Stimulant medications are used to treat ADHD because, in many cases, they improve mental focus and reduce distractibility, hyperactivity, and impulsivity. But not all stimulants are manufactured in pharmaceutical laboratories. Many naturally growing plants contain compounds that have stimulant activity—such as the caffeine in your morning coffee or the nicotine in cigarettes. In fact, many ADHD folks become addicted to coffee and cigarettes because they temporarily improve the ability to focus. Eventually, the ADHD brain habituates (becomes accustomed to) these stimulants and stops responding unless the person keeps increasing the amounts. We have found that some people drink gallons of coffee and smoke cigarettes non-stop trying to maintain their mental focus. Unfortunately, this approach can have disastrous side effects, including ulcers, obstructive lung disease, heart disease, stroke, and cancer.
Fortunately, Mother Nature has also provided us with many plants whose stimulating compounds do not cause as many side effects or addictions. And, being the master chemist, she has enriched many of her herbs with antioxidants and other compounds that provide a cornucopia of health benefits. Thus, humankind may live long and prosper on the roots, berries, and leaves of Mother Nature’s medicinal plants.
Although scientific studies have shown that certain plants improve attention and learning, only a few studies have been conducted using people with ADHD. When we have tried these herbs in clinical practice with patients who have ADHD, many of them have had excellent responses. It is possible to combine herbs with other substances and complementary and alternative medicine (CAM) treatments to further enhance learning. Here we introduce you to some of the most useful herbs and show you how to combine them with other treatments.
In addition to herbs, this chapter covers the use of melatonin to aid sleep and a group of nootropics, or brain boosters, called racetams. Melatonin is a natural sleep hormone produced by a small brain structure, the pineal gland, to regulate sleep and other natural body rhythms. Melatonin is safe and effective for treating sleep problems that are commonly found with ADHD. Nootropics are synthetic compounds that enhance brain function through a variety of mechanisms. In general, they are very low in side effects. Nootropics have been studied and used in clinical practice in Europe and Russia for decades, but they are not well known in the United States.
At the end of this chapter you will find lists of all the treatments we presented in Tables 3.1 and 3.2. Table 3.1 reviews how to use each treatment including dosage guidelines and side effects, and Table 3.2 provides information on where to buy good quality brands. We want to assure you that we do not sell any of these products. Also, we have no financial relationship with any company that grows, processes, or markets these supplements. For additional information, you will find websites, organizations, books, and journals in the Resources sections at the end of this chapter.
Before getting into specifics about these various substances, let’s consider an often-asked question of why certain treatments work in some of the people some of the time, but not in all of the people all of the time. This is a very important question to keep in mind while pursuing solutions to symptoms of ADHD. In Chapter 2 we introduced you to some of the genetic and neurological differences among people with ADHD, which may account for the wide spectrum of symptoms that can be present. Through scientific research, we are learning more about the neuroanatomy, brain functions, neurotransmitters, and genetics that may determine why some people respond better to certain treatments than others. ADHD comes in many forms with many genetic variations affecting how the symptoms emerge and how various brain areas are affected. The bottom line is: it can be difficult to predict the extent to which an individual will to respond to different therapies. It is often necessary to do a treatment trial.
There is no one magic silver bullet that will fix ADHD. If you go trawling on the Internet, you will find websites touting hundreds of treatment regimens. While we do advocate using more than one kind of treatment, we do not advocate a kitchen-sink approach. From a seemingly infinite menu of options, we have selected only those therapies that have a sound scientific basis and that we have found to be effective in our work with patients. Our approach is to use multiple treatments that target specific aspects of brain dysfunction and behavior found in ADHD in order to accomplish the following:
• Improve overall brain growth and development.
• Optimize the health of neurons.
• Strengthen cellular maintenance and repair systems.
• Protect against further injury.
• Improve neurotransmitter function.
• Improve brain-wave patterns.
• Strengthen compensatory systems, such as the autonomic nervous system.
• Balance the stress response systems.
By enhancing these aspects of brain function, we can help improve many symptoms of ADHD, such as attention, memory, planning, organization, impulse control, emotion regulation, hyperactivity, academic and work performance, and behavior.
The safety and effectiveness of any product, whether it is a supplement or a prescription medication, depend upon its quality. This is especially true for herbs because the quality and potency (strength) can be affected by numerous factors, including where it was grown, whether the soil was certified free of contaminants, when it was harvested, the method used to dry and extract the medicinal compounds, what percentage of the product is in an active versus an inactive form, whether the herbal extract was tested for contaminants, the process of standardization, and the stability of the medicinal components. It is difficult for consumers to get all the information needed to be certain that they are buying a good-quality product. However, there are things that you can do to help identify the best brands.
1. Read the labels on each supplement bottle. Check to see if the product is certified organic and free of contaminants. Read the full name of the herb to be sure you are buying the correct species. Look for evidence of standardization. Some herbs are standardized by the percent of “marker compounds.” Markers are specific components used to identify an herb as genuine and help assure that it contains the minimum amount of pure herb to be effective. So, on the label you may see “standardized extract” and then the percent of the marker compound.
2. Check the number of milligrams (mg) of the herb in each capsule so that you will know how many capsules to take for therapeutic effects.
3. If a specific herbal preparation has been used in a research study and shown to be effective, then it is a good choice. Untested brands of the same herb may not be as effective.
You may wish to visit websites showing the results of impartial evaluations of many supplements. Although these sites do not present every possible aspect of product quality, they do cover important basics such as whether the product in the bottle is exactly what it is claims to be on the label, what percent of the product is in an active form, and whether it contains contaminants:
We have done a good deal of your homework for you by checking out supplements for quality and efficacy. Remember, you may take a shortcut by simply consulting the tables at the end of this chapter. There you will find lists of supplement brands that we have found to be consistently effective. This is not a comprehensive list, but it will provide you with some reliable choices for each of the supplements discussed in this book.
Rhodiola rosea (golden root, arctic root), an ancient medicinal herb, improves alertness, attention, and accuracy. It is especially effective in reducing the number of errors during tedious tasks such as computer work or homework that require many hours of attention. Rhodiola grows in extremely cold environments at high altitudes, above 8,000 feet, in the Caucusus Mountains of the Republic of Georgia, the Altai Range in the former Soviet Union, Scandinavia, Alaska and northern Canada. Large farms are cultivating R. rosea in Scandinavia and the former Soviet Union. In the last five years, as the demand for this versatile herb have soared R. rosea farms have been started in Canada and Alaska. Dr. Petra Illig initiated the Alaska Rhodiola Products, a non-profit farmer’s co-op by growing 90,000 R. rosea seedlings in her front yard (http://www.alaskarhodiolaproducts.com). After two years of growth the plants were distributed to Alaskan farms. The picture on the cover of this book shows a stunning three-year old R. rosea plant blooming in Bethel on the Yukon–Koskoquim River delta on the southwest coast of Alaska. The flowers are bright yellow at their peak, turning to rose, purple, and rust colors as fall approaches. Rhodiola rosea (R. rosea) is the perfect example of an herb that has long- term health benefits rather than health risks. Here is an example of how this herb helped a student with ADHD get better grades naturally.
Joseph was a highly intelligent 16-year-old. Despite having an IQ in the superior range, he maintained only a B average in school. He got by on whatever he picked up in class, spent no time studying, and dashed off assignments while riding the bus or eating lunch in a noisy cafeteria. His parents chalked it up to immaturity and assumed he would get serious about his studies as college approached. Instead, as the high school courses became harder, his grades slipped to C’s and then D’s. Talking, offering rewards, arguing, shouting, punishing, or confinement—nothing worked. Joseph became resentful and frustrated. He was getting to the point of giving up rather than repeatedly trying and failing.
Joseph’s high school guidance counselor called a meeting because he had begun skipping classes, and his English teacher was alarmed by an essay in which he wrote, “I wish I was dead.” The parents immediately made an appointment with a child psychiatrist, who concluded that Joseph had the inattentive form of attention-deficit disorder (ADD)—that is, without hyperactivity. He also had depression secondary to all of the negative effects of ADD on his life. The psychiatrist recommended individual therapy and a stimulant medication, Ritalin, for Joseph, as well as family therapy. Joseph adamantly refused. Like many teenagers, he did not want to be labeled or seen as abnormal, different, or “crazy.” However, he did agree to meet with the psychiatrist alone to see if anything else could be worked out. During these sessions, the psychiatrist listened to Joseph’s frustrations and engaged him in trying to find some solution other than medication. When he suggested an herb, Joseph got interested because, to him, herbs, unlike medicine, were natural. Once the doctor explained that Rhodiola rosea had been shown to improve both mental and physical performance in athletes, military cadets, and cosmonauts (Russian astronauts), Joseph was eager to try it. The fact that Rhodiola rosea had been used by the Vikings for strength and endurance added to its appeal.
The next day, Joseph began taking R. rosea (Rosavin Plus brand) 150 mg in the morning on an empty stomach. Each week he increased the dose by one capsule until he was up to 300 mg twice a day. This dosage enabled him to sit and study, complete writing assignments on time, and prepare for exams. His average rose to a B+ with A’s in math and science. Although he was no longer at odds with his parents, he still couldn’t wait to leave home, especially with the chance of going to a great college.
Joseph was lucky to have such a good response to R. rosea. In other people, the herb may help, but to a lesser degree. Yet, even a smaller improvement can make a big difference in the quality of life, particularly when added to other treatments. In our practices, we find a range of responses to this herb. We use it often, because most people report improvements in energy, mood, mental clarity, and focus. For some people, like Joseph and Brad (the Gentle Giant from Chapter 1), this herb can make an enormous difference.
Let us update you on what happened to Brad. Taking 150 mg a day of Rosavin Plus, Brad was able to finish school and get a job as a counselor. Although he loved working with clients, it was difficult for him to communicate with his superiors. He was often criticized for how he spoke to the clients and after about 5 months, when he did not show enough improvement, he lost the job. When I (Dr. Gerbarg) spoke with Brad, it was apparent that he was so caught up in his own circular thoughts about what had gone wrong at work, he could not listen to or respond to my questions.
I suggested that he increase his Rosavin to take two 150 mg capsules in the morning and one mid-day. The increased dose helped him to think more clearly and the effects lasted longer. Six weeks later he found a new job with higher pay. So far he is getting along well there. The supervisors are satisfied with his work, and the staff enjoys and appreciates him.
Before moving on to the next herb, we review the scientific evidence, risks, benefits, and dosage details that you and your doctor will need in deciding whether to try R. rosea.
Most of the research on Rhodiola rosea (R. rosea), done by the Soviet Union and the Swedish Herbal Institute, was hidden in classified documents and kept from publication until the late 1990s (after the collapse of the former Soviet Union). The Soviet Ministry of Defense tested Rhodiola rosea and other herbs to increase the intellectual productivity of scientists and the performance of military personnel, Olympic athletes, and cosmonauts (Baranov, 1994; Panossian & Wikman, 2009). In numerous studies their researchers found that R. rosea root enhanced learning, memory, intellectual work capacity, speed, and accuracy. Tests run for many hours showed that over time, under the stress of fatigue and boredom, this herb significantly reduced the rate of errors, for example, in a tedious symbol correction test, compared to placebo (Brown & Gerbarg, 2004).
Rhodiola rosea is one of an elite class of medicinal herbs called adaptogens, based on their ability to protect living organisms from multiple stressors—infections, toxins, free radicals, radiation, heat, cold, low oxygen, physical strain or injury, and psychological stress (Brekhman & Dardymov, 1969). The following list describes some of the most useful adaptogens and their benefits:
1. Eleutherococcus senticosus (Siberian ginseng)—antistress, strength, endurance, intellectual productivity, immune cell response
2. Panax ginseng (Asian ginseng, Korean ginseng)—antistress, antifatigue, muscle strength, reaction time, alertness, intellectual performance, immune function, anticancer
3. Rhodiola rosea (Arctic Root, Golden Root)—anti-stress, antifatigue, physical and mental energy, physical and mental performance and endurance, alertness, memory, accuracy, learning, strength, recovery time, depression, anxiety, PTSD, menopausal symptoms, sexual function, high altitude sickness, liver protection and detoxification, anticancer, recovery from stroke or other brain injury
4. Rhaponticum carthemoides (luzea)—antistress, strength, endurance, work capacity, recovery following illness, liver health, antibiotic, blocks absorption of carcinogens
5. Schizandra chinensis (Schizandra)—antistress, antianxiety, energy, sleep, memory, physical strength and endurance, liver health
6. Withania somnifera (Ashwaganda)—antistress, physical strength and endurance
Other medicinal herbs that are used in combination with adaptogens to enhance their benefits include:
1. Aralia mandshurica (Manchurian thorn tree) –physical performance, energy, antiradiation
2. Ginkgo biloba (Ginkgo) –antioxidant, mental performance, erectile function, stroke prevention, vascular disease, macular degeneration
3. Rhododendron caucasicum (Georgian snow rose) –antistress, antifatigue, physical and mental performance, strength, recovery time, work capacity, alertness, memory
4. Ribes nigrum or Rives nibrum (black currant) –anti-inflammatory, atopic dermatitis, essential nutrients
One of the main differences between the contents of a prescription medication and the root of a plant is that most synthetic medications contain only one biologically active compound designed to have one specific effect, whereas the root of the Rhodiola rosea plant contains hundreds of bioactive compounds with countless effects on organ systems throughout the body. For example, studies have shown that extracts of R. rosea can increase the ability of chemotherapy drugs to kill many kinds of cancer cells, while at the same time protecting normal cells of the liver, breast, and bone marrow from the toxic effects of the chemotherapy (Brown, Gerbarg, & Muskin, 2009).
Rhodiola rosea improves brain functions through a number of different mechanisms. At the cellular level, its arsenal of antioxidants prevents free radical damage to energy-producing mitochondria, DNA, and cell membranes. Studies suggest that it also increases production of creatine phosphate (CP) and adenosine triphosphate (ATP)—the high-energy molecules that transport energy wherever it is needed to keep brain cells running and to fuel cellular repair mechanisms (Furmanowa, Skopinska-Rozewska, Rogala, & Malgorzata, 1998; Kurkin & Zapesochnaya, 1986). In brain cells, this prevents mental fatigue, maintains focus, and enhances intellectual functioning.
Rhodiola rosea stimulates a network of nerves in the brainstem, called the reticular activating system, which literally wakes up the brain, increases attention and alertness, and raises the level of neurotransmitters such as dopamine, serotonin, and norepinephrine (Petkov et al., 1986). These neurotransmitters are essential for intellectual activity, regulation of mood and emotion, organization and planning, and inhibition of impulsivity. Furthermore, Rhodiola rosea helps balance the stress-response system, preventing the excess release of stress hormones (e.g., cortisol) and excitatory neurotransmitters, which can damage brain cells (Panossian & Wikman, 2009).
One unexpected finding was that although Rhodiola rosea was mentally stimulating, at the same time it was emotionally calming. As a result, people given the herb not only performed better on tests, but they also did not get frustrated, even after 12 or 18 hours of testing. In contrast, those given an inactive placebo became crabby, tired, and negative after so many hours of repeated testing. This unintended benefit was attributed in part to the herb’s effects on the stress response system as well as on neurotransmitters—serotonin, norepinephrine, and dopamine.
The following information provides guidelines for using Rhodiola rosea as a complementary treatment for people with ADHD. This herb is not intended to replace medication. Be sure to check with your doctor and to ask him or her to monitor your response (or the response of your child) before using this or any of the other treatments we describe.
Sidebar 3.1
Scientific Studies of Rhodiola rosea
In double-blind, placebo-controlled studies, Rhodiola rosea prevented mental fatigue, reduced errors, enhanced learning, and improved the quality of work. Here are examples of a few of these studies.
• Sixty Indian medical students studying in Russia were randomly assigned to groups given 100 mg/day of Rhodiola rosea extract (SRH-5 Swedish Herbal Institute), placebo, or nothing. Those given R. rosea had less mental fatigue, higher final exam grades, better physical fitness and coordination, and a greater sense of well-being compared to those who didn’t take the herb (Spasov, Wikman, Mandrikov, Mironova, & Neumoin, 2000).
• Out of 60 foreign seniors at Russian high schools, 20 were given 660 mg/day of a Rhodiola rosea preparation with vitamin C, called Rodaxin; 20 got a placebo; and 20 got no treatment. The group given Rodaxin had less mental fatigue and anxiety as well as better work performance, higher final exam grades, improved coordination and well-being, and a 60.7% increase in their language-learning ability compared to the students who didn’t take the extract (Spasov, Mandrikov, & Mironova, 2000).
• The Russian Ministry of Health evaluated two different doses of standardized Rhodiola rosea extract on mental functioning under conditions of stress and fatigue. In a randomized, double-blind, placebo-controlled study of healthy military cadets, ages 19–21, Rhodiola rosea showed a pronounced anti-fatigue effect as well as significant improvements in pulse and blood pressure. The cadets also reported greater feelings of general well-being (Shevstov et al., 2003).
Although very small doses of R. rosea can be helpful in children, it can also cause overstimulation and difficulty sleeping and therefore should be used cautiously. If agitation or insomnia occurs, the dose should be reduced or the herb discontinued. Soviet research on R. rosea in children was never published in any detail. However, among the people living at 8,000–10,000 feet in the Caucasus Mountains, where the herb grows wild, families brew a tea from the herb and drink it daily. It is given to children there without harm.
One way to try R. rosea in young children is to use a brand that comes in capsule form—for example, Rosavin (Ameriden International) containing 100 mg Rhodiola rosea. Open the capsule and dissolve the contents in one 8-ounce cup of any drink, such as juice, milk, tea, or cocoa. Stir thoroughly and give 1/16 cup (that is ½ ounce or 6.25 mg of herb) for the first dose. Store the rest in the refrigerator with a cover and a label so no one else drinks it by mistake. Rhodiola rosea should be given in the morning. See what effect it has that day. If that does not cause agitation or difficulty sleeping, increase to 1/8 cup (i.e., 1 ounce or 12.5 mg of herb) the next morning. The next day, increase to 1/4 cup (2 ounces or 25 mg of herb). Repeat this same dose for 3 or 4 days to determine the effect. If there are no problems, use 3/8 cup (3 ounces or 37.5 mg of herb) for 3 or 4 days. Then try ½ cup (4 ounces or 50 mg of herb).
Continue this for 1 week to evaluate the results. After this trial, you may increase by ¼ cup or 25 mg of herb every 5–7 days as long as there are no problems. When you get up to a full capsule, continue that same dose for 2 weeks before increasing further. The idea is to allow enough time to evaluate the effects before increasing the dose further. If significant side effects occur, then the dose should not be increased. Depending on the size of the child and his or her sensitivity to the herb, the final dose could range from ¼ of a capsule (25 mg) up to a maximum of 4 capsules (400 mg) per day for an older child.
R. rosea 50 mg/day; increase by 50 mg every 5–7 days, up to a maximum of 500 mg/day, as long as this dose does not cause anxiety, agitation, or insomnia. It is best taken about 30 minutes before breakfast on an empty stomach. To start with a 50 mg dose, get the 100 mg capsules. Open the capsule and pour the contents into a cup containing 8 ounces of juice, milk, or a hot drink. Drink half of the liquid and store the rest in the refrigerator for use the next morning.
Rhodiola rosea 150 mg capsules: Start with one capsule 30 minutes before breakfast on an empty stomach for 1 week. Then add one capsule 30 minutes before lunch for 1 week. As long as you are comfortable and experience no agitation, irritability, or sleep disturbance, add a second capsule before breakfast for 1 week for a total of 450 mg a day. Wait several weeks to see the effects. If you feel you need more, add a second capsule before lunch for a total of four capsules (600 mg) daily.
Doses above 600 mg a day are not generally recommended because they have not been adequately studied. At higher doses (above 600 mg), the herb may have some effect on the function of blood platelets (as do many antidepressants), leading to bruising or increased bleeding, especially when combined with aspirin or other anticoagulants (e.g., heparin). Rarely, we find a patient who has a better response on higher doses.
Like many herbs, R. rosea is highly sociable. It works even better when teamed up with other herbs. In traditional folk medicine, herbs are often used in combinations rather than as solo treatments because they work best in good company. One limitation of research studies, with a few exceptions, is that they test one herb at a time. Other herbs that may be added to R. rosea to improve cognitive stimulation, learning, and productivity include ginkgo, Asian ginseng, American ginseng, passionflower, Schizandra chinensis, acanthopanax (Eleutherococcus senticosus), and ashwaganda (Withania somnifera).
Studies have shown that ginkgo and ginseng can improve learning in animals and humans. These herbs affect neurotransmitter systems and are known to be natural cognitive activators. A few studies of ginkgo and ginseng in people with ADHD have shown weak or mixed results. This is probably because the majority of people with ADHD do not benefit from these herbs. However, we find that a small number of individuals improve considerably. In situations where the person has not responded well to standard treatments or does not want prescription medications, it is reasonable to try these herbs. Using good products with high potency in adequate doses and combinations can make all the difference in response.
At the age of 31, Angie came across as a tense, critical, mistrustful, no-nonsense woman with a Pollyanna smile plastered on her face. She had held numerous secretarial and administrative jobs for short periods of time, but had been unemployed for 5 years. As a mother, she had been incompetent and custody was assigned to her husband during their divorce. In the middle of a sentence, she would abruptly stop talking, glance away, and then look back asking, “Where was I?” Lost, confused, unable to make decisions, she required constant oversight from her mother, who worried about whether she would ever become independent and self-supporting. A psychologist told her that she had ADHD and processing problems that needed treatment. Angie was afraid to take any medication because in the past she had experienced allergic reactions to many of them.
She finally agreed to see me (Dr. Brown), hoping for a non-medication treatment that would enable her to pursue a career. Angie’s mother brought her to the first appointment. Her conversation was so disjointed that it was difficult to follow her meaning. After the first visit, she was unable to find my office. Month after month she would go to the wrong entrance, wander the halls, and finally get the doorman to lead her to my door.
She agreed to try Rhodiola rosea. The first improvement was that her conversation became clearer and easier to follow. However, the effect was lost after a few days, possibly because she was inconsistent in taking the herb. Biofeedback (see Chapter 6) never had a chance because she missed most of the sessions. Aniracetam, a nootropic compound (see below) that improves language-related functions, did help her process better by enabling her to listen and retain more when people were talking (see Chapter 4 for more information on aniracetam). A second trial of Rhodiola rosea (Rosavin Plus) at 300 mg twice a day somewhat improved her mental focus and clarity. Angie’s mother finally convinced her to try Adderall. After 3 days she sounded calmer, but she did not like the feeling of being quieted down, preferring to feel energized and bubbly. She refused to continue the medication.
I decided to treat her with a combination of ginkgo plus ginseng: Ginkgold 120 mg twice a day, plus a mixture of Korean, Chinese, American, and Siberian ginseng (Action Labs PowerMax 4X) taken once a day. One month later she found her way to my office alone, without the doorman. The big, natural smile on her face told me that the herbs were working and that they helped her feel the way she wanted to feel.
Angie was not totally cured, but with the ginkgo and ginseng her focus and attention improved enough that she became able to go on the Internet, read and retain better, complete household chores more consistently, and go places without getting hopelessly lost.
Ginkgo biloba, extracted from leaves of the maidenhair tree, has been used for centuries in traditional Chinese medicine to treat cognitive and memory impairment. The mechanisms of action believed to be responsible for the effects of various components of the extract include:
• Increasing blood supply to brain tissues by dilating blood vessels and reducing blood viscosity (thickness).
• Stimulating the activity of neurotransmitter systems, including dopamine.
• Stimulating the brain’s “wakeup” pathways in the reticular activating system.
• Counteracting oxygen free radicals.
• Improving cell membrane fluidity.
Research on the effects of ginkgo on memory has shown mixed results, possibly due to the use of unproven products, variations in the populations studied, or other factors. Ginkgo was used in a small pilot study of six adolescents (17–19 years old) who had ADHD with additional diagnoses: three with oppositional defiant disorder; two with conduct disorder; and one with learning disabilities. All were given 200 mg a day of ginkgo extract EGb 761, a product that has proven to be clinically effective in many studies for other conditions. Significant benefits were found in arousal, hyperactivity, calming, anxiety, frustration tolerance, affect regulation, irritability, cognitive aspects of selective attention and processing, and discriminant attention. Adolescents with higher levels of arousal, irritability, and hyperactivity obtained the most benefit (Niederhofer, 2010). Although this was a small, uncontrolled study, the use of a ginkgo product with proven potency led to significant improvements in these complex cases.
In contrast, a 6-week randomized, double-blind, placebo-controlled study of 50 children with ADHD compared the effects of 80–120 mg per day of G. biloba (Ginkgo T.D., Tolidaru, Iran) to 20–30 mg per day of methylphenidate. Although it caused more side effects, methylphenidate was far more effective than Ginkgo T.D. for ADHD (Salehi et al., 2010). We could not find previous published studies using this Ginkgo T.D. preparation. This study is an example of the difficulty of interpreting research studies. We have seen a number of studies of herbs reporting negative or weak results. Looking more deeply into the details, we usually find that the researchers either used an untested product or they gave too low a dose. When interpreting new research studies, particularly when they are inconsistent with previous information, we have to get the details before accepting the results.
Ginkgo rarely causes side effects, but when it does, these can be minimized by starting with 60 mg/day and gradually increasing to 120 mg twice daily. Side effects may include nausea, headaches, and skin rashes. Although ginkgo somewhat decreases platelet aggregation (i.e., ability of blood cells to clump together to form clots), it does not appear to affect other measures of coagulation (clotting). Nevertheless, caution is needed when using ginkgo in patients who are also taking anticoagulants such as heparin, warfarin, or aspirin. Gingko should be discontinued 2 weeks prior to surgery. Ginkgo works well with nootropics, special substances that improve brain function, which are discussed below.
Q: Who should take gingko?
A: Although ginkgo is not the first herb we would recommend for ADHD, it does have a place because it is less stimulating than some of the other treatments. Gingko can be useful for:
• People who are overly sensitive to, and overly stimulated by, prescription stimulants, Rhodiola rosea, or other treatments.
• People with ADHD who also have anxiety—they may find that gingko is calming.
• People who want to enhance their alertness and attention—ginkgo can be added to any other herb or nootropic.
Compared to Asian ginseng (Panax ginseng), American ginseng (Panax quinquefolius) is gentler, less stimulating, and less likely to cause agitation or headaches. So, although there is less research on American ginseng compared with Asian ginseng, it may be less likely to cause overstimulation in children. American ginseng also can improve immune function. A 4-week open study of 36 children with ADHD given American ginseng 400 mg per day, plus gingko 100 mg per day, found that 74% improved significantly on the Conner’s ADHD scale and 44% improved on a social problems measure. Only two children experienced mild side effects (agitation) (Lyon et al., 2001). Interpretation of the impact of ginkgo on improving test scores in this study is limited because 25 of the children were also taking methylphenidate and there was no comparison control group.
Q: Who could benefit from American ginseng?
A: American ginseng should be considered for:
• Young children under the supervision of a physician
• People who want to avoid overstimulation
• People with ADHD who also want to improve their immune response.
Pycnogenol® is the brand name for an herb that is made from an extract of French maritime pine bark (Pinus pinaster). Extracts from boiled tree barks used in traditional medicines in many countries may contain polyphenols and other antioxidants whose modes of action may include:
• Reducing oxidative stress.
• Increasing blood flow to areas of the brain that are impaired in ADHD by dilatation of cerebral blood vessels.
• Regulation of catecholamine metabolism.
• Regeneration and protection of vitamins C and E.
In a 1-month double-blind, placebo-controlled study 61 children with ADHD were randomly assigned to receive either Pycnogenol or a placebo. Standardized measures and teacher and parent ratings showed that the students given Pycnogenol had significantly greater improvements in hyperactivity, attention, concentration, and visual–motor coordination (Trebaticka et al., 2006).
A smaller study of 24 adults with ADHD randomized to receive Pycnogenol, methylphenidate, or placebo showed no differences among the three groups. This negative result may have been caused by usage of too low a dose of Pycnogenol, too short a trial period (3 weeks), or lack of herbal effect. However, some of the subjects given Pycnogenol had significant improvements and continued to take it after the study (Tenenbaum, Paul, Sparrow, Dodd, & Green, 2002). Larger randomized controlled trials (RCTs) are needed to validate these interesting findings and to determine whether people with certain polymorphisms are more likely to benefit from Pycnogenol.
There may be an association between increased levels of copper and decreased levels of zinc with hyperactivity, learning disabilities, and depression. (See Chapter 3 for a discussion of the importance of trace minerals in the diet.) Pycnogenol contains polyphenols, natural compounds with antioxidant properties. Polyphenols modulate antioxidant enzyme activities and have the ability to chelate (bind to and remove) metal ions such as copper and iron. Copper tends to increase oxidative stress whereas zinc tends to reduce it. A 1-month randomized double-blind study compared 65 children with ADHD, ages 6–14, with 54 healthy children of the same ages. At the beginning of the study, children with ADHD had significantly lower zinc levels and higher copper-to-zinc ratios than the children who did not have ADHD. In other words, they had an imbalance of trace minerals that would be associated with increased oxidative damage. Copper levels were higher in the ADHD group. Children with ADHD given Pycnogenol (1mg/kg body weight/day) showed significant decreases in copper levels and decreases in copper-to-zinc ratios, although zinc levels did not change significantly. There were no significant changes in copper, zinc, or copper-to-zinc ratios in the children who did not have ADHD. This study supports the theory that Pycnogenol may modify levels of trace minerals, normalizing antioxidant status by decreasing copper and copper-to-zinc ratios. The study also found a correlation between reduced iron levels and response to Pycnogenol with improvements in ADHD in children (Viktorinova et al., 2009).
Q: Who could benefit from Pycnogenol?
A:
• People who need a gentler, less stimulating treatment.
• People with low ferritin (iron) levels.
Lemon balm and passionflower, common ingredients in over-the-counter preparations, have modest benefits, such as reducing anxiety and restlessness (Akhondzadeh et al., 2001; Kennedy, Little, & Scholey, 2004). Studies show that valerian may improve sleep (Krystal & Ressler, 2002). Although no studies have been done in people formally diagnosed with ADHD, one trial of a combination of valerian and lemon balm (Euvegal forte) was tested in an uncontrolled (meaning, no placebo comparison group) study of 918 children under the age of 12 who had restlessness and difficulty sleeping. Substantial improvements occurred in 80.9% of the children with sleep problems and 70.4 % of those with restlessness (Muller & Klement, 2006). It is likely that some of the children in this study had ADHD. Overall, studies have reported few side effects. Side effects and toxicity have not been investigated. These mild herbs may be tried, starting with lemon balm first for:
• People with ADHD and anxiety.
• People who need a mild, less powerful effect.
While St. John’s wort may be helpful in mild-to-moderate depression, there is no indication that this herb is useful for ADHD alone. The activity of St. John’s wort is similar to the antidepressants called serotonin reuptake inhibitors (SRIs). Since SRI antidepressants are not beneficial in ADHD, we would not expect St. John’s wort to be. One study of 54 children with ADHD, ages 6–17, did not find any effect from St. John’s wort (Weber et al., 2008). However, for people with ADHD who also suffer from mild depression, it can be useful to improve mood. St. John’s wort can interfere with the activity of many medications. Nevertheless, in 17 studies, the herb was well tolerated. Among these studies, at most, 5.7% of participants dropped out because of side effects, and these side effects were not serious. Before trying this herb, check with your doctor to be sure it is safe to take with your medications.
Q: Who might benefit from St. John’s wort?
A:
• People with ADHD and mild depression.
• People with a history of improving on a serotonin reuptake inhibitor (SSRI) antidepressant (such as Zoloft, Paxil, or Prozac), but who could not tolerate the side effects of the prescription medications. People with ADHD and symptoms of Obsessive Compulsive Disorder such as repeatedly checking things, perfectionism, repeating certain actions (for example hand washing) or rituals to control their anxiety.
Brahmi has been used in Ayurvedic medicine for thousands of years to enhance stress resilience, reduce anxiety, and improve cognitive function. Antioxidant effects on brain areas involved in ADHD (hippocampus, frontal cortex, and striatum) have been demonstrated in animal studies. Clinical trials of brahmi in healthy adults as well as in children with ADHD have found it can mildly enhance certain aspects of learning. For example, in a small but well-done 12-week (randomized, double-blind, placebo-controlled) study of 36 children with ADHD, those given brahmi performed better on tests of sentence repetition, logical memory, and paired associate learning (Negi, Singh, Kushwaha, et al., 2000).
Brahmi shows mild cognitive enhancing effects, anti-stress effects, and other health benefits in asthma, gastric ulcers, hypothyroidism, and cardiovascular disease. In our practices, we have found it to have relatively weak benefits for ADHD. Side effects from brahmi are negligible.
We tend to customize combination treatments based upon the needs and responses of the individual. Many of these treatments are described in examples throughout the book. However, studies are being pursued to develop preparations containing many herbs, vitamins, and other nutrients believed to be of benefit for most people with ADHD. Although this may sound like a shotgun approach, it has some merits. For example, if subgroups of patients with ADHD show responses to different supplements, then preparations containing combinations of herbs and nutrients might help a fair number of people. If such combination products prove to be effective, they would provide an option for people who do not have access to health care professionals who are willing or able to administer customized complementary treatment combinations.
Many systems of medicine, developed over thousands of years throughout the world, have understood and included the essential elements we use in treating ADHD today. One of the most elaborate, Ayurvedic medicine, began in India, spread throughout Asia, and is now practiced worldwide. While it is based on the science available thousands of years ago, each generation of master practitioners has expanded and refined the techniques. Just as we are trying to understand Eastern therapies in terms of Western science, modern-day Ayurvedic specialists are using Western scientific discoveries to enrich their work. For example, both Western integrative medicine and Ayurveda prescribe dietary and lifestyle changes in the treatment of ADHD: elimination of artificial food additives; supplementation with herbs containing antioxidant, calming, energizing, and cognitive-enhancing compounds, family involvement in treatment, and personal development. Although we cannot review the myriad of herbal and mind–body therapies developed in other countries, we would like to introduce you to the work of Dr. Pankaj Naram, an Indian physician who uses Siddha Veda, a system of Himalayan medicine that predates Ayurveda and that has been passed down through a lineage of clinical practitioners. Based on texts written 2,500 years ago, and the guidance of his master teacher, Dr. Naram developed protocols for treating ADHD, autism, and other developmental disorders.
Before describing Dr. Naram’s work, we will tell you how we met him. It began with the September 11 terrorist attacks on the World Trade Center in 2001. A small group of volunteers formed an organization called Serving Those Who Serve (STWS). Their mission was to provide support, yoga, mind–body treatments, and herbal medicines to help first responders, Ground Zero workers, and area residents recover from the physical and psychological effects of the disaster. The staff of STWS asked Dr. Brown to teach his Breath∼Body∼Mind© practices to members of the 9/11 community to relieve severe respiratory problems as well as symptoms of anxiety, depression, and PTSD. (In Chapter 5 we discuss the Breath∼Body∼Mind program, which includes movement, breathing, and meditation.) We (Drs. Brown and Gerbarg) heard that they were also distributing packets of Dr. Naram’s herbs to the first responders and others exposed to the toxins from Ground Zero. Over time the combination of Breath∼Body∼Mind and Dr. Naram’s herbs produced major improvements in both psychological and respiratory symptoms. Eventually we were able to meet Dr. Naram and learn more about how he developed his formulas as well as the treatments he found to be effective for ADHD. Following is an interview with Dr. Naram.
Dr. Naram: Thirty years ago, my master sent me to work in one of the largest slums in India, Dharavi, near Mumbai. You know, the one in that movie.
Dr. Gerbarg: Slum Dog Millionaire?
Dr. Naram: Yes, that one. There were extremely bad health problems. So many children had chronic coughs, heart problems, and skin diseases. Regular medicines did not help them. So I asked my master what to do. He told me to find out where the children were working. I could not believe that these children, 12, 13, 14 years old were working. But it was true. The children took me to their workplace, a chemical plant where they spent all day, stripped down to their underwear, walking around inside the vats of chemicals in order to stir and mix the sludge. It was cheaper to pay children 10 rupees a day, about 10 pennies, than to use a machine. The vats contained industrial chemicals including lead, arsenic, and cadmium—serious toxins. I had to create a formula to detoxify them. In one of our ancient texts I read about an army of warriors who poisoned the tips of their arrows with lead and arsenic. Exposure to these toxic metals would have made them sick if they had not been treated regularly with herbs to detoxify (eliminate the toxins) from their bodies. They had to be strong, healthy, and battle ready. I created a new formula, based on those same herbs, to heal the children of Dharavi.
Years later, on the night of December 2, 1984, the world’s worst industrial accident occurred at a pesticide manufacturing plant in Bhopal, India. Hundreds of thousands of people were exposed to a cloud of toxic gases. Government agencies estimate 15,000 deaths and over 500,000 injuries. I was able to help many recover with herbal formulas. Then, in 2001, I saw on television two planes strike the World Trade Center and set the towers on fire. I knew there would be deadly toxic exposure and a cloud of toxic gases, so I went to New York to help. There I met the volunteers of STWS and gave them the herbs. They had to take three formulas every day for 6–24 months.
Dr. Gerbarg: We met people who were very sick after working at Ground Zero and they told us how much your herbs had helped them.
Q: Are there scientific studies of Dr. Naram’s herbs?
A: There have been very few controlled studies of Ayurvedic therapies, in general. Although there are many case reports, overall, we find that Indian doctors are reluctant to do placebo-controlled studies because they do not want to withhold treatment from people who would be assigned to the control groups. However, 18 people affected by the 9/11 attacks participated in a small pilot study of Dr. Naram’s herbs (Dahl & Falk, 2008). Participants were given the following compounds, made up of herbs grown and prepared in India and certified by the U.S. Food and Drug Administration (FDA) as over-the-counter herbal supplements marketable here:
Pulmo—respiration support
Herbal Detox—multilevel toxin formula
Mento—mind-nourishing formula
Immuno—strengthens immune system
Participants reported significant improvements during Ayurvedic treatment for symptoms that had not improved during 7 years of conventional medical treatment. The symptoms included cough, difficulty breathing, fatigue, exhaustion, depression, not feeling well, difficulty sleeping, among others. The only side effect, stomach upset during the first few weeks of treatment, was reported by 15% of the respondents.
Q: Do Dr. Naram’s herbs have contaminants such as heavy metals?
A: No. Dr. Naram’s herbs were independently tested in a laboratory and found to be free of contaminants.
Dr. Naram treats people in many countries. While in Italy, he was asked to evaluate Ricardo, a 14-year-old boy who was so hyperactive, impulsive, and violent that his father developed anxiety, high blood pressure, heart problems, and diabetes from the stress of being his parent. An eminent psychiatrist in Rome had diagnosed Ricky as having extreme ADHD. He never slept and never stopped moving. When he watched television, he changed the channels every second, driving everyone crazy. His attention and memory were so impaired that whatever he did would be forgotten 2 minutes later. Lacking impulse control, he hit and punched his parents, teachers, and classmates.
When Ricky first visited Dr. Naram’s office, he punched the secretary in the face, breaking her glasses. The boy was being treated with nine medications, including stimulants, sedatives, major tranquilizers (antipsychotics), and mood stabilizers. Nothing worked. Dr. Naram concluded that Ricky’s mind was in a state of extreme turmoil and that the different parts of his mind had to be brought into balance. He started Ricky on an ADHD regimen that included (1) dietary changes, (2) herbal formulas, (3) special juices, and (4) a mind–body technique called Marma.
1. Dietary changes involved the elimination of dairy products, wheat products, sugar, pesticides, and artificial food colorings and preservatives (we discuss these in Chapter 4).
2. The herbal formulas were Calm Mind, Healthy Mind, Healthy Brain, Herbal Antioxidants, Heart Health, Cough and Cold formula, Ghee Treatments.
3. The special juices were white pumpkin, ginger, and holy basil.
4. Dr. Naram taught Ricky’s parents to give him a set of Marma treatments. The basic Marma sequence is done nine times a day:
a. Apply gentle pressure while moving the hands on the head, repeated six times.
b. Press the right earlobe gently between two fingers six times.
c. Use the tip of one index (pointer) finger to gently press the center of the area between the upper lip and the bottom of the nose six times.
d. Use the tip of the left index finger to gently press the tip of the right index finger just under the top edge of the nail.
After 3 weeks of these treatments, Ricky showed marked improvements in sleep, mood, hyperactivity, anger, violence, speech clarity, memory, and learning. Over the next 6 months he got even better. Ricky secured a job in a pizza and gelato (ice cream) shop and later joined the army. His mental focus was sharp enough for him to win second prize in an army marksmanship competition.
Ricky visits Dr. Naram once a year when he is in Italy. Whenever he comes, the secretary takes her broken glasses out of the drawer to remind him. Now 21 years old, Ricky offers to fix them for her, but she always says, “You fixed yourself. That is enough.”
Once a year Dr. Naram breaks his very strict Ayurvedic diet to enjoy pizza and gelato made especially for him by Ricky. Dr. Naram explains that the pizza and gelato are good for his “emotional mind,” but, afterward, he takes mung soup and Healthy Detox formula to restore the clarity of his “intellectual mind.”\CASE\
How does Marma work? According to Vedic medicine, Marma helps remove blocks to the blood circulation and the natural flow of metabolites (body chemicals), nutrients, hormones, and neurotransmitters. The use of tapping and pressure points can be found in many medical systems, including modern treatments such as Emotional Freedom Technique (EFT; Church, Hawk, Books, et al., in press). EFT is becoming widely used to relieve symptoms of military trauma in veterans and others. According to Eastern medicine, the tapping affects certain meridians (energy channels) in the body. We think that Marma techniques activate the parasympathetic nervous system, the soothing, recharging, healing, calming, anti-inflammatory part of the nervous system. This may be one among many physiological mechanisms that could account for the therapeutic effects. We hope that future research will enable us to understand these fascinating treatments more completely.
Sleep problems occur in about 50% of children with ADHD and may persist into adulthood. These include difficulty falling asleep, resistance to sleep at bedtime, morning tiredness, and daytime sleepiness. An analysis of sleep studies in children with ADHD found a greater risk for sleep onset latency (difficulty falling asleep), decreased sleep efficiency, reduced sleep time, and increased daytime sleepiness (Cortese, Faraone, Konofal, & Lecendreux, 2009). Furthermore, the sleep problems of a child can affect the parents, who may have to stay up to make sure that their child is safe. Parents whose children sleep less than 8 hours a night are at higher risk to develop anxiety, depression, exhaustion, and loss of the patience that is so important in dealing with a child who has ADHD. Dr. Margaret Weiss and Dr. Jay Salpekar (2010) stress the importance of careful diagnosis to determine the causes of sleep problems associated with ADHD.
1. Stimulant medication. If the effects of stimulant medications used to treat ADHD persist into nighttime, they can delay sleep. Another effect of stimulant medications is loss of appetite. When appetite suppression reduces daytime eating, hunger may not be felt until the medication wears off at night. In this situation, it is better to eat some healthy food at night and go to bed on a full stomach (Weiss & Salpekar, 2010).
2. Restless leg syndrome (RLS). This syndrome is characterized by frequent leg movements that can interfere with sleep. We mentioned earlier that iron deficiency, one of the causes of RLS, can be treated easily with iron supplements. However, in some cases, medications that affect the dopamine system, such as levodopa-carbidopa, ropinirole (Requip), or pergolide (Permax), are needed.
3. Sleep-disordered breathing. Obstructive sleep apnea (OSA) in adults, and less commonly, sleep-disordered breathing in children can lead to daytime tiredness, inattention, hyperactivity, and irritability.
4. Chronic sleep onset insomnia. Chronic sleep onset insomnia—that is, delay in falling asleep—accounts for up to half of these sleep difficulties (Bendz & Scates, 2010). Difficulty sleeping can lead to reduced academic performance as well as increased hyperactivity, irritability, impulsivity, and accidental injuries.
5. Other psychiatric conditions. Other conditions that may occur along with ADHD can contribute to sleep problems. Insomnia is often part of the picture in people who suffer from depression, anxiety disorders, PTSD, bipolar disorder, tic disorder, or substance abuse.
6. Poor sleep hygiene. The term sleep hygiene refers to all the things you do during the evening before sleep (and once you get into bed) that influence how well you sleep. It includes bedtime routines, activities leading up to bedtime, and substances ingested within a few hours of bedtime. Some adults have irregular sleep habits, and they may have difficulty establishing the consistent sleep routines that they and their children need. This problem can be addressed by educational counseling and behavior therapy. The American Academy of Sleep Medicine (AASM) publishes best practices for good sleep hygiene, including specific behavioral treatments for ADHD-related sleep problems.
Weiss and Salpekar (2010) explain a comprehensive process used by health care professionals to accurately diagnose sleep disorders that includes the use of parent–child questionnaires, sleep questionnaires, sleep diaries, and clinical interviews. If the results of these measures suggest a sleep disorder, the next step would be either an overnight sleep study such as polysomnography (monitoring electrical activity on the scalp with electroencephalogram [EEG] and other body function measures in a sleep laboratory) or actinography (wearing a small device on the wrist to record movements over several days and nights in the patient’s normal environment). Your doctor will be able to arrange sleep studies for you in a nearby hospital.
Whatever is conducive to sleep for an individual constitutes good sleep hygiene. Typically good sleep hygiene includes establishing a regular bedtime and avoiding stimulating activities during the hour before sleep, such as playing computer games, watching suspenseful television shows, or listening to loud music. The hour before bedtime should be used for quiet activities such as reading (not emotionally disturbing material), taking a warm bath, or doing calming breathing and relaxation practices (see chapter 5).
Melatonin is a natural hormone produced primarily in the pineal gland, a small anatomical structure at the base of the brain. Melatonin binds to receptors in the hypothalamus, which synchronize melatonin secretion with the 24-hour day–night cycle. Prior to sleep, melatonin levels rise and help induce sleep onset. Children and adults with ADHD can have a delay in the rise of melatonin that should occur in the evening to facilitate sleep (Van Veen, Kooij, Boonstra, Gordijn, & Van Someren, 2010). The result is that it takes longer to fall asleep.
If sleep onset delay persists despite good sleep hygiene, then it may be time to discuss a trial of melatonin with your doctor. Good sleep hygiene is necessary for melatonin to be effective. For example, if you stay up until 2:00 A.M. playing Lara Croft Tomb Raider, Call of Duty, or World of Warcraft on your computer and drinking caffeinated soda, it is unlikely that melatonin will put you to sleep. Bright light from computer screens tends to suppress melatonin and may interfere with the action of melatonin supplements. Once the melatonin is effective, it should be taken for a month or two and then discontinued just to see if it is still needed. If sleep difficulties return, then it should be resumed. Every few months, discontinuation can be tried to check on whether the melatonin is still necessary. It is reassuring that at least one study found the hormone to be safe for 3 years. Many of our patients have used melatonin every night for decades without any problems. Additional, long-term studies in larger numbers of people would further confirm its safety.
Melatonin supplements have been shown to increase melatonin levels and shorten the time needed to fall asleep. In a rigorous (double-blind, randomized, placebo- controlled) 4-week study of 105 children (ages 6–12) with sleep onset insomnia and ADHD, those given melatonin showed significant improvements in sleep (Van der Heijden, Smits, Van Someren, Ridderinkhof, & Gunning, 2007). A 3-year follow-up study of these children found that 65% continued to use melatonin every evening, and 12% used it occasionally (Hoebert, van der Heijden., van Geijlswijk, & Smits, 2009). Melatonin was safe and effective for long-term use in children ages 6–12.
Overall, melatonin is beneficial for sleep in children and adults. Melatonin supplements cause very few side effects. Rarely, it can cause headache or activation instead of sedation. Doses range from 1 to 3 mg for children weighing 100 pounds (40 kg) or less, 3–6 mg for those over 100 pounds (40 kg), and 3–9 mg for adults. Melatonin comes in short-acting and long-acting forms. The short-acting form helps you fall asleep, whereas the long-acting form helps you stay asleep. For sleep onset insomnia, short-acting melatonin is preferable. However, for problems falling and staying asleep, a 50–50 mix of short- and long-acting forms may work better. This mix can be achieved either by taking two pills (one short- and one long-acting) or by finding a product that contains both forms. The quality of melatonin used in different products varies. You can check the chart on Quality Products at the end of this book to be sure you are buying a high quality product that will be effective.
After careful evaluation, as described above, and depending on the cause of the sleep disorder, there are numerous approaches to treatment:
1. Stimulant medication doses and timing can be adjusted.
2. Specific behavioral treatments, including sleep hygiene education, can be combined with other approaches.
3. Melatonin can be added.
4. Relaxation techniques such as paced breathing (see Chapter 5) and relaxation CDs can be used.
5. Biofeedback or brain stimulation (see Chapter 6) sessions can be tried.
6. When stimulant medication cannot be reduced and causes sleep problems that do not respond to the natural treatments described above, it may be necessary for your doctor to prescribe either clonidine or guanfacine for sleep onset insomnia and nighttime agitation.
For more information on the diagnosis and management of sleep disorders, see the Resources section at the end of this chapter.
Nootropics (pronounced no-o-tró-pics) improve how the brain functions and protect neurons from damage. How do they work? There are numerous ways in which nootropics may improve brain functions:
1. Scavenging of free radicals and preventing them from damaging delicate cell structures.
2. Increasing antioxidants and thereby raising the levels of other free radical fighters.
3. Improving membrane fluidity enhancing electrical conduction in nerve pathways.
4. Increasing neurotransmitter levels improving the communication between neurons and among the neural networks that coordinate thinking, problem solving, and behavior.
5. Improving mitochondrial function increases and maintains energy supplies needed to fuel cellular functions, including cellular repair.
6. Stimulating messenger ribonucleic acid (mRNA) protein synthesis helps the cell produce all the compounds necessary for the brain to function properly.
7. Enhancing/increasing cerebral blood flow by slightly increasing the diameter of the small blood vessels in areas of the brain that are underactive can enhance functioning by transporting more oxygen and nutrients to brain structures.
The nootropics we find most useful for ADHD are meclofenoxate (centrophenoxine), picamilon, and the racetams (pyrrolidones). Meclofenoxate and picamilon are discussed in Chapter 4.
Racetams (pyrrolidones) bind to and modulate the activity of glutamate alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) receptors involved in excitatory neurotransmission, learning, and memory (Ahmed & Oswald, 2010; Gouliaev & Senning, 1994; Mizuno et al., 2005). Whether this activity contributes to the clinical effects is not yet known. Racetams may contribute to neuroprotection and improved function through the release of brain-derived neurotrophic factor (BDNF), essential for neuroplasticity (IuIu et al., 2009; Wu et al., 2004). Furthermore, they improve interhemispheric transmission, thereby improving communication between the right and left sides of the brain. While racetams such as piracetam, aniracetam, and pramiracetam are useful, in general, for learning disabilities, they are especially effective for language disabilities, including reading, listening, and speaking disabilities (Tallal, Chase, Russell, & Schmitt, 1986). In people with dyslexia (reading disability), racetams activate the verbal processing areas in the left hemisphere. One double-blind, randomized, placebo-controlled multicenter study of 225 children with dyslexia (ages 7–12 years) found that those given 3,600 mg/day of piracetam had significant improvements in reading and comprehension. The improvements were evident after 12 weeks and were maintained through the full 36 weeks of the trial. There were no adverse reactions to the piracetam (Wilsher et al., 1987).
Pramiracetam tends to be more calming, whereas aniracetam is more stimulating. In our patients, we find 750 mg twice a day of aniracetam to be particularly effective, well tolerated, and unlikely to cause agitation or other side effects. In one of our cases, aniracetam cleared up stuttering.
Because racetams are so low in side effects, they are easy to try. Although they may work within a few weeks, it is worth giving them a full 12-week trial to determine whether or not they will make a difference in verbal processing, other learning disabilities, and symptoms related to ADHD.
Oppositional defiant disorder is the DSM term used to describe children who are extremely uncooperative to the degree that their behavior significantly impairs their ability to function. This disorder can occur alone or in combination with other disorders, including ADHD. Technically, it is supposed to be separate from ADHD, but sometimes when the ADHD is treated, the oppositional behavior also remits. Although there are no formal studies of the use of racetams for oppositional behavior, we would like to report one case in which piracetam transformed a child’s life.
Marlene was the child who always said no. Whatever she was asked or told or expected to do, Marlene was sure to oppose. Explaining, coaxing, bribing, threatening—all the usual tactics failed. And if any physical force was applied, the child went wild—kicking, screaming, biting. By the age of 10, Marlene had been evaluated many times by specialists who diagnosed her as having ADHD, oppositional defiant disorder, dyslexia, anxiety, and obsessive–compulsive disorder. Treatments included numerous medications, neurofeedback (see Chapter 6), cognitive–behavior therapy, and family therapy—and all failed. Sertraline (Zoloft) reduced her anxiety and OCD symptoms, but nothing more. Finally, her parents brought her to me (Dr. Brown) for a consultation. Intending to improve her brain function and dyslexia, I gave Marlene a trial of piracetam 1300 mg twice a day. The results exceeded all expectations. The next time Marlene came to see me she did not have to be dragged. Her parents said, “She’s transformed … a different child. Marlene is calmer, happier. She smiles and sings all the time. She still loses her temper about once a day when she doesn’t get her way, but it only lasts a minute and then she’s fine. She remembers to use the breathing you taught her (see Chapter 5) and it calms her down quickly. Before, she hated books. Now she reads all the time.”
Q: When should racetams be tried?
A:
1. When the person with ADHD also has problems reading and other language-related disabilities. Racetams are even more effective when combined with remediation or rehabilitation.
2. Other learning disabilities such as slow processing.
3. In cases of learning disabilities where there is a history of brain injury, due to trauma or cerebrovascular disease (e.g. stroke) racetams can improve recovery.
You may be eager to try some of the treatments described in this chapter, but where should you begin? Begin with your doctor by discussing your interest in trying non-drug treatments. If your doctor does not know about them, give the doctor a copy of this book or a copy of the relevant pages. Ask your doctor to review the material and look up whatever references are needed. There should be enough material for your doctor to integrate this information with his or her medical background. The principles for doing safe trials of complementary treatments are the same as for standard treatments. If your doctor still feels uncomfortable overseeing your use of complementary treatments, you can either ask for a referral to someone experienced in integrative medicine or suggest that your doctor contact us (Dr. Brown and Dr. Gerbarg) for guidance.
The treatments you and your doctor choose should depend on the following considerations:
1. Age: With children less than 12 years of age, start with the mildest treatments that have the fewest side effects, such as Pycnogenol, picamilon, centrophenoxine, or aniracetam. Adolescents and adults may want to start with one of the stronger treatments such as Rhodiola rosea and add the other treatments to enhance benefits. People over the age of 60 may also benefit from improving brain circulation with picamilon.
2. Presence of other concurrent diagnoses, such as insomnia, learning disabilities, developmental disorders, brain injury, stroke, seizures, anxiety, or mood disorders. Focus on treatments that are particularly helpful in these disorders; for example, melatonin for sleep or racetams for learning disabilities.
3. ADHD subtype and whether the treatment is more effective for ADHD of the inattentive, hyperactive/impulsive, or mixed type (inattentive with hyperactive/impulsive).
1. Obtain a careful evaluation for ADHD and other possible concurrent diagnoses from your doctor and whatever specialists may be needed, such as a psychiatrist, a pediatric psychiatrist, a psychologist, a sleep specialist, or a neurologist.
2. Consult with your health care professionals to develop a plan for treatment trials and monitoring. Monitoring is important in order to evaluate changes over time as well as to watch for side effects.
• Decide how you will evaluate the effects over time. This may include observing changes in target symptoms, getting feedback from those who know you well, and repeating brief symptom questionnaires. Getting feedback is important because other people may notice improvements before you do.
• Start only one new treatment at a time so that you can clearly evaluate the effects.
3. Begin with moderate doses for treatments that have potential side effects and increase gradually every 3–7 days until you reach a maximum dose, see clear benefits, or encounter side effects. When side effects occur, back off a bit by returning to the previous lower dose, wait another week to see if the side effects clear, and then proceed. If the side effects are severe or there is an allergic reaction, discontinue the treatment. The trial period for most of these treatments should be between 6 and 12 weeks once you have attained the maximum dose. However, if you see results sooner and these appear stable, then it may not be necessary to increase the dose further. Maintain that dose and move on to the next supplement trial. If you see no results after a full trial, then discontinue it and start the next supplement trial. If you see partial benefits that plateau, then continue at that dose and add the next treatment for further improvements.
Table 3.1 Supplement Guidelines for Herbs, Melatonin, and Nootropics
Note. ADHD = Attention-deficit/hyperactivity disorder (includes all three subtypes); mg/d = milligrams per day; tabs = tablets; b.i.d. = twice a day; t.i.d. = three times a day; A.M. = in the morning; P.M. = in the evening; h.s. = at bedtime; g = grams; mg = milligrams; BP = blood pressure; GI = gastrointestinal side effects; D/C = discontinue.
a The dosages on this table are meant only as guidelines. People who are more sensitive may need to use lower doses. Readers should discuss the choice of supplements and the adjustment of doses with their personal physician.
b Common side effects are listed. There are additional rare side effects. Individuals with high blood pressure, diabetes, pregnancy (or during breastfeeding), or any chronic or serious medical condition should check with their physician before taking supplements. Patients taking anticoagulants should consult their physician before using supplements. Parents are advised to consult a qualified physician to prescribe and monitor all supplements given to children.
c Cholinergic = causes effects similar to acetylcholine such as reduced heart rate and vasodilation. Necessary for arousal, learning, and memory.
Table 3.2 Guide to Quality Products for Herbs, Melatonin, and Nootropics
Note. Parents are advised to consult a qualified physician to prescribe and monitor supplements given to children. R. rosea = Rhodiola rosea; E. senticocus = Eleutherococcus senticosus; S. chinensis = Schizandra chinensis; A. mandshurica = Aralia mandshurica; R. carthamoides = Rhaponticum carthamoides. LEF = Life Extension Foundation; IAS = International Antiaging Systems.
a Costs of products may vary. This table lists approximate costs at the time of publication. Unless noted otherwise, all prices are costs per day based upon recommended treatment dosages. This is not a comprehensive list of all available products.
bMajor brands: indicates that there is no one “best brand” and that as long as you purchase well known brands with good manufacturing standards, you are likely to get a good product. This is true of supplements that are more easily available and that do not require as much special care in processing.
The following are resources for additional and updated information on herbs, melatonin, and nootropics.
Alaska Rhodiola Products: http://www.alaskarhodiolaproducts.com
A non-profit farmer’s co-op growing Rhodiola rosea in Alaska.
American Academy of Sleep Medicine (AASM): www.aasmnet.org and www.Sleepeducation.com
Information on diagnosis and treatment of sleep disorders.
American Psychiatric Association Caucus on Complementary, Alternative and Integrative medicine: www.APACAIM.org
Information for health care providers seeking courses, workshops, references, and options for networking and advocacy.
ConsumerLab.com—www.consumerlab.com
Rates many brands of herbs and supplements on some measures of quality and labeling accuracy. Does not assess shelf life, the length of time the product may sit on a shelf without losing potency.
Drugs.com—www.drugs.com
Provides concise updated presentation of CAM, including risks and interactions.
National Center for Complementary and Alternative Medicine, National Institutes of Health, National Library of Health Complementary and Alternative Medicine Specialist Library (NeLCAM): www.library.nhs.uk/cam. Database for scientific publications.
Natural Medicines Comprehensive Database: www.naturaldatabase.com.
Database of information on natural treatments. Descriptions of adverse reactions are often overstated and based on unsubstantiated cases.
Research Council for Complementary Medicine: www.rccm.org.uk/default.aspx? m=o.
Devloping database of references on CAM.
Serving Those Who Serve (STWS): www.stws.org.
Non-profit organization providing complementary, herbal, and mind-body workshops to First Responders and others affected by the 9/11 World Trade Center Attacks.
Supplement Watch: www.supplementwatch.com.
Undated information on quality and safety of supplements.
U.S. Food and Drug Administration: www.fda.gov/medwatch. Updated information on quality and safety of supplements.
BMC Complementary and Alternative Medicine: www.biomedcentral.com.
Peer-reviewed journal publishes articles on CAM.
Evidence-Based Complementary and Alternative Medicine: www.hindawi.com.
Peer-reviewed journal publishes articles on CAM.
Herbalgram: Journal of the American Botanical Council: www.Herbalgram.org.
In depth, authoritative articles on herbs from around the world.
Journal of Complementary and Alternative Medicine: www.liebertpub.com.
Peer-reviewed journal publishes articles on CAM.
Dr. Naram, information and videotapes: www.drnaram.com.
Ayurvedic treatments
Emotional Freedom Techniques (EFT): www.eftuniverse.com/index.php?option=com_content&view=article&id=18.
Used to relieve symptoms of military trauma in veterans and others.
Blumenthal, M. (Ed.). (2003). The ABC Clinical Guide to Herbs. Austin, TX: American Botanical Council. Authoritative, comprehensive publication of nonprofit research and education organization, clearly written overview of herbs including their uses, doses, contraindications, and adverse reactions.
Brown, R.P., Gerbarg, P.L., & Muskin, P.R. (2009). How to Use Herbs, Nutrients, and Yoga in Mental Health Care. New York: Norton. Synthesis of 30 years experience shows the reader how to integrate herbs, nutrients, and yoga with standard treatments for all categories of mental health and illness. Suitable for training health care practitioners as well as providing information for the general public.
Ernst, E., Pittler, M.H., & Wider, B. (Ed.). (2006). The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2nd ed.). Mosby: London.
Concise, well-organized quick-reference resource, provides a more conservative approach based on very stringent evidence requirements that cannot yet be met by many beneficial herbs.
Harkness, R., & Bratman, S. (2003). Mosby’s Handbook of Drug–Herb and Drug–Supplement Interactions. St. Louis, MO: Mosby. Useful reference to check on interactions between herbs or between herbs and medications.
Lake, J., & Spiegel, D. (2007). Complementary and Alternative Treatments in Mental Health Care. Washington, DC: American Psychiatric Association. Chapters are written by experts in different areas of CAM, for example, Chinese medicine, homeopathy, Ayurveda.