ADHD, Adderall and your future brain.

Attention-deficit/hyperactivity disorder (ADHD) is a typically a childhood-onset neuropsychiatric disorder, although adults can be diagnosed as well, characterized by persistent and impairing inattention, hyperactivity, and impulsivity. ADHD involves dysregulated dopaminergic pathways. In 2011 over 50 million prescriptions for Adderall were filled. 

According to the Centers for Disease Control and Prevention (CDC) approximately 11% of children 4–17 years of age (6.4 million) have been diagnosed with the disorder. A recent CDC report of children in the United States covered by employer-sponsored insurance or Medicaid indicates that 75% of young children under care for ADHD received medications, usually psychostimulants such as amphetamine-based (AMPH) or methylphenidate-based products.  Many patients will stay on neurostimulant drugs for years and years, which could have impactful brain effects over time.

In this research published in JAMA Network Open, “Twenty-Year Trends in Diagnosed Attention-Deficit/Hyperactivity Disorder among U.S. Children and Adolescents” showed from 1997-2016 a continuous increase in the prevalence of diagnosed ADHD among US children and adolescents. In the late 1990s, 7.2 percent of non-Hispanic white children, 4.7 percent of non-Hispanic black children and 3.6 percent of Hispanic children were diagnosed with ADHD, according to the study. By 2016, it was 12 percent of non-Hispanic white children, 12.8 percent of non-Hispanic black individuals and 6.1 percent of Hispanic children. Additionally, there were significant differences in the prevalence according to age, sex, race/ethnicity, family income, and geographic region. You may view full study details at: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2698633

Epidemic vs. over-diagnosis?
The rise in numbers of children with ADHD are concerning. Some might say that we are just over-diagnosing ADHD although that is actually a problem in itself; high-energy children who may have difficulty sitting still in classes all day or completing assignments are frequently being referred for assessment that in fact is often unnecessary. Nonetheless, we should be alarmed at the statistics. I have written about the rise of chronic disease in other blogs and scientific articles. So once again, here we have a chronic disorder that has risen in numbers over the last few decades that we have to consider is attributable to our environment and not some independent or sudden change in our genes.

But why and what can explain further these statistics?   
ADHD does have a genetic component with an estimated heritability of 70% to 80%. There are also without a doubt environmental influences that cause these genes to “turn on” through the process of epigenetics, which is essentially genetic control by factors other than an individual's DNA sequence. (See Table 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3277258/)

The brain on years of Adderall.
Studies have shown what years and years of stimulant medication can do to the brain. In this study investigators looked at over 32,000 records of patients with ADHD as a diagnosis and  found that these patients compared to non-ADHD controls had a significantly higher risk of developing a disease of the basal ganglia and or cerebellum with young-onset Parkinson’s and tremor being the most commonly reported consequence.  It appeared that those who are weaning off neurostimulants had an even higher risk.  

A 2009 report in Scientific American suggests too that long-term Adderall use could change brain function enough to boost depression and anxiety. The journal Molecular Psychiatry warns that prolonged exposure of the brain to the amphetamine contained in Adderall can have neurotoxic effects. This may occur because high levels of dopamine can cause the brain to actually strip itself of dopamine receptors in an effort to “balance” itself. There is now substantial evidence that these medications may damage the nucleus accumbens, an area of the brain crucial to motivation and drive.

Neuroscience of ADHD.
The prefrontal lobes, the part of the brain vital for attention, memory and cognition, are the areas involved in ADHD. One study published in 2010 found that children with ADHD do not have the same connections between the frontal cortex of the brain and visual processing area. This means that the ADHD brain processes information differently than a non-ADHD brain. Further research confirmed as these findings. Neurotransmitters (our chemical messengers) in the ADHD brain reflect abnormalities in key chemicals including norepinephrine and serotonin that influence mood, social behavior, sleep, and memory and dopamine, which impacts movement, mood, motivation, and attention. Stimulate medications like Adderall work by increasing dopamine.

A recent study has also shed light on the differences and even lags in development in the actual brain structures in individuals with ADHD compared to non-ADHD study participants. These structures include the basal ganglia (typically dopamine-rich), the amygdala (regulates emotion), the nucleus accumbens (essentially the heart of the brain that connects many different sensory and motor pathways) and the hippocampus (our primary memory center). The study’s authors say “the findings could help improve understanding of the disorder, and might be important in challenging beliefs that ADHD is a label for difficult children or the result of poor parenting.”

Natural and safe way to treat ADHD, cognitive function and fatigue.
It is important to identify the root causes of these health issues prior to addressing through any means to ensure the most appropriate treatment. We evaluate each patient individually looking at diet, lifestyle, genetics, psycho-emotional makeup, socioeconomic position, environmental issues, and more. Generally a care plan may focus on several components:

▪ Supplements.
Key supplements can be helpful (e.g. iron, omega 3s, probiotics, zinc, magnesium, B vitamins, A and C; CBD has also been used where appropriate). It’s important to note that lower iron stores, as opposed to iron blood levels, are correlated with more severe ADHD symptoms and iron deficiency is common in ADHD-diagnosed individuals. While ideally it’s always best to get our nutrients primarily from whole foods, we know that can be a struggle for all us and especially when it comes to our children’s diets!

Clinical trials have found that a number of herbal treatments, providing a patient has no underlying allergies, known intolerance or other medical considerations, may show promise as well for treating ADHD. These include:
a.  French Maritime pine bark extract: This plant-based material may increase visual-motor coordination and reduce hyperactivity and inattentiveness.
b. Ginseng: This Chinese herb may alleviate hyperactivity and inattentiveness.
c.  Ningdong: Another Chinese medicine that may help to reduce some ADHD symptoms.
d.  Bacopa: This traditional Indian or Ayurvedic treatment derives from a plant also known as Brahmi or water hyssop. Studies have suggested it might reduce restlessness and improve self-control.

▪ Sleep  
Improving sleep hygiene (developing good sleep habits) can play a significant role in managing ADHD symptoms. https://doi.org/10.1016/B978-0-12-814180-9.00005-3

▪ Get moving.
Emerging evidence shows that physical exercise, yoga, and time spent in nature (and away from devices) can benefit children with ADHD.  

▪ Neurofeedback.
A number of studies have shown that neurofeedback may improve certain ADHD symptoms. https://www.psychcongress.com/article/neurofeedback-treatments-rated-effective-adhd

▪ Screen time.
The American Academy of Pediatrics in 2016 released updated screen-time guidelines to include developing a family media plan that considers the content and context of your children’s screen sessions as it also made some changes to its former recommendations regarding use by very young children. But it’s critical to keep in mind studies that show how screens may also contribute to additional ADHD-like symptoms such as issues with memory and learning as also reported in another study where researchers tracked children’s cognitive performance following a bout of computer gaming. The findings suggest that gaming may impact not only sleep quality, but also lead to significant declines in verbal memory.

If your child has been diagnosed with ADHD, it’s important to know how to be their best advocate for appropriate treatments that lead to successful outcomes. While medication may be necessary, there is an increasing amount of research that shows the impact of long-term, neuro-stimulant use. However, inadequately treating ADHD can also increase the risk of brain and mental health issues over time. So it’s wise to do your own research to understand the options and always discuss these with your pediatrician. For adults with this disorder, many of the same recommendations apply so be sure to consult a physician with questions or concerns. And consider the tenets of integrative medicine that does exactly what the name implies – combines approaches, focuses on the root causes of any disorder and has wellness as the overriding goal.

As always, we are here for you if you need us!

In health and hope,
Dr. Suzanne Gazda

For more information about the impact of electronics on attention and impulse control, see “Reset Your Child's Brain: a Four Week Plan to End Meltdowns, Raise Grades and Boost Social Skills by Reversing the Effects of Electronic Screen Time.” by Victoria Dunckley, MD. https://www.goodreads.com/book/show/25801055-reset-your-child-s-brain

Additional references and resources:

Exercise and ADHD
https://pediatrics.aappublications.org/content/134/4/e1063.full#sec-8

Child Mind Institute
https://childmind.org/

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
https://chadd.org/

Thapar A, Cooper M. Attention deficit hyperactivity disorder. Lancet. 2016;387(10024):1240-
1250. doi:10.1016/S0140-6736(15)00238-X

Thomas R, Sanders S, Doust J, Beller E, Glasziou P. Prevalence of attention-deficit/hyperactivity
disorder: a systematic review and meta-analysis. Pediatrics. 2015;135(4):e994-e1001.
doi:10.1542/peds.2014-3482

Thapar A, Cooper M, Eyre O, Langley K. What have we learnt about the causes of ADHD? Journal of Child Psychology and Psychiatry. 2013;54(1):3-16. doi:10.1111/j.1469-7610.2012.02611.x