Integrative approaches to treating ADHD have become increasingly sought after by parents, especially those who are concerned about the side effects and potential overuse of psychostimulant medication. Surveys report that over 60% of child psychiatry patients are employing integrative tools on their own such as vitamins, specific diets, and herbal remedies. The most recent study of parents of children with autism found that 88% used complementary and alternative medical (CAM) treatments in the previous three months of care (Smith DL et al, Sleep Med 2017 34:170–178).

Whether you are personally interested in the integrative approach or not, it’s important to understand the basics, if only to be able to converse about the approach with patients. Integrative medicine (IM) focuses on supporting the innate healing powers of the body, whereas conventional medicine focuses on identifying illness/pathology and then using medications to treat illnesses or reduce symptoms. Integrative psychiatrists, such as myself, prefer the safest options, as these are the least likely to impair an individual’s ability to recover. The Hippocratic dictum “first do no harm” resonates deeply.

IM is not without its disadvantages. Firstly and chiefly, the evidence base for efficacy is deficient by the standards of conventional medicine. In part, this is due to a lack of financial incentives. Most natural remedies cannot be patented, and therefore it is rare for companies to invest the many millions of dollars required for large-scale clinical trials, as the resulting products would be unlikely to yield a good return on investment. Secondly, the IM approach demands more of the patient and can also take more of the practitioner’s time. Symptomatic improvement usually takes longer for IM treatments, and parents may not be able to tolerate the wait, especially if their children are in crisis. Finally, many integrative treatments are not covered by insurance.

Nonetheless, many patients are seeking alternatives to conventional psychiatry, and practicing integrative psychiatry can be quite fulfilling. I’ll give you a snapshot of my approach to assessment and treatment of ADHD.

Assessment
ADHD assessment in integrative practice is a bit more time-consuming, and may take 60–90 minutes. Like traditional evaluations, it is based primarily on a comprehensive interview, and includes results from ADHD symptom scales (I tend to prefer the Vanderbilt over the Connors scale, as the former is broader in scope). My assessment protocol includes the following elements.

• Assessment of the child’s six realms (environmental, physical, mental, emotional, social, and spiritual), which can be viewed as an expansion of the popular biopsychosocial approach in psychiatry.


• Identification of the child’s strengths in addition to deficiencies.


• Focus on diet issues, food quality, food allergies, or gut issues. I will often refer to a nutritionist or naturopath (a clinician who emphasizes use of natural healing agents) as needed. About 30%–40% of my patients work collaboratively with a naturopath.


• An especially detailed examination of family issues, in order to assess for the need of a behavioral management and parenting program.


• Lab testing (typically on the more extensive side), in order to assess the need for supplements. I routinely check TSH, vitamin D (25 OH), ferritin, serum zinc, lipid profile (for low cholesterol), homocysteine (methylation), and high-sensitivity C-reactive protein (HS CRP). I will also order a sleep study if there is snoring or extremely restless sleep.


• A detailed assessment of learning issues in order to recommend educational supports if needed.

Subtypes of ADHD
In the conventional view, there are three DSM presentations of ADHD: inattentive, hyperactive, and combined. But in reality, children with ADHD present with many variations. Integrative practitioners tend to be particularly attuned to these variations, and they often categorize patients into subtypes, each of which has implications for mechanism and treatment approaches. The following eight subtypes are based on a combination of my clinical experience and a review of current research. Not all patients fit a single subtype; many have qualities of more than one. Nonetheless, I find this a helpful system for better understanding the complexities of individual patients.

1. Classic ADHD. High energy, positive mood, and good sleep characterize these patients, who usually respond well to psychostimulants.


2. Anxious and over-focused. These children have an incredible ability to focus when they are alone. They can read a book for five hours straight, but decompensate in a social setting, becoming anxious and distracted. I consider a supplement like L-theanine or a medication like atomoxetine that both reduces anxiety and improves focus.


3. Angry and oppositional. These children may have mood issues with a volatile rejection of limits. Their parents may be too permissive or too harsh. I work on mood stability and parental limit setting. I recommend a behavioral management and parenting method called the Nurtured Heart Approach by Howard Glasser (see http://difficultchild.com/ for more info).


4. Apathetic with learning issues. Some children with learning issues don’t thrive in the typical classroom. Processing speed may be low, or a true learning disability may exist. Over time, they may drift into a passive-avoidant approach to learning and withdraw from engagement. Parents and teachers flail at finding motivation. The path to reaching these children is by emphasizing their particular gifts and talents, which are almost always non-academic.


5. Lack of structure. These kids suffer from a lack of structure. They may respond to this by overusing electronic devices; their diet is often poor, and sleep is erratic. Here, the challenge is effective parental engagement.


6. Sleep issues. Many children are obese, and obstructive sleep apnea has become common. Since low iron levels have been correlated with sleep apnea, I routinely test ferritin to gauge total body iron stores and replenish as needed. Sometimes oxygen saturation and airway limitations are the issue. Several clinical trials have shown that surgery for enlarged tonsils has improved attentional symptoms. Most recently, a prospective study of 59 children with ADHD found that all but 8 demonstrated significant improvements in ADHD after a tonsillectomy (Ahmadi MS et al, Int J Pediatr Otorhinolaryngol 2016;86:193–195).


7. Food allergies and gut imbalance. These children often have a history of colic, reflux, eczema, and chronic otitis. Multiple courses of antibiotics may have disrupted the microbiome. These children may crave carbohydrates, especially sugars. An elimination diet and treatment of the gut issues can often bring dramatic relief.


8. Developmental delays. These children present with a history of significant delay in developmental milestones. Walking or talking may have lagged months behind. Exercise tolerance may be low; they wear out quickly and often nap.

Integrative treatment
Regardless of the subtype of patient, I view treatment in three phases. The first involves commonsense adjustments; the second looks to specific complementary treatments based on subtype and often some form of psychotherapy or education; and the third is conventional medication treatment, if needed.

Commonsense adjustments
These strategies focus on lifestyle issues, which are helpful for both conventional and integrative practitioners to address.

• Are the school and teacher a good fit based on learning style, temperament, and other factors? Will a school change make a difference?


• Is the child getting adequate sleep? Is there sleep apnea or sleep-disordered breathing?


• Is the child over-stimulated? Excessive electronics can create more attentional imbalance. Limit screen time (I recommend the book Reset Your Child’s Brain by Victoria Dunckley, MD).


• Outdoor activities. Does the child spend time outside? Is the child getting enough sunlight, activity, and exercise? Exercise is a helpful tool for ADHD symptoms, according to a recent meta-analysis of eight studies (Cerrillo-Urbina AJ et al, Child Care Health Dev 2015; 41(6):779–788).


• A high-protein breakfast may be the single best piece of advice. High carb/low protein (e.g., waffles or pancakes) is worse for cognitive performance than no breakfast at all. I sometimes will humorously write out the following “prescription” that I refer to as my basic remedy for the American breakfast: “Protein, 15 to 20 grams in AM on empty stomach.”


• What else in the child’s ecosystem seems out of balance and easy to correct? We need to honor our intuitive ability to recognize imbalances.

Typical integrative treatments

1. Nutrition and diet. Children with ADHD often benefit from more well-balanced diets, including high-protein breakfasts. Another specific intervention is the elimination diet, focusing on foods that often cause allergic or other reactions, such as dairy, wheat, corn, citrus, chocolate, yeast, and soy. Typically the foods are eliminated for four weeks, then items are added back one at a time over a two-week period looking for relapse or reaction. One randomized controlled trial of 100 children with ADHD found this approach effective (Pelsser LM, Lancet 2011;377(9764):494–503). The mechanism of the food-ADHD connection is unclear, but it may be due to the immune system creating antibodies to food antigens, antibodies which then cross-react to parts of the brain, disrupting attention and other behaviors.


2. Natural supplements. The term “natural supplements” refers to non-prescription substances that are not regulated by the FDA. A few of these are supported by randomized controlled trials, but in many cases the evidence is weaker, such as small case series or small uncontrolled trials. Nonetheless, these supplements are safe, are likely to activate a robust placebo effect, and may have specific efficacy as well. There are several supplements that I frequently use in children with ADHD.

• Eicosapentanoic acid (EPA). EPA is likely the most efficacious fatty acid found in fish oil, and a meta-analysis found it to be moderately effective for ADHD symptoms (Bloch MH, J Am Acad Child Adolesc Psych 2011;50(10):991–1000). I prescribe 1 gram of EPA per day with a meal and find that it generally takes 3 months for the benefit to appear, as it is a nutritional effect, rather than a neurotransmitter effect.


• L-theanine. This component of green tea has been shown to improve both anxiety, focus, and sleep. I use 200–400 mg twice daily, and I’ve found it particularly effective in the over-focused or traumatized child.


• Acetyl-l-carnitine. A multisite, placebo-controlled pilot study of 112 children with diagnosed ADHD found that acetyl-l-carnitine (which transports fatty acids into the mitochondria for energy) was ineffective overall, but subtype analysis found it effective in children with the inattentive subtype of ADHD (Arnold LE et al, J Child Adolesc Psychopharmacol 2007;17(6):791–802). In my experience, this works well for slowed, low-energy, inattentive, or learning-delayed children. I use 1–2 grams twice daily. I look for increased energy, reduced sleep needs, and more engagement. Acetyl-l-carnitine is often best combined with 100 mg of Coenzyme Q10 (CoQ10), which is an antioxidant.


• Iron. Iron is a needed cofactor for the production of dopamine in the CNS. I use chelated iron (which may be more easily absorbed than ferrous sulfate) 10–20 mg a day if low ferritin is present (under 30 ng/mL) on a standard blood test.


• Zinc. Two studies showed a positive effect in ADHD with zinc sulfate (Salehi B, J Res Pharm Pract 2016;5(1):22–26) but not with zinc gluconate. You can test RBC zinc to assess this common deficiency. Doses of at least 20 mg once per day are best if children test low. Zinc sulfate can cause nausea if given on an empty stomach.


• Pycnogenol. This supplement comes from the bark of French pine trees. It is a powerful antioxidant and has one randomized controlled trial with 61 children supporting its use in hyperactivity at 1 mg/kg (Tribaticka J et al, Eur Child Adolesc Psychiatry 2006;15(6):329–335). I typically recommend 25–50 mg twice daily in the classically hyperactive child.


• Ginkgo biloba. Gingko biloba has some limited evidence for efficacy in small, uncontrolled trials. I use 160 mg twice daily, and have found that it enhances cognitive function and alertness—but can disrupt sleep.


• This classic ayurvedic remedy from India has been used for centuries for learning and memory. An open-label trial of 31 children found it helpful (Dave UP et al, Adv Mind Body Med 2014;28(2):10–15), and a large randomized controlled trial is underway. I recommend one to two capsules twice daily for learning disabilities or memory problems.

3. Neurofeedback. Neurofeedback is a type of biofeedback that engages the child in real-time brain wave training designed to compensate for abnormalities demonstrated on a quantitative EEG. The child, through operant conditioning, learns to adjust brain wave patterns based on visual or other types of feedback. The FDA recently approved a device to diagnose ADHD based on the brain waves (the ratio of slow to fast waves), though the utility of this method is controversial. A large NIMH-sponsored multisite study on neurofeedback in the treatment of ADHD is currently in process (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4134464/).


4. Parenting and behavioral interventions. In the Multimodal Treatment of ADHD (MTA) study, the best outcomes were found in the combined group that received both parenting support and medication. Parenting and behavioral treatments are a well-proven but underused treatment avenue in ADHD.


5. Psychotherapy and education. In addition to all of the evidence-based forms of psychotherapy, IM embraces any proven treatment that emphasizes skill building. Mind-body skills that enhance self-care and awareness, like meditation, are valuable approaches. Meditation builds awareness on many levels and has been shown to augment response to psychotherapy in anxiety and depression. It does this by enhancing our awareness of the repetitive loops of thought we engage in that pull us from our immediate experience. Enhanced immediate awareness forms the core of mindfulness. A recent review of mindfulness meditation in ADHD in young adults found 17 relevant studies, and these studies indicated positive results (Aadil M et al, Cureus 2017;9(5):e1269). For children, the evidence is less clear, but a large multisite study is underway.

Medications if needed
I use stimulants if other approaches fail. I try to avoid stimulants in over-focused, angry, or traumatized children, as I’ve found over the years that these children tend to be more prone to negative side effects such as autonomic overarousal, insomnia, and anxiety. Overall, I use the lowest possible dose and avoid progressive dose escalation.

Conclusion
Tremendous resources have been spent on ADHD research. Sadly, we have no reasonable path to prevention, and prevalence rates are significantly escalating. In my opinion, this indicates a need to move beyond the medication-only approach to treating ADHD that characterizes most current clinical care. Integrative psychiatry offers a different approach based on a holistic appreciation of the child.

CCPR Verdict: Patients and parents are going to ask you about alternatives for ADHD, so whether or not you decide to use an integrative psychiatry approach, you should at least be familiar with some of the supplements used.