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Finding Your Focus

Naturally

Shabana Khan, MDGreg Thorkelson, MD

Lindsey Herman, LCSW

Western Psychiatric Institute & ClinicUniversity of Pittsburgh Medical Center

September 5, 2014

Overview• Environmental Factors• Role of Exercise• Mindfulness• Biofeedback• Cognitive Techniques• Television• Diet • Supplements• References

Environmental Factors,

Exercise & Mindfulness

Lindsey Herman, LCSW

ADHD Across the Lifespan Clinic

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Prenatal and Perinatal Risk Factors

• Maternal smoking during pregnancy

• Maternal stress

• Exposure to alcohol

Environmental Toxins• Pesticides

• Urinary Dialkyl Phosphate (DAP metabolites)

• Toxic Industrial Products• PBC

• Lead

What is Exercise?

Any physical activity or movement by skeletal muscles, which result in energy

expenditure.

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Benefits of Exercise

Effect of Exercise on Neurobiology• Hypothesis: exercise increases

levels of norepinephrine, dopamine, and serotonin in PFC, Hippocampus, and Striatum

• Increased BDNF (Brain-Derived Neurotrophic Factor) in hippocampus

• Better attention, less impulsivity, improved learning

Dopamine: better attention and focusNorepinephrine: less distractibility, modulate arousal levelSerotonin and endorphins: modulate mood and affectIncrease arousal and blood flow to PFC

Impact of Exercise on ADHD Symptoms

• 10-Week physical activity program

• 3 days/week moderate to vigorous exercise in ADHD students

• Better attention and social behavior

• Maintained for only short period of time after stopping exercise

• Meta-analysis of 44 studies suggested that younger children with ADHD benefited from an exercise regimen the most

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Role of Exercise in Management of ADHD

• May be helpful in managing symptoms of ADHD

• Regular and schedule exercise likely most useful.

• Many other variables need to be considered

• More research needs to be done in role of dopamine and NE release in individuals with ADHD while exercising

• More research needed in older teenagers and young adults

• No extensive, long-term exercise protocol established

Practical Tips for Busy Individuals

• Choose activities you enjoy.

• Piece your work out together

• Keep it brisk

• Maximize lunch break

• Pedometer

• Minimize screen time

• Extra bus stop

• Farthest parking space

Fitting Exercise into Daily Life

• Bring along a friend• Sign up for a class• Take the stairs• Use a pedometer• Turn sit time into fit time• Walks during lunch break

• Walk or bike to complete errands

• Get off the bus one stop early

• Take the furthest parking spot

• Plan your exercise• Reward yourself

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Quick Workouts for Busy Lives

High Intensity Interval Training (HIIT)• No need for gym membership or equipment• Can be done almost anywhere!

• Run for 1 minute, walk for 2 minutes. Repeat 5 times for a 15 minute workout.

• 30 seconds on, 30 seconds off (push ups, sit ups, squats, jumping jacks, lunges, calf raises, jump rope)

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What is Mindfulness?

• Act of becoming more aware - noticing our thoughts, feelings, bodily sensations, and anything that is around us and happening right now.

• Mindfulness can help individuals increase their ability to pay attention, focus, self calm and reduce impulsivity.

• Improves emotional regulation and cognitive focus.• Recognize thoughts as thoughts, recognize when

attention has wandered, and to practice skills for impulse control.

Why Mindfulness?Research Study:

• 8-week mindfulness training (group format) for children aged 8–12 with ADHD and their parents & input from teachers.

• Significant reduction of parent-rated ADHD behavior of themselves and their child

• Significant increase of mindful awareness and significant reduction of parental stress and overreactivity

• Preliminary evidence for the effectiveness of mindfulness for children with ADHD and their parents, as rated by parents.

Why Mindfulness?

Increasing in cognitive control can result in reduced impulsivity, increased emotional self-regulation/self-control, improved gratification

delay, increased focus/attention

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Mindfulness in Daily Life

• Listen to the bell• Watch your breath• Sensory walks• Activate your senses• Evening/bedtime routines

– daily gratitudes

Mindful Eating in 5 MinutesPreparation:• Sit comfortably in a chair - starting with feet, focus on

relaxing each part of the body one at a time• Notice your breathing – breath in slowly through nose

allowing your chest to fill first, then belly. • Exhale slowly watching stomach deflate• Repeat 2-3 more times

Mindful Eating in 5 MinutesSelect a small amount of a desirable food

“Look at the (food’s name). What is its shape? What size is it? What color is the (food)? What smell do you notice? What sensation do you notice in your mouth as you look at the (food)? What’s the feeling in your stomach? Pick up the food slowly. Hold the (food) in your fingers and look at it in your grasp. What does the (food) feel like in your hand: its texture, temperature?

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Mindful Eating in 5 MinutesBring the (food) slowly to your lips. Before putting the food to your mouth, pause and be aware of what you are experiencing in your mouth. Slowly open and place the (food) on your tongue for a moment without biting into it. Feel what you mouth wants to do with this (food). Take a few moments before you bite into it. Feel its texture on your tongue and in your mouth. What do you taste?

Mindful Eating in 5 MinutesNow bite into it noticing what you taste and what it feels like. As you continue to taste, try not to swallow the (food) right away. Does the taste and feeling change as you are chewing? Feel the food going down as you swallow. Refocus on your mouth. Notice your stomach and what it may be feeling. Notice what you are feeling? Now you have finished your exercise.”

Adapted from: Willard, Christopher, 2010, A Child’s Mind: Mindful Practice to Help Our Children Be More Focused, Calm, and Relaxed, Parallax Press, CA

Biofeedback,Cognitive

Techniques &Television

Greg Thorkelson, MD

Assistant Professor of PsychiatryUniversity Pittsburgh Medical Center

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EEG

• Nerves communicate by electrical impulses• Measure voltage/charge changes over time• Milliseconds• Electrodes on scalp• Uses: Epilepsy, determine brain death, sleep disorders

EEG Frequencies

Comparison of EEG frequency bands• Delta• Theta• Alpha• Beta• Gamma

EEG and ADHD

• Increased front to central theta activity • Increased theta:beta• Subgroup with elevated overall beta

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EEG and ADHD – Diagnosis

• NEBA – Neuropsychiatric EEG-Based Assessment• Current diagnosis: Interview, scales• Two frequency bands (theta, beta)• Fast• Improves reliability of diagnosis

EEG and ADHD – Diagnosis Limitations

• NEBA – Neuropsychiatric EEG-Based Assessment• Ratios appear to change with age • Confounded by co-occurring conditions • Subtypes? • Cost• Does not eliminate current methods of diagnosis

Neurofeedback for ADHD – Treatment

• EEG measures theta, beta• Client interacts with computer screen• Software modifies visual output to promote desirable EEG

patterns• General biofeedback uses:

• Heart rate / blood pressure alterations• Skin temperature changes• Migraines • Epilepsy

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Neurofeedback for ADHD – Treatment

Drawbacks• Cost• Time• Durability/generalizability

Future directions• Higher density EEG • 3-D modeling using EEG• Larger data pool• Subgroup analysis

Working Memory Training

• Working memory• Definition• Important for comprehension (reading) and analysis (math)

• Training decreases "off-task" behavior• Associated with specific brain and receptor activity

changes• Used in ADHD, elderly?

Working Memory Training

• Drawbacks• Time• Cost• Durability/generalizability• Proprietary – Cogmed• Detriment from increased stress?

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TelevisionSome positives• Entertainment• Distraction• Education

Some problems• Impact on sleep • Socialization issues• Aggression

TV and ADHD

Chronology of selected recent studies:• 2004: TV age 1-3 attention problems age 7• 2007:

• Entertainment type matters• Effects of childhood viewing lasts into adolescence

• 2010:• Effects may persist into adulthood• May include video games

TV – Recommendations, Thoughts

• No TV <2 years of age• Limit to 1-2hrs/day• High quality programming• Currently for US Adults:

• >4hrs/day TV time• >4hrs/day mobile device & computer time

• TV exposure: Parental viewing predicts child viewing• Role of non-TV electronic devices?

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Diet and Supplements

in ADHD

Shabana Khan, MD

Assistant Professor of Psychiatry

ADHD Across the Lifespan Clinic

Diet and ADHD

• Causes of ADHD are likely multifactorial

• Nutrition plays a major role

• Poor diet can contribute to problems with focus, difficulty sitting still, and problems with learning

Diet and ADHD

• Healthy dietary pattern is one of the most important and promising complementary treatments for ADHD

• What is a healthful diet anyway? Low fat? High protein? Low carbs? What are whole grains?

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Diet and ADHD

• Overall nutrition for ADHD• Basics of good nutrition

• Elimination Diets

• Supplementation

Basics of Good Nutrition• Society spends a lot of time

worrying about food, trying various diets

• Vast variety of foods to choose from

• Despite plethora of nutritional information, we continue to eat poorly

Macronutrients

• Nutrients that provide calories or energy for growth, metabolism, other body functions

• Protein: 4 calories per gram.• Carbohydrate: 4 calories per

gram• Fat: 9 calories per gram

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Proteins• Essential to maintain

health and grow

• Most people get enough in their diet but not when needed most: breakfast

• Digested to sugar slowly so maintains relatively stable blood sugars

• Lean and less processed forms of proteins ideal

• Children need about ½ gram protein per pound of body weight per day

• Try to shift from an animal based diet to a more plant based diet

Common Sources of Protein

• Fish, Meat, Poultry, Soy, Beans, Nuts, Milk, Cheese, Some Grains such as Quinoa

• According to the USDA Dietary Reference Intakes, 10% - 35% of calories should come from protein

Carbohydrates

• Large molecules of combinations of simple sugars

• All carbs are bad myth!

• Body uses carbs to make glucose to fuel basic energy needs of all cells in the body

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Carbohydrates

• Most people get >50% of their calories from carbs

• What matters is the kinds of carbs we eat

• Two categories of carbs

Type of Carbohydrates• Whole unprocessed foods

provide complex carbohydrates

• Processed foods provide mainly simple carbohydrates

• According to the USDA Dietary Reference Intakes, 45-65% of calories should come from carbohydrate

• Carbs are digested to small glucose molecules

• Glucose then goes from bloodstream to individual cells

• Difference between complex and simple carbs is how fast they’re converted to sugar

Why does it matter?

• Simple carbs, processed foods digested very quickly to sugar – “Sugar rush”

• Pancreas secretes insulin and blood sugar drops very low –fidgety, nervous, can’t focus

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CarbohydratesGoal - shift away from: • Sugary foods • Rice• Pasta• Potatoes• Bread

Eat more complex carbs (fruits and vegetables, whole grains,

beans)

Glycemic Index (GI)• Measures how quickly foods

are turned to sugar in the body

• Highly processed simple carbs turn to sugar quickly –High GI

• Less processed complex carbs – Low GI

• GI of glucose is 100

Why does it matter?

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“Good”Fats

• Monounsaturated Fats• Good sources include olive oil, nuts, avocados,

olives

• Polyunsaturated Fats• Include omega-3 and omega-6

“Bad”Fats

• Saturated Fats• Dairy, animal fat: milk, eggs, butter, cheese, lard• In excess, can raise cholesterol levels

• Trans Fats• Most are man-made, behave like a saturated fat• Try to avoid foods with “hydrogenated oil” or trans fats

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Diet and ADHD

• Overall nutrition for ADHD

• Elimination Diets

• Supplementation Diets

Elimination Diets

• Removing foods or ingredients suspected of contributing to ADHD symptoms

• Typically involves removing a suspected food from the diet for a period of time and waiting to see if symptoms resolve during that time

• Scientific research on ADHD diets is limited and results are mixed

Elimination Diets

• Single Food Elimination Diet

• Oligoantigenic or “few foods” diet

• Multiple food elimination diet

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Top Eight Food Allergens

• Milk• Wheat• Eggs• Peanuts

• Tree Nuts• Fish• Shellfish• Soy

History of Diet and ADHD

Diet and ADHD

Benjamin Feingold (1899-1982)

• Chief of Allergy Department at Kaiser Permanente

• In the 1970’s, he proposed that artificial food coloring, artificial flavors, and salicylates may lead to hyperactivity in children

• Feingold Diet

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Feingold Diet

• One of the first attempts at treating children with ADHD with nutritional intervention

• Focus of great controversy

• Elimination of all artificial food colorings, flavors, preservatives, and naturally occurring salicylates

Food Dye Labeling Regulations Abroad

• July 20, 2010: European Union requires mandatory labeling of foods containing certain dyes

• Label: “may have an adverse effect on activity and attention in children”

• These dyes include: Quinoline Yellow, Tartrazine(Yellow No. 5), Yellow No. 6, Azorubine/Carmoisine, Cochineal Red, Red No. 40

Soft Drinks Consumption Is Associated with Behavior Problems in 5-Year-Olds

• 2929 children age 5, 52% were boys, 43% consumed at least one serving of soda per day, and 4% consumed 4 or more servings per day

• Noted an association between soda consumption and negative behavior, aggression, withdrawal, and inattention

Suglia S, et al. The Journal of Pediatrics August 19, 2013

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Diet and ADHD

• Overall nutrition for ADHD

• Elimination Diets

• Supplements

Omega 3 supplementation

• Essential fatty acids are needed for normal neuronal structure and function and must be supplied through food or supplements

• Omega-3 and Omega-6 are components of the myelin sheath which insulates every neuron in the brain

Omega 3 supplementation• Omega-3 fatty acids, particularly DHA and EPA,

appear to improve neurotransmitter reception in the brain

• Ratio between omega-3 and omega-6 is important and our modern Western diet has an imbalance, with more foods rich in omega-6

• This imbalance may be a potential a risk factor for ADHD. Correcting underlying fatty acid deficiencies may improve ADHD symptoms

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Iron Deficiency in ADHD• Iron is essential for optimal production of

norepinephrine and dopamine

• Iron deficiency associated with many neurologic disorders

• Serum ferritin is the blood test that measures the total level or iron stored in the body

• Iron supplementation recommended in individuals who are iron deficient

Zinc Deficiency in ADHD• Zinc is an important cofactor for many reactions

and is important for normal brain function and immune function

• Research studies of ADHD and Zinc levels are limited

• Zinc supplementation recommended in individuals who are zinc deficient

Magnesium Deficiency in ADHD• Necessary for >300

biochemical reactions in the body

• Helps maintain normal muscle and nerve function, regulates blood sugar levels

• Relaxant effects, helpful in treatment of migraines and insomnia

• Studies suggest that children with ADHD may have lower levels of magnesium

• If magnesium levels are below normal, supplement as appropriate

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Supplements• Herbal supplements - more

research needed

• Useful resource for providers: Natural Medicines Comprehensive Database

• NIH National Center for Complementary and Alternative Medicine (NCCAM)

Questions?

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• Field, T. (2012). Exercise Research on Children and Adolescents. Complementary Therapies in Clinical Practice. 18, 54-59

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