Adding Herbs to a Pediatric ADHD Protocol

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common mental disorders affecting children.

According to the American Psychiatric Association, an estimated 8.4 percent of children in the U.S. have been diagnosed with ADHD.

Memory, concentration and ‘appropriate behavior’ are key in a child’s ability to learn and be successful in school. The 3 subtypes of ADHD include inattentive, hyperactive/impulsive or mixed. It can be challenging to tease out the subtypes with younger children but usually the reports from parents and teachers will eventually bring clarity. Screening tools such as the Vanderbilt ADHD assessment can be helpful for diagnosing ADHD accurately.

Ruling out other causes for challenges with learning are important and a comprehensive work-up should include assessing blood sugar regulation, visual and hearing tests. No matter what the child is presenting with in office and experiencing at home and at school, it is helpful to come from a whole-person perspective and treat the individual.

First Do No Harm: the risks of stimulant medication

Of course, the best approach in medicine is to first, do no harm. In the book, ADHD is not a four letter word, Karen Ryan states, “even though stimulant medication sometimes improves ADHD symptoms, that improvement comes at a price”. Stimulant medications are sympathomimetic so some of the common side effects include loss of appetite, anxiousness, seizures, depression, disturbed sleep, increased heart rate and blood pressure. Even the non-stimulant drugs on the market, such as Strattera or atomoxetine, come with black box warning of increased suicide risk⁷.

Ryan goes on to explain the six main components of a secure multi-pronged approach to ADHD: Education, Support at Home and School, Routine, Proper Nutrition and Exercise, Vitamins and Minerals, Patience and Love⁷.

Herbal Medicine for Pediatric ADHD

As Naturopathic Doctors, we appreciate the healing power of nature so let’s add one more prong; herbal medicine! Incorporating adaptogenic herbs that help modulate brain and motor activity have been shown to not only be effective in pediatric ADHD but well tolerated. Bacopa, Rosemary and Celastrus paniculatus have the ability to regulate brain activity for learning and focus, while also inhibiting impulsive behavior.

Bacopa monnieri

Bacopa monnieri, or Brahmi in Ayurvedic Medicine is considered a rasayana or rejuvenative tonic that promotes longevity and vitality. Herbs in this category can be compared to adaptogenic, nootropic, and immunomodulatory herbs. Bacopa is native to India and Australia and is also known as water hyssop as it grows in warm wetlands. Brahmi was used by ancient Vedic scholars to memorize lengthy sacred hymns and scriptures¹.

According to a neuropharmacological review of bacopa, it is considered nutritive to neurons as opposed to depleting when compared to psychostimulants¹. Bacopa contains flavonoids, alkaloids, triterpenes and steroidal saponins called Bacosides, most famously Bacoside A & B. The nootropic properties include neuroprotection due to antioxidants, increased cerebral blood flow, beta amyloid reduction, and neurotransmitter modulation. Bacopa regulates serotonin, dopamine, and acetylcholine via acetylcholinesterase inhibition and choline acetyltransferase activation¹. This neuromodulation not only affects short-term and long-term memory but can diminish impulsive behavior as well.

In just 12 weeks, children with ADHD who were treated with 50 mg Bacopa extract bid showed improvement in sentence repetition, logical memory, & paired associate learning tasks. Interestingly, these positive changes persisted even after stopping treatment and receiving 4 weeks of placebo⁹. In general, bacopa is well tolerated and safe for children with little (G.I. upset) to no adverse effects reported⁴.

Rosmarinus officinalis

Rosemary is known as ‘the herb of remembrance’ and was recently reclassified as a sage so the Latin name is now, Salvia rosmarinus, instead of Rosmarinus officinalis. It originates in the Mediterranean and is known for its aromatic properties. It contains flavonoids, phenolic acids like rosmarinic acid, diterpenes and triterpenes such as carnosic acid and oleanolic acid, respectively⁵. Rosemary is used regularly as a culinary herb but when taken by mouth as a medicinal extract, it shows promising effects on neuronal potentiation and memory.

The active constituents, mainly carnosic and rosmarinic acid have shown to enhance memory and learning by increasing the levels of acetylcholine in the brain. In fact, carnosic acid was compared with 35 other phenolic compounds that inhibit acetylcholinesterase and was found to be the most potent³. Rosemary extract showed improvement in long-term memory during the passive avoidance test of scopolamine-induced memory impaired rats by inhibiting acetylcholinesterase (AChE) in the hippocampus and frontal cortexes of the brain⁵. Both muscarinic and nicotinic acetylcholine receptors play a role in encoding new memories, so it is no wonder why this aspect is being researched in nootropic herbs².

Celastrus paniculatus

Celastrus paniculatus is not as well-known as the other herbs discussed thus far but it is definitely one worth learning about. It is known as the Tree of Intellect in India and also called Jyotishmati in Sanskrit. ‘Jyotish’ means to bring light and ‘mati’ is the mind, so it increases ‘light’ in the brain. The seeds produce 52% oil by weight and are used medicinally to enhance cognition. They are rich in fatty acids including palmitic, stearic, oleic, linoleic, and linolenic acids. The oil also contains flavonoids, tannins, saponins, phytosterols, terpenoids, and alkaloids such as celastrine and paniculatin^6,8. Along with healthy fats for supporting brain health, Celastrus also has cholinergic properties which aide in memory similarly to Bacopa and Rosemary.

Celastrus is neuroprotective due to its anti-inflammatory and antioxidant properties. In a study against monosodium glutamate (MSG) toxicity on human neuroblastoma cells, Celastrus paniculatus oil was found to increase free radical scavenging and help regeneration of neurons. MSG is free glutamic acid, an unbound protein which leads to unregulated neuroexcitation, neurotoxicity, and eventually, cell death. Un-regulated glutamate leads to the inability to concentrate and create memories which can be a contributing factor to ADHD in any age. The oil from Celastrus enhances superoxide dismutase, catalase, and glutathione regeneration by revitalizing the activity of glutathione peroxidase, glutathione S-transferase and glutathione reductase enzymes⁸. Of course, the best option is to avoid MSG but neuronal protection against free radical damage from any neurotoxic substance can be helpful in improving cognition.

Treat the Whole

Naturopathic Physicians are always looking at treating the individual and the whole person. So, what other factors might we be looking at that could be affecting attention and memory in a child?

Some additional aspects to consider include:

• Food dyes: excitatory to CNS leading to hyperkinetic behavior & neurobehavioral toxicity⁷.
• Aspartame: breaks down into phenylalanine, aspartic acid and methanol. Phenylalanine is excitatory in the brain and neurotoxic (Diet soda, artificial sweeteners, gum).
• Food allergies/intolerances: inflammation due to allergic response leading to brain fog and a decrease in positive neurotransmitters such as G.I. Serotonin production.
• Drug and alcohol use: affect the brain in many ways, depletion of neurotransmitters leading to anxiety, depression, paranoia, etc.
• Other: Environmental factors, heavy metal toxicity, secondhand smoke, fluorescent lighting, sugar, caffeine, & preservatives such as sodium benzoate (energy drinks) ⁷.

As with any Naturopathic treatment plan, a multi-pronged approach will be the most successful in treating pediatric ADHD. Adding in efficacious herbs that are well tolerated and safe in children can further success while staying in alignment with the principle ‘First, do no harm.’

References

1. 1. Aguiar S, Borowski T. Neuropharmacological review of the nootropic herb Bacopa monnieri. Rejuvenation Res. 2013;16(4):313–326. doi:10.1089/rej.2013.1431
   2. Bhanumathy M, Harish MS, Shivaprasad HN, & Sushma G. Nootropic activity of Celastrus paniculatus seed. Pharmaceutical Biology. 2010; 48:3, 324-327, doi: 10.3109/13880200903127391
   3. Habtemariam S. The Therapeutic Potential of Rosemary (Rosmarinus officinalis) Diterpenes for Alzheimer’s Disease. Evid Based Complement Alternat Med. 2016; 2016:2680409. doi:10.1155/2016/2680409
   4. Kean JD, Downey LA, Stough C. Systematic Overview of Bacopa monnieri (L.) Wettst. Dominant Poly-Herbal Formulas in Children and Adolescents. Medicines (Basel). 2017;4(4):86. doi:10.3390/medicines4040086
   5. Ożarowski M, Mikolajczak PL, Bogacz A, Gryszczyńska A, Kujawska M, Jodynis-Liebert J, Piasecka A, Napieczynska H, Szulc M, Kujawski R, Bartkowiak-Wieczorek J, Cichocka J, Bobkiewicz-Kozlowska T, Czerny B, & Mrozikiewicz P. Rosmarinus officinalis L. leaf extract improves memory impairment and affects acetylcholinesterase and butyrylcholinesterase activities in rat brain. Fitoterapia. 2013; 91.10.1016/j.fitote.2013.09.012.
   6. Ryan, K. ADHD is not a four letter word: Drug Free strategies for managing the gift that is ADHD, Victoria, BC, Canada: FriesenPress; 2014: 17-18 & 39-42.
   7. Shah N, Nariya A, Pathan A, Patel A, Chettiar SS, & Jhala D. Neuroprotection Effects of Celastrus paniculatus Seed Oil against Monosodium Glutamate in Human IMR-32 Cells. Annual Research & Review in Biology. 2018; 24.1-9. 10.9734/ARRB/2018/39256.
   8. Sodhi V, Ayurvedic Herbs: The Comprehensive Resource for Ayurvedic Healing Solutions, Bothell, WA: Book Publishers Network; 2014: 74-76