Natural Treatments to Try Before ADHD Medication

We have been spending a lot of time recently on medications for ADHD. However, one question we should always be asking ourselves is: "Are medications always necessary?".

Believe it or not, there are a number of nutritional deficiencies that can trigger ADHD-like symptoms or worsen the disorder. There are definitely instances where merely fixing key nutritional imbalances over a period of a few weeks can lead to positive results.

Before we go any further, we need to examine how this all works out. It helps to think of ADHD as a puzzle, where one or more pieces are missing. If we can correctly fill in the missing puzzle piece(s), then we can treat the disorder. Of course this is oversimplifying it a bit, and no, nutritional and "natural" strategies do not always work. Nevertheless, I believe they are grossly under-utilized. After all, if a vitamin supplement gave the same results as an amphetamine-based drug, which one would you choose for you or your child? The answer is a no-brainer.

Based on a keynote article on Ritalin vs. supplement treatments for ADHD, which is frequently cited by the "natural cures for ADHD" crowd, we see compelling (albeit limited) evidence that natural supplementation can be as effective as Ritalin for treating ADHD. It sounds intriguing, but it is also important to note that too much weight is often placed on this study. Why? Because all of this information is based on the results of only 20 individuals (10 whom took the Ritalin and 10 who took the dietary supplements). Of course we should not discount the research because of a small sample size, but out of the millions who suffer from ADHD, do we really want to hinge a bunch of expectations on 20 individuals? Nevertheless, the results are worth reporting and are due much further investigation.

Here are 9 different possibilities cited by the article for nutritional deficiencies or environmental factors which could affect the onset of ADHD (I subdivided one of the categories, there are only 8 in the original article). I will list them here, and investigate each one in more detail in later posts:

1. Food allergies and food additives
2. Toxic effects of heavy metals or environmental contaminants
3. Protein-carbohydrate imbalances
4. Mineral deficiencies or imbalances
5. Fatty acid deficiencies or imbalances
6. Amino acid deficiencies or imbalances
7. Thyroid dysfunction and iodine deficiencies
8. B vitamin deficiencies
9. Antioxidant levels, including phytonutrients and polyphenols (found in fruits, vegetables, coffee, teas, wines, beer and a few other sources).

Increasing Concerta Medication Dosage: Benefits and Risks

In the last post, we introduced the concept of dosage windows for ADHD medications. In other words, we see that the dosage level of an ADHD medication can be of equal importance to the type of medication used. For more info on this topic, please check out the blog site of Dr. Charles Parker called CorePsychBlog. It is extremely well-organized, concise, and easy to follow, in my humble opinion. This is where I was first introduced to the "window" concept of medications, the term which I have borrowed for the last couple of posts.

This post is meant to expound on the dosage principle in the context of on of the more popular ADHD stimulant medications currently on the market, Concerta (slow-release methylphenidate). We will be drawing information from a few key articles, including one from the 2003 Journal of Pediatrics by Mark A. Stein and coworkers. A copy of the original online journal containing a summary of this article can be found here.

If you do not have time to read all of this post, feel free to skip to the last paragraph at the bottom of the page to get the overall message of this blog entry. If you are looking for more detail, I have addressed the key points made in this article in the major points below:

• The drug Concerta releases the active methylphenidate ingredient into the system at slowly increasing levels over roughly a 12-hour period. The overall effect is similar to that of the traditional tri-daily methylphenidate medication.

• The article studied the positive and negative effects of this medication in 5 to 16 year-old children under three different common prescription doses, 18, 36 and 54 milligram doses. These children were of average or above-average IQ, with about 1/3 being diagnosed as Learning Disabled. About two-thirds of the children had never taken any type of stimulant medication for ADHD before the study.

• Noticeable differences were seen between different ADHD subtypes. For the Inattentive subtype, lower levels doses were optimal, while for the Combined subtype (inattention plus impulsive behavior plus hyperactivity), higher amounts were typically optimal. When the effects of co-occuring disorders such as oppositional defiance (ODD) and learning disabilities were factored out to focus in the ADHD itself, the subtype differences were even greater. This underscores the need for proper subtype diagnosis as opposed to just labeling an individual ADHD.

• For the Primarily Inattentive (PI) subtype of ADHD, the inattention difficulties improved most dramatically with the first 18 mg of medication. Beyond this dosage, only slight effects were seen. This is in agreement with another earlier study which analyzed different doses of another form of methylphenidate for treating ADHD. For the accompanying hyperactivity and impulsive behavioral symptoms (which are often present in the inattentive subtype, just not at the same elevated level of the Combined subtype) were most effectively reduced with the first 18 mg of the medication. While the effectiveness of higher doses leveled off, slight but noticeable improvements were also seen as medication dosage was increased from 18 to 36 mg. At 54 mg, however, improvements stopped or even regressed. This suggests that the "sweet spot" for the Inattentive Subtype of ADHD is somewhere around 18 mg (or slightly higher). Note that Concerta is also available in the 27 mg level, a dosage which was not tested in the study.

• In contrast to the Inattentive Subtype, where the greatest gains were seen from 0 to 18 mg of Concerta, for the Combined Subtype of ADHD, the greatest overall boost in effectivness was seen between 36 to 54 mg. Based on the trends of the graphs in the paper, as well as data from other studies, it appears that doses beyond 54 mg may still be of benefit for several individuals with the combined subtype. In other words, treatment of individuals with the Combined ADHD Subtype typically requires at least 18 mg more medication than those of the Inattentive Subtype (see note at end of the post for an important caveat and exception to this).

• Negative side effects of the medication were minimal at low (18 mg) to middle (36 mg) doses. However, beyond 36 mg, these negative side effects became more pronounced.

• Sleep problems (such as insomnia) began at the 36 mg dosage for Concerta, with the most pronounced effects seen in younger and smaller children.

• Noticeable appetite suppression was seen even at low doses (from 0 to 18 mg), especially for younger and smaller children. However, the overall severity of this was limited. However, the percentage of children who experienced "severe" appetite suppression dramatically increased between 36 to 54 mg treatments of Concerta.

• At 36 mg, the presence of or increase in tics (see related post on ADHD and tics) was seen, and a further increase was seen for some children at the 54 mg dosage.

• None of the dosage levels corresponded to blood pressure increases, and only minimal increases in pulse rates were seen. Compare this to another post on the cardiovascular risks of ADHD stimulant medications.

• A much earlier study on the ADHD medication methylphenidate (an earlier non-Concerta form) suggested that while hyperactive behavior continued to improve at higher doses, the ability to perform cognitive tasks decreased at higher levels of medication. While these effects were difficult to duplicate in future studies, it does suggest an upper limit for certain medications in which going above may lead to a reduction in improvement. We have seen similar effects in previous posts (see the "upside down U curve" in point #6 for tyrosine and clozapine treatment for ADHD here as an example).

A caveat and final blogger's note: Based on the conclusions of the study, it appears that going above the 54 mg limit may be beneficial for certain individuals of the Combined Subtype. While the data of the study may support this, it is important to note that the study only lasted 3 weeks. As a result, long-term effects of high doses of medication were unable to be observed. Additionally, we saw in one of the points above that negative side effects began to creep in at the 36-54 mg level. Based on other blog posts with regards to risk factors of certain ADHD medications as well as potential medication side effects, I urge you to err on the side of caution, especially on issues concerning young and small children (who are at much greater risk for developing severe side effects). In the above study, the highest dosage (54 mg of Concerta) was omitted for the smallest study participant as a precautionary measure.

A quick overall summary of this post: It is imperative that we take ADHD subtype seriously. The take-home message of this blog post should be that lower doses of methylphenidate are often optimal individuals with the Inattentive subtype for ADHD, while those of the Hyperactive-Impulsive (not studied in the above journal article) and Combined subtypes of ADHD typically require significantly higher levels of medication.

ADHD Medication Dosage Windows

Blogger's note: I was first introduced to the concept of a "window" in the blog of Dr. Charles Parker. I highly recommend it. A link to his site, CorePsychBlog, can be found here. I would like to borrow his "window" analogy, as I think it is a very relevant description for what is going on here.

We have spent quite a bit of time discussing the different medications for treating ADHD. Recent attention has been given to methylphenidate (Ritalin, Concerta, Daytrana) treatment. While the choice of drug is extremely important for treating ADHD, there is often a less discussed, but equally important, factor for medication treatments: the actual dosages used. Of related interest is the timing effect of ADHD medications. If you are interested in the need for proper timing for ADHD medications, please visit the site here.

In treatment areas such as homeopathic medicine, we see that specific volumes and concentrations of the desired compounds are essential for the effectiveness of the agent used. In these treatments, treatment effectiveness depends on extremely low concentrations of the treatment agent being used.

While there are stark differences between standard ADHD medications and homeopathic remedies, it is important to realize one common overlapping factor the two treatments often share is overdosage is countereffective and often harmful. While this seems inherently obvious, it is important to note that "overdosage" here can refer to even a slight excess of medication, and is not limited just to exceedingly high amounts.

Going one step further, we even see that specific ADHD medications actually have completely different modes of action and completely different effects when taken at different dosage levels. For example, a 15 mg dose of Ritalin may not only be "overkill" for a patient who should be taking the 5 mg dose, but the extra 10 mg may actually offset or even counteract the benefits derived from the first 5 mg. We have seen similar effects in previous posts such as the one on tyrosine and clozapine. With regards to the medication and amino acid combination treatment, we see that tyrosine supplementation boosts the effectiveness of clozapine to a certain point, but beyond this point, excess tyrosine is counterproductive. Essentially, tyrosine supplementation follows an upside down "U" curve (see bullet point #6 in this post).

This same effect can also be seen in medications, especially when minimizing negative side effects is a concern. In other words, the ADHD medication dosage window is often extremely small. Given the fact that multiple other factors including diet, sleep patterns, other medications, co-existing conditions and health of the patient, etc. can all interfere with medication effects, it is no wonder that even at the right prescription doses individuals frequently shift between "on" or "off" days for medication-controlled treatments. In the next post, we will be examining the effects of different doses of the ADHD medication methylphenidate (Concerta).

Using Zinc to Boost Ritalin's Effectiveness

We have seen that combining stimulant and non-stimulant medications for ADHD can be effective, as evidenced in a previous post on how Risperidone boosts ADHD stimulant medication effectiveness. We have also explored how supplementation with the amino acid tyrosine can boost the effectiveness of clozapine. Now we will be examining another non-medication compound, zinc sulfate and its effects on the popular ADHD drug methylphenidate (Ritalin, Concerta).

Most of the information in this post is gleaned from a 2004 article in the journal BMC Psychiatry on Zinc Sulfate and methylphenidate for children with ADHD. Some key points are listed below:

• The study compared children with ADHD of both genders, ages 5-11 who took either: methylphenidate with zinc sulfate (15 mg zinc) to those who took methylphenidate by itself (with a sugar placebo) for 6 weeks. Results on treatment effectiveness were determined based on both parent and teacher ratings for ADHD behaviors, as well as psychiatrist evaluations every 2 weeks.


• Zinc is required for the proper function of over 100 different enzymes in the body and previous research has shown that a deficiency in this important mineral can be associated with ADHD.


• Zinc also helps regulate levels of the important compound melatonin, which plays a significant role in regulating sleep patterns in individuals both with or without ADHD. Melatonin also plays an important role in regulating levels of the brain chemical dopamine, which is a key factor in ADHD.


• All children in the sample were of the combined subtype (one of the 3 major subtypes of ADHD, which includes hyperactivity, impulsive behavior and inattention), and had not received previous ADHD medications.

• The study found that ADHD symptoms decreased following the 6 week period for the methylphenidate group, but an even more pronounced decrease in negative symptoms when the methylphenidate was combined with zinc. These trends were statistically significant in both the parent and teacher rating studies.

• (Blogger's point, not from article): Based on previous studies and blog posts on the ADHD stimulant medication Adderall, we have seen that psychiatrists generally see even greater levels of improvements for ADHD treatments than do parents or teachers. If this trend holds true to this treatment, then it is possible that these positive effects may be under-representations of the real potential of zinc-methylphenidate combination treatment.

• (Blogger's remark, not from article): While this study showed promise, it did not compare zinc-methylphenidate treatment to zinc treatment by itself. In other words, we cannot tell if zinc treatment actually amplifies the effects of the medication or if it simply targets additional symptoms of the disorder. Given the fact that zinc deficiency is common in individuals with ADHD, it may be the case that zinc supplementation, not methylphenidate may be the main effective treatment factor. Look for future posts on zinc supplementation and ADHD.

ADHD medications protect against drug abuse

There is often a heated debate amongst professionals, families and individuals surrounding the safety of ADHD stimulant medications and their potential for abuse. One camp claims that exposing the brain to amphetamines or amphetamine-like substances (drug categories in which almost every ADHD stimulant medication falls) fosters a long-term dependance and subsequent drug addiction later in life. The other side claims that these medications are safe and that by not taking them, most individuals with ADHD will attempt to "self-medicate" with illegal drugs, nicotine or alcohol. So which side is correct?



While arguments and information support both sides of the issue, it appears that, as of now, the overall safety and efficacy of stimulant medications for ADHD is relatively high. In an earlier post, we discussed the overall safety and addiction potential of Ritalin for treating ADHD. It appears that amidst the hype, the overall potential for addiction with this drug is relatively low. This is not to say that there is no risk at all, the discussion suggested that individuals with ADHD are able to handle the stimulant drug with less of a risk for abuse than those without the disorder.



Nevertheless, this was but one study on ADHD drugs and abuse potential, so I have decided to review additional articles on the topic. Based on an evaluation done by Joseph Biederman, and published in the Journal of Clinical Psychiatry, on the topic of ADHD medications and substance abuse, it appears that taking proper medications for ADHD at the correct dose results in a reduced risk of having a drug addiction later in life.

Some key findings of this study include:

• A high percentage of previous studies on ADHD and drug abuse fail to take into account the factor of conduct disorders, which often occur alongside (but are not directly connected to) ADHD. Individuals with conduct disorders are more prone to abuse of stimulants and other drugs. Because of this, a number of these studies incorrectly label ADHD individuals on medication for having higher rates of substance abuse, when in fact, it is often the co-occuring conduct disorder.

• Along the same lines, instead of viewing ADHD as one disorder, it is more accurate to see it as a mosaic, occuring in multiple different forms and with multiple different side effects and overlapping related disorders. For example, issues such as depression, bipolar disorders, behavioral issues and learning disabilities, one or more of which often occur alongside ADHD all become influencing factors in areas such as substance abuse. Failure to allocate a "correction factor" for these co-existing and overlapping disorders unfairly puts the blame on ADHD and results in an inaccurately high level of negative effects being placed on the disorder.

• For studies which did factor out these co-existing conditions, it was determined that childhood ADHD by itself does increase both the potential for and earlier onset of substance abuse, by two-fold. The duration of abuse was also longer, and typically followed individuals into adulthood. Therefore, both ADHD, as well as symptoms which commonly occur alongside it can each, independently as well as in conjunction, increase the risk of future persistent substance abuse.

• The article referred to a large study done previously (by the same author, which included a 4-year follow-up for test subjects), which observed that siblings of ADHD children were much more likely to have substance abuse issues than the ADHD children themselves (around 4 times greater). Adults with ADHD were higher than either the ADHD children or their siblings.

• While unmedicated children with ADHD made up only 25% of the test subjects in the 4-year study listed above, they made up 75% of the substance abuse disorder cases. This was true not just for amphetamines (which are chemically similar to most ADHD stimulant medications), but also other drugs such as marijuana, cocaine, hallucinogens and alcohol.

• The article concluded that proper medication for ADHD in individuals (with a focus on males in their mid to late teens and early 20's) resulted in a significant reduction in later substance-abuse risk.

Based on these findings, we should strongly challenge the assumption that ADHD medications promote stimulant (or other types of chemical) abuse in individuals. Nevertheless, we should still be aware of some potential safety risks for ADHD medications.