adhd overview history preliminary diagnosis examination diagnosis treatment outcome assessments

ADHD Overview

• History• Preliminary Diagnosis• Examination• Diagnosis• Treatment• Outcome Assessments

History• A mother presents to your office with her

8 year old son. Her primary complaint concerning her son is academic/behavioral issues and she has noticed he is clumsy compared to other children his age. She states he seems to run in an odd manner and has noticed he constantly bumps into furniture when walking and has poor eye contact. She was given a case history and a 7 day food diary to fill out and present at her next visit with her son.

History Continued

Upon review of the intake forms, her son had a previous diagnosis of ADHD but had only taken medication for a few months. He is up to date on his vaccinations as recommended by his pediatrician.

History Continued

• Motor Characteristics– Clumsiness and odd posture, muscles

seem floppy, runs oddly, fidgets excessively, poor eye contact, when he began walking he would walk on his toes when he was younger

• Sensory Characteristics– Poor spatial orientation, bumps into

things when walking, extremely picky eater, likes to swing, spin, and go on rides

History Continued

• Emotional Characteristics– Worries a lot, face lacks expression,

uptight, has several phobias

• Academic Characteristics– Poor math reasoning, poor reading

comprehension, takes everything literally, impatient, poor nonverbal communicator

• Immune Characteristics– Allergies, asthma, craves certain foods,

especially dairy and wheat products

Relevant Hx Questions

• How long have these behaviors been going on?

• How much exercises does your son get each day?

• Have you noticed certain times of day when behaviors are worse or after eating certain foods?

• How much time does your son spend watching TV/playing video games?

• How has this affected family life & his social life?

Exam

• Posture Findings– Anterior head carriage– Internally rotated shoulders– High left hip– High left shoulder– Slumped/stooped posture

Exam Continued

• Palpation & Listings– C6 Spinous Left– T4-T8 extension restrictions– Left AS– Tender nodules at base of skull– Tender nodules in rhomboids bilaterally

• Cervical ROM– Flexion 40/50– Extension 40/60– (L) Lateral Flexion 20/45 (R) Lat Flex. 20/45– (L) Rotation 55/80 (R) Rotation 55/80

Neurological Exam

• Motor– Cervical Flexion 2/5– Cervical Extension 2/5– Muscle Testing• C5 Anterior: 4/5

Middle: 4/5

Posterior: 3+/5• C6 – 4/5 C7 – 4/5• C8 – 4/5 T1 – 4/5

Neurological Exam Continued

• Sensory – WNL• Reflexes:– C5: 2-– C6: 2+– C7: 2+

• Romberg’s Sway: Falls to the left• Mittlemeyer’s March: Turns to the left• Tandem Gait: Falls to the left with eyes

open and even more so with eyes closed

Neurological Exam Continued

• MMS– Tight/Facilitated Muscles

• Pectoralis major/minor, Upper Traps, Levator Scapula• Bilateral SCMs/Scalenes

– Weak/Inhibited Muscles• Deep Neck Flexors, Lower/Middle Traps, • Posterior neck extensors, & Rhomboids

– Functional Movement Assessment:• Sit to Reach – Tight hamstring, knees buckled• Lunge – Falls to the left during lunge• Squat – Excessive swaying and wobbling

X-Rays

7 Day Food Diary

7 Day Food Diary

• Monday:– B – Chocolate milk and cereal– L – Lunchable, 3 Little Debbie cookies, Coke– D – Meatloaf, nacho cheese chips, 2 Coke’s

• Tuesday:– B – Chocolate milk, 3 Twinkies– L – Lunchable, Snickers, Dr. Pepper– D – TV Dinner, homemade brownies, Coke

7 Day Food Diary

• Wednesday:– B – Chocolate milk, leftover brownies– L – Butterfinger’s, Dr. Pepper– D – McDonald’s chicken nuggets, Dr. Pepper

• Thursday:– B – Chocolate milk, cereal– L – Hamburger & Fries, 4 cookies, Coke– D – McDonalds quarter pounder, Dr. Pepper,

Apple Pie

7 Day Food Diary

• Friday:– B – Chocolate milk, pancakes, blueberry

muffins– L – Chicken nuggets, brownie, Coke– D - On the Border Burrito, 3 Dr. Peppers,

Brownie fudge Sunday

• Saturday:– B – Chocolate milk, 9 doughnuts– L – PBJ, 2 Butterfingers, 2 Dr. Peppers– D – 4 slices of Pizza Hut pizza, half liter of

Coke

7 Day Food Diary

• Sunday:– B – Chocolate milk, 5 doughnuts & saussage– L – McDonald’s chicken nuggets w/Coke– D – Hamburger Helper, chips, 3 peanut butter

cookies, 2 Dr. Peppers

Working Diagnosis

Acquired Cervical Kyphosis 737.10

Additional Tests & Labs

• TOVA – Test of Variables of Attention www.tovatest.com

• NutrEval from Genova DiagnosticsBased on information from food diary a test assessing nutritional/functional status of patient was ordered

http://www.tovatest.com/

Test results

What is ADHD

• ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development.

• This pattern usually becomes evident in the preschool or early elementary years.

SymptomsFrontal lobe syndrome

• Inattentive symptoms:• easily distracted, forget things, and frequently switch from

one activity to another• Have difficulty maintaining focus on one task• Become bored with a task after only a few minutes, unless

doing something enjoyable• Have difficulty focusing attention on organizing and

completing a task or learning something new• Not seem to listen when spoken to• Daydream, become easily confused, and move slowly• Have difficulty processing information as quickly and

accurately as others• Struggle to follow instructions.• Hyperactive-impulsive symptoms:• Talk nonstop• Dash around, touching or playing with anything and

everything in sight• Have trouble sitting still during dinner and story time• Have difficulty doing quiet tasks or activities.• Impulsivity symptoms:• Be very impatient• Blurt out inappropriate comments, show their emotions

without restraint, and act without regard for consequences• Have difficulty waiting for things they want or waiting their

turns in games

AD/HD• Cognitive symptoms• Short attention span• Poor working memory• Poor short term memory• Difficulty in planning and reasoning• Emotional symptoms• Difficulty in inhibiting emotions, anger,

excitement, sadness etc...• Depression, possibly due to above.• Occasionally, difficulty in understanding others

points of view, leading to anger and frustration.• Behavioural symptoms• Utilization behavior• Perseveration behavior• Inappropriate aggression

M/C Treatments

• Ritalin and Adderall = Stimulants• All stimulants work by increasing dopamine

levels in the brain—dopamine is a neurotransmitter associated with pleasure, movement, and attention.

• Effects = they suppress appetite, increase wakefulness, and increase focus and attention.

• Ritalin = cocaine • Adderall = speed (amphetamine)• Addictives? Tolerance? @ 8 y/o?

Ritalin side effects• Common Side Effects• Addiction• Nervousness including agitation, anxiety and

irritability• Trouble sleeping (insomnia) • Decreased appetite • Headache• Stomach ache• Nausea• Dizziness• Heart palpitations

• Other Serious Side Effects Include• Slowing of growth (height and weight) in

children• Seizures, mainly in patients with a history of

seizures• Eyesight changes or blurred vision

• Less Common Side Effects• High blood pressure • Rapid pulse rate (and other heart problems)• Tolerance (constant need to raise the dose) • Feelings of suspicion and paranoia• Visual hallucinations (seeing things that are

not there)• Depression• Cocaine craving • Dermatoses (infected or diseased skin) • Urinary tract infection• Infection or viral infection • Elevated ALT enzyme levels in the blood

(signaling liver damage)

• This is why it carries the BLACK BOX label. (Highest warning available by the FDA) Meaning that can cause sudden death.

BIOMEDICAL RISK FACTORS FOR ADHD

• 1) Food and Additive Allergies and Sensitivities• 2) Heavy Metal Toxicity • 3) Low-Protein, High-Carbohydrate Diet • 4) Mineral Imbalances • 5) Essential Fatty Acid and Phospholipid

Deficiencies• 6) Amino Acid Deficiencies • 7) Thyroid Disorders • 8) B Vitamin Deficiencies

Case Type:Ritalin vs. Nutritional supplements• Table 1a. Supplements Used in the Alternative Treatment Group• Gastrointestinal and Immune Support (Risk Factor #1)• (1) Lactobacillus acidophilus and bifidus• (2) Lactoferrin (5 mg)• (3) Silymarin (5 mg)• Sulfur-Containing Supplements and Glycine (Risk Factor #2)• (1) Taurine (275-425 mg)• (2) Glycine (700-1830 mg)• (3) Methionine (25-75 mg)• (4) N-acetylcysteine (NAC) (0-10 mg)• (5) L-cysteine (0-25 mg)• (6) Glutathione (20 mg)• (7) alpha Lipoic acid (5 mg)• (8) Garlic extract (200 mg)• Amino Acids (Risk Factors #3 and #6)• (1)Tyrosine (900-1800 mg)• (2) Histidine (25-75 mg)• (3) Glutamine (600-1400 mg)• (4) alpha Ketoglutarate (AKG) (25-75 mg)• (5) L-carnitine (30 mg)• Minerals (Risk Factor #4)• (1) Magnesium (as magnesium glycinate) (220-480 mg)• (2) Calcium (as calcium ascorbate) (110-170 mg)• (3) Potassium (as glycerol phosphate) (46-70 mg)• (4) Chromium (as nicotinate) (140-200 mcg)• (5) Selenium (as methionate) (26-32 mcg)• (6) Zinc (as monomethionate) (9-15 mg)• (7) Manganese (as arginate) (2.5-4 mg)• (8) Boron (as citrate) (1200-1800 mcg)• (9) Copper (as tyrosinate) (1.2-2.4 mg)• (10) Silica (4 mg)• (11) Molybdenum (as chelate) (5-40 mcg)• (12) Vanadium (chelate) (2-20 mcg)• (13) Iron (as glycinate) (1-2 mg)

• Table 1b. Supplements Used in the Alternative Treatment Group

• Essential Fatty Acids and Phospholipids (Risk Factor #5)• (1) Salmon oil 1000 mg (EPA 180 mg; DHA 120 mg)• (2) Borage oil 200 mg (GLA 45 mg)• (3) Purified Soy Lecithin (Phosphatidyl choline 50-150 mg; Inositol 20-25• mg)• (4) Choline bitartrate (2.5-7.5 mg)• Agents to Support Thyroid Functioning (Risk Factor #7)• (1) Iodine (from kelp) (25-150 mcg)• (2) Tyrosine (900-1800 mg)• B Vitamins and Phytonutrients (Risk Factor #8)• (1) Vitamin B1 (as thiamine and thiamine pyrophosphate) (22.5-27.5 mg)• (2) Vitamin B2 (as riboflavin and riboflavin phosphate) (22.5-27.5 mg)• (3) Vitamin B3 (as niacin and niacinamide) (75-140 mg)• (4) Vitamin B5 (as D-calcium pantothenate and pantethine) (50-70 mg)• (5) Vitamin B6 (as pyridoxine and pyridoxal-5-phosphate) (43-86 mg)• (6) Vitamin B12 (cyanocobalamin) (90-175 mcg)• (7) Folic acid (435-760 mcg)• (8) Biotin (20-400 mcg)• (9) PABA (22.5-27.5 mg)• (10) Vitamin E (140-200 IU)• (11) Vitamin C (750-1000 mg)• (12) Vitamin A (as vitamin A and beta carotene) (2000-4500 IU)• (13) Vitamin D3 (40-100 IU)• (14) Vitamin K (20 mcg)• (15) Royal bee jelly (source of biopterin) (75-150 mg)• (16) Dimethyl glycine (10 mg)• (17) Citrus bioflavonoids (10-20 mg)• (18) Proanthocyanidins (grape seed) (5 mg)• (19) Bilberry extract (20 mg)• (20) Soy constituents (saponins, isoflavones, phytosterols) (20 mg)

• Ritalin: All children in the Ritalin group received prescribed doses of 5-15 mg Ritalin 2-3 times daily, as determined by the prescribing physician.

Facts• Did you know that a child taking a psycho-

tropic, psycho-stimulant drugs like Ritalin after the age of 12 is ineligible for military service?

• Did you know that the subjective checklists that are being used as criteria for diagnosis are very similar to the checklists used to determine Gifted and Talented Children? These two checklists are almost identical.

• One toy might be recalled if 1 or 2 children die from it. How many children have to die from these drugs before we realize and put an end to this horror.

• Source: www.ritalindeath.com

http://www.ritalindeath.com/

Treatment Plan: Mix Fix Set

• Phase I of Treatment – Frequency: 5x/wk for 2 weeks

• Goals: – Reduce global somatic dysfunction by reducing

kyphosis• Patient is to undergo another complete set of films

at the end of Phase II

Treatment Plan Cont.

• Increase cervical range of motion– Flexion – 40 ⁰ to 45 ⁰– Extension – 40 ⁰ to 50 ⁰– L lat flex. - 20 ⁰ to 30 ⁰– R lat flex. - 20 ⁰ to 30 ⁰– R Rotation - 55 ⁰ to 75 ⁰– L Rotation - 55 ⁰ to 75 ⁰


• Decrease abnormal posture– Activate and strengthen core muscles

(Transverse abs, Int. and Ext. Obliques)• Planks with cervical extension

– Stretch shortened muscles• Bilateral Pecs• Bilateral SCMs/Scalenes

– Strengthen weak/inhibited muscles• Posterior neck muscles• Upper, middle & lower traps• Posterior deltoids


• Whole body extension exercises– Supermans

• Coronal Plane Exercises– Bilateral overhead arm raises– Side to side 2 foot jumps

• Increase proprioception from left side of body– Increase time standing on left leg on vibe

• Nutritional Support– See protocol below


• Mix (Warm up)– One legged stands recorded first thing

bilaterally– 8 minutes of wobbling in wobble chair (all

planes of motion)– 50 prone neck rotations

• Fix (Adjustment)– Post to Ant. Prone cervicals along the planes of

the facets– Spinous contact C6/C7 Left Lat Flexion

Restriction– Ant. Thoracics to correct hyper-flexion of

thoracic spine– Left AS Ilium


• Set (stabilize soft tissue)– Assisted one legged stands on vibe for 3x 1

minute on left leg– Post-isometric Relaxation on hypertonic

muscles– Vibe platform for 10 min while wearing

glasses with tape covering the top half of lens

– Right Shoulder weight– Right posterior and left anterior hip weights


• Exercises– 3 sets of 20 reps bilateral standing overhead

arm raises– 3 sets of 8 reps lateral cervical flexion– 3 sets of 20 second prone extensions aka

superman exercises– 3 sets of 20 second prone planks with head held

in extension– 3 sets of 10 2 footed hops to Left and 5 to Right

in coronal plane– Repeated 1-legged stands – bilaterally recorded

time

Re-evaluation/Outcome Assessments

• Retake ranges of motion• Take into account weekly grade report from

school• One legged stands – both should be improving,

left catching up to right• Go over weekly food logs with pts – make

recommendations as necessary• Brain balance tests – mittlemeyer march test,

heel to toe walk eyes open and closed, rhombergs

• Recheck previously weak muscles and grade• Functional movement assessments – see exam

Phase II Treatment Plan Cont.

• Phase II of Treatment – Frequency: 3x/wk for 8 weeks

• Goals:– Reduce global somatic dysfunction by

reducing kyphosis/restoring normal cervical lordosis

– Patient is to undergo another complete set of films at the end of Phase II Tx plan


• Increase cervical ranges of motion– Flexion - 45 ⁰ to 50 ⁰– Extension - 50 ⁰ to 60 ⁰– L lat flex - 30 ⁰ to 45 ⁰– R lat flex - 30 ⁰ to 45 ⁰– R rotation - 75 ⁰ to 80 ⁰– L rotation - 75 ⁰ to 80 ⁰


• Decrease abnormal posture– Stretch shortened muscles as needed from last

re-exam• Bilateral pec major/minor• Bilateral SCMs/Scalenes

– Strengthen weak/inhibited muscles – increased sets and reps from Phase I• Post. Neck muscles• Middle and lower trap• Post. Deltoid


• Whole body extension exercises– Superman– Coronal Plane Exercises

• Bilateral overhead arm raises• Side to side 2 foot jumps

• Increase proprioception from left side of body– Increased time standing on left leg on vibe

• Nutritional Support– See protocol below


• Mix (warm up)– One legged stands recorded first thing bilaterally– 8 minutes of wobbling in wobble chair– 100 prone neck rotations

• Fix (adjustment)– Post. to Ant. Prone cervicals along the planes of

the facets– Spinous contact C6/C7 left lat. flexion restriction– Ant. Thoracics to correct hyperflexion of thoracic

spine– Left AS ilium


• Set (stabilize soft tissue)– Assisted one legged stand on vibe for 3x 1

min on left leg– Post-isometric relaxation of hypertonic

muscles– Vibe platform for 10 min w/glasses that

have tape on top half on lens– Right shoulder weight– Right posterior and left anterior hip weights


• Exercises– 4 sets of 20 reps bilateral standing overhead

arm raises– 4 sets of 30 second prone extensions aka

superman exercises– 4 sets of 30 second prone planks with head

held in extension– 3 sets of 10 2 footed hops to left and 5 to

right in coronal plane– Repeated 1-legged stands bilaterally and

record time

Phase II Treatment Plan Cont.• Re-evaluation – taken on 7 week of care– Retake ranges of motion– Take into account weekly grade report from

school– One legged stands, both should be improving,

left catching up with right– Go over weekly food logs with pts, make

recommendations as necessary– Brain balance tests – mittlemeyer march test,

heel to toe walk eyes open & closed, rhombergs– Recheck previously weak muscles and grade– Re-xray at the end of Phase II

Phase II evaluation X-rays

Re-evaluation/Outcome Assessments

• Retake ranges of motion• Take into account weekly grade report from

school• One legged stands – both should be improving,

left catching up to right• Go over weekly food logs with pts – make

recommendations as necessary• Brain balance tests – mittlemeyer march test,

heel to toe walk eyes open and closed, rhombergs

• Recheck previously weak muscles and grade• Functional movement assessments – see exam

Outcome Assessment• One Leg Stance: Unable to stand for

30/60 seconds on either leg without falling– Timed (eyes closed) Left leg stance – 4 sec. Right leg stance – 10 sec– Timed (eyes open) Left leg stance – 8 sec Right leg stance – 10 sec

• TOVA scores

Phase III Treatment Plan Cont.

• Phase III– Once goals are achieved continue with

regular weekly proactive maintenance

Nutrition & Lifestyle modification for ADHD

• Diet– Elimination diet helps detoxifying. Link between

GI system and behavior.• Ex. – sugar, additives, colors, and preservatives

– Impaired catecholamine control (Epi/Norepi) of sugar was found in children with ADHD and may be associated with worsening of behavior following a sucrose challenge.

– Allergies and ADHD: may have an increase of EFA requirements. Mechanism: Inflammatory mediators and neuro-peptides have been shown to be increased in blood after exposure to a sensitizing food


• Essential Fatty Acids– DHA plays a critical role during pregnancy,

infant development, adult life and old age– Imbalance of EFA in the brain plays a role in

ADHD because EFAs are essential for normal neuronal structure and function, maintenance of membrane fluidity, impulse transmission, receptor sensitivity, and maintenance of adequate NT pool


• Omega – 3– Abnormalities of FA membrane phospholipids

metabolism play role in neuro developmental and psychiatric disorders. Some studies found that children with ADHD have a measurable decrease in tissue levels of Omega -3 FA when compared with age matched controls.

– 30ml/day of liquid concentrate EPA & DHA


• ADHD kids show an increase in oxidation of Omega 3, and impaired ability to synthesize DHA from regular diet.

• Recommendations to keep Omega 3, Omega 6 ratio 1:1 or 1:6 to maintain membrane and receptor sensitivity.

• Diets with high trans-fat causes a block on enzymatic conversion of vegetable derived Omega 3 and Omega 6 FA into critical long chain FA of DHA.


• Probiotics:– An increase in intestinal permeability due to

diet, antibiotic treatments and medications.– Bifidobacteria and Lactobacilli: to maintain

normal gut flora with normal species is important in preserving the mucosa barrier of the gut.


• Vitamins and Minerals– Zinc• Co-factor in metabolism of NT like dopamine,

and melatonin. For positive effects to be seen you need about 150mg/day of Zinc Sulphate• Improvement in impulsive behaviors and

socialization skills

– Magnesium• 100mg/day to improve behavior


• B complex– 500mg/day Co-factor in metabolism of NT

dopamine.

• Iron & copper– 2mg/day Co-factor in metabolism of NT

dopamine.

• Tyrosine– 1500mg/day Essential amino acid to

produce dopamine.


• Ginkobiloba & Panax Quinquefolious– 200mg/day to improve both school

performance and behavior in 74% of ADHD patients in 4 weeks

• L-theanine (amino acid found in green tea)– Recent double blind studies show that it

may improve dopaminergic activity, stabilize mood, increase concentration, decrease anxiety, and improve quality of sleep.


• Valerian– Helps you fall asleep– Most effective in children with hyperactive

behavior

• Melatonin– 5mg/day showed an increase in total sleep

time in children with chronic insomnia and ADHD


• Aromatherapy– Essential oils (EO) molecules interact with

receptors on nerves. When inhaled, the EO directly access the limbic system• Lavender

– Relaxing neurostimulant (computational speed and accuracy)

• Rosemary– Mild stimulant and increases computational speed without

decreasing accuracy


• Massage– Releases endogenous endorphins in the

body, improving short term mood and long term class behavior

– In adolescents with ADHD, more “on time and on task”

– A decrease in hyperactivity scores were reported by teachers


• Lifestyle Modification– Developing a routine and rhythms that help with

the regulatory disturbances that are described in children with ADHD

– Green surroundings widely effective in symptoms– Establish a sleep routine and limit TV viewing

• Less than 2 hours/day of TV is recommended by the American Academy of Pediatrics

• Lack of sleep and overstimulation are known to be associated with symptoms of inattention, hyperactivity, irritability, and aggression in children

adhd overview history preliminary diagnosis examination diagnosis treatment outcome assessments

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