The revered Sir William Osler said it best--"Medicine is a science of uncertainty and an art of probability." Nowhere in medicine is Dr. Osler's observation more astute than in the diagnosis and treatment of ADHD. With no objective test available, ADHD is often a label, not a valid medical diagnosis.

It is my opinion that the primary problem with prescribing stimulants (Ritalin, Adderall and Dexedrine) is not the medications themselves. Although these drugs may benefit a child who really has ADHD, they are often prescribed in a indiscriminate manner, i.e. a child who may fit the ADHD label but has other underlying reasons for being inattentive, impulsive and hyperactive.

Frequently, there is an overlap of underlying causes. For example, many children may have a history of an increased need for antibiotics, multiple allergic symptoms, sensory integration issues, and/or a learning disability that factor into the disruptive behavior pattern. Rather than automatically resorting to medication as the first option, we should focus on each child's medical history.

The following is a summary of how I evaluate a child with a presumptive diagnosis of ADHD.

I. Making The Diagnosis: ADHD vs. The Disruptive Child

1. ADHD vs. The Disruptive Child
   True ADHD — Inattention, Impulsivity, Hyperactivity
   ADD — Inattention, Impulsivity

2. Allergy-induced ADHD (Allergy/Hypersensitivity — induced)

3. Learning Disability
   Examples:
   1. Auditory Processing Disorder
   2. Visual Processing Disorder

4. Incorrect Behavioral Diagnosis
   Examples:
   1. Childhood Depression
   2. BiPolar Disorder

5. Overlapping Diagnoses
   1. Sensory Integration Disorder (Sensory Modulation)
   2. Leaky Gut (2o increased antibiotics)

II. The Medical History

To make the diagnosis — Base therapeutic approach on the individual patient's medical history. Listening is the key.

Complete Medical History

1. Genetic - Family History

2. Pregnancy

3. Delivery

4. Feeding

5. Infancy

6. Development: Motor Coordination--Large & Fine Motor Language - Receptive and Expressive

7. Infections/Antibiotics

8. Allergies (Review of systems)
   • Ear-Nose-Throat — stuffiness, itching, post-nasal drip
   • Eye — allergic shiners
   • Respiratory — cough, wheezing
   • GI — pain, diarrhea, bloating
   • GU — urinary frequency, enuresis
   • MS — muscle and joint pain ("growing pains")
   • CNS — "Jekyll/Hyde" behavior, fatigue, headaches

9. Behavior — Details of inattention, impulsivity, hyperactivity

10. Sensory Integration — (Sensory Overload)
    Tactile — Smell-Sound-Vestibular/Proprioceptive

11. Self-Esteem

12. Social skills/Peer relations

III. Allergy Concepts

1. Total Allergy Load

   Seasonal — Grasses, Trees, Weeds
   Perennial — Dust, Molds, Foods

   Allergy	Sensory Integration
   BEHAVIOR
   Learning Disability	Infections

2. Elimination Diet

   Single Food Elimination — Eliminate 1 food for 7-10 days - then add one food back as a food challenge

   Multiple Food Elimination — Eliminate Dairy, Wheat, Egg, Corn, Chocolate, Citrus, Peanut, Preservatives, Additives, and craved foods for 7-10 days — then add 1 food back every 1-2 days as a food challenge. A child will usually improve after 5-7 days of an elimination diet.

   Main Culprits:

   • Dairy, Wheat, Corn Syrup
   • Artificial coloring, preservatives & flavorings - Chemicals Ex. red and yellow dye
   • Craved foods

IV. DIAGNOSTIC

1. Conners Checklist

2. Educational Assessment — Cognitive/Psychological (to diagnosis Specific Learning Disability)

3. Testing
   • IUDR (Computerized)
   • Tova
   • Gordon Diagnostic

4. Lab:
   • Comprehensive Digestive Stool Analyses (CDSA)
   • Urine Organic Acids — an objective test to document urinary fungal metabolites
   • Amino Acids

5. Neuroimaging

V. BOOKS/Articles

1. Is This Your Child? — Doris Rapp, M.D.

2. Help for the Hyperactive Child — William Crook, M.D.

3. Superimmunity for Kids — Leo Galland, M.D.

4. The Attention Deficit/Hyperactivity Disorder — William Crook, M.D. (ADHD) and other Kinds of Cerebral Functioning
   A Compendium (available — International Health Foundation, Inc.)

5. Childhood Illness and the Allergy Connection — Zoltan P. Rona, M.D.

6. Solving the Puzzle of Your Hard To Raise Child — William Crook, M.D., Laura Stevens

7. What Are We Feeding Our Kids? — Michael F. Jacobson, Ph.D.

8. Detoxification: Cleansing the Body of Poisons We Take In And Those We Create — Sidney Baker, M.D.

9. Is This Your Child's World? — Doris Rapp, M.D.

10. Article — Treatment Alternatives for ADHD — L.E. Arnold, M.D. Journal of Attention Disorders Vol. 3 #1 April 1999, pages 30-48

A number of medical interventions and supplements have been suggested by proponents to help a child who fits the ADHD label. I have attempted to list these therapies in a concise and accurate manner (and apologize for any omissions or errors).

I. MEDICAL INTERVENTIONS

1. Auditory Integration Training Techniques - Berrard, Tomatis, Semones

2. Vision Therapy

3. Sensory Integration

4. Biofeedback
   • *Relaxation EMG Biofeedback
   • Neurolinguistic Programming - *EEG Biofeedback
   • Hypnotherapy
   • *Meditation - Mirror Feedback
   • *Channel - Specific Perceptual Training
   • *Vestibular Stimulation

5. Magnet Therapy

6. Allergy Treatment
   • *Enzyme Potentiated Desensitization (EPD)
   • Provocation Neutralization
   • NAET

7. *Acupuncture (Laser)

8. Homeopathy

9. Chiropractic (Craniosacral Therapy)

II. SUPPLEMENTATION PROGRAM

1. Vitamins
   • C, E, B--Carotene
   • B6 (B1, B2, B3, B5, B12)
   • Biotin, Choline, Inositol, Folic Acid

2. Minerals
   • *Zinc, Calcium, *Magnesium
   • *Iron, Chromium Picolinate, Manganese

3. Essential Fatty Acids
   • *Omega 3: Flaxseed, DHA, EPA
   • *Omega 6: Evening Primrose Oil, GLA, DGLA, Archadonic

4. Digestive Enzymes
   • Pancreatin (Animal based)
   • Pancrease, Amylase, Lipase
   • Increased Acidity - Betaine (HCL), Pepsin, Glutamic Acid, Apple Cider Vinegar
   • Plant-based - Bromelain, Papain, Aloe Vera

5. Antioxidants
   • B-Carotene, B Complex, Vitamin C, Vitamin E, Zinc, Selenium, Germanium, CoEnzyme Q10, Bioflavanoids, Quercetin, Catechin, Hesperidin, Rutin, Pycnogenol, (Proanthocyanidins, Pine Bark Extract, Grapeseed Extract), Superoxide Dismutase (SOD), Bilberry, Glutathione, Rutin,

6. Anti-candida program
   • Non-Prescription Agents: Probiotic (Lactobacillus, Acidophilus, Bifidobacterium, FOS); Garlic, Caprylic Acid Prescription Agents: Nystatin, Nizoral, Sporanox, Lamisil, Diflucan

IIB. Other measures some observers claim to be effective

1. Amino Acids:
   • GABA, Taurine, Glycine, Tyrosine
   • L-Glutamine, Methionine, L-Glutathione
   • DMAE, Tryptophan, N-Acetyl Cysteine (NAC)

2. Colostrum, Phosphatidyl Serine, NADH, Carotenoids, Phytosterols, Isoflavones, Indoles, Isothiocyanates, Piracetam, Rexall Sun

3. Multi-level Marketing
   • Phosphatidyl Serine, Blue Green Algae, *Glyconutritionals (Mannetech), MSM,
   • DHA (Neuromins)

4. Herbal
   • Chinese Herbal
     Gingko, St. John's Wort, Ginseng, Uva Ursi
   • *High Chlorophyll Green Drinks
     Bee Pollen Spirulina, Royal Chorella Jelly, Blue Green Algae, Barley Green, Burdock, Slippery Elm, Turkish Rhubarb, Bismuth, Green Tea, Jerusalem Artichoke
     Licorice Root, Ginger Root, Goldenseal, Bentonite, Garlic

5. Antiparasitic Therapy
   • Paragone, Clear Herbal, Flagyl (Metronidazole)

6. Thyroid

7. IV Secretin (now limited to Autism Spectrum Disorder)
   • Improved spontaneity (social skills, language, cognitive), often a calming effect
   • Main side effects— insomnia, hyperactivity

* Medical interventions mentioned in L.E. Arnold's review article that have "controlled evidence of efficacy" or "promising prospective pilot data" for "restricted etiologic groups."

In my medical practice, I have found the most effective interventions to be:

1. Improved nutrition — Decreased food dyes and additives, dairy, wheat, sugar and often craved foods.

2. Clean up environment--Limit dust and chemical exposure (perfume, formaldehyde, pesticides, cigarette smoke, etc.).

3. Provocation/Neutralization Allergy testing and appropriate sublingual immunotherapy.

4. Nutritional supplementation program especially Zinc, Calcium, Magnesium, Antioxidants, Essential fatty acids, B6, Digestive enzymes.

5. Anti-Candida program including Probiotic containing Lactobacillus, Bifidus + FOS, and Nystatin or Diflucan if indicated.

6. Exercise program

7. Sensory Integration program if indicated.

8. Auditory Integration Training

9. Vision Therapy

10. Love

11. Counselling

12. Appropriate medication — may be necessary for some children.

Our priority should be children reaching their potential and good self-esteem. To reach this goal the medical world should acknowledge the observations of parents and teachers.

By listening to the complete medical history, observing child for longer than 15 minutes and relying more on common sense and clinical judgment, we can better determine what is the best course of action for each child.