Fish Oil- Omega 3’s- and AD/HD

February 20, 2012

Many people with AD/HD benefit from taking omega-3 fish oil. There are many brands, including some specialized ones that your doctor may recommend because he or she wants you to have the right EPA/DHA dosage for brain health vs. heart health.

Just read an interesting piece in Consumer Reports ShopSmart magazine, January 2012 issue. If you are taking, or thinking of taking, a more standard omega-3, this could be helpful for you.

They tested for:
Do they show the listed amount of omega-3 fatty acids EPA and DHA?
Do they properly disintegrate, show sign of spoilage, or contain contaminants such as lead, mercury, dioxins, or PCBs?

Even brands they recommend contained detectable levels of most contaminants, even though many claim they’re free of them. Consumer’s still recommends them because they don’t exceed USP and other regulatory limits.

Check with your physician before taking fish-oil supplements because they can interfere with some medications. Dr. Cerulli generally suggests high grade fish oil for her AD/HD patients. She tailors the dosage to at least 2,000mg combined EPA+DHA for adults and 1,000mg for children. Some patients need to increase in order to target specific clinical symptoms such as depression. Talk with her if you are taking omega 3 or have questions about your dosage.

Jay and I have taken other more expensive ones to get the EPA/DHA ratio we were looking for…

Here are the 9 that passed all their tests listed in order of price based on cost of taking 1000 milligrams of EPA and DHA daily-the dose they say is recommended for heart health. Check with your doctor to tailor this for you.

1. Spring Valley Omega 3 Walmart
2. Finest Natural Walgreens
3. Walgreens Omega 3 Concentrate
4. Barlean’s Organic
5. Nature Made 1200 mg
6. Vitamin Shoppe Meg 3
7. Carlson Super omega3 gems
8. Norweigian Gold Ultimate Fish Oil’s Critical Omega
9. Nature’s Way

NO
1. Kirkland Signature Omega 3 Costco
2. Nordic Naturals Ultimate Omega
3. CVS Natural
4. GNC Triple Strength
5. Nature’s Bounty Odorless
6. Sundown Naturals

I hope this is helpful for you.

Best to you,

Szifra

P.S. The article suggests keeping them in the freezer or eat with meals for reduced fish burps…

ADHD and Tic Disorders

May 14, 2011

Tic Disorders can co-occur with ADHD 8-15% of the time. In other words, children diagnosed with ADHD are at greater risk for developing tics than the general population. If you have a child with ADHD, know what to watch for. Tics can be either motor tics (involuntary muscle movements) or vocal tics often characterized by throat clearing, repetitive cough, or other involuntary noises. Motor tics frequently involve muscles around the face or neck area, but can occur anywhere. Vocal tics, particularly of the throat clearing/coughing type, tend to be initially mistaken as an allergy.

If your ADHD child does develop tics, don’t panic. Most of the time tics are benign and kids grow out of them even with no medical intervention. The peak age for symptoms of tics is approximately age 10 or 11 and then by adolescence usually the tics will begin to fade. Knowing that tics will generally improve on their own, how do you decide when to treat them? My simple answer – treat the tic if it’s bothersome to the individual and/or interfering with daily functioning. The decision should be a collaborative one among the patient, the patient’s family, and the treating physician.

Some of the medications we use to treat tics are actually blood pressure medications called clonidine and guanfacine. They work well to decrease the frequency and severity of tics. If you do decide to try these medicines, be patient. They take time to work and initially can cause some sedation, particularly in the first few weeks.

In children with combined ADHD and tics, prior studies have shown stimulant medications can exacerbate tics so the treatment may simply be to stop the stimulant. This is not to say that stimulant medications cause tics, in fact they don’t. Many patients with ADHD and co-existing tics are able to successfully take the stimulants. If however the stimulant medications do cause problematic side effects for your child, remember there are also non-stimluant medications for treating ADHD such as Strattera or Intuniv.

In summary, tics are fairly common with ADHD, are usually benign, and tend to improve by late adolescence even without treatment. Be able to recognize symptoms of motor and vocal tics in your ADHD child so you can talk to your doctor about treatment options.

Theresa Cerulli, M.D.

Link found between APGAR scores at birth and future risk of ADHD

February 14, 2011

According to a recent study in the Journal of Pediatrics, Neonatal Health Can be Associated With Risk For AD/HD.

ADHD is known to be highly genetic. Approximately 77% of the time someone diagnosed with ADHD has the condition because of the genes they carry. However, genes are not the only factor. Researchers are finding other issues can “correlate” with ADHD. In this recent study published in January’s Journal of Pediatrics researchers show that neonatal health is an important risk factor for ADHD.

An astounding 980,902 children born in Denmark between 1988-2001 were monitored. The baby’s health immediately after birth was measured by commonly used Apgar scores. Then all children were followed from age 3 until a diagnosis of hyperkinetic disorder, a first medication for ADHD, migration, death, or the end of 2006, whichever came first.

The results – The lower the Apgar score the greater the risk for the child developing ADHD. Compared with children with Apgar scores of 9 or 10 at 5 minutes, the risk for ADHD was 75% higher in children than with Apgar scores of 1 to 4 and 63% higher for those with Apgar scores of 5 to 6.

Doctors concluded from this study that a low Apgar score is associated with risk of ADHD in childhood. Perhaps low Apgar scores and ADHD share common causes, or a low Apgar score reflects at least one possible pathway leading to ADHD.


CAM for ADHD

July 27, 2010

I recently saw an interesting statistic reporting more than 50% of parents use complementary and alternative medicine (CAM) to treat their children’s ADHD. Many parents of ADHD children and adults with ADHD opt to combine conventional treatments, such as stimulant medication, with CAM while others prefer to use nonpharmacological therapies alone. Although most nonpharmacological interventions have limited data to support their benefit, 80% of patients who use natural products consider these to be their primary treatment modality. Yet few disclose this information to their treating physician. If you are using any alternative therapies I would urge you to discuss these with your doctor. The goal is to promote optimal integrative treatment and avoid any potential pitfalls.

Given the frequent use of CAM, I thought it would be helpful to review the common nonpharmacological treatment options for ADHD. Currently the most popular nonconventional ADHD therapies are as follows: dietary changes, herbal supplements, trace elements/vitamins, neurofeedback, essential fatty acids (EFA’s), and yoga/massage for ADHD.

In my experience complimentary and alternative treatments can be safely and effectively integrated with conventional approaches to treating ADHD. Despite the limited data, nonpharmacological treatments have indeed shown some benefits. For example in one research study using dietary changes to treat ADHD, 75% of children showed improvement in their symptoms when food colorings and additives were removed from their diet. Another study showed children and adolescents with low blood levels of ferritin (the storage form of iron in the body) experienced higher rates of ADHD-type symptoms, which improved with taking 80 mg per day of iron. More specifically the kids hyperactive and impulsive symptoms improved with the iron supplementation, but their inattentive symptoms did not.

In a separate small study, ADHD children practicing yoga demonstrated improvements in their symptoms over time compared to the group of ADHD children who did conventional exercise. In support of the argument for combined treatment, children who continued to take simulant medication simultaneously while practicing yoga showed the greatest benefit.

In summary, an integrative care approach – combining conventional with nonconventional therapies – may offer the best potential outcomes for those with ADHD. I encourage patients to talk with their doctors about all treatment options. It is important to inform your treatment providers of any and all interventions you are utilizing (or wish to utilize) so that safe and appropriate care can be implemented and the greatest benefit received.

Calming Strategies for Children

June 7, 2010

“He’s a terror when things don’t go his way … We’re always worried that he’s going to make a scene and embarrass us … We find ourselves walking on eggshells, trying to avoid one of his meltdowns.”

I hear a lot of that kind of thing from parents of children I work with in my practice. They tell me they often feel stressed, overwhelmed and exhausted from their child’s frequent struggles and outbursts. Parents jump at the opportunity to learn some effective strategies for coping with this common challenge.

As children move through their day, they are bound to bump into situations that are potentially upsetting. Some children are born with calmer temperments and better self quieting skills, while others need to actively learn and be taught how to cope with everyday disappointments and frustrations in a positive way. This is one of the most important things a parent can help a child do. No child enjoys being out of control … it’s simply the only tactic he knows. The good news is you can help your child learn strategies to cope with his emotions constructively and have an easier time getting along in the family, with peers and in school. The bonus — you get to have stress relief, too!

Creating a “My Hard Times Board” (suggested by Peg Dawson EdD and Richard Guare PhD in their book “Smart but Scattered”) with your child utilizes an excellent tool for teaching him new calming and coping strategies. Remember these few tips before you begin:

  • Child and parent collaborate throughout this entire process. 
  • Choose a time to design this plan when your child is calm and receptive. Nothing constructive can be developed during an outburst!
  • Make sure there’s plenty of opportunity for practice each day. After all, Tiger Woods could never make those spectacular putts without lots of it. Even he misses on occasion and so will your child. Mistakes will happen – you can bank on that. But, your child will be reassured when you let him know that there’s always another chance to try again later.   

STEP I: Together with your child, identify and record a couple of the most common triggers to your child’s outbursts (i.e. parents say “no,” plans don’t work out as anticipated, your child is told to stop doing something fun to do something less enjoyable, your child thinks things aren’t fair).

STEP II: Together, list and record your child’s “can’t do” behaviors that he often uses when he is frustrated (i.e. yell, hit, throw things).

STEP III: Together make a list of your child’s “can do” behaviors to replace the undesirable ones that occur when he is beginning to feel upset. This list is most effective when your child’s personal interests are represented so that his choices are engaging and interesting to him. (Examples of “can do” strategies follow after Step IV).

STEP IV: Now that the board or chart has been designed and your child is invested in the process, it’s important to keep it going by implementing the following concepts.

  • A good way to get started is to have your child choose one of these strategies (that follow) and practice the technique with your child for a few minutes each morning and after school. During each practice have your child pretend he is getting upset, describe the body sensations he feels when he is angry and rehearse his calming strategy. Expect to practice these strategies many times before seeing your child using them successfully. Research tells us that it takes 21 days to make a new habit.
  • You and your child might want to develop a special signal, a visual or verbal cue, that is a reminder to use one of his calming strategies. Remember, when your child chooses one of the positive behaviors on his “can do” list, it’s time to offer up enthusiastic praise and even tangible incentives such as stickers, rewards or special activities. Everyone loves a prize for a job well-done! 

Here’s a sampling of “can do” strategies for calming and redirecting behavior. Personalize this list by creating names that resonate with your child.  

  • Happy Birthday:  Teaching children to take deep breaths when they begin to get upset may seem simplistic, but it’s a lifelong skill for managing stress that has emotional, behavioral and physical benefits. Explain to your child that we all have warning signs that tell us we are getting angry. Help your child recognize the signs his body is sending out that lets him know that he’s getting angry (i.e. face gets red; fists clench; heart pounds; breathe faster). When he feels the warning signs, have him take three deep breaths. Next have your child hold up his hand, palm toward his face with fingers spread. Coach your child to blow on each finger as if he is blowing out five birthday candles, one at a time and very slowly. When you see your child getting frustrated, you might say, “Now might be a great time to blow out the candles.” In the beginning you might want to do the breathing along with your child. Set the pace, modeling for your child and letting your calm presence soothe him. 
  • Cozy & Cool:  With your child’s help, create a “safe spot” where he can go to regroup. This special, positive place in the house is where he can go to calm down, sort things out or just chill out when he needs to be alone. It could be a teepee, a beanbag chair, a hammock, or any space your child sees as comfortable and inviting. In the “safe spot” include soft items like blankets, stuffed animals and a basket of quiet time activities that he can play with while relaxing (books, puzzles). Encourage your child to go to his “safe spot” when he feels himself becoming upset. Teach him that sometimes in an angry situation it is best to walk away, go to his “safe spot” and cool down.
  • My Never Never Land:  Use relaxation visualization to design an imaginary place that makes your child feel calm. Help your child create a mind picture of a special place that makes him feel peaceful with all of the colors, sounds, textures, and smells that go with the memory. For example, a child may have a happy memory of a time at the beach. When he feels upset, he can take a “trip to the beach.” He can close his eyes, smell the ocean air, feel the sand between his toes, and feel the sun shining on him. Given the opportunity to run with this, your child may add props to further enhance the experience. One child I know took his towel and sunglasses to his “beach retreat” whenever he needed a “beach break.”  How clever is that!
  • Picasso’s Playground.  Build a spot that includes an array of art materials that can be used independently as a calming and quieting activity. For some children, working with clay, drawing, or doing crafts is soothing and distracts them from the dilemma at hand. As time goes on, try adding new items to keep up the novelty and high interest of the center. Parents, keep a ready supply of items to have on hand so that you can change and rotate art supplies as needed. Keep your eye out for those treasures that might hold your child’s interest.
  • Shake, Rattle & Roll:  Your child can take a walk, shoot baskets, jump rope, swing on a swing, kick a soccer ball, bounce a ball, or dance to his favorite music. Some children get calming benefits from physical release. 
  • Beatles & Beethoven:  Create a listening center with a CD player and earphones where your child can go to listen to music, books on tape or sing a song into a microphone. Dust off that old karaoke machine!
  • Splish Splash … Takin’ a Bath?  For some children, water is soothing and comforting and gives distance from the problem at hand. Try bubbles in the sink, sprinklers in the yard or an old fashioned bubble bath.

There is no single strategy that is good for every child and every family but with lots of practice, role playing, and simulations, children learn new calming techniques that can help them think before they act. Over time, the goal is for your child to develop both the skill and confidence to handle difficult situations on his own without getting upset and losing control. Remember the best way to teach kids how to manage upsetting feelings constructively is to model calmness through your example. Together, and with a lot of patience, much love and lightheartedness, you and your child will find a calmer and more joyful path.

  Doreen Fay EdD

Emotional Impulsivity – A Core Component of ADHD

June 6, 2010

Throughout history disorders of attention were described to include symptoms of emotional impulsivity, as seen in writings by Alexander Crichton (1798) and George Still (1902). Problems with regulating emotion were intially recognized as a core feature of ADHD. But during the 1960’s and 1970’s symptoms of emotional impulsivity/emotional self regulation were split off from the core criteria of ADHD as we know them today: inattention, hyperactivity, and impulsivity. Dr. Russell Barkley just published a wonderful discussion article in the Journal of ADHD and Related Disorders arguing that emotional impulsivity should be returned to its proper status as a core symptom of ADHD.

What do we mean by emotional impulsivity? Why does this matter? Examples of emotional impulsivity include impatience, quickness to anger, easily frustrated, over-reactive, and easily excited. These characteristics are frequently seen with ADHD, yet often unrecognized as a core part of the condition. Frighteningly, these folks may be misdiagnosed as having a mood problem such as depression or bipolar disorder instead of what is really going on – their ADHD!

Over the years in practice I have seen many ADHD kids mistakenly labeled as bipolar. Their over-reactive nature gives an impression of a mood problem when the child is instead struggling with self regulation of attention and behavior. They have difficulty putting on the brakes in their brain. Similarly adults with ADHD can be impatient or emotionally over-reactive, which could lead to misdiagnosis. Unrecognized and untreated these features of ADHD can lead to problems at work and home.

I should also mention ADHD frequently does co-exist with Depression, Anxiety, Sleep Disorders, Bipolar disorder,etc so it is indeed possible to have more than one condition. Making an accurate diagnosis can be tricky. If you are seeking an evaluation for ADHD, I encourage you to work with professionals who are specialized in this area. Getting an accurate diagnosis is essential to getting the right treatment.

Theresa Cerulli, M.D.

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