An Apple A Day

The rate of Attention Deficit Hyperactivity Disorder (ADHD) is rapidly rising and estimated to be 12% nationwide by US Census Bureau data.  According to community estimates, ADHD rates are as high as 20% in some areas.  Nationwide the percentage of children receiving prescription medication for ADHD is approaching 5% (and well over that in some areas).  As the number of children diagnosed with ADHD soars in the US, parents, educators, health care providers and scientists are asking, “why”?

The list of answers and possible explanations is quite long.  With no blood test to diagnose ADHD, and many reasons why overworked teachers, stressed parents and hurried doctors would want easy fixes, stamping a child with the ADHD label and starting that child on medication is an appealingly quick shovel-it-under-the-carpet response.  Anyone with the most superficial experience of the challenges posed by these children will be sympathetic.

One reasons for over-diagnosis is uncertainty about what really is normal.  Kids who are creative and unusually smart, need challenges or they will often create them for those around them.  Kids who learn well but need a lot of physical activity also draw negative attention.  Sadly, a child who sits quietly underachieving is often neglected.  We live in a culture where driving a two ton metal projectile hurtling down the road, inches away from dozens or even hundreds of other vehicles, is boring.  So we crank it up by talking on the phone, messing with CDs, running videos in the car and TEXTING!  Driving has become our most popular extreme sport.  Our culture is ADHD.  We create children in our own image.

Cultural elements have a huge impact.  So does diet.  As I’ve discussed before, many in the medical community have decades-long experience of the ADHD-reducing effects of a diet limited in additives, preservatives and sugar.  Even the British government is on board with this idea, after they funded a study expecting to discredit the theory.  Prenatal care is vital, as is getting enough of the right nutrients, physical activity, positive parenting and teaching.  Besides avoiding food additives, more and more research is linking unwanted “environmental additives” (ie, toxins) to ADHD.

The latest is a newly released Harvard study of nearly 250 pregnant women.  Researchers tested their urine for BPA, finding it in over 97% of the women, and compared those BPA levels to mothers’ reports of ADHD behaviors in their children at age 3.  With each 10 fold rise in BPA levels, there was a significant rise in mothers’ reports of their daughters’ emotional instability, anxiety and depression.  Although ADHD is much more common in boys, there was no correlation between BPA levels and the behaviors of boys in this sample.

For decades now, we have known that the poisons we dump into our world poison our brains, causing ADHD and other problems.  In the early 1970’s Harvard researcher Herbert Needleman discovered a very close correlation between blood lead levels and IQ.  Since then the list of bad actors grows year by year.  Organophosphates, developed for chemical warfare and present now in herbicides, pesticides and other chemicals, cause severe neurologic damage, as originally intended.  Studies by UC Berkeley on the young children of agricultural workers in California’s Central Valley, by Harvard on preteen and early teens and by Columbia have all found links between even barely detectable levels of organophosphates and ADHD. In 2008, 20-30% of US samples of foods such as celery, strawberries and blueberries found contamination with one or more organophosphates.  Korean studies have discovered strong links between phthalates and ADHD in school-aged children.  Government research shows that nearly every American man, woman and child now has detectable levels of phthalates in our bodies.

What to do?  Follow the essential health habits.  Drink enough water.  Exercise.  Eat a healthy diet.  Take a moderate amount of vitamin and mineral supplementation. Develop and maintain a positive attitude and social interactions. Avoid the stuff that makes us sick.  That covers a broad range.  Avoid food additives, including preservatives and flavoring agents.  Select foods least likely to expose you to unwanted chemicals (review the list below and favor organic and local).  Make your water as clean as possible. Create a stable, calm and pleasant environment.  Use music and physical activity to help your child move in the rhythm that suits him or her.

Most contaminated

Fruits – peaches, apples, nectarines, strawberries, cherries, imported grapes, pears

Vegetables – bell peppers, celery, kale, lettuce, carrots

Least contaminated

Fruit – pineapples, mangoes, kiwis, papayas, watermelons

Vegetables – onions, avocados, sweet corn, asparagus, sweet peas, cabbages, eggplants, broccoli, tomatoes, sweet potatoes

Most of my patients are concerned about adverse effects of prescription medications. My own skeptical attitude on this and other issues underlies my approach to patient care, and has done so for as long as I have been practicing medicine.

Prescription medications can be life saving, but for many reasons, they can also cause problems. Most of the problems they cause are not so bad, but others are lethal. Some of their most devastating ill effects are quite unpredictable. Too often the medications do not work that well either, despite the incredible sums spent marketing them to all of us (doctors and patients) as simultaneously powerful and harmless. Using these medications is a trade-off between risk and benefit. None of them are “a sure thing”, and it is wise to carefully consider all options before choosing the prescription route.

Generally Americans are not as critical of prescription medications as we should be. Almost on a daily basis I see patients who are suffering the ill effects of some medication, and too often the connection between the medication and the patient’s distress is unrecognized. Sadly, it is not only the patients who are unaware. In fact, numerous patients have complained to me that another physician denied that the bad reaction they had been suffering was caused by the medication. Usually that adverse effect has been well-known, or at least well-documented in the medical literature, and it only takes a minute to look it up. Other times the particular adverse effect is rare and the physician’s adoration of prescription medication keeps him/her blind to the harm it is causing. Regardless of the reasons for this problem, a new study adds to the evidence affirming that those of us with this world view are right to be skeptical.

The study looked for a connection between a variety of medications and violent behavior. Twenty three drugs apparently made those using them more likely to commit acts of violence. Eleven of those 23 were antidepressant medications. Six were sedatives. Three were medications for ADHD.

It would make sense for these findings to be spurious. People with emotional problems are more likely to be violent at some point. We have seen a correlation between ADHD and violent behavior. However, like all reviewers I know of, in my opinion these findings are meaningful because of how the study was designed and the unpredictability of some of the results.

One surprise was that the worst drug was a drug used for smoking cessation varenicline (Chantix). Another surprise was that there was little if any increase in violent behavior linked to anti-seizure medication. Only one antipsychotic medication (ABILIFY – arpiprazole) was associated with increased risk of violence. The lack of a general association betwen antipsychotic medication and violent behavior is striking, as those are the patienst most likely to be violent in the first place. This nonassociation strengthens the contention that the other drugs are in fact causative.

In a side note – although ABILIFY was not strongly linked to violent behavior, I am concerned by how intense the marketing campaign supporting it has become. Magazine ads and TV commercials are pushing people to add ABILIFY to their antidepressant medication. At this point in time antipsychotic drugs like ABILIFY have become the most commonly prescribed drugs in America.

Medicine has an unfortunately well-established pattern of relying on drugs that we think are safe and effective, only to later determine that they are so bad that they are banned. Patients complain of bad reactions. The medical community at first disparages these concerns, especially if the ill effects of the medication are psychological. Early reports of PROZAC and other SSRI drugs leading to suicide, and the anti-malaria drug LARIAM causing anxiety, paranoia and psychosis were pooh-poohed by the medical profession. Those adverse effects are now well-recognized.

The bottom line is that you should be careful about using prescription medications. If you feel a medication is causing you harm, seek expert help, but honor your own sense. You know more about you than anyone. You are the resident expert in your own health care team.