Updates in ADHD Bradley Siu, Psy.D. Kaiser SSF Child Psychiatry
Pediatric Grand Rounds: 8/23/2017 Please sign the attendance sheet in the room to claim your credit. 1
Epidemiological Data ❖ ADHD prevalence rates for youth have increased considerably in the past 25 years. Growth rates were about 4.5% annually from 26.2 per1000 office visits in 2008 to 107 per 1000 in 2013. ❖ A history of ADHD diagnosis by a health care provider increased by 42% between 2003 and 2011: ❖ 7.8% had ever had a diagnosis in 2003 ❖ 9.5% had ever had a diagnosis in 2007 ❖ 11.0% had ever had a diagnosis in 2011 ❖ The percentage of US children 4-17 years of age with an ADHD diagnosis by a health care provider, as reported by parents, continues to increase. Since then the growth has been about 2.9% annually ❖ For Adults there was an eightfold increase in ADHD
Epidemiological Data ❖ 2012-2013 visits made by African American youths were 24% more likely to include an ADHD diagnosis and 19% more likely to include a diagnosis and drug prescription than were visits made by White youths. ❖ The youth of other races predominantly Asian/Pacific Islander, were less likely than White youths to receive an ADHD diagnosis or drug prescription. ❖ For adults and children interaction of a mood or anxiety disorder with FEMALES increased the odds of ADHD diagnosis and treatment by a factor between 1.7 to 2.5x. ❖ This fulfills the AB 1195 requirement for incorporation of CLC into CME.
The Prefrontal Cortex ❖ Consist of a collection of cortical areas. Collectively these have important ties to other brain areas that together manage Executive Functions, cognitive control, and self regulation. ❖ Also has interconnections with brain areas responsible for processing of external information: sensory systems, motor systems, and internal information. It is connected to the motor system, Basal Ganglia, and Limbic system.
Executive Functions ❖ Executive Functions is a widely used term in the Neuropsychological literature, and is now broadly used in general psychology, clinical psychology, and in education. ❖ Executive Functioning is a meta construct or an umbrella term that describes a set of cognitive functions, or group of tools necessary in goal directed action, behavior towards the future, and self regulation.
ADHD = Executive Functioning Deficit Disorder ❖ Executive Functions are skills and task that are managed by the prefrontal cortex and corresponding neuropathways: – Organizing – Planning – Inhibition – Activation – Emotional Self Control – Time Management – Attention and Focus ❖ ADHD can be seen as a disorder of the neuropathways that involve the PFC’s connection to the other areas of the brain.
ADHD = Executive Functioning Deficit Disorder
Devolving Attention? ❖ Non Biological ADHD - Lifestyle Disorder? ❖ Digital Dementia ❖ Distracted Lifestyle ❖ Gut Health: Nutrition ❖ Non-Omega 3 FA (inflammatory oils) ❖ Sleep ❖ Addiction
Addiction ❖ All Addiction looks the same under FMRI - nucleus accumbens ❖ Addiction is most Industries’ goal. ❖ Many Industries use neuroscientist and neuro-imaging.
Addiction - Electronics ❖ There are number of industries in which neuroscientist are used to create programs or patterns in the ❖ Casino Player Tracking the end game is to keep the player at their preferred machine. “Today’s higher performance processors are allowing abilities such as facial recognition to monitor player engagement.” ❖ Food industry - these companies rely on pure science to understand how we’re attracted to food and how they make their foods attractive to us. ❖ Internet apps and mobile apps - Facebook
Addiction - Electronics ❖ Evidence that the neural mechanisms underlying Internet Gaming Disorder (IGD) resemble those of drug addiction and share similar neurobiological abnormalities with other addictive disorders. ❖ Previous studies showed dopamine release in the ventral striatum in a similar magnitude to amphetamine-induced dopamine release. ❖ Video game playing induced stratal dopamine release indicating that this is a major force promoting addictive behavior. ❖ Video game playing involved changes in reward inhibitory mechanisms and loss of control. - Alterations in ventral striatum that is an important part of the brains reward mechanisms.
Neurological Changes ❖ FMRI shows changes to brain regions responsible for attention and control, impulse control, motor function, emotional regulation, sensory motor coordination. ❖ Associated with lower white matter density in brain regions that are involved in decision-making, behavioral inhibition and emotional regulation. ❖ IGD is an interaction of limbic and prefrontal brain areas that diminished executive and inhibitory control. ❖ Video game playing as associated with dopamine release similar in magnitude to those of drug abuse and lower dopamine transporter and dopamine receptor D2 occupancy indicating sub-sensitivity of dopamine reward mechanisms.
Neuroregulation and Addiction ❖ Diminished efficiency of response-inhibition. ❖ Excessive use of the brain’s dopamine reward system resembles the down-regulation seen in the cases of drug and alcohol abuse. ❖ Associated with impaired function of the prefrontal cortex and its connection with limbic regions that relates to high impulsivity that in turn may contribute to impaired cognitive control.
Essential Supplements for ADHD Most ADHD professionals recommend eating a diet full of vegetables, fruit, complex carbs, and protein with every meal to help manage symptoms. This is should be interpreted as “whole unprocessed foods” diet.
Omega 3 Fatty Acids ❖ Omega-3 fatty acids are essential fatty acids necessary for human health. There are two families of essential fatty acids: Omega-3 fatty acids and Omega-6 fatty acids. They are termed “essential” because they cannot be produced by the body, and must therefore be obtained from the diet. ❖ Both omega-6 and omega-3 fatty acids are stored in the cell membranes of tissues and have two primary functions. First, they are structural components of cell membranes where they ensure fluidity, stability, and act as gate-keepers in the cell. Second, both omega-6 and omega-3 fatty acids are converted into a number of important, active molecules called prostaglandins.
Omega 3 Fatty Acids ❖ Some studies have suggested that children with ADHD have an abnormal Poly Unsaturated Fat profile and, in particular, a decrease in the plasma concentration of DHA and EPA. ❖ Depletion of essential fatty acids may impact the brain, which contains the highest lipid content and requires Omega 3 PUFA for development, intercommunication and function; DHA plays a significant role in brain development whereas EPA is important mostly for function. ❖ Omega 3 Fatty Acids are a crucial part of the cell membrane that surround the cells of the brain and nervous system. ❖ Recent studies have shown that omega-3 fatty acids improve symptoms of ADHD. A comprehensive look at many studies showed that omega-3’s are about 40 percent as effective as stimulants in relieving symptoms.
Omega 3 Fatty Acids ❖ Fats play a significant role in the brain. Specifically, the amount and type of fat one consumes directly affects the composition of nerve cell membranes. ❖ According to Kaiser Regional ADHD committee all children with ADHD should be on or have tried an Omega 3 supplement. ❖ Take Optimal Amounts of Omega-3s - According to Dr. Sandy Newmark, kids between four and eight years old should take between 1,000-1,500 mg. a day. Older kids should get 2,000-2,500 mg. daily. ❖ More commonly available size: 1200mg with 600mg total DHA & EPA
Omega 3 Fatty Acids The AI (Adequate Intake) of Omega-3 is 1.6g/day for men and 1.1 g/day for women. There is no Daily Value for omega-3s. Salmon 4 oz: 1.45g Sardines 4 oz: 1.34 g Mackerel 4 oz: 1.25g Grass-fed beef 4 oz: 1.1g Flaxseed 2 Tbsp: 3.2g Chia Seeds 2 tbsp: 2.5g Walnuts ¼ cup: 2.3g Natto 4 oz: 0.52g Tuna 4 oz: 0.33g Grass-fed Dairy 8 oz: .25g
Iron ❖ Iron for Better Behavior ❖ Iron deficiency affects the hemoglobin in red blood cells, causes significant learning problems in infants and children. At least 16 research studies performed in countries around the world found that cognitive, motor, and/or social/emotional functioning was reduced in infants who had iron deficiency anemia. ❖ A 2008 study appeared in Pediatric Neurology showed that children who were not anemic but had low ferritin levels, a protein needed to store iron in the blood, showed improvement of ADHD symptoms after 12 weeks of iron supplements.
Iron ❖ Iron is essential for the optimal production of both noradrenalin and dopamine and is a necessary component for the enzymes involved in their production. ❖ Before recommending an iron supplement, have iron levels checked. Research studies used iron levels below 30 as falling into the treatment category.
Iron Rich Foods Red Meat Chicken Turkey Beans Shell Fish Whole Grains Ascorbic acid or vitamin C occurs naturally in vegetables and fruits, especially citrus. Ascorbic acid enhances the absorption of iron. Studies indicate 100 milligrams of ascorbic acid increased iron absorption from a specific meal (eaten in the same sitting) by 4.14 times.
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