI - nucleus accumbens ❖ Addiction is most Industries’ goal. ❖ Many Industries use neuroscientist and neuro-imaging.

Addiction - Electronics

❖ There are number of industries in which neuroscientist are used

to create programs or patterns in the

❖ Casino Player Tracking the end game is to keep the player at

their preferred machine. “Today’s higher performance processors are allowing abilities such as facial recognition to monitor player engagement.”

❖ Food industry - these companies rely on pure science to

understand how we’re attracted to food and how they make their foods attractive to us.

❖ Internet apps and mobile apps - Facebook

Addiction - Electronics

❖ Evidence that the neural mechanisms underlying Internet Gaming

Disorder (IGD) resemble those of drug addiction and share similar neurobiological abnormalities with other addictive disorders.

❖ Previous studies showed dopamine release in the ventral striatum

in a similar magnitude to amphetamine-induced dopamine release.

❖ Video game playing induced stratal dopamine release indicating

that this is a major force promoting addictive behavior.

❖ Video game playing involved changes in reward inhibitory

mechanisms and loss of control. - Alterations in ventral striatum that is an important part of the brains reward mechanisms.

Neurological Changes

❖ FMRI shows changes to brain regions responsible for attention and

control, impulse control, motor function, emotional regulation, sensory motor coordination.

❖ Associated with lower white matter density in brain regions that are

involved in decision-making, behavioral inhibition and emotional regulation.

❖ IGD is an interaction of limbic and prefrontal brain areas that diminished

executive and inhibitory control.

❖ Video game playing as associated with dopamine release similar in

magnitude to those of drug abuse and lower dopamine transporter and dopamine receptor D2 occupancy indicating sub-sensitivity of dopamine reward mechanisms.

Neuroregulation and Addiction

❖ Diminished efficiency of response-inhibition. ❖ Excessive use of the brain’s dopamine reward system

resembles the down-regulation seen in the cases of drug and alcohol abuse.

❖ Associated with impaired function of the prefrontal cortex and

its connection with limbic regions that relates to high impulsivity that in turn may contribute to impaired cognitive control.

Essential Supplements for ADHD

Most ADHD professionals recommend eating a diet full of vegetables, fruit, complex carbs, and protein with every meal to help manage symptoms. This is should be interpreted as “whole unprocessed foods” diet.

Omega 3 Fatty Acids

❖ Omega-3 fatty acids are essential fatty acids necessary for human

• health. There are two families of essential fatty acids: Omega-3

fatty acids and Omega-6 fatty acids. They are termed “essential” because they cannot be produced by the body, and must therefore be obtained from the diet.

❖ Both omega-6 and omega-3 fatty acids are stored in the cell

membranes of tissues and have two primary functions. First, they are structural components of cell membranes where they ensure fluidity, stability, and act as gate-keepers in the cell. Second, both

• mega-6 and omega-3 fatty acids are converted into a number of

important, active molecules called prostaglandins.

Omega 3 Fatty Acids

❖ Some studies have suggested that children with ADHD have an abnormal

Poly Unsaturated Fat profile and, in particular, a decrease in the plasma concentration of DHA and EPA.

❖ Depletion of essential fatty acids may impact the brain, which contains the

highest lipid content and requires Omega 3 PUFA for development, intercommunication and function; DHA plays a significant role in brain development whereas EPA is important mostly for function.

❖ Omega 3 Fatty Acids are a crucial part of the cell membrane that surround

the cells of the brain and nervous system.

❖ Recent studies have shown that omega-3 fatty acids improve symptoms of

• ADHD. A comprehensive look at many studies showed that omega-3’s are

about 40 percent as effective as stimulants in relieving symptoms.

Omega 3 Fatty Acids

❖ Fats play a significant role in the brain. Specifically, the amount and

type of fat one consumes directly affects the composition of nerve cell membranes.

❖ According to Kaiser Regional ADHD committee all children with

ADHD should be on or have tried an Omega 3 supplement.

❖ Take Optimal Amounts of Omega-3s - According to Dr. Sandy

Newmark, kids between four and eight years old should take between 1,000-1,500 mg. a day. Older kids should get 2,000-2,500 mg. daily.

❖ More commonly available size: 1200mg with 600mg total DHA & EPA

Omega 3 Fatty Acids

The AI (Adequate Intake) of Omega-3 is 1.6g/day for men and 1.1 g/day for women. There is no Daily Value for omega-3s. Salmon 4 oz: 1.45g Sardines 4 oz: 1.34 g Mackerel 4 oz: 1.25g Grass-fed beef 4 oz: 1.1g Flaxseed 2 Tbsp: 3.2g Chia Seeds 2 tbsp: 2.5g Walnuts ¼ cup: 2.3g Natto 4 oz: 0.52g Tuna 4 oz: 0.33g Grass-fed Dairy 8 oz: .25g

Iron

❖ Iron for Better Behavior ❖ Iron deficiency affects the hemoglobin in red blood cells, causes

significant learning problems in infants and children. At least 16 research studies performed in countries around the world found that cognitive, motor, and/or social/emotional functioning was reduced in infants who had iron deficiency anemia.

❖ A 2008 study appeared in Pediatric Neurology showed

that children who were not anemic but had low ferritin levels, a protein needed to store iron in the blood, showed improvement of ADHD symptoms after 12 weeks of iron supplements.

Iron

❖ Iron is essential for the optimal production of both

noradrenalin and dopamine and is a necessary component for the enzymes involved in their production.

❖ Before recommending an iron supplement, have iron levels

• checked. Research studies used iron levels below 30 as falling

into the treatment category.

Iron Rich Foods

Red Meat Chicken Turkey Beans Shell Fish Whole Grains Ascorbic acid or vitamin C occurs naturally in vegetables and fruits, especially citrus. Ascorbic acid enhances the absorption of iron. Studies indicate 100 milligrams of ascorbic acid increased iron absorption from a specific meal (eaten in the same sitting) by 4.14 times.

Sources of Iron

Spirulina: 1 ounce: 8 milligrams of iron (44 percent DV) Liver: 3 ounces of organic beef liver: 4.05 milligrams of iron (22.5 percent DV) Grass-Fed Beef: One lean grass-fed strip steak (214 grams): 4 milligrams of iron (22 percent DV) Lentils: ½ cup: 3.3 milligrams of iron (20.4 percent DV) Dark Chocolate: 1 ounce: 3.3 milligrams iron (19 percent DV) Spinach: ½ cup cooked: 3.2 milligrams (17.8 percent DV) Sardines: 1/4 cup: 1.8 milligrams (10 percent DV) Black beans: ½ cup: 1.8 milligrams (10 percent DV) Pistachios: 1 ounce: 1.1 milligrams (6.1 percent DV) Raisins: 1/4 cup: 1.1 milligrams (6.1 percent DV)

Zinc

❖ Zinc for Impulsivity - Some studies have shown that children

with ADHD may have lower levels of zinc. Taking zinc supplements may reduce hyperactivity and impulsivity but not

• inattentiveness. High levels of zinc, however, may be dangerous.

❖ Studies reveal that zinc levels of children with ADHD were

significantly lower than controls.

❖ There are not a lot of studies on Zinc but each study revealed

the same conclusion that children with ADHD who also were low on Zinc displayed some improvements when zinc was administered.

Zinc

❖ Like many minerals Zinc is an important co factor in many

reactions and is important in the central nervous system. It is involved in over 100 enzymes.

❖ All children with ADHD should have their zinc checked before

recommending a supplement. If necessary, Dr. Newmark (UCSF) suggests that children with ADHD take 20 mg. daily.

❖ Zinc does not store in the body very long so regular intake of

zinc containing foods should be routine.

Zinc Rich Foods

Seafood Oysters (Shellfish) Spinach Seeds (pumpkin) Nuts (cashews) Pork, Chicken Beans Zinc blocking foods are whole grains (phytates bind minerals from being absorbed in the body). Fermented foods and soaked grains are important ancestral cooking practices necessary in bringing back complete nutrition and full health.

Sources of Zinc

Pumpkin seeds – 1/2 cup: 8.4 mg (57% DV) Beef – 4 oz: 5.2 mg (32% DV) Lamb – 4 oz: 5.2 mg (32% DV) Cashews – 1/2 cup: 3.8 mg (25% DV) Chickpeas (Garbanzo beans) – 1 cup cooked: 2.5 mg (17% DV) Mushrooms – 1 cup cooked: 1.9 mg (13% DV) Chicken – 4 oz: 1.6 mg (12% DV) Kefir or Yogurt – 1 cup: 1.4 mg (10% DV) Spinach – 1 cup cooked: 1.4 mg (9% DV) Cocoa powder – 1 Tbsp: 0.4 mg (2% DV)

Magnesium

❖ Has been well documented that magnesium is necessary in more

than 300 biological processes. It is necessary for maintaining normal muscle and nerve function, keep heart rhythms steady, supports health immune functions, and keep bones strong.

❖ Magnesium functions as a relaxant, expanding blood vessels, and

• bronchioles. It has a direct effect on the nervous system: decreases

sensitivity and excitability.

❖ Used for relaxation and sleep, it is thought of as a calming mineral.

Healthy levels of magnesium in the blood can help relax children with ADHD.

❖ Severe magnesium deficiency can lead to tension, anxiety, excitability,

insomnia, high blood pressure, and seizures.

Magnesium

❖ Five studies have shown that children with ADHD have

lower levels of magnesium than children without.

❖ Some small studies have shown that adding magnesium

supplements decreases some symptoms of ADHD compared to control groups.

❖ Supplementation are more likely to show improvements in

hyperactivity and impulsivity than attention and focus.

Sources of Magnesium

Spinach — 1 cup: 157 milligrams (40% DV) Chard — 1 cup: 154 milligrams (38% DV) Pumpkin seeds — 1/8 cup: 92 milligrams (23% DV) Yogurt or Kefir — 1 cup: 50 milligrams (13% DV) Almonds — 1 ounce: 80 milligrams (20% DV) Black Beans — ½ cup: 60 milligrams (15% DV) Avocado — 1 medium: 58 milligrams (15% DV) Figs — ½ cup: 50 milligrams (13% DV) Dark Chocolate — 1 square: 95 milligrams (24% DV) Banana — 1 medium: 32 milligrams (8% DV)

Essential (and Often-Overlooked) Supplements for ADHD

Vitamin C for Dopamine - Vitamin C, says Dr. Ned Hallowell, is important in modulating the neurotransmitter dopamine at the synapses in the brain. (ADHD stimulants are effective because they increase dopamine levels in the brain.) One caution: Don't take vitamin C less than an hour before or after taking ADHD meds. It prevents the med from being absorbed. Protein for Focus - If your child doesn’t eat high-protein foods, which are key to increasing attentiveness and focus, or is a picky eater, give him a protein-powder drink in their place. Daily multivitamin, containing the recommended daily allowance of vitamins and minerals, is important for optimal brain health. Many of the multivitamin/multi mineral products on the market contain sugar, preservatives, and artificial colors, which may increase hyperactivity in children.

Essential (and Often-Overlooked) Supplements for ADHD

Help for Sleep - There is limited evidence that supports using herbs in treating ADHD. Valerian also helps with sleep problems and lessens the “rebound effect” that some kids experience when stimulants wear off. The herb valerian can calm hyperactivity and may reduce anxiety, but it doesn’t improve concentration. Melatonin is a natural hormone produced in our bodies to help us get to

• sleep. When we turn off the television, dim the lights, and settle down for

bed, our body produces melatonin and we become sleepy. But for those with ADHD, sleep is sometimes difficult to come by. Always start with the smallest possible dose and cut the pill in half. Take many melatonin holidays and watch out for the down regulation of endogenous melatonin.

ADHD: Screen Time Risk

❖ Are kids with ADHD at greater risk ❖ American Acad Ped: screens are the greatest risk: 2015 ❖ 5 hours of screen time for entertainment based. 16 minutes for

education.

❖ effect of screen time is dose dependent ❖ AAP indicated that obesity is linked to screens

ADHD: Screen Time Risk

❖ video games ver academic success: video games and tv no real

• difference. more time with screens lower acad success. social media

❖ research = more time on screen less time with school work and reading ❖ watch sitcom while sit anywhere: DTV add ❖ euro study: ban screens from school , smart device band in school:

academics improved

❖ actually more minorities (African American and hispanic) are on devices

more than white affluent kids (white kids) …3 hours more

ADHD: Screen Time Risk

❖ Tech addiction: finally made the DSM ❖ Brain scan tech: FMRI, video game addition looks the same as

the drug addiction

❖ release of dopamine - impacts the rewards center ❖ all addictions have the same affect on the brain

ADHD: Screen Time Risk

❖ ADHD increases risk of addition risk: ❖ screen and tech “overuse” ❖ How can we help our kids: ❖ Parents are in front of screens 6 hours a day for

entertainment

❖ Parents magazine “Best Baby Apps”

ADHD: Screen Time Risk

❖ What messages does the mainstream media tell our parents about

games: it’s good hand eye coordination, improves development, they socialize, it even helps depressed children stay connected. “don’t bother me mom, I’m learning”

❖ The negative side is that depressed teens compare their insides with

• ther peoples outside. the more screen time the increase in suicidal

thoughts.

❖ There have been a large number of media campaigns in history that

turned out to be wrong: smoking, food pyramid,

❖ US Forest Service Unplug Campaign ❖ Gifting Books!

ADHD: Screen Time Risk

❖ the more tv at 2 years old the more tv at 6 ❖ the more tv at 4 years the more protest turn off at 6 ❖ at age 4 kids spend more than 4 hours per day ❖ earlier gaming start gaming, more obsessed later ❖ difficult to treat obsessed kids; this is so much easier to prevent

than treat

❖ “normal decisions can have a profoundly negative effect ❖ Our role is to help parents understand that tech/screens are a

remarkably harmful babysitter

ADHD: Screen Time Risk

❖ avoid mobile devices ❖ when kids use screen avoid gaming ❖ books, books, books, ❖ enlist caregiver support ❖ the myth of “digital natives” and we are digital immigrants ❖ teens have 9x more likelihood of getting into accidents. ❖ “Time magazine” “Let kids Run Wild Online” written by someone who works for

Microsoft.

❖ Tech Execs are limiting their children’s screen use! they asked steve jobs “how do

your kids like the new iPad?” “they haven’t used it”

❖ Temple Grandon says don’t give your ASD