Attention deficit hyperactivity disorder.

This presentation explores the misty road from biology to behaviour and the key issues of whether ADHD is a social or medical problem. Includes a discussion of appropriate herbal remedies.

Presented at the NHAA 6th International Conference on Phytotherapeutics, Canberra September 2007

Historical context

"Zappel Philip" or Fidgety Philip, a poem in a children's book written by Dr Heinrich Hoffman, a German Psychiatrist published in 1846 describes a child with the typical symptoms of attention deficit hyperactivity disorder (ADHD). This represents the first documented historical reference to the disorder (Thome 2005).

In 1902 Dr Frederick Still describes a group of children with an abnormal incapacity for sustained attention, restlessness and fidgetiness and proposes that the children had deficiencies in volitional inhibition. He offered no treatment other than discipline (Timimi 2005).

During the 1920s hyperactivity and poor attention became linked with brain damage. It had been observed that following epidemics of encephalitis children often presented with restlessness, personality changes and learning difficulties. The term minimal brain damage (MBD) was coined. During the 1930s came the chance discovery that psycho-stimulant medication could reduce these symptoms (Timimi 2005).

By the 1960s the term MBD had lost favour, as evidence for brain damage had not been found. It was during this time that interest grew in behavioral factors. By the mid 1960s the American Psychiatric Association expanded the 2nd edition of the Diagnostic Statistical Manual (DSM-2) and developed the term 'hyperkinetic reaction of children' to describe the condition. By the early 1980s DSM-3 renamed the disorder Attention deficit disorder (ADD).

DSM-IV diagnostic criteria

ADHD is diagnosed using a number of steps. Firstly the symptoms detailed in relation to inattention and distractibility must appear before the age of 7. The symptoms must occur in two settings, i.e. home and school (or work in the case of an adult). There must be clear evidence of clinically significant impairment in social, academic or occupational functioning, and clear evidence that the symptoms are not secondary to some other disorder or life event.

A critique of the DSM-IV

A key premise of the DSM-IV is that a syndrome occurs in an individual, suggesting that the fault lies within the individual. It therefore excludes the possibility that the symptoms may be a response to external events. Thus the priority appears to be the naming of the disorder over understanding the experience in the context of the individual's life and interactions with their social world (Crowe 2000).

This has perhaps led to the medicalisation of the condition, i.e. there must be a biological cause, whilst ignoring social and other factors. The highly subjective nature allows for a liberal interpretation, perhaps making ADHD a convenient dumping ground for a host of difficult problems.

* It has been shown that in only 30% of already diagnosed ADHD children, the home and school report fulfill the diagnostic criteria (Wolraich 1990).

* The ratings of hyperactivity, inattention and disruptiveness are highly culturally dependent.

* Inattention, impulsivity and motor restlessness is found in all children (and adults) to some degree.

* Diagnosis is based on what is felt to be inappropriate intensity, frequency and duration of behaviours.

* All the symptoms are subjective and therefore influenced by the rater's cultural influences.

* How do you define and understand non specific terms such as 'often' and 'excessive'? (Timimi 2005).

Epidemiology

Depending on the source of information the prevalence of ADHD is between 2% and 12% of children worldwide. A possible reason for the discrepancy is that studies use either one of two slightly differing diagnostic criteria:

* Diagnostic and Statistical Manual of the American Psychiatric Association 4th ed (DSMIV); or

* European diagnostic criteria for hyperkinetic disorder (HKD) as defined by the International Classification of Diseases 10th ed (ICD-10).

The ICD-10 is more restrictive, demanding a greater degree of symptom expression (Biedermann 2005). This is a possible explanation why ADHD numbers are often said to be greater in the US when compared to European countries. Biedermann & Faraone (2005) cite a recent review of epidemiological studies using the DSM-IV criteria that found the prevalence of ADHD to be similar worldwide.

The study demonstrated an association with the male sex (3M:1F), and low socioeconomic status. Some papers quote a 4M:1F ratio

Australian statistics

A 1997 National Mental Health & Wellbeing Survey estimated a prevalence rate of 19.3% in boys between 6 and 12 years, and 13% of children between 6 and 14 years (Sawyer 2000).

Research looking at data from the US and Australia has shown that ADHD diagnosis and prescription rates concentrate at two points:

* Low income

* High unemployment (Prosser 2002).

Co-morbidity

Factors include:

* Anxiety

* Depression

* Oppositional defiant disorder 

* Conduct disorder

* Learning disorder

* Sleep difficulties including delayed sleep onset, night time waking, shorter duration of sleep and morning fatigue (Dey 2003).

Co-morbidity is so prevalent that more than 75% of ADHD diagnosed children will have at least one other diagnosable psychiatric condition. The rate of co-morbidity strongly suggests that the current diagnostic framework does not reflect boundaries between symptoms and a biological cause (Hazell 1997).

Psychiatrist breaks rank

Dr Robert Spitzer, an architect of the DSM-IV, commented in the media that 30% of children diagnosed with ADHD as defined by the DSM-IV, don't actually have ADHD but are instead showing normal signs of being happy or sad, and that many of these conditions might be normal reactions which are not really disorders (Kamper 2007).

Schools: the silent partner

An area of power that often escapes attention in the diagnosis and pharmacological control of children is the school. The school completes a triangle of power: medicine, psychology and the school. It is between these points that the colourful child comes to attention. If these children have not been identified in the private family realm, they are soon identified once enrolled in school. Teachers have become 'disease spotters' (Phillips 2006).

Teachers are often the first to suggest the diagnosis of ADHD to parents (Sax 2003). Pharmaceutical companies exploit the internet to access teachers and to influence their disease spotting role. Novartis (manufacturers of Ritalin) has an educational website separate from the industry site which contains resources for teachers (www.adhdinfo.com).

Impact on family life

There is a significant impact on family life, with considerable stress for parents in relation to parenting skills/methods, social boundaries, family and community support, frustration and guilt. For the child there is peer group and adult judgment, disapproval and rejection (Podolski 2001).

Medical treatment

For 40 years the primary treatment of ADHD has been the stimulant drugs methylphenidate (Ritalin) and amphetamine. The use of an amphetamine in ADHD is obviously a 'paradoxical effect' or indeed a like cures like effect. Studies also demonstrate that methylphenidate at therapeutic doses has a calming effect on both 'normal' and ADHD children.

Methylphenidate pharmacology

Methylphenidate causes an amplification of dopamine signals; dopamine enhances neuronal signaling thereby improving attention and reducing distractibility. The variation in therapeutic effect may be due to individual differences in dopamine tone between subjects (Volkow 2002).

Concern over side effects of Ritalin

A controlled study raised concerns that methylphenidate may have a growth suppressive effect in developing children (Lisska 2003). Side effects include insomnia, anorexia, dependence, tolerance, liver dysfunction and neuroleptic malignant syndrome (MIMS 2004).

A small yet to be published study of 12 children found that Ritalin caused chromosome breaks associated with increased cancer risk (Drug News 2005).

Multimodal treatment (MTA) study

The 14 month MTA study to resolve controversies and clinical quandaries about the relative value of medication and behavioural therapies compared 4 groups of children who were given:

* medication only (methylphenidate)

* intensive behavioural treatment

* combined behavioral treatment and medication and/or

* standard community care.

The study concluded that the medication only and combined behavioural treatment and medication had the best outcome (MTA 1999).

The proponents of the study claim that it demonstrated the superiority of stimulant medication over behavioural treatment and routine community treatment (Timimi 2005). The study has attracted much criticism:

* Outcome was measured 4 months after the most intensive phase of behavioural therapy had ended but while medication was still active.

* No placebo or blinding.

* Behavioural therapy flawed.

* No improvement in academic performance.

* Little effect on social skills.

* Hawthorne effect (being observed can change behaviour) (Breggin 2000).

Ritalin effectiveness

Of concern are the consistent findings that despite an improvement in core symptoms, Ritalin has little impact on academic achievement and social skills. In contrast clinical behavioural therapy, parent training and contingency management have produced beneficial effects (NIH 1998).

Ritalin prescriptions

A study throughout 10 countries examining the prescription of psychostimulants between 1994 and 2000, found the total psychostimulant consumption increased by an average of 12% per year, with the highest increase from 1998 to 2000. Canada and the USA ranked highest followed by Australia and NZ , then the UK, Sweden, Spain, Netherlands, France and Denmark (Berbatis 2002).

Australian prescribing

From 1991 to 1998 prescriptions dispensed for Ritalin increased from 13,398 to 96,582, an increase of 620%. Ritalin was added to the PBS in 2005 resulting in a 10 fold increase in prescriptions (Pirani 2006).

Increase in daily dose

Not only are more individuals being prescribed Ritalin, but the amount being consumed is increasing (Davis 1998). In the face of a poor response to stimulant medication some doctors are upping the dosage (Rushworth 2006)

Neurochemistry 

Several neurotransmitters have been implicated in ADHD including dopamine and norephinephrine, however studies demonstrate either inconsistent or conflicting results (Dey 2003).

Brain scans

Neuroimaging studies are often cited as confirmation that ADHD is a brain disorder. A recent review of these studies has demonstrated a number of methodological flaws. Most subjects used in the studies had prior medication use and often for years which invalidates any suggestion of ADHD specific neuropathology. Other studies using unmedicated ADHD subjects have avoided the use of matched controls (Leo 2003). Animal models suggest that any brain differences observed in the studies may well be due to the medication that most subjects had taken (Moll 2001).

Genetics

Family aggregation, adoption and twin studies suggest that ADHD is an hereditary conditions. Molecular genetic studies conclude that ADHD is associated with the dopamine transporter gene (DAT1) and the dopamine receptor gene (D4) (Dey 2003.) A more recent study of 126 sibling pairs concluded that these 2 genes, if they are involved in ADHD etiology at all, make only a minor contribution to overall genetic susceptibility (Fisher 2002).

Nature versus nurture 

It has been estimated that genetic factors account for between 20% and 60% of the phenotypic variance in personality, which means that the remaining 80% to 40% of the variance is attributed to environmental factors (Saudino 2005).

NIH Consensus report

Despite investigations over the last 20 years or more endeavouring to establish ADHD as a neurological disorder no concrete relationship has been established. The national Institutes of Health (NIH) stated in 1998 that there is no evidence to support the proposition that ADHD is a biological brain disorder and that the causes are speculative, however evidence supporting the validity of the disorder can be found (Consensus 1998).

ADHD as a social construct

The social/cultural constructionists argue that the medical model of ADHD is a decontextualised and simplistic view that leads to a disengagement from social responsibilities by parents, teachers and doctors; that it supports the profit motive of the pharmaceutical industry; is a means of social control that stifles diversity in children; and promotes the attitude of a 'pill for life's problems'.

The social/cultural constructionists argue that modern western cultural factors adversely affect mental health such as loss of extended family support and shared responsibility for child raising, mother blame, pressure on schools and overworked teacher, breakdown in moral authority of parents in relation to discipline, family life is busy and hyperactive, and a market economy value system that emphasises individuality, competitiveness and independence (Timimi 2004).

The dark side of economic reform

It is not acknowledged that capitalism, whilst producing healthy GDP and current account figures, has not been conducive towards social health and well being. Public policy informed by neoliberal political rationality copied from the US and UK has forged a new Australia and the effects on family life have been ignored. Parents, particularly mothers, are working more and have less time for their children.

This, with the traditional absence of working fathers, translates to greater restrictions on the flexibility to co-parent (Pusey 2003, Goward 2006).

Electronic media

The central role of electronic media that is fast paced, non-linguistic and visually distracting may have changed the minds of children so that sustained attention such as reading and listening has become less appealing.

Exposure to TV and computer games from a young age could lead to a sensory addiction, leading to problems in less stimulatory environments such as school (Timimi 2005).

Is ADHD a stress response?

Could increased life stressors for children cause a rise in ADHD type behaviours? Numerous papers, pursuing a neurobiological approach note that the symptoms of ADHD closely parallel those that occur during trauma: hyper-alertness, the need to act quickly, the need to be 'on the go' all the time in the expectation of danger, and the inability to turn attention to anything other than physical safety.

Their hypothesis is that in a critical period in infancy some children experience trauma which initiates a habitual autonomic response as though to some external threat. When older, such children are sensitive to threat to a much greater extent than other children and revert to a state of 'red alert' very easily (Perry 1995).

Thus as with post traumatic stress, such children react quickly and over actively. It is proposed that many children suffering multiple stressors display symptoms of post traumatic stress disorder and are wrongly diagnosed with ADHD (Thomas 1995).

Nutritional factors

* Sensitivities to food additives

* Food intolerances

* Sugar and reactive hypoglycemia 

* Heavy metal toxicity

* Environmental illness

* Maternal hypothyroidism and an abnormal thyroid responsiveness

* Essential fatty acid deficiencies and other nutrients

* Gut and liver dysfunction

Food additives and food intolerances

Work on food additives and intolerances began in the 1920s however it was not until the 1970s that Feingold broke through with the message that up to 50% of hyperactive children respond favourably to his diet (Kaiser-Permanente) which removes artificial flavours, colours, preservatives and salicylates. His conclusions are based on clinical observation not rigorous scientific evidence (Schnoll 2003).

A review of the older studies

In 23 double blinded studies examining whether foods or food additives worsened the behavior of ADHD children, 8 of 9 studies using ADHD subjects showed behaviour was worsened by the consumption of additives or improved on a diet free of additives. The other 14 studies took ADHD children who also had asthma, eczema or more severe behavioural/neurological disorders. In 10 out of the 14 most improved on diets free of additives or certain foods such as corn, wheat, milk, oranges, eggs and chocolate (Kidd 2000).

ADHD and allergy

A small study demonstrated that many children with ADHD also suffer from allergic rhinitis with 83% reporting allergic rhinitis symptoms, 43% showed signs of allergic rhinitis and 53% had other atopic disorders (Brawley 2004).

ADHD and sleep

Many medication free ADHD diagnosed children experience chronic sleep problems including reluctance or inability to settle into sleep, difficulties in sleep onset and maintenance, frequent awakenings. higher incidence of restless sleep, nightmares and night terrors, and insufficient daytime alertness (Kirov 2004).

Artificial colourings and benzoate preservative study

Bateman and co-workers (2004) observed a significant reduction in hyperactivity in 3 year old children on a diet without artificial colourings or benzoate preservatives. There was also an increase in hyperactivity during active treatment.

A recent meta-analysis

Fifteen double blinded placebo controlled trials on artificial colourings concluded that despite indications of publication bias, there is clear evidence that neurobehavioural toxicity may characterise a variety of widely distributed chemicals (Schab 2004).

Refined sugar

In a study of 261 hyperactive children who were administered a 5 hour glucose tolerance test, 74% had abnormal glucose tolerance curves indicative of hypoglycemia. Hypoglycemia is associated with an increased production of epinepherine which in turn can stimulate a nervous or restless reaction (Schnoll 2003).

The early studies using aspartame as the placebo failed to demonstrate a relationship between sugar intake and behaviour. Recently there have been reports that aspartame is linked with adverse behavioral effects. If this is so, then perhaps this invalidates the early work. Despite this consideration studies have failed to demonstrate a clear link.

A limitation of the recent studies is the dose of sucrose used in comparison to children's normal daily intake. It is estimated that the average child consumes approximately 40-50 teaspoons of sugar per day. Children who consume 3-4 carbonated beverages per day can easily achieve this intake, especially if they are also consuming sugar coated cereals, ice cream, biscuits etc. The study dosage used falls way below this intake (Schnoll 2003).

Lead

Children exposed acutely or chronically to heavy metals are often left with neurological problems such as attention deficit, emotional instability and behavioral reactivity (Moon, cited in Kidd 2000). A study of 501 children showed a significant relationship between blood lead levels and aggressive/antisocial and hyperactive behavior (Thomson 1989).

Manganese

In several small epidemiological studies of children manganese hair levels are associated with ADHD symptoms. The concern appears to be infant formulae; breast milk contains about 6[micro]g/L whilst infant formulae can contain up to 77-100 [micro]g/L.

Fuel octane enhancers can contain manganese (Schettler 2001).

Maternal hypothyroidism

Thyroid hormones are intimately involved in the regulation of dopaminergic, noradrenergic and serotonergic neurotransmitter systems as well as fetal maturation. A causal link between hypothyroidism during pregnancy and diminished mental function of offspring has long been recognized. A multicentre controlled study of 25,216 mothers and their 7-9 year old children established a significant link between maternal hypothyroidism and ADHD type symptoms in their children (Hadlow 1999).

Generalised resistance to thyroid hormone (GRTH)

GRTH is characterised by reduced responsiveness of the pituitary and peripheral tissues to the action of thyroid hormones. Behavioural manifestations include hyperactivity, behavioural problems and cognitive deficit. Many studies have associated GRTH with ADHD whilst others argue in contrast (Builee 2004).

Thyrotoxins

Much of the blame for GRTH is linked to thyrotoxins. In a review of thyrotoxicity and industrial chemicals, 77 chemicals are listed as having proven links to thyroid damage, these include PCBs, dioxins, chlorobenzenes, phenols and related chemicals (Brucker-Davis 1998). These chemicals have been identified in human tissues and breast milk (Crinnion 2000).

In utero exposures

Studies have demonstrated a link between in utero exposures and subsequent neuron developmental problems in the offspring with ethylmercury, PCBs chlorinated dibenzofurans, cadmium, arsenic organophosphate pesticides, and brominated flame retardants (Woodruff 2004).

Essential fatty acids (EFA)

A reliable symptom of EFA deficiency is polydipsia without polyuria. It was reported as early as 1981 that hyperactive children were significantly thirstier than controls. Colquhoun and Bunday (1981) hypothesise that hyperactive children are unable to absorb, metabolise or have a greater requirement for EFA, particularly boys. They have observed that many of the foods ADHD children are allergic to, inhibit the conversion of EFA to eicosanoids; many hyperactive children have allergies which are relieved by EFA; and many are zinc deficient which is required for EFA conversion,

Plasma levels of docosahexaenoic acid, arachidonic acid and dihomo-gamma linolenic acid in ADHD boys were consistently and significantly lower than controls. ADHD children also manifested other symptoms of EFA deficiency such as dry hair, dandruff and dry skin (Stevens 1996). A review of the EFA studies concluded that supplementation may be useful in some cases (Richardson 2000).

EFA supplementation

The clinical evidence for the use of EFA supplements in ADHD patients is far from conclusive, however a recent double blind placebo controlled study concluded that unsaturated fatty acid supplementation appears to reduce ADHD related symptoms (Richardson 2002).

Oxford-Durham study

A randomised, placebo controlled cross over study of 117 children from 5 to 12 years with developmental coordination disorder gave encapsulated 80% fish oil and 20% evening primrose oil (placebo olive oil capsules), 6 capsules per day for a 3 month treatment then cross over of a further 3 month treatment. No effects on motor skills were shown, but there was significant improvement in reading, spelling and behaviour (Richardson 2005).

Oxidative stress and EFAs

Preliminary data strongly suggests that ADHD children have higher rates of oxidative breakdown of omega-3 fatty acids than controls as measured by exhalant ethane levels. This is the first evidence of a possible role of oxidative stress and the potential for antioxidant supplementation (Ross 2003).

Flax seed oil and vitamin C

A pilot study evaluating the effectiveness of [alpha]-linolenic acid rich supplements and antioxidant emulsion on blood fatty acid composition and behaviour in children with ADHD showed post supplement levels of red blood cell membrane fatty acids to be significantly higher that pretreatment with significant improvements in ADHD symptoms (Joshi 2005).

Zinc

Zinc is an important element in the conversion of EFAs to eicosanoids. Zinc deficiency has been demonstrated in ADHD children with serum zinc levels having been shown to correlate to parent/teacher inattention rating. There have been two positive clinical trials using zinc supplementation (Arnold 2005).

Iron

Iron deficiency causes abnormal dopaminergic transmission and may contribute to ADHD-like symptoms. Two published clinical evaluations show that 84% of the 53 children with ADHD had lower serum ferritin compared with the 27 controls. Low ferritin levels correlated to more severe symptoms while supplementation demonstrated a significant reduction in ADHD symptoms (Konofal 2004).

Magnesium

An epidemiological study found 95% of children with ADHD to be deficient in magnesium (levels measured in hair, red blood cells and serum). Another study by the same researchers found that a cohort of ADHD children with magnesium deficiency showed behavioural improvement after 6 months of treatment (200 mg/day). Many of the symptoms of ADHD are identical to magnesium deficiency (Dey 2003).

Ritalin versus nutraceuticals

The effect of Ritalin versus dietary supplementation was found to be essentially the same after 4 weeks of treatment. The study with 10 children in each group used the diagnostic methods of Conners' Parent Rating Scale and the Intermediate Visual and Auditory/Continuous Performance Test (IVA/CPT). IVT/CPT is a computerised standardised test developed for the assessment of response inhibition and attention problems.

Supplementation included multivitamins, multiple minerals, EFAs and phospholipids (soy lecithin), probiotics and amino acids (Harding 2003).

Gut dysfunction

A causal relationship has been established between behavioural disorders such as autism, Asperger's syndrome, ADHD and dyslexia and an increased intestinal permeability brought about gut pathogens/infections and/or inflammation (Wakefield 2000).

Liver and mood

Traditional herbal medicine associates emotional/behavioural disturbances such as anger and subsequent actions that play out that emotion, with the liver. The traditional view has it that the liver prefers calmness and is easily heated when frustrations and anger are inadequately expressed. The liver is further stressed by increased intestinal permeability and can easily become heated or congested

A Herb Use Survey for ADHD and depression through 5 community mental health care centres in Texas was completed by 117 caregivers. Continual herbal use was reported by 20%. The herbal remedies most frequently used for behavioural conditions were ginkgo (Ginkgo biloba), Echinacea spp and St John's wort (Hypericum perforatum). The survey found that 70% of psychiatrists, 56% of pediatricians and 74% of pharmacists were not aware of herbal treatments (Cala 2003).

Bacopa

Bacopa (Bacopa monnieri) is considered to be the specific herbal remedy for ADHD, being a cognitive enhancing, nervine tonic, mild sedative, mild anticonvulsant, anxiolytic and possibly adaptogenic medicine. To date no peer reviewed clinical studies have been published on its specific effectiveness for ADHD, however its specificity for ADHD is explained by its beneficial effects on concentration and information processing. Bacopa (1 g/day for 3 months) improved intellectual functions such as visual motor function, short term memory and mental reaction times in children (Bone 2003).

A layperson's publication showed the result of a double blinded placebo controlled trial using 50 gm Bacopa twice daily for 19 ADHD children and 17 children placebo. After 3 months there was significant improvement in all test areas compared to placebo group. The testing took place 4 weeks after treatment was withdrawn indicating a long lasting effect (Anon 2000).

Ginkgo and American ginseng

In a pilot study, a combination of ginkgo (Ginkgo biloba) standardised extract and American ginseng (Panax quinquefolium) was tested for its ability to improve ADHD symptoms. Results suggest a positive effect however the significance of the results is reduced due to poor study design with no blinding or control group, assessment by parents only and the short duration of 4 weeks (Lyon 2001).

Valerian 

A double blind placebo controlled cross over single case methodology of 5 children with intellectual deficits, including 2 with ADHD and 1 with moderate intellectual disability and hyperactivity, showed all subjects had marked improvement in sleep latency and maintenance with a single nightly dose of valerian (Valeriana edulis) 500 mg, leading to an improvement in daytime behaviour and better sleep for parents (Francis 2002).

Herbal treatment goals

Core goals

* Prescribe the herbal specifics.

* Support HPA axis and modify the stress response with adaptogens.

Secondary goals

* Improve digestion to decrease food reactivity and improve nutritional absorption.

* Treat allergies if present.

* Treat sleep disturbances.

* Improve diet.

* Heal the gut wall if indicated.

* Chelate heavy metals if indicated.

* Support parents/carers if required.

Herbal support

* Herbal specifics, cognitive enhancers Bacopa monnieri, Ginkgo biloba, Rosmarinus officinalis.

* Adaptogens Rhodiola rosea, Eleutherococcus senticosus, Withania somnifera

* Nervines Valeriana officinalis (sleep disturbances), Passiflora incarnata, Scutellaria lateriflora

These should be used with caution as clinical experience has demonstrated that sedative herbs can occasionally worsen ADHD symptoms.

* Food allergy and intolerance Matricaria recutita, Filipendula ulmaria, Silybum marianum, Citrus reticulata (Chen pi), Albizia lebbek, Scutellaria baicalensis

* Upper respiratory allergy (hayfever) Euphrasia officinalis, Solidago virgaurea, Hydrastis canadensis, Echinacea spp, Andrographis paniculata

* Lower respiratory allergy (asthma) Curcuma longa, Ginkgo biloba, Adhatoda vasica, Scutellaria baicalensis, Grindelia camporum, immune modulators

* Heal leaky gut Hydrastis Canadensis, Calendula officinalis

* Chelate heavy metals Silybum marianum, Crataegus oxycantha, Allium sativum

* Support parents and care givers with adaptogens and nervines.

Case study 1

Male 16 years, diagnosed with ADHD at 13 years, mother seeking alternative to Ritalin.

History: parental separation, cannabis consumption from 12 years of age. School difficulties including many clashes with teachers, truancy, poor concentration, unable to complete homework and other tasks. Diet poor with high intake of sugar, Coke etc. Has left school and is working at a supermarket as a shelf stacker and has had several work related problems.

Herbal liquid formula

Bacopa        1:2    35 mL
Rosemarinus   1:2    15 mL
Withania      1:2    35 mL
Gymnema       1:1    25 mL
                    110 mL

Dose 10 mL twice daily.

EPO capsules 2 twice daily, EPA DHA capsules 2 twice daily. Kinesiology.

Dietary recommendations: reduce sugar, Coke, refined foods and eat more fruits, vegetables and meats at home if possible, reduce/eliminate cannabis.

This patient was managed for 10 months during which time he slowly but steadily improved in concentration and task completion. At the 4 month mark after his perceived dysglycemia was under control, Gymnema sylvestre was replaced with Schizandra chinensis in the formula.

At 10 months he no longer consumed cannabis and had been appointed a section manager in the supermarket.

Rationale

* Bacopa to improve cognition and concentration.

* Rosemarinus as a choleretic, antioxidant and memory enhancer.

* Withania as an adaptogen and general tonic.

* Gymnema to improve his glucose tolerance.

* Schizandra as an adaptogen and supporter of liver detoxification.

Case study 2

Female 12 years, diagnosed ADHD by a pediatrician two years previous and has been taking Ritalin since then. The diagnosis followed a history of behavioural problems that become more evident once the child began school, although preschool teachers had reported to the parents that the child was very disruptive.

The problems experienced were disruptive behaviour, inability to complete school work and home tasks, major tantrums and defiant behaviour towards teachers and parents.

The child also suffered with allergic rhinitis and chronic respiratory tract infections with a history of antibiotic use.

The diet is typical of a child that age, a very picky eater with low appetite and a small range of preferred foods.

Treatment

A tablet containing:
Albizia extract                       800 mg
Scutellaria baicalensis extract       800 mg
Tanacetum parthenium extract           50 mg
3 tablets daily

A tablet containing:
Andrographis extract                   2.0 g
Ocimum tenuiflorum extract            500 mg
Echinacea purpurea root extract       300 mg
Echinacea angustifolia root extract   200 mg
3 tablets daily

A tablet containing:
Bacopa extract                        3.75 g
Schizandra extract                    660 mg
Eleuthrococcus extract                500 mg
Rosemarinus essential oil              10 mg
3 tablets daily

1 cup of yogurt per day.
Fruit and vegetable concentrate capsule twice daily.
Kinesiology

Rationale

* Albizia tablet to dampen the allergic response.

* Andrographis tablet to increase immune vigilance.

* Bacopa tablet to positively modify behavioural and cognition difficulties.

This patient was seen every 8 weeks for a period of 12 months during which time there was a marked improvement in both her behavioural and cognitive problems. She ceased taking the Bacopa tablet after 12 months. Currently the patient could be considered an average student in terms of academic achievement.

The allergic rhinitis was a little slower to respond to treatment. Currently she takes a Euphrasia officinalis tablet and an Andrographis tablet

The rationale for the change from the Albizia tablet is that due to the reduced frequency and intensity of acute allergic rhinitis, the priority shifted from treating allergy to the toning of upper respiratory mucous membranes and the prevention of respiratory tract infections. So far this has worked well.

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Rob Santich is a practicing herbalist of 22 years' experience and runs a herbal practice in Avalon, Sydney. Aside from seeing patients, Rob is involved with postgraduate herbal education and is involved with the Graduate Diploma of Phytotherapy at the University of New England. He has served on the Board of Directors of the NHAA for 5 years and as a member of the Complementary Medicines Evaluation Committee, Therapeutic Goods Administration for 3 years. He has a special interest in ethnobotanical studies and often travels to the Pine Ridge Indian Reservation in South Dakota USA to study traditional Lakota herb use.