Stimulant Medications in the Pediatric Population

ADHD diagnosis and stimulant medication prescription is slowly increasing overtime. Most of these diagnoses and prescriptions come from the pediatrician. The FDA approved the minimum age for most stimulants is 6 years old.

Mental health diagnoses in the pediatric population commonly included ADHD, Depression, and Anxiety. Although Depression and Anxiety are treated with SSRI’s rather than a stimulant medication as in ADHD, children may still have side effects pertaining to their nutritional intake.

Case Study - Pediatrics, 2015 [1]

Joey, a 6-year-old, 20-kg boy, presents to his pediatrician, Dr Smith, with complaints of significant hyperactivity, impulsivity, and defiance that are problematic in the classroom and at home. Presentation in the office and parent and teacher Vanderbilt rating scale scores* are consistent with a diagnosis of ADHD, and other medical, psychiatric, and learning issues are ruled out. Dr Smith provides psychological education about ADHD, refers for parent management training, and recommends school accommodations for classroom symptoms. After ensuring no contraindications, he prescribes dexmethylphenidate extended release (ER) (Focalin XR) 5 mg every morning (qAM).

At subsequent weekly or biweekly follow-ups, the dose is titrated to 10, 15, and 20 mg qAM based on parent and teacher Vanderbilt scores demonstrating little or no improvement. At the fourth follow-up, Dr Smith switches to amphetamine/dextroamphetamine ER (Adderall XR) 20 mg, after which parent and teacher report notable improvement in hyperactivity and impulsivity, although Joey experiences appetite suppression. Dr Smith counsels on high-protein and high-calorie nutrition, but Joey’s weight decreases to the point of crossing a weight percentile. The amphetamine/dextroamphetamine ER dose is decreased to 15 mg then to 10 mg over subsequent visits; although Joey’s appetite and weight improve toward baseline, Vanderbilt scores demonstrate return of hyperactivity and impulsivity, although not to the degree of severity of initial presentation. Dr Smith augments amphetamine/dextroamphetamine ER 10 mg qAM with guanfacine ER (Intuniv) 1 mg at bedtime (qHS).

Three weeks later, parent and teacher Vanderbilt scores endorse satisfactory ADHD symptom management, which is maintained through the remainder of the school year, and Joey’s weight gain follows an age-appropriate trajectory.

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Cases like Joey’s are very common when first addressing the mental diagnosis with medication. Finding what medication best suits your needs is a slow process to ensure the side effects are minimized. One of the side effects evident in Joey’s case was suppressed appetite. During a period in Joey’s life where he is still growing and developing, it is extremely important for him to follow his natural weight/height trajectory. When children are growing, they should not be losing weight. Weight loss can lead to developmental delays, including delayed onset of puberty, stunted growth, and stagnant bone growth. To prevent these serious symptoms from occurring, it is important to discuss intake and nutrition with your pediatrician and psychiatrist. If needed, get a registered dietitian involved in your child’s care to address strategies to ensure your child is eating enough to follow their age-appropriate trajectory.

[1] Southammakosane, C., & Schmitz, K. (2015). Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety. Pediatrics, 136(2), 351–359. doi: 10.1542/peds.2014-1581

Food, Why Can't I Escape It?

“You’re the apple of my eye”

“You’re so cute, I could just eat you up!”

“There's nothing like Grandma’s cooking”

“You’re sweeter than pie”

Food is everywhere. Its in our stores, on our commute to work, people eat every day, its on our billboards, in our sayings, in songs and advertisements. Just like I tell my clients, the hardest part of seeing a dietitian when you are someone who is struggling in their relationship with food is having to face the fact that food is everywhere. It is hard to sit in a room with a dietitian and talk about food for the entire hour. Eating disorders and disordered eating is a huge burden on individuals. Food is not something you can escape, avoid or ignore.

I suppose some of you reading this could look out your window and see a restaurant, grocery store or food stand a stones throw away. The war we let our emotions set on food is a war without an ending. Spoil alert, your emotions will lose eventually.

Food is neutral. It is not intentionally trying to harm you, give you a chronic disease or alter all the work you put into changing or maintaining your appearance. Your emotions and beliefs that you cast on food is what is effecting those things. Food is actually trying to help you! To keep you alive, to feed your organs and keep you young. Food is not the enemy.

Food is the scapegoat. Society tells us over and over “carbohydrates will give you diabetes.” Or shouting diet statements at you such as “Lose weight quick by participating in a 20 hour fast!” - surely we all can understand the concept of starving ourselves by not eating for 20 hours can cause weight loss… because you’re not eating!! But does fasting work for everyone? Not really, no. Because no matter how hard we try to fight our biology, our body will do whatever it can to protect us and get the energy it needs during the other 4 hours your emotions allow it to eat.

Ok, i’m off my soapbox now.

You all know this. I’m not telling you anything new. I may be telling you something you don’t want to hear, and that is, you can not escape food.

But really! Why would you want to escape food?! How amazing and easy life would be if you could walk into Panera and not immediately have to think about calories, what else you ate today, what is the “cleanest”, what is balanced, etc. I have had almost everything on Panera’s menu and I can tell you, you will survive. Your body is much stronger, much more resilient than you think. When was the last time you gave your body the chance to prove to you it can handle all the foods in the world? (Minus those with allergies of course :P).

Think of your body as the sweet, precious child you are too afraid to let grow up. Would you starve that child? Keep them isolated and unable to try new things? Eventually all you are doing is causing the child more harm in the long run. Give the child some of their own control. Its ok to start small so you can learn one step at a time that the child can handle the power it is given. Eventually the trust will come and the burden will be lifted from your shoulders. Your relationship with the child will be that much stronger and trust will come easily.

If this is too hard to do on your own, that is where a dietitian, a therapist, a doctor, significant other, etc. comes into play. Everyone needs support and that is what we are here to provide. To help your body win the war.

Food may feel like the enemy right now, and that’s ok. But you can’t escape it, so lets first learn how to live with it.

Orthorexia- When Healthy Eating Becomes an Obsession

Do you eat healthy? Great! Do whatever works for you and makes you feel good. Bamboo Nutrition in Columbia, MO is one place to look if you feel your healthy eating may becoming an unhealthy obsession.

Orethorexia is a termed coined by Steven Bratman. What began as an individual wanting to eat healthy for their own reasons (i.e. energy, longevity, activity, etc.) turned into an obsession. This obsession with healthy eating caused social anxiety, withdraw, irritability, poor sleep, and much more. The thought of food consumed this person’s thoughts all day and night. At this point, this individual may have orthorexia.

Steven Bratman’s definition of Orthorexia states: “Orthorexia is an emotionally disturbed, self-punishing relationship with food that involves a progressively shrinking universe of foods deemed acceptable. A gradual constriction of many other dimensions of life occurs so that thinking about healthy food can becomes the central theme of almost every moment of the day, the sword and shield against every kind of anxiety, and the primary source of self-esteem, value and meaning. This may result in social isolation, psychological disturbance and even, possibly, physical harm. “

In other words, When healthy eating becomes unhealthy.

Don’t get me wrong, just because a person eats healthy and likes to eat organic or follow the latest trends in the food industry does not mean they have orthorexia.

Steven Bratman’s self-test is a good place to start:

The Bratman Orthorexia Self-Test*

If you are a healthy-diet enthusiast, and you answer yes to any of the following questions, you may be developing orthorexia nervosa:

(1) I spend so much of my life thinking about, choosing and preparing healthy food that it interferes with other dimensions of my life, such as love, creativity, family, friendship, work and school.

(2) When I eat any food I regard to be unhealthy, I feel anxious, guilty, impure, unclean and/or defiled; even to be near such foods disturbs me, and I feel judgmental of others who eat such foods.

(3) My personal sense of peace, happiness, joy, safety and self-esteem is excessively dependent on the purity and rightness of what I eat.

(4) Sometimes I would like to relax my self-imposed “good food” rules for a special occasion, such as a wedding or a meal with family or friends, but I find that I cannot. (Note: If you have a medical condition in which it is unsafe for you to make ANY exception to your diet, then this item does not apply.)

(5) Over time, I have steadily eliminated more foods and expanded my list of food rules in an attempt to maintain or enhance health benefits; sometimes, I may take an existing food theory and add to it with beliefs of my own.

(6) Following my theory of healthy eating has caused me to lose more weight than most people would say is good for me, or has caused other signs of malnutrition such as hair loss, loss of menstruation or skin problems.

*There are many self-tests on the internet to use in determining if you may have orthorexia or be on the verge of developing orthorexia, however, this is the only self-test that Steven Bratman approves.

Why Self Care?

You may be thinking, “I don’t need self-care. That’s for people who need therapists and yoga.” Mmmmm….. Not quite.

Self care is something us mental health professionals preach and preach because surely enough, we all could use some TLC.

What does self-care look like?

• A bath or shower

• Curling up with your fur baby, or real baby!

• A nap

• Doing something that makes you feel beautiful such as buying new makeup, getting a haircut, getting your nails done

• Finding a place in nature and being by yourself

• Going for a walk or to a work out

• Baking

So many forms of self-care! But really, it comes down to doing what re-energizes YOU.

Self care is for all of us. It’s for when our battery needs recharged. When we’ve had a bad day. When our motivation is low.

Bottom line. Self care means taking care of yourself. And we all need it.

Don’t keep pouring from your cup without refilling it. In order to be the best version of yourself and serve those around you, you must take care of yourself too. It is not selfish, it is only giving back to yourself so you can continue to brighten those around you.

What’s your self care?

Isn't Intuitive Eating Just Another Diet?

This is a common question I get from clients, especially clients who have been dieting for many years. It can be really difficult to feel the difference between intuitive eating and a diet in the beginning. As you begin learning how to become an intuitive eater you may feel as though you are “abusing the rule book” or possibly “failing” another diet.

I assure clients that with intuitive eating there is no rule book and it is not possible to fail.

The main difference between a diet and intuitive eating is the sense of control. It may feel like you’re in control on a diet, but really, the food and the diet routine itself is the one in control. You are a slave to the limitations and restrictions that the diet places around food. Intuitive eating puts you in the drivers seat. It offers you the control and freedom to eat whatever you’d like whenever you need. There are no limitations or restrictions. No time frames that you must eat between. You are in control when you are an intuitive eater.

The subconscious dieter, inside all of those who have been on many diets before beginning to learn to eat intuitively, may slip out more than once in the beginning of your new anti-dieting journey. What is the subconscious dieter? It is the one telling you to restrict, to eat like it is the last time you will have certain foods, the one telling you to go 20 minutes longer on the stair stepper. When you are practicing eating when you’re hungry and stopping when you’re full, the subconscious dieter is the one telling you that you are full all the time or that you may feel hungry but its not really necessary that you eat. The subconscious dieter is a hard voice to quiet down. It may always be there, those precipitating thoughts and feelings will come every so often but what matters is how you respond to them.

Is intuitive eating another diet? It is not meant to be a diet, but the opposite of a diet. However, if you allow your subconscious dieting mind to take the wheel, intuitive eating may very well feel like another diet.

Remember, you cannot fail at intuitive eating. It takes time and no one is perfect all the time. Be kind to yourself as you retrain your mind to eat freely without guilt or other emotions. Eventually you will be stronger than the subconscious dieter voice and when those thoughts and urges arrive, you will quickly be able to refute them and move on.