ADHD Management: The Benefits of Lifestyle-Based Interventions & Functional Lab Testing

Kalea Wattles, ND:
Attention-deficit/hyperactivity disorder is a neurobehavioral and developmental condition that affects millions of individuals worldwide. The health-related and economic burden of this chronic condition is well documented. And standard treatments for managing ADHD often include medications and behavioral therapy. What about lifestyle-based treatments like nutrition and exercise? What benefits have these therapeutic approaches shown in addressing ADHD symptomology?

Kate Kresge, ND
Diagnosis of ADHD is typically done by a primary care provider or psychiatrist. And in those settings, typically what's gonna be recommended is parent behavior training or counseling and/or medications. And those we know work really well, but we also have an incredible amount of research about nutrients and exercise and mindfulness and supplements and herbs that can help to improve symptoms in ADHD. And so I think functional medicine is really well poised to help educate clients and empower them and to help them discover which of those interventions is right for them to use alongside the other therapies they may be doing.

Kalea Wattles
In this episode of Pathways to Well-Being, we welcome Dr. Kate Kresge from Rupa Health to discuss nutrition, exercise, and functional lab testing in the context of ADHD management. Welcome to the show, Dr. Kresge.

Kate Kresge
Thanks so much for having me. I'm so excited to talk about this today, and I'm really excited for the bootcamp we're partnering on coming up, Clinical Decision Guides in Functional Medicine Testing. It's gonna be a ton of fun. And so this feels kind of like a preview to the party today.

Kalea Wattles
This is definitely a preview to the party, and it's always so fun for me to talk to you about the health of our brains and our nervous system because you are so passionate about this topic, and I know you're constantly researching and teaching this integrative approach to supporting mental health. You and I, we both obviously have a deep love for functional medicine. We have our partnership coming up with the bootcamp. So I thought it would be fun to talk about what is it about functional medicine that is uniquely well suited or well matched to support conditions like ADHD? Let's just start there.

Kate Kresge
I think that's a great question. So in our country, diagnosis of ADHD is typically done by a primary care provider or a psychiatrist. And in those settings, typically what's gonna be recommended is parent behavior training or counseling and/or medications. And those we know work really well, but we also have an incredible amount of research about nutrients and exercise and mindfulness and supplements and herbs that can help to improve symptoms in ADHD. And so I think functional medicine is really well poised to help educate clients and empower them and to help them discover which of those interventions is right for them to use alongside the other therapies they may be doing.

Kalea Wattles
Ooh, I love it. It's a guide that helps us to deliver precision medicine, individualized medicine, using a whole spectrum of tools we have in our toolbox. And that's what we're gonna talk about today.

Kate Kresge
Absolutely.

Kalea Wattles
I think it makes sense for us to start at a place that's deeply rooted in lifestyle and in naturopathic medicine. We might call this the foundations of health, and in functional medicine, we'd call this the bottom of the matrix, but really it means all these things you talked about, nutrition, exercise, stress-coping skills, sleep. So let's start with nutrition first. And I'd love to know, based on your experience, are there some specific dietary interventions that you found to be particularly effective when we're personalizing our ADHD interventions? And then to add a layer to that, I imagine that there's some nuance here when we're looking at a pediatric population versus an adult patient. And will you walk us through that scenario?

Kate Kresge
Sure, yeah. And let me, let me step back and kind of frame the issue a bit for folks who may not know kind of how common ADHD is. So some of the newer research coming out, in 2016, we thought about 8% of our pediatric population had ADHD in the US, and then lifetime prevalence was about 8%. And those numbers are actually increasing with some of the more recent research. So s­­ome of the newer population numbers we're seeing are the estimates could be as high as 15% of our kids have ADHD. And so I think where we're at as a society is that this is becoming much more recognized. It has major impacts for our kids—and adults, as we can talk about in a second. But I think parents in particular feel like they have to choose. I've talked to parents who feel scared to have their kid diagnosed because they don't want them put on medications. They're scared of the medications. And so right away, I wanna reassure everybody who's listening, ADHD is real. Treating it can have profound positive impacts for you or your loved ones, and you aren't just limited to medications. But also, there are some really powerful tools that you can use in your kitchen to help improve outcomes. 

So I wanna start with a basic thing. So I think a lot of people know of ADHD as like a dopamine-based disorder. I think we use that term colloquially a lot because a lot of the medications that we use to treat ADHD, like stimulants, work on the dopamine and norepinephrine pathways. But most people don't even know how to make dopamine in their bodies, what foods they would need to eat to make dopamine. And so there's only two ingredients we use to make dopamine, tyrosine and B6. And B6 is the number one nutrient deficiency in the US. You get most of it from chickpeas or beef liver. And so just by focusing on those two nutrients is, like, I think kind of helps bring it home for people. Like, "Oh wow, I guess if I'm taking medications to alter my dopamine, but I'm not even eating the ingredients I need to make dopamine..." that sort of helps to start people on the path of understanding why food might be important. 

Now, I did nutrient analysis for everybody who walked in my practice, and that's what we're teaching people to do in the Rupa Bootcamp we're doing with ADHD right now. And so when we talk about tyrosine being used to make dopamine a principle, I want everybody who's listening to understand. You need to take protein and break it down into amino acids to then make that into your neurotransmitters. There's no other way to make those. So getting enough protein is really vital for people with ADHD and any mental health disorder. And most, what most of the research we have about the diets that people with ADHD tend to consume is that they tend to consume a lot of processed foods, really high sugar diets, tend to be a little bit low in protein, low in the important fats. And so just by helping someone get a hundred percent of the nutrients they need each day to thrive and increasing their protein, we often see some improved focus. But I'm happy to drill down into some specific nutrients if you'd like to.

Kalea Wattles
I would love to talk about some specific nutrients, and we've talked about this before, you and I, about how you do a nutrient analysis on your patients. And I just think that's so empowering because we are eating foods all throughout the day, but most of us, we have no idea what the nutrient composition of those foods are. And so if we do an analysis and you say there are building blocks that come from your kitchen and we know exactly how to prescribe those to you and we're seeing a lack of these in your diet, how empowering to know that it can be something fairly simple and straightforward. So all of that to say I love that that's part of your approach. And tell us, tell us about some of these most important nutrients.

Kate Kresge
Yeah, so there's four minerals that we tend to talk about a lot with ADHD: magnesium, zinc, iron, copper. There have been studies that giving iron along with methylphenidate, which is a drug used to treat ADHD, will actually improve outcomes. So kids who take iron along with methylphenidate will require less medication to manage their symptoms, which usually also means less side effects, cause you get to use a lower dose. We were taught in school, and I think all doctors were taught to check, for iron levels before prescribing iron, because iron can be dangerous, right? It builds up in the body, it can be oxidative. And so in the ADHD lab panel that we've got at Rupa, we included iron ferritin and an iron panel for that reason. 

There's evidence that when we use magnesium along with medications, we can reduce the side effects of medications as well and help with some of the things we know that kids with ADHD and adults with ADHD tend to struggle with, which is high incidents of sleep-onset disorder. So trouble sleeping and anxiety. And so what most people don't know is the top food sources of these nutrients. So they go, okay, how do I get magnesium? I guess I'll just go buy a pill or buy a gummy. And really, the top food source of magnesium in the US diet is pumpkin seeds. And so I have what I like to call little ADHD trail mix that we, I would have all my clients make if they could, which was pumpkin seeds, walnuts, almonds, cashews, sunflower seeds. Cause as we go through this, you guys will hear me talk about how those other nuts are a top food source of many of the other nutrients that we know help to improve symptoms of ADHD. And so this doesn't have to be hard. It can actually be really delicious. There is no rule against throwing some chocolate in your trail mix. But it's, it's little simple things like that that before we reach for the pill, we could really help our clients by just empowering them with like, "What do you feed your kids so they can focus better and stay more calm?"

Kalea Wattles
What I really appreciate is not only are you providing food sources of these nutrients, but you're also saying if medication is part of your journey, then there's nutrition that can walk alongside your medication. So we're kind of removing the stigma from whatever path that someone chooses and emphasizing that it doesn't necessarily have to be an "either or," it can be a "both and," and I think that is such an important part of our therapeutic partnership and how we walk alongside the lived experience of our patients. So just wanted to shout that out that you were going there, and I think that's really important. We hear a lot about an anti-inflammatory diet for, you know, a whole range of mental health concerns. And now, what I'm hearing you talk, it's like, okay, there's all these nuts and seeds and the different fiber sources and the omega-3 fatty acids. Is that really why an anti-inflammatory diet is helpful in these cases? Cause it inherently includes a lot of these nutrients that you're talking about?

Kate Kresge
Yeah, there's actually a study from 2022 in the Journal of Clinical Nutrition that found that adherence to a Mediterranean diet improved ADHD symptoms in school-age children. So you are right on the money. And yeah, because food contains nutrients, and we can only run the biochemistry in our body using nutrients, like that's where we get the co-factors for making, again, neurotransmitters, proteins for keeping inflammation low. So you're right on the money, a diet that is really rich in foods that are very nutrient dense has absolutely been proven to help people with ADHD. 

I love what you said a second ago about medication, and so I just wanna be even more explicit about that. I think especially people who come to see naturopathic doctors sometimes expect us to be anti-pharmaceutical, and I am not. And the conversation I have with usually parents of people with ADHD is like, look, let's talk about this disability for a second, because it is a disability. Kids with ADHD are more likely as adults to earn 30% less than their neurotypical peers. They're 15% more likely to require social assistance of some type. They participate in the labor market 10% less. They're more likely to be drug addicted. They're more likely to be obese. They get more traffic citations. Like this is a disorder that needs to be treated. It would be like finding out your kid needed glasses and deciding you're just not gonna do anything about it. That's not cool. You have to treat it. How you treat it is up to you, right? And so you can choose therapy, exercise, nutrition, meds, you can do a combination of all of those. But what we should not be doing is be so afraid of the medication that we do nothing. 

And so I'm so excited because I think we have a whole new generation of providers who are deciding to be part of the solution so that people don't just have medications as their only option. But that said, medications can work really beautifully. And we have solid evidence that when people are treated for their ADHD, their risk for all the things I just mentioned goes down significantly. So you never should be made to feel as though you have to choose. You don't. And that's the beauty of at least where we live, Dr. Kalea, people have access to multiple different types of practitioners. They can do it all. And really, you should do a couple, try a couple things and figure out what works best.

Kalea Wattles
Yeah, beautifully said. And I think with the visibility due to social media, you know, we see Instagram reels and TikToks all the time of adults who say, I am, you know, 32 years old, and I was just diagnosed with ADHD, but I have been this way my whole life, and if someone would've screened for this or given me the support, you know, 20 years ago, I probably would be in a different place in my life now. So I think that it's a point well made that this is worth treating to set our children, to set ourselves up for success into the future. You started talking about some minerals, and then I got so excited, I steered you in a different direction, but I wanna bring it back, because this is something I think about in the Pacific Northwest all the time is our vitamin D. Is there an association between vitamin D and ADHD symptoms? And is it, are you seeing a lot of low vitamin D in your patients who have ADHD?

Kate Kresge
Yeah, it's so, and it's not just me, this has been validated by several studies at this point and several meta-analyses, actually. So people with ADHD are more likely to have lower vitamin D than people without. And it's so pronounced of a difference in kids that kids with ADHD are actually, have an average of a level of 17 of vitamin D, which is like well below the cutoff of 30 for deficient. Whereas controls tend to have a level of 30 or above. And so in English, what that means is yes, more of our ADHD kids have a diagnosable vitamin D deficiency. And what we find is that when we treat that deficiency, symptoms improve. So let me give you some data on this. So a good meta-analysis to read if you're a practitioner and you want more information on this was published in 2019. "The effect of vitamin D supplementation on ADHD, a systematic review and meta-analysis of RCTs," and what it found was that vitamin D supplementation, including in addition to medication, appear to reduce ADHD symptoms without serious side effects, which is pretty cool. It seems like it also has like a preferential ability to improve inattentive symptoms, which is also really nice. We could talk about dosing and all that, but quick answer to your question is yes, you are right on the money.

Kalea Wattles
Yeah, this is something I'm noticing about I think a functional approach to almost any condition, a functional approach to ADHD or in my practice, it's fertility patients. When we start to unpack all of these drivers of changes to our cognition, or changes to our fertility, it's not just about that specific condition. We're also preventing or reducing risk for chronic disease, you know, 20 years down the road. So all these things that you're mentioning, the minerals and the vitamin D, you know, it's gonna help with the ADHD symptoms in the now, but then we're also reducing risk for cancer and osteoporosis and Alzheimer's and all of these things that, you know, maybe are not on our radar now. But I think that is such an important part of the work that we do to address any of these, you know, conditions in the present moment.

Kate Kresge
Yeah, we're treating people, not conditions. And I think that's the key difference, and that's all. Every single presentation I start out with where I cover nutrient interventions for ADHD, I start with the snapshot of a nutrient analysis, which goes over 80 different nutrients in somebody's diet. And I say, "I'm gonna tell you what the research says now. Your best bet is to get a diet or a supplementation routine that gives you a hundred percent of every nutrient you need in the day." Which is not as hard as it sounds because okay, maybe we don't have as good of evidence for vitamin C as an intervention for ADHD right now, but we might have it in 10 years. If we just get you as healthy as possible, if we give your brain everything it needs to work and your body everything it needs to thrive, that is always the best intervention for almost any disorder. And from there, we can get into more specific micronutrient and other interventions after we give you a really solid foundation.

Kalea Wattles
Right. So now we've talked about some important micronutrients, but we also need to make sure that our patients are absorbing these nutrients. So thinking about what's going on in their gut. And I wanted to ask you about the impact of food sensitivities or intolerances, and is this playing a role in our, especially I'm thinking of our pediatric population with ADHD? Are there some connections to be drawn here?

Kate Kresge
Yeah, and actually Dr. James Greenblatt is probably like, I would say the expert on food sensitivities and ADHD. He talks about this a lot. Here's what we know. So since the seventies, the oligoantigenic diet for ADHD has been being studied, which basically is like a low-allergen diet, and there's some evidence that that does appear to improve symptoms, but it has to be done right. You can't just remove foods from kids' diets and not make sure that they're getting enough nutrients. That's probably obvious at this point from everything we've talked about. The second thing, there's multiple different types of food reactions. So there's food sensitivities, there's food intolerances, like a lactose intolerance, and then there's food allergies. 

What I find really compelling is that kids with ADHD are much more likely to have higher levels of something called serum IgE, which is a true allergic reaction. And they're also much more likely to have things like atopic dermatitis, allergic rhinitis, so allergies. We know that if we look at the blood of moms when they're pregnant, if they have lots of allergies going on, IgE allergies, they're more likely to have kids with ADHD. I don't know that we have figured out the exact mechanism that causes this. We have some theories, but what we do know is that kids with ADHD tend to have more allergic symptoms, and they do tend to benefit from a diet that helps identify and then minimize the amount of allergic foods they're consuming.

Kalea Wattles
Wow. Let's turn this into something clinically actionable. I'm just imagining myself as a mom, and I'm listening. I'm like, okay, I have a lot of allergies, and if I am pregnant, and then how is that gonna translate? Does it just mean that then baby's born, and we're more diligent with how we watch and screen and do preventive health care and have our pediatrician onboard? Is that your typical advice?

Kate Kresge
Yeah, so take care of allergies wherever you find them, right? If it's before you get pregnant, you don't want a ton of excess histamine in your blood for any reason at any point, right? And so, and this isn't crazy, I mean you probably help people with this all the time. Like a lot of times what I'll tell folks is like go get allergy treatment, right? Just reduce your immune system overactivity. Let's help make sure you have the nutrients you need to regulate your immune system. Let's make sure that your mast cells are stabilized so they're not releasing too much histamine. And so in plain English, this just means, let's figure out what you're allergic to. Let's build up your tolerance to it. Let's make your immune system more resilient. And maybe it could be things as simple as nettle tea that you're drinking at night and including more HEPA filters in your home. Maybe if you're allergic to dust mites, washing your sheets on hot, like these are all lifestyle things that everyone should be doing. But certainly treating any sort of dysfunction where you find it in the body is likely to improve brain health because everything is connected through our blood. So if you're getting allergic reactions multiple times a day that are dropping your blood pressure, you can't perfuse your brain as well. That's gonna impact your ability to focus. So yeah, I think encouraging people, if they've got allergies, to treat them; it does generally improve a lot of other systems’ function as well.

Kalea Wattles
Yeah, that, I mean, that's systems biology, right? It's all connected. So following this train of nutrients, even vitamin C as a mast cell stabilizer, which you just talked about, like this is all connected. If we're wondering, I think a lot of us, we change what we can measure, and that really underscores the importance of doing some kind of analysis. Like you said, you're doing a micronutrient analysis. Will you just talk to us about what that looks like? Like what does testing look like? What does tracking look like? How do we even know that we're doing the right, or maybe we need a little bit of support with our nutrition?

Kate Kresge
There's two options that are often done together. The first, if you wanna know what you're consuming and if you're consuming enough nutrients, you can use a clinical tool. We're using Cronometer in the bootcamp. That's what I used in my practice. You have your patient track or you track for your patient a few days and you just see, what are they consuming? And docs, if you're not doing this with your clients yet, I highly encourage you to try it at least once, at least with yourself, because you'll be shocked at how few nutrients you consume just at the adequate intake level each day. The second part is to look in the body and at body status. So we do that with the ADHD panel that we're using, and that checks on things like a CBC and CMP, which are gonna look at, what do your red blood cells look like, what do your white blood cells look like? Are your liver and kidneys functioning? We check for specific nutrients, like we've talked about already, magnesium, zinc, copper, iron. We check for markers of B vitamin status. You heard me talk about needing B6 to make dopamine. And so we have the panel, and I can share it with you guys. If somebody just wants to literally bring that into their doctor, they can totally do it.

I think for people in the preconception stage who are wondering, what can I do? Measure your serum total IgE, measure your omega-3 fatty acids. We know those are critically important for brain development and baby. I'm seeing Dr. Kalea nodding. This is probably something that you talk about 10 times a day. And yeah, and then measuring your hormones. So making sure that you and baby have adequate thyroid hormone is absolutely gonna help with neurodevelopment. So those are the things that we typically start with. If you have a kiddo with ADHD in your practice and you haven't screened them for lead, I think that's worth doing. There is very, very clear evidence that having a high blood lead level interferes with cognitive function and leads to symptoms of ADHD, but that's rarely screened for in clinical practice anymore. And so something as simple as that can be really useful as well.

Kalea Wattles
Yeah, so many options available to us. What about, we have so many of our, you know, major lab companies that are offering some type of micronutrient analysis, either in whole blood or a combination of a finger prick and urine and all these different choices. Is there a role for that in this scenario to do some kind of micronutrient analysis? Or are you mostly looking at history and using that to guide your recommendations?

Kate Kresge
It's both. So I think there's absolutely room, and we do that frequently, and we actually include a lot of those biomarkers in the panel I'm talking about. But then I'll counsel people to say, you know, yes, all right, we've opted... because sometimes it's a matter of cost.

Kalea Wattles
Yeah.

Kate Kresge
Oftentimes the testing is maybe out of somebody's budget. That's where the nutrient analysis can come in handy because you can do that immediately. It's very cheap. But if somebody, just because someone's consuming enough nutrients doesn't mean they have enough in their body. Back to your point about gut health. If they have IBD or a malabsorptive disorder or celiac or they've had surgery on their gut, if they're taking a proton pump inhibitor, they, H. pylori, they may not be absorbing those nutrients as well. If they're taking high doses of minerals like iron, that's gonna affect their ability to absorb other things like calcium and magnesium. So a lot of times, we can only find out so much from the diet, and then we need to dive deeper to figure out what is, what are you absorbing and what's in your body. And that's where those tests can be really amazing. I love that we have so many options for measuring nutrients, including urine, because at least for my population that I worked with, and I don't know about you, but especially with kiddos, doing a blood draw often felt traumatic for them. And so we wanted to avoid that if we could. And so you can know about this body status of things like B6, for example, using a urine test, sometimes you have to collect over 24 hours. It's not completely like hitting the easy button, but absolutely, there's such a big role for all of that.

Kalea Wattles
Yeah, I tell patients it's not glamorous, but it's gonna get the job done. So yes, I really appreciate that response. Now let's say we do our assessment, whether that's through our history, through some testing, a combination of both, then we have to make some decisions about our treatment plan. And I think you've mentioned so many ways that we can get our nutrients through food. And I think both of us are definitely "food first" type of docs, but at some point, I think a case can be made for supplementation. How do you help your patients decide is this something that I can just get on board with? I have my food sources, and I'm gonna be really diligent about including those, or how do we know when we need to escalate to a supplement?

Kate Kresge
It's a lot about patient ability and preference. At least when I was chatting with people, not everyone is able to do a meal plan or to consistently prepare foods and consume them. And particularly, the more nutrient deficient you are, the less able you're going to be to be able to have optimal prefrontal cortex function, which is required for you to be like, okay, I have a meal plan, that means I have to go to the store, I have to shop, I have to prepare these foods at a certain time. I have to store them. I have to remember to take them to work. If you have really severe ADHD symptoms, that might not be something you can actually feasibly do. And so the conversation I would have with my clients is, "We have to get your brain working first. We have to get your brain the nutrients it needs first and the support it needs first. And then if you don't feel ready to cook now, you may feel ready in a couple months, and we can totally revisit this." 

I also had a lot of clients coming to my practice who would come in and they say, well yeah, I have terrible ADHD and I'm so depressed I can't get outta bed, but I don't wanna take any medications and I don't wanna eat any processed foods and I need to be waste-free. And also, I'm vegan, and I need everything to be organic. And it's like, hang on, hang on a second. We have to get your brain working. That is step one. If you wanna be a waste-free organic vegan in three years, I am with you, we will get you there healthfully. You are not there right now. I'll give you a meal plan to do it. If you can't do it in two weeks, we gotta go with something else. 

And I think there is tremendous power in being able to help people understand it is not what is best, it is when is best. Like if you can't even get up off the couch, me giving you a whole foods meal plan that requires you to cook three times a day is not responsible medicine. It's just not. So empowering people to say where are you at? What's good for this "when" in time? And then where do you wanna be and let's get you there can really help. I think take the first step and then you start to feel better, and it's just a snowball from there.

Kalea Wattles
So motivating, so beautifully said. We talk all the time like oh, meet the patient where they're at, but what does that really mean? But that, you just beautifully described in very specific detail what that actually looks like in the real world. And I think that is responsible medicine. So I think we have a good idea now of we have so many options for nutrition that both in terms of what we can choose, but also the when, when we can use them, how we can utilize these tools. Let's talk about exercise that I think walks hand in hand with nutrition. Are there some specific exercise recommendations that you find yourself counseling over and over and over?

Kate Kresge
Absolutely. Let me tie a bow on the nutrition thing because I forgot to say the important thing.

Kalea Wattles
Yeah.

Kate Kresge
We have evidence that a comprehensive multivitamin can reduce some of the symptoms of ADHD by 50% when used consistently over six months. So if the only thing you guys take away from the whole conversation we've had up until now is that a multi could help and maybe that's all you do, please feel hopeful about that, right? You don't have to take mononutrients, you don't have to eat more pumpkin seeds. Like maybe it's as simple as that. Jumping into exercise, which I do say ironically to be funny because some of the best evidence we have actually for movement in ADHD has to do with jumping, which I find very, very cute.

Kalea Wattles
Cool.

Kate Kresge
It is such an effective intervention for so many mental health disorders. For ADHD in particular, we know that something as simple as five minutes of jumping before taking a test, so having this, your kid with ADHD, jump rope for five minutes before they sit down to take a test can result in a 28% reduction in errors on that test, which is the difference between failing and passing, right? It can also improve attention by about 40% for the next couple minutes to an hour. And so it makes sense when we talk about exercises and intervention because so much of what we're trying to do with the medications we use in ADHD is to alter blood flow, increase blood flow in that farthest part of your brain from your heart, which is right behind your forehead, the prefrontal cortex, getting your blood moving by exercising is also gonna help with that. So yeah, we have a ton of awesome evidence. And the beautiful thing about exercise is it really mostly comes with side benefits rather than side effects.

Kalea Wattles
Wow. Me as a parent now writing my kid's school, I will be supplying jump ropes for all the children before their next round of testing.

Kate Kresge
Right?

Kalea Wattles
Because that's really powerful.

Kate Kresge
Yeah, when we have the numbers, it is. And that's why I'm just so grateful in the last 10 to 20 years we've had some really amazing studies come out, and these interventions are hard to get funding to study because I’m not aware at least of a jump rope lobby, right? Like you can't patent a special jump rope and prescribe it at pharmacies. And so there is no big jump rope funding research, right? So a lot of times, research is expensive. Often what ends up getting funded is something that you could patent, right? Because somebody has a financial interest in studying that intervention and proving that it works. It is so encouraging to see that we have so many researchers looking at things like nutrients and exercise and sleep and interventions that really, you know, can't be patented and people can't make money from. Jumping rope is one of them. Cardio exercise also seems to help. We do have some good evidence that chronic exercise, meaning like the more times you exercise the more profound effect you're gonna get on controlling your ADHD over time. So one of the things that was studied was cardiovascular, regular cardiovascular exercise, something like running around, this could be on the playground, right? This doesn't mean you have to put your kid on the track and they run around or on the treadmill, like no, just play tag. You know, running around at recess. That type of exercise can improve some of the core symptoms of ADHD, like attention, hyperactivity, inhibitory control, cognitive and executive function. And so what that translates to is better performance in school, better relationships and friendships, right? So this is a really powerful intervention that can have long-lasting impacts for your kid, both socially and academic.

Kalea Wattles
It seems like the takeaway here is move your body in whatever way feels approachable and nourishing and fun for you. And there's probably gonna be some benefit.

Kate Kresge
A million percent. A lot of the analogy we would use with our parents who had kids with ADHD, when I would talk to the kids, I would say, you were born with a lot of wiggles. You have a lot of wiggles every day. You have to get those wiggles out and then you're gonna feel better. And so we would give them a plan to get their wiggles out. We would give them different options at different times. The fact that we know that it only has to be five minutes at a time to have such a big improvement is beautiful because you can do that anywhere, anytime. You can get out of the car, right? Like before you went to school, do some jumping jacks. Make it fun. Make it a competition. Kids love to beat their parents at things. Let them beat you at how many times they can jump rope compared to you, right? Though, absolutely, you can take this anywhere. It doesn't have to be hard.

Kalea Wattles
Our prescription, our treatment plans are just really getting upleveled right now with all these, all these little soundbites you're giving us. And I think that is just really, really approachable. So we've talked about nutrition, now we have our exercise tips. We're all gonna get our wiggles out, adults included, need to get our wiggles out. Like sitting in a desk all day, let's get around and wiggle a little bit. I wanted to get your thoughts on some of the maybe higher order interventions. Things that are very popular in the functional medicine ecosystem right now. Things like vagal stimulation, sauna, you know, other hormetic therapies that are all over the place. Are these things that you're using for ADHD patients?

Kate Kresge
Yes, but not for ADHD specifically. So there may be research about vagal stimulation in ADHD. I haven't found that. What I have found is information about neurofeedback and mindfulness.

Kalea Wattles
Ooh.

Kate Kresge
And I think we would both argue that mindfulness is vagal stimulation.

Kalea Wattles
We could make a case for that.

Kate Kresge
Right, you're really activating that vagus nerve, kind of turning up the volume on your parasympathetic nervous system. You know, learning to turn down the volume on your sympathetic nervous system. There's definitely evidence for mindfulness-based interventions in helping to improve ADHD outcomes as well as some things like cognitive behavioral therapy, which really is just helping you learn how to, in the moment when you're activated, bring yourself back to calm. And so vagus, your vagus nerve is your body's main parasympathetic nerve. I know we've probably talked about that. You've talked about it a million times, I've talked about it a million times on podcasts. But usually, when we activate that, right? So when we do something like humming or singing or splash our face with cold water and activate that mammalian dive reflex, when you get a lot more signals being sent through your vagus to your brain, you get this sense of calm and sense of control. And so much of what we see in ADHD, particularly with the emotional ability, is that there's an increased tendency to get kind of limbic about things. So whereas your vagus helps keep you calm and helps kind of keep that prefrontal cortex online, which is the part of your brain that helps you not say things you didn't wish you said, right? Inhibit inappropriate things, right? Helps you plan for the future. So rather than reacting, saying like, okay, I'm gonna take these three steps to fix this problem, when you don't have good blood flow there, you tend to have a hard time inhibiting activity in your limbic system. 

And so what this can look like is somebody who gets triggered, they really feel bad. Like somebody else next to them who doesn't have ADHD might get equally triggered by something. Maybe something goes wrong at work or something like that. The person with ADHD, at least 67% of the people with ADHD are gonna really ruminate about that. They're gonna feel that much more deeply. They're gonna have a harder time accessing that frontal lobe to then get out of that feeling, do something productive and resolve it. And so what we can do with strengthening the connection with the vagus nerve in the brain using CBT, using mindfulness is how people overcome that so that they're not stuck feeling bad. They're able to more easily kind of move out of that emotional ability state and into a state where they're their highest self and they're able to act with intention in alignment with their values.

Kalea Wattles
Hmm. I'm just picturing, I think we've all been there. Something happens at work and some people are gonna recover more quickly than others, but I'm thinking about how this might manifest in a pediatric population. Like something happens at school or something doesn't go your way and there are gonna be those kiddos that are, the rest of their day is just ruined now. And these are the kids that we're gonna say like, oh, now they're having trouble focusing or whatever. But it's just the brain communication needs a little support. How do we, how do we give them some tools and help these teeny people to overcome these scenarios?

Kate Kresge
That is such a beautiful question, because it's the number one question actually we answer. When any kiddo under the age of six gets diagnosed with ADHD, the standard of care is to not use medications in kids under six. And it's instead to offer something called parent behavior training, which I think if you're a parent, that might feel kind of offensive when you first hear, but truthfully, the evidence with parent behavior training is it actually helps parents feel better and more in control.

So what I would say to my parents when they were in my practice was a couple things. First, if your kid has ADHD, they have a brain that literally looks different on MRI and SPECT imaging than another kid their age. They have less gray matter, less white matter, they have smaller brain volume, they are neurodevelopmentally behind, some studies say up to three years than their peers. That's a big difference. So expecting your kid to have the emotional regulation of their neurotypical peer is a losing expectation. So let's stop that right now. Secondly, parent behavior training works because you have to parent your kid with ADHD slightly differently than you're gonna parent your neurotypical kid. So you, if you have two kids, one is neurotypical, one has ADHD, you will need different parenting strategies so that there's no conflict in your home, so that you're empowering your ADHD kid to learn the skills we're gonna talk about rather than being at sort of the mercy of a brain that works a bit differently for the rest of their life. 

So behavior training for parents can look something like switching from a punishment-based model or consequence-based model to a reward-based model. And this might sound icky, let me explain. One of my favorite like clinical vignettes of this is like an example of a kid who because of their ADHD is frequently late so you feel like you have to drag them out of bed. You feel like you have to be on top of them to get them ready to leave the house each morning. It's constant conflict. This is a scenario a lot of parents find themselves in with their ADHD kids. Simply switching to a model where you say to your kid, "Hey, if you get ready by yourself without me having to remind you this morning, by the time that clock says 7:40, you get a X, Y, Z." Whatever it is. That reduces the tension in the household so much. It empowers that kid. And then it becomes actually like a pleasant experience, a confidence-building experience rather than a conflict. 

And so one of my favorite videos to have people watch if they are new to an ADHD diagnosis in their family is a video by Dr. Daniel Amen called "The Seven Different Types of ADHD." And he goes through ADHD in families. ADHD is highly heritable. We think it's about 80% heritability, which is very high. Which means if you have a kid with ADHD, you should be looking at you and their biological other parent and being like, huh, perhaps one of us has this. If that is true, we actually know that kids who have ADHD that have parents with ADHD tend to have worse outcomes if both parties are not managed, right? There's more conflict in the home, the kids don't get as much symptom resolution, even with treatment. So treating the whole family becomes really important, and reducing conflict in the household becomes really important. I like the analogy Dr. Amen uses where people who are undermedicated with ADHD often don't do things until they are late or they have some kind of adrenaline or dopamine boost, right? 

So we, one of the things that I think a lot of clinicians who deal with ADHD look for is like, is the person late to their first appointment? Because that's very often true. It's like you look at the clock, you realize you're late, you get that adrenaline burst, you get a boost of blood flow to your brain. Now you can leave the house. Often we see in families with ADHD, unknowingly, the kids are using conflict as a motivator. So they're not gonna do their homework until there's a problem in the house. Now they're activated, they might be yelling and upset, now they have enough blood flow in their brain where they can go focus for a little bit. But we don't want that to be the dynamic that helps our kids focus. So parent behavior training, CBT mindfulness for the whole family, can be life changing and can take a dynamic that maybe isn't so fun to one that like is really awesome and empowering for everybody.

Kalea Wattles
I am soaking this in both as a clinician and as a parent and someone who's around, you know, a lot of kids just by the nature of being with my children. It sounds to me that there is potentially a role for a collaborative care team in this situation. Like you're working as the primary care doc in some situations or as a specialist. What other members of the team have you found to be special or have you found to be supportive when we're giving this type of care?

Kate Kresge
Primary doctor is, actually 60% of kids with ADHD are gonna be diagnosed and managed by their primary care doc. So phenomenal primary care doc who you trust, psychiatrist who you trust. Having a full psychiatric workup is really important and neurodevelopmental workup so that we're not missing anything else. We don't, we never wanna see a kid being diagnosed with ADHD if they haven't had their hearing checked, their vision checked, if we haven't checked them for other learning difficulties. Cause those can mimic ADHD. You also need to be checked for things like depression, anxiety, that's gonna change the medications and other interventions that we might choose. So primary and psychiatrist, always. A naturopathic doctor or RD who's very specialized in nutrition can help to implement a lot of the nutrition interventions that we talked about today. 

And then when it comes to exercise, you have so many options. You could do a personal trainer, yes, but sports is so good for kids. We know this like so many studies, but also you have the option of having a movement therapist. So choosing a therapist is the other pillar. You can kind of combine both if you have a movement therapist, cause usually the movement therapist has their degree in psychology. They've also gone to get a degree to figure out, how do we make movement fun and nourishing and therapeutic? So if you can find one of those, highly recommend. And then a team that is very communicative. 

Teachers are, if your kid is going to school, the teacher has to be involved, ideally in a way that doesn't make more work for them. But you have to respect what the teacher is saying. So many of the diagnostic criteria for ADHD and the screening tools that we use rely on teacher reports. And so making sure that you're communicating with the teacher and saying, "Hey, you know, we really think this might work. We're gonna try this. Will you let us know how it goes? What are you seeing?" can be a really amazing way to bring the whole care team, the whole family, the whole educational team into one setting and get the best results for your kid. As an adult, this is the same, just minus the teacher, probably.

Kalea Wattles
I love this idea of like team sports as medicine, where you have that built in community network, there's obviously the movement piece. There's definitely gonna be some solving and conflict resolution and sportsmanship. I just am really resonating with that idea. There are so many options. We have so many tools in this arena, and for anyone who's listening and they're soaking this all in... Dr. Kate, what do you hope that people take away from this episode and your message and your experience working with patients who have ADHD?

Kate Kresge
I think the message is that ADHD is common. People who have ADHD benefit tremendously from being managed. You have a ton of options for management. It is not just medications. You have so many things you can and should try doing. And you have a whole care team who's capable of helping, right? So make sure you're relying on multiple different providers so that you can get the best outcomes for you or your loved ones.

Kalea Wattles
Very well said. And we'll continue to look to you for updates on the clinical research and how we implement this in practice and how we care for ourselves and our family. So, Dr. Kate, thank you so much for being with us today and sharing all of your insights. We're really looking forward to our partnership with a bootcamp series. We so appreciate all that you share and all that you do to make medicine approachable for families. So thank you so much for being with us.

Kate Kresge
Thank you so much for having me. And thank you so much for training clinicians all over the world to do this type of medicine that people truly need.

Kalea Wattles
Discover the latest research and innovative clinical practices at IFM's Annual International Conference, May 29–June 1, 2024, at the Bellagio in Las Vegas. For more information, visit aic.ifm.org.