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Integrative Management of ADHD: What the Evidence Suggests

Integrative Management of ADHD: What the Evidence Suggests

Table: Nonconventional and integrative treatments of ADHDTable: Nonconventional and integrative treatments of ADHD

ADHD natural medicineIt is important for mental health professionals to be familiar with emerging research findings about widely used complementary and alternative medicine (CAM) treatments of ADHD in order to provide patients with accurate information on efficacy, safety, and appropriate use.

A high percentage of children and adults who have been given a diagnosis of ADHD use alternative therapies alone or in combination with conventional pharmacological treatment.1 More than half of parents of children with ADHD treat their children’s symptoms using 1 or more CAM therapies, most commonly vitamins, dietary changes, and expressive therapies; yet only about 10% disclose use of such nonpharmacological therapies to their child’s pediatrician.2 Most nonpharmacological therapies used to treat ADHD are supported by limited evidence; however, as many as 80% of patients who use herbal preparations and other natural products regard these therapies as the primary treatment of their symptoms.2

Conventional treatment

Stimulant medications, including dextroamphetamine, methylphenidate, and related compounds, are the most widely used treatments of ADHD. The nonstimulant atomoxetine has less potential for abuse but also may be less effective than stimulants.3 SSRIs and other antidepressants are used with varying degrees of success. Behavioral modification aimed at rewarding desirable behavior and extinguishing disruptive or inappropriate behavior continues to be a mainstay of conventional treatment. Psychotherapy and psychosocial support help reduce anxiety and feelings of loss of control that frequently accompany ADHD. It is estimated that ADHD is correctly diagnosed and treated in fewer than one-fifth of adults, which results in significant social and occupational morbidity.

Limitations and risks of conventional treatment

Long-term amphetamine use in childhood is associated with delays in normal development.4 One-third of individuals of all ages who take stimulants for ADHD report significant adverse effects, including insomnia, decreased appetite, and abdominal pain.5 Cases of stimulant-induced psychosis have also been reported.6 Stimulants and other conventional treatments of ADHD in adults are probably only half as effective as they are in children.4

Adverse effects of nonstimulant drugs used to treat ADHD include hypertension, decreased appetite, nausea, fatigue, liver toxicity, insomnia, and seizures. A meta-analysis of 6 controlled trials concluded that stimulant therapy started in childhood reduces the risk of subsequent substance abuse by as much as one-half. In contrast, stimulants started in adolescence or adulthood increase the risk of future substance abuse.7 Nonstimulant medications and extended-release stimulants are less likely to be abused.8

As many as 80% of patients who use herbal preparations and other natural products regard these therapies as the primary treatment of their [ADHD] symptoms.

Nonconventional therapies

Dietary changes. Early studies on a highly restrictive diet that eliminates all processed foods reported promising findings in children with ADHD9; however, a review of controlled studies failed to support these findings.10 The oligoantigenic diet (OAD) is a highly restrictive elimination diet in which food colorings and additives as well as dairy products, sugar, wheat, corn, citrus, eggs, soy, yeast, nuts, and chocolate are eliminated. Numerous studies on the OAD reported significant reductions in hyperactivity in children with ADHD when specific food items were eliminated from the diet using an open-label protocol.11 In most studies, symptoms recurred when children were subsequently challenged with the eliminated food item following a placebo-controlled protocol. The significance of findings on elimination diets is limited by study design flaws, including heterogeneity of patient populations, absence of standardized outcome measures, high dropout rates and, in some studies, nonblinded raters.

Although research findings are mixed, sugar has long been suspected as an underlying causative factor in ADHD. In a 9-week placebo-controlled study, children without ADHD who were randomized to diets high in sucrose, aspartame, or saccharin showed no differences in behavior.12 The expectations of parents may bias the perceptions of their children’s behavior following the consumption of large quantities of sugar. In one controlled trial, mothers who believed their child had eaten sugar were more likely to label their child’s behavior as hyperactive.13

In their comprehensive review of nonpharmacological therapies for ADHD, Weber and Newmark14 remarked that the study design did not adequately control for fruits, juices, or other dietary sources of sugar and suggested that future studies should not focus primarily on sugar but rather on a possible link between high-glycemic-index foods and hyperactivity. Large prospective controlled studies on dietary restrictions as therapeutic interventions in ADHD have been elusive because of difficulties in controlling eating behavior in both children and adults.15

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