Focus, Attention, and Hyperactivity
The incidence of ADHD is increasing in children and in adults in Canada. If your child is part of the 6.1% of children aged 4-16 diagnosed with ADHD, of if you’re one of the many adults struggling with ADHD symptoms, you may be looking beyond conventional treatment for more answers about why this is happening, and what you can do about it.
What you need to know about stimulant medications
Part of conventional treatment is to use stimulant medications like Ritalin, Dexedrine, Vyvanse, and Adderall, among others. These medications purposely induce the body’s fight-or-flight response as a way to improve focus.
Think about our evolutionary ancestry: the ability to focus on detail and pay close attention would be very helpful when our ancestors were in an acutely stressful situation. We developed good focus under extreme pressure because it helped us stay alive.
Very creatively, medications induce a similar response that also happens to increase focus by blocking the clearance of stimulating neurotransmitters like dopamine and norepinephrine.
Unfortunately, this approach to creating more focus response also decreases blood flow to the digestive tract, decreases appetite and absorption of nutrients, and can contribute to the reported adverse effects of medication like:
· Sleep problems
· Decreased appetite
· Weight loss
· Increased blood pressure
· Headaches and stomachaches
· Rebound irritability when the medication wears off
· Moodiness and irritability
Medication may be helpful, but it’s not the only option: there are treatments that don’t harness the fight-or-flight response, and instead look at what is causing the inattention and inability to focus in the first place. These treatments can also reduce medication side effects if you have already started a medication.
The integrative approach to ADHD looks at why the neurotransmitters that affect focus are out of balance in the first place.
The most common root causes for inattention and difficulty focusing are:
1. Nutrient deficiency
2. Mineral imbalance
3. Food sensitivities
4. Intestinal dysbiosis (aka unbalanced gut bacteria)
5. Blood sugar imbalance
6. Non-restful sleep
7. Not enough exposure to natural environments
Integrative approach to ADHD symptoms:
1. Correcting a nutrient deficiency or imbalance
Copper and zinc balance: difficulty focusing and hyperactivity are both associated with low zinc status. Copper and zinc have a delicate balance in the body; if one is high, the other is often lowered. Low zinc can either result from high copper intake (copper water pipes, uncoated copper cookware), from low zinc intake (vegetarianism, high-carb diet, meat avoidance), or increased need for zinc (puberty, high exercise, stress). The oral contraceptive pill also raises copper and decreases zinc, contributing to the adverse mental and physical effects that are seen by some on the OCP.
Magnesium: This is one of the most common deficiencies seen with inability to concentrate, especially when also seen with irritability, mood swings, and difficulty sleeping. It plays a role in more than 300 enzymatic reactions in the body that have to do with cellular energy production, the immune system, and neurotransmitter production.
B vitamins, iron: These are other common deficiencies seen in adolescents with high metabolic demands from growth and puberty. Iron and B vitamin deficiencies, specifically B6 and B9, are associated with low stress resiliency (feeling over-reactive to most stimuli), lethargy, low mood, irritability, and poor focus.
Omega 3s: EPA, DHA, and GLA are fatty acids that are necessary for proper brain development. Studies show that children with ADHD have lower levels of these fatty acids, and that supplementing significantly reduces severity of symptoms.
Neurotransmitter precursors: a diet that is deficient in protein and green vegetables is more likely to be lacking in the important amino acids than a whole-foods balanced diet. Amino acids from protein are the building blocks that create neurotransmitters. Without the proper ingredients, no matter how hard the brain works, things like dopamine, norepinephrine, serotonin, and GABA aren’t created in the brain, resulting in deregulated mood and behaviour, and even abnormal sleep patterns.
2. Eliminating food sensitivities and delayed reactivity to foods
Gluten, dairy: A portion of the population has a genetic deficiency in the enzyme DPP-IV, that breaks down gluten and dairy proteins (called gliadin and casein, respectively), and as a result, the body can have a strong response when either gluten or dairy are ingested. It becomes almost an addiction; the child has cravings and is irritable and agitated without it, and feels soothed when they finally get it, until they start craving again, exhibiting ADHD-like behaviour. This deficiency is easily tested for, or can be elucidated with an elimination diet, and treatment is a combination of dietary adjustment and supplemental digestive enzymes to help break the proteins down properly.
Sugar: No surprise here, but sugar-sweetened beverages (especially with caffeine) are one of the biggest contributors to hyperactivity, impulsivity, and mood swings. Decreasing these in the diet can sound daunting, but with specific nutritional hacks like increasing protein and fats especially in the morning, you can balance blood sugar effectively without intense sugar cravings and midday energy crashes.
Artificial colours: Approximately 15% of children being treated for ADHD have sensitivity to artificial colours found in many foods marketed to children, resulting in inflammation and impulsive behaviour. Eliminating artificially-coloured and dyed foods can decrease the inflammatory response in this population, decreasing symptoms of ADHD and impulsivity.
3. Correcting intestinal dysbiosis and bacterial imbalance
HPHPA and clostridia: We now know how important the gut microbiome is for mental health. That’s right: bacterial composition in the gut affects mood, anxiety, and behaviour, and an imbalance in bacteria can cause a range of physical and mental symptoms, including ADHD. An overgrowth of a certain kind of bacteria in the gut called clostridia can cause an increase in hyperactivity, and is associated with an increase in behavioural difficulties. The clostridia bacteria produce a molecule called HPHPA, which induces hyperactive states in the brain. This is more common in patients who struggle with hyperactivity and digestive complaints like bloating, abdominal pain, constipation and/or diarrhea, gas, and undigested food in stools. Assessment and treatment involve an organic acids test and a protocol for reestablishing a healthy microbiome in the gut, using probiotics and/or antimicrobials.
4. Sleep and exercise
Proper nighttime rest and daytime exercise are helpful for managing energy levels, but also very important for regulating the circadian rhythm of hormones that dictate sleepiness and wakefulness. Using exercise and natural light exposure at appropriate times in the day can re-set a circadian rhythm and help sleep happen naturally at night. Likewise, it is important to assess and diagnose sleep conditions like night terrors, sleepwalking, apnea, and insomnia to make sure that an appropriate amount of restful sleep is happening.
5. Exposure to Natural and Green Environments
A 2004 report on the effect of outdoor activities on children with ADHD symptoms concluded that leisure activities conducted outdoors significantly reduced symptoms of ADHD greater than the same leisure activities conducted indoors. Results were even better when the activities were in a predominantly "green" environment. Families who regularly spent time in natural green environments were less likely to have children with symptoms of ADHD. No long-term intervention studies have been done (because you can't have a control group that has 0 access to nature, that would be unethical!) but the association is strong, indicating that green healing spaces are calming to the nervous systems of children and adults alike.
Figuring out the best path forward (aka test, don’t guess)
Not every person struggling with attention and focus has issues with every single point above. It isn’t always feasible to take the “all-at-once” approach; won’t know what’s working, or if it’s all necessary.
Assessment and treatment is always individualized, but I like to categorize my approach in groups of patients that suffer with particular clusters of symptoms with a type of testing:
1) Inattention and digestive issues: bloating, cramping, pain, diarrhea or constipation, burping, reflux: Organic Acids Test (urinary test) + HPHPA
2) Inattention and irritability, adolescence, sleeplessness: Hair mineral test for copper/zinc balance and magnesium status
3) Inattention and strong mood swings plus cravings, skin symptoms like eczema: test for food sensitivities with an elimination diet or Organic Acids Test (urinary test) +/- IgG food sensitivity testing for delayed reactions
The best approach is with a thorough intake and detailed medical history that then helps direct strategic testing to know exactly what needs to be prioritized first.
If you struggle with inattention and any of the other symptoms above, book a 15-min consult to discuss the approach that is right for you.
Kuo, F. E., & Faber Taylor, A. (2004). A potential natural treatment for attention-deficit/hyperactivity disorder: evidence from a national study. American journal of public health, 94(9), 1580-1586
Gonzalez, A., Stombaugh, J., Lozupone, C., Turnbaugh, P. J., Gordon, J. I., & Knight, R. (2011). The mind-body-microbial continuum. Dialogues in clinical neuroscience, 13(1), 55
Finally Focused (book). Dr James Greenblatt and Bill Gottleib (2017).
Bloch, M. H., & Mulqueen, J. (2014). Nutritional supplements for the treatment of ADHD. Child and Adolescent Psychiatric Clinics, 23(4), 883-897
Ly, V., Bottelier, M., Hoekstra, P. J., Vasquez, A. A., Buitelaar, J. K., & Rommelse, N. N. (2017). Elimination diets’ efficacy and mechanisms in attention deficit hyperactivity disorder and autism spectrum disorder. European child & adolescent psychiatry, 26(9), 1067-1079
Landaas, E. T., Aarsland, T. I. M., Ulvik, A., Halmøy, A., Ueland, P. M., & Haavik, J. (2016). Vitamin levels in adults with ADHD. BJPsych open, 2(6), 377-384