Functional Medicine Case Attention Deficit Hyperactivity Disorder … · 2019-05-07 · Functional...

Functional Medicine Case

Attention Deficit Hyperactivity Disorder (ADHD)

Kara N. Fitzgerald, ND, and Mark Hyman, MD

© 2010 The Institute for Functional Medicine 4411 Pt Fosdick Dr NW, Ste 305 Gig Harbor, WA 98335 800.228.0622 www.functionalmedicine.org

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Functional Medicine Cases

Functional Medicine Case: Attention Deficit Hyperactivity Disorder (ADHD)

Findings and Assessment at Initial Visit

History of Present Illness

LC, 12 years old, presented with attention deficit hyperactivity disorder (ADHD), dysgraphia, environmental allergies, asthma, insomnia, eczema, canker sores, migraine headaches, muscle cramps, stomach pain, nausea and diarrhea. He was first diagnosed with ADHD at age 5. He repeated kindergarten because of attention and behavioral difficulties. He began methylphenidate (Ritalin®) in first grade and continued to take it through fourth grade, although it did not change his behavior significantly. The drug was discontinued in fourth grade due to growth retardation. Off the medication, he gained weight but also increased his intake of junk food and deli meats.

LC had never received a positive teacher’s report. Off the methylphenidate, he continued to be disruptive and unfocused. He excelled in math but had severe dysgraphia (Figure 1). (Dysgraphia is defined as illegible handwriting and spelling errors and is associated with ADHD.1) LC’s environmental allergy symptoms were sinus congestion, postnasal drip, sore throats, and hives, for which he took cetirizine (Zyrtec®). His mother had removed his bedroom carpet and installed hardwood floors, but there was minimal improvement in his symptoms after these changes. His mother noted that dairy worsened his sinus congestion and postnasal drip. LC usually developed full-blown sinusitis about twice a year, for which he was prescribed antibiotics.

As a toddler, LC had developed asthma, hyperkeratosis pilaris, and eczema. For the asthma, LC was maintained on albuterol, levalbuterol (Xopenex®) and flunisolide (AeroBid®). The asthma caused difficulty with breathing at night, and therefore he did not sleep well. LC also suffered with cold-induced asthma attacks. His skin and anus were frequently itchy, and he got frequent canker sores in his mouth.

LC suffered from migraine headaches with hypersensitivity to light and sound, and had muscle cramps and spasms. For these complaints, he was given acetaminophen and ibuprofen. His stomach pain was treated with cimetidine. He also complained of nausea and had frequent bouts of diarrhea.

Comment: In most realms of psychiatry all the physical problems covered in LC’s HPI are considered irrelevant in guiding diagnosis and therapy of brain disorders or ADHD. In looking at his case from a functional perspective, however, they are the most relevant findings in his history and provide clear treatment direction.

Past Medical History

Birth and Infancy:

LC was a healthy seven lb, 10 oz baby, but the vaginal delivery was difficult. He was treated for hyperbilirubinemia. LC was breastfed for 10 months, and then he was given soy formula due to a “sensitive stomach.” Gluten-containing grains were introduced before one year of age. He was prone to diaper rash, had sensitive skin, and received frequent antibiotics for otitis media as a toddler.

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Comment: When introduced into the diet prior to the age of one, gluten-containing grains are associated with a statistically significant increase in the incidence of celiac disease in susceptible patients.2 Further, the use of soy formula in infants with a first degree relative with allergies may be associated with increased incidence of allergies, food intolerances and eczema.3 Early antibiotic use is also associated with increased incidence of atopic conditions, including asthma.4-7

Immunizations:

LC received a full vaccine schedule, including annual influenza shots.

Trauma:

LC sustained a concussion at 5 years old, but the CAT scan was normal.

Family Medical History

LC’s mother had migraine headaches, sinusitis, and food allergies. His sister had environmental allergies. LC’s father was in good health.

Medications

Cetirizine (Zyrtec) Albuterol Levalbuterol Inhaler (Xopenex) Flunisolide (Nasarel) Cimetidine (Tagamet®) Acetaminophen Ibuprofen

Comment: This is an overwhelming pharmacopoeia for a 12-year-old boy, and his physical, mental, and behavioral symptoms still were not under control. Even the methylphenidate did not significantly help his school performance or behavior or “cure” his ADHD, although it did cause growth retardation, and was therefore discontinued. Side effects of his other medications may also have been involved in the pathogenesis of his complaints. For example, cimetidine has been associated with nutritional deficiencies and gastrointestinal bacterial overgrowth from gastric acid inhibition.8 Glutathione depletion results from acetaminophen use9; and intestinal permeability increases with use of nonsteroidal anti-inflammatory medications such as ibuprofen.10 Flunisolide has also been shown to inhibit growth in children.1

Nutrition and Environmental Exposures

Usual Dietary Intake:

Breakfast: eggs and bacon, cereals with soy milk, occasional fruit

Lunch: deli meat sandwiches, cookies, peanut butter and crackers, carrots, and lemonade

Dinner: pizza, pork or chicken, broccoli, green beans, and rice/pasta/potatoes

LC had strong sugar and pasta cravings. He ate candy, cookies, or ice cream on a daily basis, although he felt better when he avoided dairy.

Environmental Exposures:

LC’s house had an unaddressed mold infestation. The type of mold was unknown. LC had no known drug allergies, but had numerous environmental allergies, including tree pollen and mold.

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Initial Assessment and Laboratory Recommendations

Organized According to the Functional Medicine Matrix

Initial Clinical Assessment Laboratory Tests Ordered

LIFESTYLE FACTORS: NUTRIENT IMBALANCES

Nutrient-poor dietMuscle spasmsAudio sensitivityHyperkeratosis pilaris AnxietyADHD

1. RBC essential minerals2. Serum vitamins A, E, & beta carotene3. Serum fatty acids 4. Organic acid B vitamin markers

IMMUNE SURVEILLANCE AND INFLAMMATORY PROCESS

ADHDAsthma Allergies Headaches Hives SinusitisAtopic dermatitisAphthous stomatitisPMH: diaper rash, otitis mediaFMH: food and environmental allergies, migraine headaches, sinusitis

5. Vitamin D6. IgG food sensitivities7. Celiac panel

DIGESTION AND ABSORPTION

GERDIBSPruritus ani > GI yeast infectionNauseaFrequent antibiotic useADHD

8. Complete blood count and metabolic panel (assesses yeast or parasite infection)

9. Organic acids microbial markers * IgG food sensitivities, celiac panel

DETOXIFICATION AND BIOTRANSFORMATION

ADHDFood additives

10. 6-hour urine toxic metal challenge test with 250 mg DMPS (2,3-dimercapto-1-propane-sulphonic acid) provocation

HORMONE AND NEUROTRANSMITTER REGULATION

ADHD DysgraphiaInsomniaAnxiety

11. Plasma amino acids 12. Urine neurotransmitter metabolites

*Laboratory tests frequently pertain to multiple areas of imbalance, and therefore may be listed in more than one Matrix category.

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Significant Laboratory Findings


LIFESTYLE FACTORS: NUTRITIONAL IMBALANCES

Test Results 95% Reference Interval

1. Red Blood Cell Minerals

Zinc 2.5 L 3.3-7.7 ppm

Magnesium 15 L 18-40 ppm

Copper 260 LN 257-500 ppb

Manganese 22 LN 19-41ppb

Chromium 1.7 LN 1.4-7.9 ppb

LC was very low in zinc and magnesium; low-normal levels were reported for the rest of the minerals. These findings were not surprising given LC’s poor diet, GI inflammation, and cimetidine use. Zinc deficiency is implicated in asthma, atopic dermatitis, allergies, and ADHD.12-14 Magnesium deficiency is also implicated in headaches, insomnia, muscle cramps, and spasms.15 Copper and manganese are important cofactors in the antioxidant enzyme superoxide dismutase. Chromium as chromodulin may improve cellular glucose uptake by potentiating insulin receptor activity.16

Test Results mg/L 95% Reference Interval

2. Serum Vitamins

Vitamin E 7.2 LN 7.1-31.0

Vitamin A 0.55 LN 0.41-1.5

Beta-carotene <0.2 L 0.22-2.7

Fat-soluble vitamins were found to be low (vitamins E and A) or undetectable (beta carotene) in LC’s serum, including vitamin D (discussed below). While sometimes such a pattern can indicate fat malabsorption, in LC’s case this was most likely due to poor dietary habits.

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Test Results uM 80% and 95% Reference Intervals

3. Serum Fatty Acids

Plasma saturated fatty acids:

Palmitic 3,425 HN 1,610-2,946; 1,364-3,525

Stearic 951 HN 546-851; 501-1,007

Arachidic 23.0 H 11.3-19.9; 9.7-22.8

Behenic 84 H 31-57; 27-66

Lignoceric 53 H 24-45; 20-52

Plasma trans fatty acids:

Palmitelaidic 14.5 HN ≤10.8; ≤18.6

Total C:18 Trans 199 HN ≤107; ≤210

Plasma omega-3 fatty acids:

Alpha Linolenic Acid (ALA) 60 >37; 22-144

Eicosapentaenoic Acid (EPA) 100 >44; 19-362

Docosahexaenoic Acid (DHA) 60 >46; 31-112

Omega-6 fatty acids:

Arachidonic Acid (AA) 785 H 330-630; 260-750

Plasma free fatty acids (primarily palmitic acid) roughly approximate plasma triglyceride levels.17 The numerous high-normal saturated fatty acids indicated that, at 12 years old, LC probably had higher triglycerides as well, most likely caused by insulin-stimulated upregulation of liver fatty acid synthesis. Given LC’s high-sugar diet, early onset dysinsulinemia was not surprising. As discussed above, mild chromium deficiency could be another underlying factor contributing to dysinsulinemia.

The elevated trans fatty acids (TFAs) were further evidence of LC’s poor food choices. TFAs are strongly implicated in metabolic syndrome and cardiovascular disease.18

Of the polyunsaturated omega fatty acids, the inflammatory eicosanoid precursor arachidonic acid (AA) was very elevated. It was found in much greater quantity than the anti-inflammatory omega-3 fatty acid eicosapentaenoic acid (EPA), creating a relative deficiency of EPA. AA is implicated in the pathogenesis of allergies and asthma,19,20 while EPA insufficiency and a low EPA/AA ratio are implicated in ADHD.21,22

Comment: Had LC continued with his presenting diet and lifestyle, the plasma fatty acid analysis reveals the likelihood for continued inflammatory conditions as an adult, including possibly heart disease, diabetes, and cancer. Addressing these findings early not only treated his initial complaints, but significantly reduced his risk for a future of ill health.

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Test Results ug/mg creatinine

80% and 95% Reference Intervals

4. Urinary Organic Acids

Kynurenate 3.0 HN ≤2.9; ≤4.7

Xanthurenate 0.9 HN ≤0.90; ≤1.50

When elevated, the organic acids above demonstrate a functional B6 insufficiency.23 A number of LC’s symptoms may have been attributable to insufficient B6, including ADHD, mood disturbances, and insomnia.24


Test Result Reference Intervals

5. Serum Vitamin D 25 OH 24 ng/m L < 20 ng/mL: Insufficiency20-40 ng/mL: Hypovitaminosis40-100 ng/mL: Sufficiency> 100 ng/mL: Toxicity

Hypovitaminosis D likely played a role in LC’s imbalanced immune response, contributing to both his chronic infections and hypersensitivities. Low vitamin D has been implicated in asthma, general development problems, and mood disorders.25 Optimal serum vitamin D is now thought to be between 40-70 ng/mL; individuals with serious diseases should maintain levels between 55-70 ng/mL.26

Test

6. IgG (total) Reactive Foods*

Bean, Kidney (+1) Cheese (+1)

Milk, Cow’s (+4) Mustard (+1)

Peanut (+4) R. Seed (Canola) (+1)

Walnut (+1) Yeast, Brewer’s (+2)

* Results range from 0 = no reaction to +5 = severe reaction.

ELISA testing for IgG response to 90 different foods demonstrated a strong positive reaction to dairy and peanuts, and mild positive reactions (+1 or +2) to six other foods, indicating intestinal hyperpermeability and GI inflammation.27-29 These sensitivities may be associated with the pathogenesis of atopic dermatitis, asthma, and ADHD.30-32

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Test Result 95 % Reference Interval

7. IgG Antigliadin 17 HN 0-19 units

LC’s IgG antigliadin antibodies were trending high at 17 units. Clinical experience warranted minimizing gluten intake.


Test #8: Complete Blood Count and Metabolic PanelLC’s serum chemistries and complete blood count were within normal limits, although his lymphocyte count was higher than his neutrophil count. Clinical experience suggested that this finding, when combined with his history of antibiotic use and complaint of anal itching, probably indicated a fungal or viral infection.

Test #9: Organic Acid Microbial MarkersSurprisingly, LC’s organic acid microbial markers were within normal limits, ruling against significant GI dysbiosis, although he did demonstrate intestinal hyperpermeability with multiple food sensitivities, as discussed above in “Immune Surveillance and Inflammatory Process.”


Test Result ug/g creatinine 95% Reference Interval

10. Urine Toxic Metals (6-hour challenge test)

Lead 17 H ≤5

DMPS (2,3-dimercapto-1-propanesulfonic acid) provocation challenge demonstrated an elevated urine lead level in LC. While whole blood is considered the gold standard for identifying lead toxicity, urinary lead concentration has also been shown to increase with toxicity.33 Chelating agents have been shown to accelerate the urinary excretion of lead and therefore may be useful for revealing lead exposure. Lead exposure may produce cognitive deficits at levels commonly encountered in blood, and therefore numerous recommendations have been made to reduce safe threshold levels.34 Lead toxicity and environmental toxins such as household mold have been linked to cognitive and behavioral problems in children, including ADHD.35-38 Sources of lead include toys, paint, contaminated soil, lead plumbing, and glazed pottery.34 Since essential mineral deficiencies may allow for increased uptake of toxic metals,39 repletion prior to and during treatment of toxicity is important.

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HORMONAL AND NEUROTRANSMITTER REGULATION

Test Result 80% and 95% Reference Intervals

11. Plasma Amino Acids

Tryptophan 36 LN >40; 26-62

Test Result ug/mg creatinine 80% and 95% Reference Intervals

12. Urine Neurotransmitter Metabolites

Homovanillate 3.0 LN 3.2-16.7; 1.0-23.0

5-Hydroxyindoleacetate 2.6 LN 2.7-14.0 1.2-39.0

The urinary neurotransmitter metabolites for dopamine and serotonin, homovanillate (HVA) and 5-hydroxyindoleacetate (5-HIAA), were low normal in LC, suggesting lower total body neurotransmitter turnover. Corroborative evidence for the risk of serotonin insufficiency was found with low plasma tryptophan, the amino acid precursor to serotonin. Furthermore, 2 important nutrients involved in dopamine and serotonin synthesis, B6 and magnesium, were both reported insufficient in LC (discussed above in “Lifestyle Factors: Nutritional Imbalances”). Genetic and metabolic research has linked imbalances of CNS dopamine and serotonin to ADHD with regard to uptake, synthesis, and breakdown, although there has not been a consistent pattern noted.40 Serotonin imbalance has also been implicated in insomnia41 and IBS.42

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Summary of Initial Assessments, Laboratory Findings, Treatments, and Treatment Rationale



Clinical Assessment and Diagnoses

Laboratory Results Recommended Treatment

Treatment Rationale

• Nutrient deficiencies • Fatty acid imbalance• Anxiety• Muscle spasms • Audio sensitivity• Hyperkeratosis

pilaris

• Low RBC essential minerals

• Low serum vitamins A, E, and beta carotene

• Elevated plasma AA:EPA ratio

• Low B6 (organic acid functional markers)

• Elevated plasma saturated and trans fatty acids

• Zinc citrate 20 mg; 1 tab QD

• Magnesium glycinate 120 mg; 2 caps QHS

• Multivitamin/mineral (MVM); 2 tabs QD

• MVM for general nutrient needs with extra zinc for immune dysfunction, diarrhea and allergies, and magnesium for muscle cramps, insomnia, anxiety, and auto sensitivity.

• EPA/DHA 6:1; 1 cap BID

• Anti-inflammatory omega-3 fatty acid used to minimize pro-inflammatory arachidonic acid cascade as seen clinically with asthma, allergies, dermatitis hyperkeratosis pilaris

• Pyridoxal 5’ phosphate (activated B6) 50 mg; 1 cap QD

• B6: evidence supports its use in ADHD, serotonin metabolism, and methylation/sulfuration

• Dietary changes as noted in “Immune Surveillance and Inflammatory Process” below

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Treatment Rationale

• Hypovitaminosis D• Multiple food

sensitivities• Intestinal

hyperpermeability• ADHD• Asthma • Allergies • Headache • Hives • Sinusitis• Atopic dermatitis• Aphthous stomatitis• PMH: diaper rash,

otitis media• FMH: food and

environmental allergies, migraine headaches, sinusitis

• Low serum vitamin D

• Multiple + IgG food sensitivities

• Elevated IgG antigliadin antibodies

• Vitamin D3 1000 U; 1 cap QD

• Serum vitamin D goal: 40-70 ng/mL

• Diet: Modified elimination diet based on test results. No dairy, peanuts, gluten, sugar, or trans fatty acids. Reduce saturated fat intake. Whole foods, minimally processed; organic diet. Organic dark chocolate is fine. (See also Nutritionist Comments below.)

• Dietary changes based on clinical history, IgG food sensitivities, antigliadin antibodies, intestinal hyperpermeability, fatty acid deficiency, and suspected fungal overgrowth

*Also supportive: zinc, magnesium, probiotics

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Treatment Rationale

• Yeast overgrowth• GERD• IBS• Pruritus ani• Intestinal

hyperpermeability• Nausea

• Elevated lymphocyte: neutrophil ratio

* +IgG food sensitivities, IgG antigliadin antibodies

• Fluconazole 100 mg; 1 tab QD x 30 days

• Clinical and laboratory evidence for Candida overgrowth. Clinical experience suggests long-term fluconazole with dietary changes for best outcome

• Broad spectrum probiotics; 2 caps Q AM

• Probiotic therapy to support microbiota. Beneficial for treatment of intestinal hyperpermeability and immune hypersensitivity, food sensitivities, and IBS

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Treatment Rationale

• Mild lead toxicity • ADHD• Food additives

• Elevated 6-hour urine lead after 250 mg DMPS (2,3-dimercapto-1-propane-sulphonic acid) provocation

• After 2 months on treatment protocol: Start DMSA (dimercaptosuccinic acid) 100 mg, one twice a day, every other week for 3 days (such as MTW), then 11 days off. Do this for 6 months and then repeat the DMPS challenge test

• Oral chelation with DMSA is one of the main treatments for lead toxicity. Pulse dosing DMSA and concurrent detoxification and essential minerals supplementation will minimize adverse reactions. It is important to ensure normal kidney function and bowel movements and treat nutrient deficiencies first, particularly essential minerals, amino acid deficiencies, and impaired methylation

• Dietary changes as noted in Immune Surveillance and Inflammatory Process (above)

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Treatment Rationale

• ADHD • Dysgraphia• Insomnia

• Low-normal plasma tryptophan

• Low-normal urine HVA, 5HIAA

• 5HTP 50-100 mg QHS as needed for sleep

• 5HTP is a serotonin precursor. It will provide substrate for serotonin production while preserving tryptophan. CNS serotonin is methylated to produce melatonin. Increased serotonin may therefore help with insomnia

*Assessments, laboratory tests, and treatments frequently pertain to multiple areas of imbalance and may therefore be listed in more than one Matrix category.

Follow-up Visit at Two Months

After starting his treatment, which included removing yeast and antigenic foods and adding the needed micronutrients and probiotics, LC’s mother stated that he was much less disruptive in the classroom. He was sleeping though the night. His headaches and runny nose improved. He hadn’t required cetirizine or flunisolide for some time. His asthma symptoms improved and were no longer triggered by cold. Light, sound, and smell sensitivities were reduced considerably. LC tolerated supplements and diet changes well, because he felt so much better when he followed the plan. No changes were made to LC’s treatment plan at his 2-month visit.

Follow-up Visit at Six Months

LC’s mother reported that he was free from his chronic symptoms for the first time in his life. His dysgraphia improved considerably (see Figures 1 and 2 for the pre- and post-treatment writing samples). He no longer required his medications, including antihistamines (cetirizine and cimetidine), bronchodilators, steroid inhaler, acetaminophen, and ibuprofen. His mood and behavior had stabilized, and his ability to focus improved greatly. His hyperactivity symptoms, including disruptiveness, irritability, and anxiety, were gone. His hives, asthma, runny nose and postnasal drip, anal itching, stomach aches, nausea, diarrhea, headaches, muscle cramps, and sensitivity to loud noises were all completely resolved. He slept soundly at night. He was doing well in school, academically and socially.

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Just after his 6-month follow-up, LC’s mother wrote the following:

We had a meeting at LC’s school this morning, where the teachers, school counselor, parents, and principal all get together to review “the plan” for kids with special educational needs (in LC’s case prompted by the ADHD diagnosis). This was the first time in his entire schooling history that everything seems to be going well. The input from his teachers was that he is “a different kid” than they saw in the first half of the year and that they’re amazed by the difference. The school nurse hasn’t seen him [in months] (and he used to be in her office several times a week). The school psychologist said his social skills are very good, age appropriate, and that she sees no problems at all. She also noted that LC seems very proud of himself and his new health and that he’s taking good ownership of all the changes in his diet. He even seems to be shrugging it off when the other kids at school tell him he’s an “alien” because he doesn’t drink soda.

This was just such a fantastic meeting and I wanted to pass along the good news and say Thank You!

Laboratory Tests:

Follow-up testing revealed normalization of the lymphocyte:neutrophil ratio and improvement in his nutritional status, including normalized levels of vitamin E and beta carotene, RBC minerals, and tryptophan. His saturated fatty acids and trans fatty acids were all within their normal ranges, reducing the concern for dysinsulinemia and confirming LC’s commitment to following dietary changes. He still required vitamins D and A. The dietary changes and supplement interventions reversed not only his presenting complaints, but radically improved the prognosis for his future health.

The RD/Nutritionist’s Comments:

LC made remarkable changes, and he was very motivated to do so because he received the immediate feedback of improved health. Most notable, of course, was the resolution of the ADHD symptoms. LC’s changes did not come overnight. Indeed, his was a “top-down” change, with his mother making the first moves toward wellness in her life, and experiencing the fruits of good health herself, and then bringing along her family. Wellness of this nature is an ecological shift, like a pebble tossed in a pond that ripples slowly to those around us.

I had been working with LC’s mom for a long time before we saw LC. With his mom (as with most people), we started slowly. We did an initial clean-up of the worst (most problematic/toxic) foods in the house, and then removed one problem food per week from her diet. (Sometimes we would negotiate one food change a month. It’s important to move at the patient’s pace and ability to integrate change.)

Generally, when a child needs to make major dietary changes, it does require the family’s buy-in. A significant move away from being unconscious about what we eat toward paying very close attention to where food comes from, what it’s made of, the toxin and nutrient content, and the macronutrient composition requires a powerful and intentional return to our roots, how we evolved to eat. We must also pay attention to how we feel after we eat, and notice the impact of food on our health and well-being. We need to have everyone on board in the family, even if only a little, when thinking about food from this perspective. The home front is the nutritional frontier!

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To succeed with such changes, the basics need to be addressed:

� Where to shop/what to buy

� How to avoid antigenic foods

� How to replace the foods being eliminated from the diet with healthy alternatives

� How to read and understand food labels

� Identifying hidden food additives and antigens

� “Natural” versus “organic”

� Healthful, affordable foods

� Easy, quick recipe ideas

� Eating healthy on the go

� Eating well at restaurants

� Knowing the nutrient content of foods

� Relying on foods, rather than supplements, for long-term nutrient needs

� Understanding the appropriate balance and quantity of food

� Stress-free eating: rest and digest

� Resources for healthy eating: cookbooks, internet sites

The team approach to treatment in the case of LC was vital to his success. In addition to his medical doctor, he worked with me, a support RN, and of course his mother, father, and siblings. I am not sure we would have seen such a significant turnaround, as demonstrated by his writing specimens, without this approach to care.

Additional Forms

� A completed Matrix form for LC is provided in Figure 3.

� A convenient case-at-a-glance summary for LC is provided in Figure 4.

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Figure 1: LC’s Pre-treatment Writing Sample

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Figure 2: LC’s Post-treatment Writing Sample

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Figure 3: Completed Matrix Form for LC

Lifestyle Factors:Nutrient Imbalances

Digestion& Absorption

Detoxification &Biotransformation

Hormone &Neurotransmitter

Regulation

The Patient’s Story RetoldAntecedents(Predisposing)

Triggering Events(Activation)

Immune Surveillance& Inflammatory Process

Nutrient-poor dietMuscle spasmsAudio sensitivity

Hyperkeratosis pilarisAnxietyADHD

ADHD, asthma, headacheAllergies, hives, sinusitis

Atopic dermatitisAphthous stomatitis

PMH: Diaper rash, otitis mediaFMH: Allergies, sinusitis, headaches

ADHD Dysgraphia Insomnia Anxiety

ADHDFood additives

GERD IBS

Pruritus ani Nausea

Headache ADHA

Frequent antibiotic use

Nutrition Status Exercise Sleep Beliefs & Self-Care Relationships

©2010 The Institute for Functional Medicine

SAD, sugar and pasta cravings. Candy, cookies, and ice creamdaily. Congestion with dairy.Likes veggies.

Minimal Insomnia worsened bynightime asthma.

Wants to get better. Supportive familyand school.

Family history of migraines, sinusitis, food and environmental allergiesAtopyEarly introduction of potentially antigenic foods

Infectious and/or toxic exposuresEarly introduction (and chronic use) of antiboticsPoor dietIBSNSAID use

Exposure to environmental allergies and/or toxinsIngestion of antigenic foods

Functional Medicine Matrix ModelPatient: LC Age: 12 Sex: Male

Chief Complaint: ADHD

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Case at a Glance: ADHD

History of Present IllnessLC presented at age 12 with attention deficit hyperactivity disorder (ADHD), dysgraphia, environmental allergies, asthma, insomnia, eczema, canker sores, migraine headaches, muscle cramps, stomach pain, nausea, and diarrhea. LC was first diagnosed with ADHD at age 5. He repeated kindergarten because of attention and behavioral difficulties. He began methylphenidate (Ritalin®) in 1st grade and continued to take it through 4th grade, although his behavior did not change significantly. The drug was discontinued in 4th grade due to growth retardation. Off the medication, he gained weight and increased his intake of junk food and deli meats. He continued to have trouble focusing in school and was still disruptive. He had never received a positive teacher report. He had severe dysgraphia, but excelled in math. His medications included: cetirizine (Zyrtec®), albuterol, levalbuterol inhaler (Xopenex®), flunisolide (Nasarel or AeroBid®), cimetidine (Tagamet®), acetaminophen, and ibuprofen. He liked pasta, sweets, and ice cream despite the fact that he felt better avoiding dairy.

Abbreviated Assessments, Laboratory Findings and Treatments Organized According to the Functional Medicine Matrix

(Refer to full case presentation for details, including treatment rationale.)

Clinical Assessment Laboratory results Recommended Treatment


Nutrient deficiencies Fatty acid imbalanceAnxietyMuscle spasms Audio sensitivityHyperkeratosis pilaris

Low essential mineralsLow vitamins A, E, beta caroteneElevated AA:EPA ratioLow B6 (organic acid markers) Elevated saturated and trans fatty acids

Zinc citrate Magnesium glycinate Multivitamin/mineral EPA/DHA Pyridoxal 5’ phosphate Dietary changes as noted below


Hypovitaminosis DFood sensitivities Intestinal hyperpermeabilityADHDAsthma, allergies, headache, hives, sinusitisAtopic dermatitisAphthous stomatitis

Low serum vitamin DMultiple + IgG food sensitivities Elevated IgG antigliadin antibodies

Vitamin D3Dietary changes: Modified elimination diet based on test results. No dairy, peanuts, gluten, sugar, or trans fatty acids. Reduce saturated fat intake. Whole foods, minimally processed, organic diet. (Nutritionist comments available in full case presentation.)


Yeast overgrowthGERD, IBS, pruritus aniNausea

Elevated lymphocyte:neutrophil ratio+IgG food sensitivities, IgG antigliadin antibodies

Fluconazole Broad spectrum probiotics


Mild lead toxicity ADHDFood additives

Elevated 6-hour urine lead after 250 mg DMPS (2,3-dimercapto-1-propane-sulphonic acid) provocation

After 2 months on treatment protocol: Start DMSA (refer to full case presentation for details)Dietary changes as noted above


ADHD, dysgraphiaInsomnia

Low-normal plasma tryptophanLow-normal urine HVA, 5HIAA

6-Month Follow-up:LC’s mother reported that he was free from his chronic symptoms for the first time in his life. His dysgraphia improved dramatically (compare Figures 1 and 2 in full case presentation). He no longer required his medications, including antihistamines (cetirizine and cimetidine), bronchodilators, steroid inhaler, acetaminophen, and ibuprofen. His mood and behavior stabilized, and his ability to focus improved greatly. His hyperactivity symptoms, including disruptiveness, irritability, and anxiety, were gone. His hives, asthma, runny nose and postnasal drip, anal itching, stomachaches, nausea, diarrhea, headaches, muscle cramps, and sensitivity to loud noises were all completely resolved. He slept soundly at night. He was doing well in school, academically and socially (see mother’s comments in full case presentation). LC tolerated supplements and dietary changes well, because he felt so much better when he followed the plan.

Figure 4: LC Case-at-a-Glance

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