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Hi Dr. Mariano,
My nephew (7 years old) has recently been diagnosed with ADD. I’m not sure if this diagnosis was given by his Pediatrician or a specialist but he’s been put on a low dose of Adderall.
From my own personal observations during homework time and even conversationally, my nephew does have a a great deal of difficulty focusing and paying attention. Of course, stick him in front of TV or an IPad and he can ‘focus’ for hours on end. I suppose this scenario is not all that unique.
What are your thoughts on using Adderall at such a young age, ie. potential risks, effects on brain development, complications?
Are there any alternative interventions that parents should consider before resorting to a serious drug such as Adderall? My sister doesn’t want to medicate him but she’s concerned that he’s going to fall behind in school.
Thanks for your thoughts and for returning to the forum!
Adderall is approved by the US Food and Drug Administration for treatment of ADHD in people 6 years and older.
Adderall, when used well, is relatively safe treatment that improves a patient’s ability to function.
Generally, problems with ADHD start showing up when the school work a person has to do becomes more than they can handle. For most people, this starts occurring when they are in the 4th grade in the US. The coursework is exponentially more difficult starting at that grade. However, if a person is intelligent enough, then they can get by all the way past medical school before realizing they have attentional problems for which they compensated. Untreated, it always prevents a person from achieving the best performance they can.
The key with ADHD is that most Psychiatric Diagnoses are syndromes with no well-established and complete pathophysiologic description. DSM-IV, the manual containing the criteria for diagnosis, usually does not describe the pathophysiology (causes) of any illness. It is an external description of the illness, not an under the hood description.
It is thus important, even if one uses a stimulant, to evaluate the person for other causes of ADHD. These other causes (or pathophysiologies) can then be targeted in treatment to achieve a better treatment with less risk.
The three other areas, aside from the nervous system, to consider are:
1. Nutrition. People with ADHD generally have poor nutrition that impairs metabolic function, leading to impaired brain function and impaired ability to think.
2. Thyroid hormone. Without optimal thyroid hormone signaling, brain metabolism and thus metabolism is impaired. There are other cascade effects in the body that can lead to further impairments in one’s ability to think.
3. Pro-inflammatory Illnesses and the immune system. Inflammatory signaling directly impairs brain function and metabolism, shearing off neuron synapses, impairing one’s ability to think.
4. Gastrointestinal health
5. Particularly in adults, the rest of the endocrine system.When these areas are evaluated, addressed if needed, and function optimized, then if a stimulant is needed, it is easy to get away with using low doses.
Stimulants, like Adderall, always increase stress and inflammatory signaling. Thus, it is important to assess whether or not a person can tolerate these increases. Most generally healthy people can tolerate them. However, if they are not tolerated, then the stimulants will cause mood problems or may not work at all. Proinflammatory signaling can impair thinking and concentration direction and increased stress signaling can increase distractibility as a person is overwhelmed by all the sensory information flooding them. Sometimes the practitioner makes the mistake of increasing the dose thinking tolerance has developed, making the problem worse. Then the practitioner makes the further mistake of using other medications to stabilize the mood problem that the stimulant caused. It would have been much easier to evaluate for the underlying causes of ADHD to anticipate when problems may occur.
There are also behavioral and psychosocial interventions and exercise to consider in people with ADHD that would help in improve one’s ability to focus in tasks other than those with intense stimuli like video games.
@DrMariano 4745 wrote:
Adderall is approved by the US Food and Drug Administration for treatment of ADHD in people 6 years and older.
Adderall, when used well, is relatively safe treatment that improves a patient’s ability to function.
Generally, problems with ADHD start showing up when the school work a person has to do becomes more than they can handle. For most people, this starts occurring when they are in the 4th grade in the US. The coursework is exponentially more difficult starting at that grade. However, if a person is intelligent enough, then they can get by all the way past medical school before realizing they have attentional problems for which they compensated. Untreated, it always prevents a person from achieving the best performance they can.
The key with ADHD is that most Psychiatric Diagnoses are syndromes with no well-established and complete pathophysiologic description. DSM-IV, the manual containing the criteria for diagnosis, usually does not describe the pathophysiology (causes) of any illness. It is an external description of the illness, not an under the hood description.
It is thus important, even if one uses a stimulant, to evaluate the person for other causes of ADHD. These other causes (or pathophysiologies) can then be targeted in treatment to achieve a better treatment with less risk.
The three other areas, aside from the nervous system, to consider are:
1. Nutrition. People with ADHD generally have poor nutrition that impairs metabolic function, leading to impaired brain function and impaired ability to think.
2. Thyroid hormone. Without optimal thyroid hormone signaling, brain metabolism and thus metabolism is impaired. There are other cascade effects in the body that can lead to further impairments in one’s ability to think.
3. Pro-inflammatory Illnesses and the immune system. Inflammatory signaling directly impairs brain function and metabolism, shearing off neuron synapses, impairing one’s ability to think.
4. Gastrointestinal health
5. Particularly in adults, the rest of the endocrine system.When these areas are evaluated, addressed if needed, and function optimized, then if a stimulant is needed, it is easy to get away with using low doses.
Stimulants, like Adderall, always increase stress and inflammatory signaling. Thus, it is important to assess whether or not a person can tolerate these increases. Most generally healthy people can tolerate them. However, if they are not tolerated, then the stimulants will cause mood problems or may not work at all. Proinflammatory signaling can impair thinking and concentration direction and increased stress signaling can increase distractibility as a person is overwhelmed by all the sensory information flooding them. Sometimes the practitioner makes the mistake of increasing the dose thinking tolerance has developed, making the problem worse. Then the practitioner makes the further mistake of using other medications to stabilize the mood problem that the stimulant caused. It would have been much easier to evaluate for the underlying causes of ADHD to anticipate when problems may occur.
There are also behavioral and psychosocial interventions and exercise to consider in people with ADHD that would help in improve one’s ability to focus in tasks other than those with intense stimuli like video games.
Check MTHFR mutation. I find this common in children with ADDHD. One may want to look at hidden food allergies or other possible triggers. Also now taking into consideration the parents of these children is a huge factor. Finding children born of parents who have been in Iraq are at higher risk of these conditions. So you need to look at the total history including potential toxic exposures.
Thanks for the response!
The root cause of my nephew’s ADD was not investigated. A diagnosis was given and they went straight to Adderall.
The points below are of interest to me because I’d like to help determine where the ADD is stemming from.
@DrMariano 4745 wrote:
The three other areas, aside from the nervous system, to consider are:
1. Nutrition. People with ADHD generally have poor nutrition that impairs metabolic function, leading to impaired brain function and impaired ability to think.I’ve often pushed for him to be eating a more nutrient dense diet (before ADD even became an issue) but have been met with resistance from his parents. “Practicalities” and all. They certainly have the financial means to feed him better food but I can only push so much.
Would something simple like EPA/DHA supplementation be a potential help? Do you consider fish oil to be a mandatory supplement in children eating a SAD?
He has a younger brother who does not display any symptoms of ADD. If nutrition were at the root of the problem would it be logical that both children would suffer from ADD given that they eat the exact same diet? Or is this a poor assumption?
2. Thyroid hormone.
There is a history of hypothyroidism in the family. However, my nephew has not been checked for hypothyroidism because he is skinny. Poor assumption to assume that a skinny child has normal thyroid function?
3. Pro-inflammatory Illnesses and the immune system.
How would one investigate these areas as well as nervous system functioning?
Thanks again!
Omega-3 fatty acids are important. But they are secondary players when it comes to the nutrients needed for treatment of ADHD. It doesn’t give as much bang for the buck. And if it did work, the question I have is what pro-inflammatory process is occurring, if any, that may be better directly treated, if Omega-3s are working via anti-inflammatory pathways. Fish oil tends to be also expensive, particularly for patients at or near poverty.
I generally do common blood tests for nutritional status to help targets what nutrients are needed.
Would it be wise to test for thyroid hormone regardless of whether the child is skinny or overweight?
The American Academy of Child and Adolescent Psychiatry recommends against regular testing for thyroid hormone in children and lab testing in general.
I think this is a huge mistake.
It keeps child psychiatrists blinded to thinking about and identifying the underlying physiologic causes of mental illnesses . These should be the actual targets of medical treatment that they give.
In part, however, what contributes to this problem is that lab test results are usually not interpreted with regard to both mental function and physical function. Usually, physicians will regard a lab result as “normal” if it is within the reference range. They don’t realize that often the reference range is usually arbitrarily or statistically decided and not correlated with physical function, nor even mental function. The physician isn’t doing the extra work to think about the physiology that results in that particular lab finding and is instead employing cookbook thinking.
A lab finding may be abnormal, then, in regard to mental function yet can be completely within the reference range. And thus, the abnormal lab finding would be missed. For example, B12 deficiency with regard to mental function occurs right in the midrange of the B12 reference range. At that level, neuron demyelination starts occurring. And subtle signs or even overt signs of mental dysfunction occur. But such a level would be considered “normal” if it blindly thought to be within the reference range rather than correlated with function.
If possible (e.g. covered by health insurance, affordable to the patient and parents), I always test thyroid hormone levels in children since thyroid problems are one of the primary contributing pathopathologies that can contribute to mental illness. Ignoring testing for this is simply non-medical thinking.
Whether or not a child is skinny or overweight is a non-central issue when it comes to thyroid lab testing. A child can be either skin or overweight if he or she is hypothyroid.
Many of the skinniest kids I treat ended up having low thyroid hormone. When I added thyroid hormone to treatment, their appetite improved, their growth rate significantly improved, their weight normalized, their mental abilities improved. With improvement in appetite, nutritional status improved. The combination of thyroid and nutritional improvements greatly improved their mental function and growth.
Realize that growth hormone does not work well without optimized thyroid hormone levels.
Very interesting. Thank you for your response.
I wonder if doctors shy away from performing extensive blood work in children due to the uncomfortable nature of testing.
Any time I show up at Labcorp and see a child waiting ahead of me I know that I’m going to be there for a long time. It takes forever to get their blood draw complete and I can hear the screaming and crying from the waiting room. Seems like it can almost be a traumatic experience for the child.
Pediatricians do lumbar punctures on babies and other lab tests on kids all the time when they present with fevers with seizures or if the baby is particularly ill. And it is necessary since brain infections can be lethal. The physician isn’t going to be shying away from sticking a needle into a baby’s spine when the risk of not doing so can be devastating. But then, they are well aware of the pathologies they need to assess.
Outpatient physicians are going to be distanced from the actual lab test since it is the lab technician that will be drawing the blood.
In my experience, the kids and parents I treat very rarely complain about the discomfort of lab testing. I approach it in a calm, matter-of-fact manner. And it becomes an expected and a usual experience. Promoting a good doctor-parent-patient relationship to help the parent does a lot to reduce the child’s discomfort.
To reduce discomfort, I specify the use of a butterfly needle with flexible tube which has a small gauge and is taped to the skin so that the child can have some movement rather than have to hold still. To minimize the loss of blood volume, particularly for younger children, I would reduce the number of tests done, cherry-picking the ones which can give the most information in the smallest volume. Other tests can be done gradually over time. For the rare child who cries and becomes agitated requiring several persons to hold, a small dose of a sedative prior to the lab test works. And if the child cannot fast for the test or come in early in the morning, I can interpret the non-fasting levels and any time levels, allowing the child to get the lab test done at any time.
Some reasons physicians may not order labs are:
1. inadequate education about the pathophysiology underlying the illnesses they evaluate and treat. If they know the pathophysiology involved, they would have a target to test.
2. inability to evaluate the lab test results in regard to mental illness – without this, the labs will nearly always look “normal”. After repeated “normal” results, the physician simply stops thinking about labs.
3. medical system limitations on ordering labs. Kaiser Permanente, for example, prohibits their primary physicians from ordering MRIs. Only specialists can do so. Insurance companies may limit what tests they will cover. Some labs are non-existent in some countries.
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