A Fireside Chat with Dr. Goh: Part 3 of 5
Next in our fireside chat series, Dr. Kevin Shapiro and Erin Hildebrandt answer questions about ADHD and nutrition.
Transcript from the Video:
Today we're going to hear from Dr. Kevin Shapiro, who is one of our pediatric neurologists. He will be speaking about ADHD and the approach that we take at Cortica. We'll also be hearing from Erin Hildebrandt, one of our amazing pediatric nurse practitioners, to answer some of your questions about nutrition.
Questions about ADHD
We’ve received a couple of questions from parents who aren’t sure whether Cortica treats kids with diagnoses other than autism. The answer is definitely yes! Although a lot of the kids we see do have an autism diagnosis, our model is really designed for any child who has challenges with motor control, sensory processing, communication, attention, or executive function - in short, any difference affecting the development of the nervous system. That includes differences with known causes like genetic conditions, epilepsy, or brain injuries, as well as differences that don’t have a single identifiable cause.
Today, I’m going to talk a bit about one of the most common neurodevelopmental differences, attention deficit-hyperactivity disorder, or ADHD. According to the CDC, almost 10% of children in the U.S. under the age of 18 have had a diagnosis of ADHD. Boys are diagnosed about twice as often as girls, but that might be in part because symptoms in girls are more often overlooked.
Like other neurodevelopmental conditions, I prefer to think of ADHD as a difference rather than a disorder. It might even have some advantages; for example, sometimes people with attention deficit “disorder” can be better at managing in high-stress situations. On the other hand, there can certainly be challenges when it comes to everyday situations like school, sports, or social interactions.
One parent sent in this question: "Could you please address the pros and cons of medicating my child with ADHD? Would my child need to take ADHD medication every day for the rest of his life, or else risk struggling with the symptoms of his disorder?"
Whether or not to use a medication to help with symptoms of ADHD can be a tough decision. Medication is rarely any parent’s first choice after getting a diagnosis, and in fact, a lot of the time symptoms can be managed very effectively by making some changes to a child’s environment and learning strategies to cope with situations that might otherwise be overwhelming. But sometimes it turns out that these accommodations just aren’t enough—the child is still struggling with schoolwork or daily life skills—and that’s where medication can come in.
There are different types of medications that can be used for ADHD. The most commonly prescribed medications are stimulants, which are forms of either amphetamine (like Adderall) or methylphenidate (like Ritalin). Within each of these two basic classes of stimulant medication, there are many options that differ mostly in terms of how they are administered and how long they last. All stimulants are thought to work by increasing the brain’s levels of norepinephrine and dopamine, which are neurotransmitters that are important for maintaining alertness and focus. In people with ADHD, the brain networks that process information tend to be noisy and sensitive to interference, like a radio picking up signals from multiple stations. Norepinephrine and dopamine help those networks tune in to the appropriate channel. Even though medications that increase these neurotransmitters are called “stimulants,” getting rid of the static can feel calming to many people with ADHD.
At the same time, stimulants can also suppress some signals that are coming from the body, like hunger and fatigue, which is why their major side effects are loss of appetite and difficulty falling asleep. Not everyone experiences these side effects, but when they do occur, they can often be managed—for example, by picking a medication that’s taken after breakfast and wears off by dinner time. Unlike some other medications, stimulants typically start working quickly and wear off completely; they don’t generally require a ramp-up or wash-out. For that reason, some people choose to take them only on school days, skipping weekends and vacations. This is a perfectly safe and effective strategy. But because stimulants can be calming to people with ADHD, many do choose to take them every day. In large studies, the only significant long-term side-effect of stimulants taken in childhood is a slight decrease in adult height - about a centimeter. When prescribed appropriately, stimulants aren’t addictive.
Some people don’t respond well to stimulant medications. Children who are prone to irregular heart rhythms—because of certain genetic conditions, for example—in most cases should not take them. Others already have high levels of norepinephrine or dopamine; for these kids, stimulants can cause agitation and irritability. At Cortica, we sometimes use a tool called pharmacogenomic testing to predict how likely a child is to do well with a medication based on his or her body’s ability to process various biological substances. This test is easy to do—it’s done by a cheek swab—and can be especially useful if a medication has been tried in the past and didn’t work, or if a family member has had a negative experience with medication. If a stimulant isn’t the right choice, other options could include medications like atomoxetine (which goes by the brand name Strattera) or guanfacine (also known as Tenex or Intuniv).
Many children eventually outgrow the need for medication—they might still have ADHD traits, but they learn to manage them effectively as they mature, or they choose a path in life where those traits can actually work to their advantage. High-intensity, creative, passion-driven fields—like health care, art and design, or journalism, to name a few—can be a great fit for people with ADHD.
Another question we received was, "I'd also like to learn about combining medication with treatment such as neurofeedback, occupational therapy, and cognitive behavior therapy—might we see improved outcomes with these treatments if my son is on ADHD medication?"
This is a great question. I like to think of medication as just one of the tools in the toolkit for ADHD. As I said a few moments ago, medication can act quickly to suppress some of the noise in brain networks that are important for attention and information processing. Other therapies can help re-wire those networks so they work more efficiently. These therapies take longer to be effective, but the end result is often a more robust and resilient brain.
The main difference between non-pharmacologic treatments is the level at which they work. Cognitive-behavioral therapy and other types of psychotherapy are what we call “top-down:” in other words, they help you consciously think about strategies for attention and organization. On the other hand, occupational therapy is an example of a “bottom-up” approach: by focusing on physical awareness and sensory processing, it helps improve control of the body and the subconscious ability to navigate situations where there might be a lot going on. Music therapy works in a similar way. In theory, neurofeedback works at an even more basic level, by training the brain to modulate its own level of arousal.
In addition, there are other ways to affect the physiological systems involved in attention and arousal besides using medication. For example, diet is a huge factor. Reducing sugar and processed carbohydrates can help stabilize energy levels. Some children respond well to eliminating foods with dyes and additives. Deficiencies in nutrients like iron and folate impact the body’s ability to produce key neurotransmitters (like dopamine and norepinephrine), which can also impact attention. There are even studies showing that supplements like fish oil rich in omega 3s can improve attention as much as medication in some children.
So to sum things up, when treating ADHD, it’s important to think about both short-term and long-term strategies. Both medication and non-pharmacologic treatments can have an important role. Sometimes medication calms things down just enough for a child to begin to really engage with therapy. Sometimes it’s the missing puzzle piece, and sometimes it’s not needed at all. We always have to consider the whole child—and their environment—to achieve the best results.
Questions about Nutrition
A parent asks, "What is the ideal diet for a child with autism spectrum disorder? Which foods should be avoided and which should be included?"
This is a commonly asked question because nutrition and diet tend to be some of the most confusing and evolving areas in medicine and in the general population. It becomes even more complex in the setting of a child with a neurodevelopmental difference.
There are many diets, "secrets," and opinions out there about the importance of different nutrients, foods, and even whole food categories. But, in general, there are a few principles that most nutrition specialists, medical providers, and researchers agree upon.
First, it is helpful to think about diet in terms of expansion prior to restriction. We know many children with autism have dietary preferences related to taste, texture, smell, and even their visual presentation. So it is always important to think first about how we can improve the diet by adding in nutrient-dense foods prior to phasing out some of the less nutrient-dense food items. Generally, though, a few principles to keep in mind are:
Focusing on a predominately whole foods, plant-based diet, with sources of high-quality protein
Incorporating a diet with a variety of different fruits and vegetables to increase fiber content and improve digestion
Drinking predominately water and avoiding sugar-sweetened or calorically dense drinks
Avoiding processed foods (foods high in sugar, preservatives, dyes) as much as possible, because we know children may have an adverse reaction to these additives
Trying to incorporate natural sources of pro and prebiotics including foods such as sauerkraut, miso, kimchi, asparagus, onion, garlic, and more.
We also know that, due to the limited diets of children with autism, they may sometimes lack basic nutrients. These can be evaluated and identified by your healthcare provider and targeted specifically, but ensuring your child is getting a variety of different fruits and vegetables, minerals, and fortified foods can help with some nutritional gaps.
Some children have different energy needs and requirements and would benefit from additional supports such as nutritional supplements. Other children have food allergies or sensitivities and may benefit from what is called an elimination diet. If you think that your child falls into one of these categories, your healthcare provider can partner with your family to provide guidance and ensure that your child is getting a well-rounded diet to help their growth and development as those needs continue to change.
If you are interested in additional guidance on nutrition and eating habits, both myself and our nurse practitioner Meghan at our Torrance center are happy to meet with your family to support your needs and answer questions specific to your child and their unique nutritional journey.