Category: Mental Health

ADHD and useful Phytomedicines

On By philrasmIn Anxiety, Mental Health, Plant Medicine, StressLeave a comment

Introduction

ADHD (Attention deficit hyperactivity disorder) is a chronic neuro-behavioural condition characterised by a persistent pattern of inattention, hyperactivity and impulsiveness. It can disrupt education and social development of children and teenagers, and have a huge impact on a person’s life, yet is often undiagnosed.

The DSM (Diagnostic and Statistical Manual of Mental Disorders) describes three subtypes of ADHD. These include: ADHD-Inattentive type (ADHD-I), ADHD-Hyperactive/impulsive (ADHD-H), and ADHD-Combined type (ADHD-C). The presentation can change over time though, and a diagnosis provided at one specific time may differ from that provided at another time in a person’s life.

While reported rates of ADHD are higher than in the past, this is likely to be at least partially due to better recognition of the condition. It is a common condition among young children, and an estimated 50% of these retain ADHD symptoms for the rest of their lives. Research suggests around 5-8 percent of the population has ADHD but only 1-2 percent are diagnosed.  Diagnosis rates have historically been higher in boys than in girls, although rates are now thought to be similar for both genders.

Diagnosis of ADHD can be difficult and there is no diagnostic biological marker. Symptoms should have been present and persistent for a minimum of six months prior to the age of 12, are maladaptive, and cannot be explained by other psychiatric or medical disorders. However, often symptoms may not meet the criteria for a formal diagnosis of ADHD, despite causing significant issues in learning, social and family relationships.  

Symptoms

Impairing levels of inattention, disorganisazion, and/or hyperactivity-impulsivity, are key features of ADHD.  These symptoms are excessive for the age or development level.

In a classroom setting, children with ADHD will often tune out or appear to daydream. They can talk a lot, interrupt others and are unable to wait for their turn. Such children are frequently called out in class or a group or become known as the ‘class clown’, or the subject of bullying. These behaviours can exacerbate difficulties in ‘fitting in’ with peer groups or societal expectations.

While not an anxiety disorder as such, a large proportion of children with ADHD have coexisting psychiatric disorders, including but not limited to depression, bipolar disorder, autism spectrum disorders, eating disorders, and anxiety disorders (1). Adults with ADHD also often have an anxiety or substance use disorder, which can mask ADHD symptoms, sometimes for many years(2). Those with ADHD are also more likely to do dangerous and impulsive things.

Aetiology

Several potentially aetiological factors have been identified. ADHD has a significant familial and genetic predisposition, although the extent of the latter is somewhat contentious. Approximately 30% of children with epilepsy have ADHD .

Environmental contributions such as early childhood exposure to toxic heavy metals (especially lead) or phthalates, have received increased attention in recent years(3-7). Air pollution has also been associated with neurodevelopmental disorders including ADHD(8).

Other studies have associated ADHD with a higher prevalence of smoking, alcohol consumption, and excessive screen time among adolescents(9-11). Dysfunctions have been reported with BDNF (Brain derived neurotrophic factor) metabolism, dopaminergic neurotransmission, and with neurochemical parthways within the prefrontal cortex(12, 13).

However, these associations are complex, and to what extent they are aetiological versus outcome manifestations in those with ADHD, remains debatable.

Increasing greenness exposure or ‘nature medicine’, is likely to help protect against ADHD and other mental health conditions. A large New Zealand study has reported that children who always lived in a rural area after 2 years of age, were significantly less likely to develop ADHD(14 ).  Similar findings were reported in a German study, with residential greenness being protective, but air pollution being a risk factor(15).

Dietary factors may be contributory in some cases. Inattention was negatively correlated with fruit and vegetable consumption and a healthy dietary pattern, in a large population-based Swedish study (16). Some evidence suggests Vitamin D deficiency may be relevant to the pathogenesis of ADHD and autism, and supplementation with this as well as zinc and magnesium, both important cofactors in dopamine metabolism, may be useful(17, 18).

Treatments

The use of stimulant medications and particularly methylphenidate, is the usual treatment for ADHD. Methylphenidate is structurally similar to amphetamines, inhibits the reuptake of dopamine and noradrenaline, and leads to symptom improvement in around seventy percent of patients.  

Dexamphetamine is also occasionally used, as is its prodrug lisdexamfetamine. The selective noradrenaline reuptake inhibitors atomoxetine and viloxazine, are sometimes prescribed. These and alpha-2 adrenergic agonists guanfacine and clonidine, which stimulate noradrenergic neurotransmission in the prefrontal cortex, are occasionally used when stimulants or these drugs are not suitable or tolerated.

Reduced appetite, sleeping difficulties, nausea and abdominal pain are the most common adverse events to stimulant medication. Rare but serious adverse events can include cardiac problems, weight loss, mood fluctuations and psychotic disorders. These can cause concern as treatment can continue from childhood into adolescence and beyond.

Official guidelines discourage the use of medication in children under the age of six, although these are sometimes prescribed by a specialist in severe cases. ‘Off-label’ use of medicines in this age group, is increasingly common. However, few studies have taken place involving the use of ADHD drugs in very young children, and safety and efficacy data is generally lacking. 

Treatment programmes should also include psychological interventions such as counselling or psychotherapy, with patients’ and parents’ preferences and need for such treatment, always considered(19).  It is also often beneficial to not only treat a child, teenager or adult with ADHD, but also offer phytotherapy or other treatment support to their parents, partners or other family members. Adjunctive phytomedicines and sometimes lifestyle and dietary changes, can be very helpful.

Of note is that there are several disparities  in treatment guidelines and the selection and sequencing of various medications  in different countries. Danish guidelines for instance, do not recommend methylphenidate, lisdexamfetamine or atomoxetine as first line treatment options, while German guidelines provide specific drug recommendations tailored to individual comorbidities (1). A greater emphasis on psychotherapy, school and parental support systems and a higher bar before methylphenidate medication is trialed, is applied in some jurisdictions, particularly those where health care expenditure per capita is higher.

Some Useful Phytomedicines

An individualised treatment protocol incorporating plant medicines can offer much to ADHD patients. They can also help children who are resistant to stimulant medications, or those who wish to not take these medicines, or to keep drug dosage needs as low as possible.

Treatment selection depends on the particular type of ADHD, its symptomatology, and of course individual patient needs and wishes.  Given the diverse presentation of ADHD, a range of phytomedicines should be considered. An individualised but ‘trial and error’ approach is recommended, but desirable actions can include neuroprotection, cognition enhancement, anxiolytic and stimulant properties. Any use of other medications or presence of other health conditions should be taken into account.  Addressing other co –existing mental or physical health issues, can in itself often produce significant benefits, and sometimes avoid the need for additional drug-based interventions.

Where restlessness or accompanying anxiety are part of the symptomatology, anxiolytic and relaxant phytomedicines can be useful.  They include Bacopa, Chamomile, Holy basil, Kava, Lavender, Lemon balm, Skullcap, Passionflower, Skullcap, Valerian, Withania and more(20).  Many of these (Ginkgo, Bacopa, Lemon Balm, Valerian, Withania) also have neuroprotective activities and when used appropriately, can help improve cognition and learning outcomes.

Leaves of the Indian plant Bacopa (Bacopa monniera) have been used for anxiolytic and memory enhancing purposes for centuries. As with Ginkgo and Lemon Balm, it is neuroprotective and may help with cognition and attention deficit disorders. It is frequently used in the management of ADHD and autism in children and teenagers.

A recent 14 week Australian clinical trial into Bacopa’s effects in boys with ADHD aged 6-14, found no significant behavioural improvement. However, improvements occurred in their sleep routine and in cognitive flexibility and interpersonal problems(21).  Reduced symptoms of restlessness and improvement in self control, were reported in a smaller open label study in children with ADHD(22).  It is safe in children, although as a liquid its bitter taste can be an issue, particularly as dosage needs tend to be quite high.

Ginkgo (Ginkgo biloba) can be helpful in ADHD or for cognitive deficits in children, and combines very well with other psychoactive phytomedicines such as St Johns wort and anxiolytics. It is also hepatoprotective, and can be helpful when concomitant drug medications which can cause liver or kidney damage, are being taken.

Lemon balm (Melissa officinalis) is another generally safe anxiolytic, and like chamomile is indicated particularly where gastrointestinal upsets or eating disorders are associated with feelings of anxiety(23).  It can also help with cognition in teenagers, though large doses are generally required.

The Chinese medicinal herb Rehmannia (Rehmannia glutinosa) was reported to reduce impulsive and spontaneous behaviour and ameliorate hippocampal neurodevelopmental abnormalities an a rat model of ADHD(24).

Passionflower (Passiflora incarnata), has been shown to help control anxiety in several studies involving adult patients(25) . A combination with St Johns wort and Valerian was reported to reduce nervous agitation in children aged between 6 and 12 years(26)  .  Potential benefits in ADHD and autism, have been reported(27, 28), although larger and better controlled clinical trials are needed.

Kava (Piper methysticum) also has a place in the management of ADHD in some children and adults. Its effectiveness in treating anxiety has been affirmed through several clinical trials and meta-analyses. It may also exhibit a mild antipsychotic effect and be helpful for children with OCD or autism.

Withania (Withania somnifera) is a useful allrounder when it comes to anxiety and stress-associated conditions. As with all adaptogens, it acts on multiple relevant sites of action, neurotransmitter and hormonal systems(29), and is often an effective component of the treatment of ADHD in both young and older people.

St Johns wort (Hypericum perforatum) is our best known clinically effective antidepressant, and I have used it successfully in many hundreds of patients, over the past thirty years. While beyond the scope of this article, concerns about its safety and interactions with other medications, are also often unjustified, this depending on the type of St Johns wort used, and its phytochemical profile(30).

ADHD is now recognised as a common neurodivergent condition, which if not well managed and treated can cause enormous emotional and mental suffering in children, teenagers, adults and their friends and families.

Summary

As with most chronic health conditions, early diagnosis and interventions which are natural and affordable and incorporate a selfcare approach, can produce huge benefits and avoid the need for more serious treatments later on.  While not denying the usefulness of drug medications such as methylphenidate and atomoxetine, it is concerning given the frequency at which these can cause adverse events, that they are being so widely prescribed and relied upon.

If the need for a long term drug prescription can be avoided or drug dosage requirements kept to a minimum through the concomitant use of more natural interventions, then this is a preferred approach. While there is a need for further and larger clinical trials involving phytomedicines in the treatment of ADHD, many medicinal plants exhibit pharmacological actions of benefit to those dealing with this condition, and treatment targeted for each person’s individual clinical presentation, can produce huge benefits.

References:

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