Louis B. Cady, MD, FAPA – CEO & Founder – Cady Louis B. Cady, MD, FAPA – CEO & Founder – Cady Wellness Institute Wellness Institute Adjunct Clinical Lecturer – Indiana University School of Medicine Department of PsychiatryFunctional & Integrative Neuropsychiatry – Evansville,

Indiana

The Natural Treatment of ADHD: New Hope and New Directions

Presented at: ADHD/SPD Parent Support Group

Saint Marys Hospital – Evansville, INDecember 7, 2016

Prevalence: how much, and “why so much”?

Increased methylphenidate usage for attention deficit disorder in the 1990’s.

Safer DJ et al. Pediatrics. 1996 Dec; 98(6 Pt 1):1084-8}

• 2.5 X increase in MPH tx between 1990 and 1995– 2.8% (1.5 million) US youths aged 5-18 received this

medication in mid-1995• “The increase in methylphenidate…appears

largely related to– an increased duration of treatment;– More girls, adolescents and inattentive youths on the

medication– And a recent improved public image of medication

treatment.”

www.billfoster.com - Reviving American Manufacturing, accessed 1 27 2014

http://www.scdigest.com/assets/newsViews/08-06-12-2.php accessed 01 27 2014

Unemployment, underemployment are contemporary problems…

Genetic tendencies in ADHD

Faraone SV et al. Biol Psychiatry 2005 June 1;57(11):1313-1323.

Graphic from CNS Spectr. 2007;12:4 (Suppl 6): 6- 7

Genetic etiologies• Genes most commonly associated with ADHD

involve dopamine.– Faraone SV, Perlis RH, Doyle AE, et al. Molecular genetics of attention-

deficit/hyperactivity disorder. Biol Psychiatry. 2005;57:1313-1323.

• PET studies show excess DAT into presynaptic neuron (15% higher than in controls)– Spencer TJ, Biederman J, Ciccone PE, et al. PET study examining

pharmacokinetics, detection and likeability, and dopamine transporter receptor occupancy of short- and long-acting oral methylphenidate. Am J Psychiatry. 2006;163(3):387-395.

What does it “look like”?

A section for kinesthetic and visual learners…

ADHD – not concentratingInferior Orbital pre-frontal cortex

Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

ADHD - concentrating

ADHD – concentrating, on RX

ADD – inattentive, without Rx

ADD – inattentive, on Amph

Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

Integrated: how to avoid over-reliance on meds

• Holistic treatment and supplementation!– Cf: The Physician in Spite of Himself, Part II

• Smart prescribing!• School:

– Excellent working relationships with school– Good teaching

• HOME:– Diminish “electronic screens” effect– Good home discipline– Good sleep/wake schedules– Good diet– Adequate exercise

• Parent training: parenting, stress tips

What happened to those, anyway?!What happened to those, anyway?!

New Concepts in the Epidemiology, Diagnosis and Precision Treatment of ADHD in Children, Adolescents, and Adults

IMMH 5th Annual ConferenceSan Antonio, TX Sunday, Sept. 21

But what about the functional medicine aspects??

My Previous Notion of Therapeutic Options

My experience with a child with out of control ADHD - the story of Billy

• 8/1998 – 4 yo Eastern European adopted child – “ADD & behavioral problems, destructive.”– First 3 years of life in orphanage

• Fam Psych Hx:– Dad – “substance induced paranoid psychosis”– Mother – “recurrent schizophrenic

decompensations”

Billy, cont.

• Some improvement• 3/1999 – increasingly vile temper. Sad, dysphoric.

“Back to square one.”– Zoloft added.– Ritalin only lasting 1 ½ hours

• 5/1999 - 4 ½ yoa. Rehab Center testing:– Auditory comprehension = 2 y 11 mo’s– Total language = 2 y 11 mo’s

• 6/1999 – Flaxseed oil, L-tyrosine, Pediactive tabs added. In constant trouble Dad getting depressed.

Billy, cont – 1999 - 2000

• Ritalin and Adderall not working• Temper to the point of clawing at his face.

Sniffing. Now urinating in bed.• 12/1999 – started on Risperdal – 1mg in a.m. and

½ mg later in day• 2/2000 – Psych testing – IQ 78

– ADHD– Borderline intelligence– Processing problems– “r/o childhood psychosis”

Billy, late 2000• Fall 2000:

– Bit and stabbed his teacher with a pencil, kicked chair, wall, and desk, spat on floor and teacher. Obsessively lining up his cars in his room, tongue thrusting and smacking (? Tardive dyskinesia?)

• On Risperdal, Depakote, and Concerta.• 8/2001 – 2002 some better but still

unpredictable. Meltdowns. Depakote increased. Zyprexa added.

• 8/2002 – throwing things against windows. Depakote not working. Mood cycling.

Billy, 2003

• Ongoing unpredictability until Geodon started. – Less hyper– Dry in a.m.– Clearer speech and better eye contact.

• July 2003 – IgG food allergy testing ordered

Billy – IgG Food SensitvitiesJuly 2003

• 21 + IgG reactions.. Of these…..– Cheese (3+)– Cow’s milk (3+)– Goat’s milk (2+)– Brewer’s yeast (3+)– Millet (+1)– Lettuce (!) (+1)

Reviewed labs with internet savvy Mom (who did NOTHING).

June 7, 2004 – 6 years of tx; ONE YEAR AFTER IgG Testing!

• “Literally bouncing off the walls in the a.m.”• Almost knocked brother off second floor balcony• Could not tolerate < 2 g VPA• Threw stool over banister and tried to hit Mom on

way up stairs. (Missed) • Told Mom: “You’re going to die, I’m going to

make sure you’re going to die.” • Things that make him angry: not putting peanut

butter sandwich on plate “correctly.” • Waking up screaming. Making non-human,

guttural sounds.• Parents pursuing IP treatment

Radical interventions/ workup

• June 2004 – Lithium added– Made him briefly toxic but symptoms improved.– Worked on getting him inpatient tx.

• Fatty acid panel ordered.

• Told Mom to GET SERIOUS about food allergies/sensitivities

Clinical manifestations of EFAD• Dermatitis• Increased appetite and

caloric intake in infants (adults?!)

• Failure of wound healing• Irritability• Alopecia, dry hair, dandruff• Brittle nails• Increased susceptibility of

infections

• Thirst, polydipsia, polyuria

• Liver fatty infiltration• Increased capillary

fragility• RBC fragility• Increased

Cholesterol/HDL ratio

Essential Fatty Acid findings

Value Reference range

EPA 3 (L) 20 - 80

DHA 32 (L) 70 - 150

FEB 2005

• The present study found that 53 subjects with ADHD had significantly lower concentrations of key fatty acids in the plasma polar lipids (20:4n-6, 20:5n-3, and 22:6n-3) and in red blood cell total lipids (20:4n-6 and 22:4n-6) than did the 43 control subjects

• “…but the precise reason for lower fatty acid concentrations in some children with ADHD is not clear.”

• “We argue that a change in the ratio of n-6/n-3, especially during early life, may induce developmental changes in brain connectivity, synaptogenesis, cognition and behavior that are directly related to ASD.”

• Western diet: omega 3 fatty acid deficiency and increased fructose intake. • “Both promote brain insulin resistance and increase the

vulnerability to cognitive dysfunction.” • “Multiple cognitive domains are affected by metabolic

syndrome in adults and in obese adolescents, with volume losses in the hippocampus and frontal lobe, affecting executive function.” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775234/

• In Adults with ADHD:• DECREASED DHA, AA, and DHGLA

• “We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.HGLA were lower than controls.”

Reduced Levels of Omega-3 Fatty Acids are Associated with ADHD

Antalis et al., Prostaglandins Leukot Essent Fatty Acids, 2006. 75(4-5): p. 299-308.

This summary demonstrates that a deficiency in brain PUFAs will lead to cognitive deficits, while supplementation of PUFAs can rehabilitate cognitive deficits, as manifested in attention deficit hyperactivity disorder, stress/anxiety, and aging.

Should we use this??

Further elongation problems:

lack of nutrients

• REQUIRED for delta-6 desaturase:– Magnesium– Zinc– B vitamins

• FAD (B2)• Niacin (B3)• P-5-P (B6)

– C– insulin

“chiropractic” “psychiatric”

Extra slide of online viewing• Key principles of essential fatty acid

supplementation are:– Do not use large doses of a generic omega 6 or omega

3 fish oil and presume that you are going to get adequate amounts of EPA and DHA out the bottom of the pathways.

– The only two sources of fish oil high in PUFA’s that we get are from eating fish or taking fish oil. Period. If we don’t eat fish, we should probably be on fish oil.

– We DO have the ability to synthesize the critical PUFA’s, including EPA and DHA, from precursors, but in order to do so, we must have adequate amounts of the critical trace minerals.

Vayarin – a new prescription “medical food” – the theory behind development

• Lipids are important for brain health • Abnormal lipid balances are associated with

ADHD.• Lipid levels (in blood and brain) might be

affected by different parameters (e.g., diet, metabolism)

• Therefore, why not put more of the good lipids into the brain?

Polar head

Fatty acids

Phosphate group

Glycerol backbone

Phospholipid molecule

omega-3 Fatty acids

Vaisman, N. et al., Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2009: p. 952-959.

What’s the best way to get Omega 3 into mouse brain?

NOTE: The essential elements portion of this test include:•Elemental lithium•Iron•Magnesium •Zinc•copper

IRON - Most common of all nutrient deficiencies in U.S. school-aged children

Murray & Pizzorno. Encyclopedia of Natural medicine. Rocklin, CA: Prima Publishing; 1998.

• Deficiency associated with: markedly decreased attentiveness, narrower attention span, decreased persistence, and lowered activity level – all of which respond positively to supplementation.

• Kidd. ADHD in Children: Rationale for Its Integrative Management. Alt Med Review 2000; 5(5):402-427.

• 30% improvement in Conners ADHD Rating Scale following iron supplementation [(Ferrocal), 5 mg/kg/day for 30 days] in one uncontrolled Israeli study of boys.

• Sever et al. Iron treatment in children with attention deficit hyperactivity disorder. A preliminary report. Neuropyshcobiology 1997;35:178-180.

05

1015202530354045

serumferritin

Conners

beforeafter

–significant increase in serum ferritin levels (from 25.9 +/- 9.2 to 44.6 +/- 18 ng/ml) and a significant decrease on the parents' Connors Rating Scale scores (from 17.6 +/- 4.5 to 12.7 +/- 5.4).

Zinc link --- and friends• Psychiatr Pol 1994 May-Jun;28(3):345-53

[Deficiency of certain trace elements in children with hyperactivity][Article in Polish]Kozielec T, Starobrat-Hermelin B, Kotkowiak L.

Zakladu Medycyny Rodzinnej Pomorskiej Akademii Medycznej.

• The magnesium, zinc, copper, iron and calcium level of plasma, erythrocytes, urine and hair in 50 children aged from 4 to 13 years with hyperactivity, were examined by AAS. The average concentration of all trace elements was lower compared with the control group--healthy children from Szczecin. The highest deficit was noted in hair.

• Our results show that it is necessary to supplement trace elements in children with hyperactivity.

Magnes Res 1997 Jun;10(2):143-8 Kozielec T, Starobrat-Hermelin B.,, 1997, cont.• 116 children with ADHD• Magnesium deficiency was found in 95 per

cent of those examined:– most frequently in hair (77.6 per cent)– in red blood cells (58.6 per cent) – and in blood serum (33.6 per cent)

• CONCLUSIONS: magnesium deficiency in children with ADHD occurs more frequently than in healthy children. Analysis of the material indicated the correlation between levels of magnesium and the quotient of development to freedom from distractibility.

Putting it all together with new technology…

Two illustrative cases

The adorable rager – parents concerned; interested in natural

treatment

• Clinical details removed for internet post

THEREFORE:informed treatment decisions

• Diet – eliminate dairy and wheat• L-Methylfolate support to bypass MTHFR• Vayarin for membrane stabilization• 5HTP to supply more raw material for

serotonin synthesis• Lithium – 10 drops = 0.5 mg

“Nothing but marijuana makes me happy” – 14 yoa

• Clinical details removed for internet posting

Antioxidant assessment

Reference:www.cadywellness.com/cadywhitepaper2008.pdf

(c) 2013 Louis B. Cady, M.D. - all rights reserved

Search – 12/7/2016 1:51 pm

Search – 12/7/2016 1:54 pm

treatment decisions

• Enlyte – (L-methylfolate plus methylate Bvitamins and trace iron)

• Based on other labs:– Selenium and magnesium– Low dose thyroid (T3)

• Ultra low dose Bupropion if needed to be started in 2 – 3 weeks.

“Don’t think ‘either/or.’ Think ‘both/and.’”- Dan Burrus

“There are things known and there are things unknown, and in between are the doors.”- Jim Morrison

Contact information:Louis B. Cady, M.D.

www.cadywellness.com

www.tmsrelief.com

Office: 812-429-0772E-mail: lcady@cadywellness.com

4727 Rosebud Lane – Suite FInterstate Office Park

Newburgh, IN 47630 (USA)