RHR: The Functional Medicine Approach to ADHD, with Dr. Jim Greenblatt

supIn this episode, we discuss:

• Greenblatt’s background in Functional Medicine
• What ADHD is
• Reframing our ideas about ADHD
• The root causes of ADHD and how they’re addressed with the Functional Medicine approach
• The role that medication plays in ADHD treatment
• Non-biochemical treatments for ADHD
• How “SAIL” can help parents understand kids with ADHD
• How to find a Functional Medicine practitioner and get help with ADHD

Show notes:

• Finally Focused: The Breakthrough Natural Treatment Plan for ADHD That Restores Attention, Minimizes Hyperactivity, and Helps Eliminate Drug Side Effects, by Dr. Jim Greenblatt and Bill Gottlieb
• Sitting Still Like a Frog: Mindfulness Exercises for Kids (and Their Parents), by Eline Snel
• Mindful Monkey, Happy Panda, by Lauren Alderfer
• Psychiatry Redefined: Functional and integrative Psychiatry Education

Hey, everybody, Chris Kresser here. This week, I’m really excited to welcome Dr. Jim Greenblatt as a guest on the show. Dr. Greenblatt is a pioneer in the field of integrative medicine, and he’s been treating patients since 1988. After receiving his medical degree and completing a psychiatry residency at George Washington University, he completed a fellowship in Child and Adolescent Psychiatry at Johns Hopkins Medical School. He currently serves as the Chief Medical Officer at Walden Behavioral Care in Waltham, Massachusetts, and serves as an Assistant Clinical Professor of Psychiatry at Tufts University School of Medicine, and Dartmouth College Geisel School of Medicine.

So I’m really excited to talk to Dr. Greenblatt. He wrote a book that I recently read called Finally Focused, which explains a Functional Medicine approach to treating ADHD [attention-deficit/hyperactivity disorder] and similar behavioral disorders. I was really excited to find the book. I’ve been treating ADHD from a Functional Medicine perspective for several years. But somehow, I had missed this book and Dr. Greenblatt’s work previously. So it was a hidden treasure that I recently discovered. And as soon as I finished the book, I reached out to him, and he generously agreed to join us as a guest on the show. He has deep expertise in this field and I’m really, really looking forward to talking to him about this. Because this is an area that so many kids struggle with these days, and their parents and caregivers. And so many of the treatments that are available, while they can sometimes be effective, often are not. And even if they are effective, [they] can have pretty debilitating side effects.

And I’ve long believed that we need a radically different approach to treating these behavioral disorders, getting to their root cause, as we do in Functional Medicine, instead of just trying to suppress the symptoms with medication. That doesn’t mean medication doesn’t play a role. It definitely can. But I think we can all agree that a more comprehensive and holistic long-term solution is in the best interest of these kids and their families. So without further delay, I bring you Dr. Jim Greenblatt.

Chris Kresser:  Dr. Greenblatt, thank you so much for joining me on the show. I’ve really been looking forward to this.

Jim Greenblatt:  Chris, it’s a pleasure to be part of the show. Appreciate the opportunity.

Dr. Greenblatt’s Background in Functional Medicine

Chris Kresser:  So why don’t we just start with a little background? How did you originally get interested in a Functional Medicine approach to treating ADHD?

Jim Greenblatt:  Well, it’s been a long time. I actually went to medical school interested in, at the time, it was orthomolecular medicine. I did a paper on it in college and that’s what I wanted to do after medical school. So I was always interested in nutrition and brain function. I completed medical school and did a year of pediatrics, and got a little bored with ear infections and prescribing antibiotics, and then went on to child psychiatry and specialized in ADHD.

Chris Kresser:  And since you’ve been at this for a really long time, the Functional Medicine approach to treating ADHD is not necessarily the conventional approach. What’s been your experience of that as a pioneer in this field? When you speak to colleagues in the field that maybe don’t share this perspective, what’s the reception typically like? I’m just curious.

Jim Greenblatt:  Well, it certainly changed over the years. So 30 years ago, there were a few isolated pioneers focusing on a particular area, food allergies, yeast overgrowth, high dose of certain nutrients, and everyone had their pocket of interest. And I maintained an interest, but didn’t put a single [focus area] and said I was an integrative functional psychiatrist. Those people that sought the information found me. But now we’re being asked to do presentations for pediatricians, traditional grand rounds.

So the medical community has certainly changed and [is] much more open. It still has a long way to go. But certainly, the community now is looking for the research, and we have it. So some of the information I discussed in the book I was talking about 20 years ago, but I didn’t have 10 academic references to support it. So, once we got the references, it’s [been] much easier to talk to colleagues.

What Is ADHD?

Chris Kresser:  Of course. Yeah, that’s an encouraging development. Let’s talk a little bit about what ADHD is. Because maybe even how it’s viewed from a functional and integrative perspective is different than from a conventional perspective. It’s often discussed as a behavioral disorder or a problem with discipline. But what’s wrong with that perspective?

Jim Greenblatt:  I think when we label ADHD a behavior problem, we’re also labeling a bad child or a child who can’t control it. And then our response as parents is just disciplining punishment, and blame. And that sets off a course of really devastating low self-esteem and consequences that affect some of these kids over a lifetime.

So I kind of reframe ADHD as a medical disorder. The neurochemistry is different. The poor impulse control, inability to pay attention, overactivity, it is not kind of a willful oppositional behavior. So my goal is to kind of reframe it as a medical neurobiological problem, and try to understand if there are underlying factors that can be treated.

Chris Kresser:  I may be getting this wrong, but I was reading a book recently. It’s called Beyond Behaviors by Mona Delahooke, I think. And she, I think I recall, she said that even within conventional psychiatry and conventional understanding of these disorders, there’s a movement to try to seek underlying causes and move away from the specific labels for specific behaviors and try to find underlying causes or perhaps patterns that stretch across many of these different behaviors. Have you seen that? And is that, do you think that’s the right approach?

Jim Greenblatt:  It’s absolutely the right approach, and some very bright thinkers have articulated that. But I don’t think we’ll see that in our lifetime in terms of the psychiatric community. Pretty much the entire treatment model based on this list of symptoms across all psychiatric diagnosis, anxiety, depression, and ADHD. So I think people are writing about it and we’re trying to get rid of the DSM [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)], but I just think it’s so much a part of how we diagnose and assess our children with ADHD, that I don’t see much changing.

Reframing Our Ideas about ADHD

Chris Kresser:  Right. So, with that in mind, let’s talk a little bit more about how the Functional Medicine approach differs from the conventional approach. So most people are very familiar with the conventional approach. It typically involves medication. It may sometimes involve referral to a therapist and maybe an occupational therapist, particularly if the pediatrician is more enlightened in those matters. But where do you start? When you’re consulting with a family or with a child with ADHD, where do you begin?

Jim Greenblatt:  To me, the most important part over the years is helping the parents understand that the child is not acting this certain way to irritate mom, dad, or the teachers. So kind of helping everyone understand this neurobiological disorder, and then [sharing] the opportunity that if we look at a Functional Medicine approach, which is delving into metabolic, nutritional, environmental, or genetic difficulties, we might be able to completely eliminate the symptoms, or improve the symptoms.

So the Functional Medicine approach is different from the Band-Aid, which is the medicine, which does work. It works in 80, 90 percent of these kids, but it’s a Band-Aid. And as soon as you’re off the medicine, the symptoms reappear. A Functional Medicine approach just tries to determine if there’s something that can be treated and then the symptoms will disappear as the underlying cause is treated.

Chris Kresser:  So I want to come, we’ll definitely come back to medication and talk about that in a little more detail later. But I want to stick with the kind of general topic of ADHD and it’s how we perceive it and frame it. I think there’s a perception that even with the word “disorder,” that ADHD is a liability and something that will stand in a child or an adult’s way. And there’s certainly a truth to that if it’s not treated and addressed properly. But what are the bright spots or upsides of ADHD and who are the successful people in the world that are thriving with ADHD?

Jim Greenblatt:  Well, I mean, part of the reason I was so invested in treating ADHD in children is because [adults with] ADHD are the ones [who] are changing the world. I mean, those are the employees that you want to have, those are the CEOs. Because it’s the energy, it’s the passion, it’s the creativity, that kind of makes change. So, I mean, through history, there are many leaders and athletes, from Michael Phelps to the gymnast, Simone Biles. So we just need to find the strength. So sitting at a desk for six hours might not be someone’s strength. But the core symptoms of ADHD when we get out of a school environment can be those incredibly positive, dynamic traits that make change and create incredible opportunities for others.

Chris Kresser:  Something that has always struck me about ADHD is there’s, even in the way that it’s defined or recognized clinically, there’s a recognition that the child is not conforming to the expectations of the environment. And it struck me that there’s a fundamental assumption there that the child should conform to those expectations. Like you said, sitting at a desk for six hours straight. And if the child is not able to do that, then they might be labeled with a disorder. And I certainly don’t say that to suggest that there isn’t a real disorder of ADHD, which I 100 percent believe that there is, but I’ve struggled a little bit with that interplay definitely between the environment and the expectations of adults, and then the behavior of the child and how do we kind of reconcile those different factors.

Jim Greenblatt:  I think it’s challenging now for kids and parents, but think about 30 or 40 years ago, before there were more individual plans and opportunities to help kids individualize an educational program. And to me, that was disastrous early on. So it’s really helping identify the strengths and modifying an educational program. There are things like homework that might be meaningless for certain kids. There are activities that might be incredibly helpful. And it really is focusing on finding the strengths and kind of minimizing the weaknesses that really just assault self-esteem and provide no kind of meaning for your education or growth.

When we think of ADHD as a behavior problem, it impacts the way we treat it—but when we recognize it as a medical disorder, we can address the root cause. Check out this episode of RHR for more on treating ADHD with the Functional approach. #functionalmedicine #chriskresser

The Root Causes of ADHD and How They’re Addressed with the Functional Medicine Approach

Chris Kresser:  So let’s talk a little bit more about the specific underlying causes you identified in your book Finally Focused, which I loved and highly recommend to anybody who’s interested in this topic. Whether you’re a parent, an adult with ADHD, a parent with a child with ADHD, or a clinician that wants to learn more about it. So you talk about some of the major causes and you referred to them briefly before when I asked you what you focus on when someone comes to your clinic. But let’s maybe just provide an overview of those causes and we can talk a little bit about some of the specific ones.

Jim Greenblatt:  Yeah, sure. I mean, there are many, and we picked some for the book and there are others we didn’t even get to. But the big areas that we look at would be nutritional deficiencies, and these are common deficiencies of magnesium, deficiencies of zinc, of the most research, deficiencies of a trace mineral, lithium, probably the most common. Abnormalities in the gut. There [are] certain gut bacteria that produce chemicals that affect neurotransmitters in the brain.

So we look at the gut. Just diet in general. And there’s certainly been enough attention now about refined sugars. And now we have the research. The amount of these highly sweetened beverages, as those increase, the incidents of ADHD increase. And we have sleep and lifestyle. So less sleep correlates with ADHD.

So we’re looking at kind of this big picture. Is there a nutritional cause? Is there a gut cause? Is there a genetic liability in some of the neurotransmitters or some of the nutrients like folate? And with 10 different kids, they all might have the same behaviors, but they might have 10 different underlying causes. And many kids would have two or three of the things I mentioned.

Chris Kresser:  Right. And this, of course, is one of the fundamental principles of Functional and integrative medicine: you can have the same disease, but it can [have] different causes and different treatments based on the individual manifestation.

Let’s talk a little bit about what the differences are in the brain of a child or an adult with ADHD. I found this part of the book to be really fascinating and this also speaks to what you were saying before, was understanding this as a medical disorder, not just a willful, top-down kind of behavior issue where the child is purposely trying to cause trouble. But there are actually differences that can be observed in the brain, both biochemically and also, I think with imaging, MRI [magnetic resonance imaging], and seeing how different parts of the brain respond.

Jim Greenblatt:  Yeah, and I think that’s been what makes my work much easier to talk about now because we have these researches from, as you said, from brain scans, from metabolism, to neurotransmitters to genetics, all pointing to a biological disposition or neuroanatomical differences. And so it just provides some relief [for] the kids or the parents who, again, blame it on willful behavior. So, the differences are not [as] simple as one abnormality that we have found to be a diagnostic tool. But we continue to find many kinds of metabolic abnormalities associated with what we’re calling ADHD.

Chris Kresser:  And does that ever impact the course of the treatment plan? Or is that more just interesting from understanding the ideology or the pathology of the disease?

Jim Greenblatt:  Well, no, and absolutely it affects the treatment plan. If one child has high copper, and low zinc. So copper can interfere with metabolism of some of the neurotransmitters, dopamine, norepinephrine, and we need to lower the copper before we’re going to get improvement in symptoms. There’s another underlying cause with some of the gut bacteria, [which] affects also dopamine and norepinephrine. Then we need to treat the gut bacteria abnormality before that neurotransmitter system is going to function optimally.

The Importance of Gut Health and Copper Levels in ADHD Treatment

Chris Kresser:  So is there, like, typically a hierarchy for you in terms of how you approach these? For example, let’s say there’s a gut imbalance and then there are also some nutrient issues, and then there are a few other things that you notice. Is there something that you tend to always start with because if you don’t address that thing, it’s a deal breaker and nothing else will work, as well?

Jim Greenblatt:  Yeah, I mean, I think the two that have kind of risen as some of the most important, because medications don’t work well with elevated copper and a metabolite of bacteria in the gut called HPA that we can detect on a urine test. So if there’s dysbiosis in the gut and we have this metabolite, the kids are impulsive and overactive and get worse on medications. And the same with copper. We have very, very elevated copper, which is common in our water supply. There was a study in Massachusetts a few years ago, where they were looking for lead in the elementary school water fountains, and they found elevated copper in the majority.

So we’re giving these kids, they’re getting copper through the pipes. So the copper, the HPA, those are elevated and not treated. It’s hard for therapy to work. It’s hard for medicines to work, or any kind of parent training. So those tend to be the two that I want to make sure are aggressively treated before we move on to anything else.

Chris Kresser:  What are some of the other nutrients? You mentioned, of course, copper and zinc. And then magnesium is having significant amounts of research behind [it]. But I know that you’re also a big believer in nutritional lithium, and you even wrote another book entirely on the benefits of nutritional lithium. So tell us a little bit about that and how that plays into ADHD.

How Lithium Impacts People with ADHD

Jim Greenblatt:  Sure. I think that lithium is a trace mineral; it’s in our water supply, it is required for brain function, very small amounts that we get primarily from water. And I think my belief, although not proven, is that individuals, based on their genetics, have higher needs for lithium. And those would be family histories of substance abuse, family histories of ADHD, family histories of bipolar illness. So we have some individuals that might have a genetic need for a little higher lithium, and then lithium varies in the water supply.

So we’ve done studies around the world. And like in each state, Texas, the one in Alabama, different parts of the state have different levels of lithium in their water. So we have found that looking at lithium levels in a hair sample, that over the years it’s getting less and less, more what we call undetectable lithium. And we found it associated with kind of the more hyperactive, irritable, aggressive behaviors in kids with ADHD and kids that might kind of get very upset quickly. And then they feel bad about it.

So again, it’s not willful, but they can’t control those behaviors. So we have found nutritional lithium, very low dosage, not the medication, to be incredibly helpful for those kids.

The Link between Magnesium and ADHD

Chris Kresser:  And then magnesium is another mineral that is, similarly to lithium, it seems like levels in food and soil have gone down over the years and many people don’t get enough of it. What’s the link between magnesium in the diet and ADHD?

Jim Greenblatt:  Yeah, it’s probably the most, the whole concept of my career has been on biochemical individuality and treating the individual. But I could kind of emphatically say that almost every child or adult [with ADHD] on the planet would benefit from magnesium. And just the thousands and thousands in tests that we’ve done, the vast majority have been deficient. And I think that is the one supplement that you don’t need any testing [for us to] see improvement in sleep, improvement in some of the behaviors, and also decreasing side effects of the medications with magnesium.

Chris Kresser:  Yeah, I’ve had a similar experience. I’m not a big fan of taking a fistful of supplements forever. I much prefer getting nutrients from food when possible, but magnesium has been one of the few supplements that I recommend for almost everybody. Because it just helps with so many different things, I think, and many people even with a good diet are not getting enough.

Jim Greenblatt:  Absolutely, and I do think there’s some genetic difference there. I don’t know what it is. Because some of the kids and adults we’re seeing have really high-quality diets, but they remain deficient in the testing.

The Role That Medication Plays in ADHD Treatment

Chris Kresser:  So let’s talk a little bit about medication and the role that medication plays. But more so in a holistic, functional, or integrative approach like you use. How do you see medication in the context of a more holistic approach?

Jim Greenblatt:  As the child psychiatrist, my goal is to kind of relieve the patient, which is the child or the adult with ADHD, their symptoms, and I have not thrown away my prescription pad, even though most of my career is looking at nutrition and psychiatric illness. So I think medicine does play a role for some of these kids who are in environments, as we discussed, where they’re not functioning well. But to me, it’s many months, if not years, after aggressively looking at some of [these] nutritional lifestyle and parenting approaches. So I think it’s tragic that some of our young kids, some of these medicines are approved for four-year-old children now.

Chris Kresser:  Yeah.

Jim Greenblatt:   So, at this point, I think it’s been probably 20 years since I’ve medicated a child under [age] seven or eight, because that’s when the nutritional approach can be most helpful. But there are kids that will benefit tremendously from medication. And with a kind of Functional Medicine approach, it’s very easy to eliminate all side effects. And usually, the medication is short term. It’s helping, again, find the right environment where these kids can thrive, or the right job if it’s the adults.

So, and then, if there is a role for medicine, but it is not kind of the first step, it’s more like the third step, and it, hopefully, is kind of a short-term symptomatic solution, to get someone where they need to be.

Chris Kresser:  I’ve often talked about antidepressants in a similar context and talked to psychiatrists who specialize in treating depression. And they speak about it in a similar way, where it’s one of the analogies that we’ve used is, use it as a raft to cross to the other side of the river. And ideally, when you get to the other side, you don’t need to continue carrying the raft with you.

So if the medication can help the patient to adopt new behaviors, and also in this case, the parents, give them ability, time and space and ability to develop more resources, behavioral interventions that could be more successful, and like you said, to find the right environment where the child can thrive. Do you find that in many cases if that happens, that the child or adult, for that matter, is able to get off the medication? Or once on it for a period of time, does that become more difficult?

Jim Greenblatt:  No, I think it really depends. But I like the analogy of the raft. I think what we try to prevent is that these behaviors become, the negative behaviors become reinforcing; the child is unable to succeed at school or at home and [is] getting yelled at. So then it becomes a behavior problem. So I’ll do anything that I can with medicine as that raft, as you said, to prevent the behavior problems of just treating ADHD. Often, the medication is not needed for a long period of time.

Chris Kresser:  I’m glad you brought that up, because I wanted to touch on this earlier on. Pretty early in your book, I think you mentioned that you feel like untreated ADHD is a much bigger risk than side effects from medication, assuming that’s the only option available. And is that part of why you feel that way? That if the ADHD is not treated, these behaviors can get developed that can become entrenched and much more difficult to unwind than it is to get off the medication at some point? And I think there are also statistics that you share that teens and young adults, maybe older adults with ADHD, are at much higher risk of things like car accidents and other causes of death.

Jim Greenblatt:  Yeah, it’s really dramatic. And that’s the good news in terms of having research. But yeah, [for] untreated ADHD, be it nutritional medicine or otherwise, the rates of marital discord, job dissatisfaction, financial loss, and you mentioned motor vehicle accidents. I mean, the list is pretty endless, and quite concerning, as well as some prison [time] and arrest. So there’s a clear need to understand that impulse control, overactivity untreated can lead to significant consequences.

So we need to treat aggressively and to also appreciate that if some individuals that were very bright, they got all As in school, they didn’t have to pay attention, they might not have [gotten] picked up as a diagnosis. But then in their young adult, college, or inability to kind of stick with one job, the ADHD symptoms become more prominent. So the good news is we’re now addressing adult ADHD.

Is ADHD Underdiagnosed or Overdiagnosed?

Chris Kresser:  Do you think ADHD is underdiagnosed, overdiagnosed, or about right in kids? Because I’ve seen now on the one hand, we’re aware of the statistics. I think it’s most recently one in 10 children. Correct me if I’m wrong. At the same time, I see, I’ve encountered a lot of kids in my practice over the years and just in my life that I’m virtually certain would be diagnosed with ADHD if they were evaluated, but they haven’t been evaluated. And it’s not even really on the parents’ radar. And I wonder how many kids are out there that are struggling with this and their parents and caregivers, but they don’t really know that they have it and, therefore, they can’t take effective action to address it.

Jim Greenblatt:  Yeah, it seems like a simple question, but it’s very complicated because one day, I’ll say it’s overdiagnosed, where I’ll see six kids, and parents, they’re upset because the kids are getting Bs instead of As. And then the next week, I’m just appalled that someone missed a diagnosis for 10 years and we’re treating a patient with a binge eating disorder or obesity. We have high correlates with women, untreated ADHD, and eating disorders.

So I think it’s kind of all over the place because some of the symptoms are just so much part of our life. We all have days where we don’t pay attention. We all have days [where] we’re impulsive. But that’s why I try to refocus it as a medical problem. And so the big picture, I don’t know if it’s under- or overdiagnosed, but I do think medications are probably overprescribed. That’s, I think, the simplest response there.

Chris Kresser:  Right. So with medication, you mentioned earlier, it’s effective in 89 percent of cases. But what does effective actually mean in that context? How are they measuring efficacy?

Jim Greenblatt:  Well, like most drug studies, they’re just looking at checklists of symptoms. So if the symptoms are sitting in your seat paying attention, poor impulse control, before the medicine, you had a five and now on the medicine, you have a one. So, but it has no bearing as to what happens when you stop the medicine. And it has no bearing in terms of, as we’ve talked about earlier, the underlying cause.

So just basically by keeping the neurotransmitter dopamine and norepinephrine around a little longer in the synapse, there’s improved sustained attention and improved, sometimes, motivation and assistance of effort, which can be huge benefits for these kids. So we know it helps. I think at this time, there are so many different medications available, there could be 10 or 15 different stimulants, that it is often easy to find a medication without side effects, but too much of the medications are prescribed by pediatricians often that are not doing either a Functional Medicine assessment, or even a good behavioral health assessment.

Chris Kresser:  So yeah, I think you just addressed one of my follow-up questions with everybody either has personal experience that they’ve heard stories of kids who have been medicated for ADHD and they’ve had a really difficult time finding the right medication or dose. And when they don’t, it leads, it might decrease the symptoms of hyperactivity, but it might go too far in the other direction and flatten their affect and kind of maybe suppress some of those bright spots that you mentioned of people with ADHD and what makes them [so] innovative and creative and energetic.

So is that largely, in your experience, a question of just finding the right medication and the right dose for each individual as well as making sure you address the nutritional issues, and we talked about before magnesium and things that can help reduce the side effects? Or are there other ways that you use, like, some of the genetic testing that’s used by some functional psychiatrists to determine which medication is best?

What Side Effects Mean for ADHD Medication or Dosage

Jim Greenblatt:  Yeah, for ADHD, I haven’t found the genetic tests to be that helpful. Because we’re using the same medicine, sometimes the doses might be different based on some of these genetic polymorphisms. But I’ve been doing this a long time and I’m pretty confident that I would share with a parent that I was treating that there’s no side effect that they should tolerate for medicating a child with ADHD.

If there’s any side effect, it’s the wrong medicine or the wrong dose. The only side effect that I might not be able to help with would be decreased appetite. If it’s significant, then it’s the wrong medication. But if there’s anxiety, agitation, a problem sleeping, or dulling [of] the personality, then I think it’s the wrong dose or the wrong medicine.

Chris Kresser:  So the decreased appetite is not necessarily something you can address with nutritional intervention or Functional Medicine, but you might just, in that case, need to try a different medication altogether.

Jim Greenblatt:  Correct. Yeah. And we have no way of predicting, and I don’t think the genetic tests have been [as] good as advertised in some of the stimulants Vyvanse versus Adderall versus Ritalin. You just really can’t predict. But sometimes switching a medicine can make a dramatic difference for a child.

Chris Kresser:  Do you find that the doses you use or need to use are typically lower when you’re concurrently doing the Functional Medicine approach or when you’ve already addressed many of those issues? Or does it tend to be the same? Or it just depends on the individual?

Jim Greenblatt:  Well, we certainly minimize side effects, and typically the dosages are lower. Absolutely. It’s the, some of the, a lot of the kids that we end up seeing are [those] who had horrible side effects to medication. So they’re coming because they couldn’t tolerate the medicine. And then when we find the underlying reason why they couldn’t tolerate the medicine, they can take it, whether it’s magnesium, copper, or the gut.

Chris Kresser:  Are there any concerns in terms of stopping these medications quickly as there are with SSRIs [selective serotonin reuptake inhibitors] that they need to be titrated very carefully and often much more slowly than even most physicians realize? Are there any similar concerns with stimulant medications?

Jim Greenblatt:  Not if they’re taken at appropriate dosages. I think the SSRI withdrawal is a very serious, significant problem in psychiatry that’s not addressed carefully. But these stimulants are short-acting medicines. They’re out of the system eight to 12 hours. So at the doses we’re using for ADHD, there shouldn’t be any withdrawal. And you can stop and start these medicines. There are kids who don’t take it on weekends or kids who might not take it over the summer, school vacations, and there shouldn’t be any problem. If you abuse the drug and take [a] high dose, absolutely you would have withdrawal.

Non-Biochemical Treatments for ADHD

Chris Kresser:  Let’s talk a little bit about some of the non-biochemical interventions. So outside of medication and even supplements and nutrition. Exercise, pretty much if you search exercise as a treatment for X and you just type any condition or disorder in place of X, you’re going to find lots and lots of research supporting it. And it seems like ADHD is no exception. You, actually, in your book, say exercise is ADHD medication.

Jim Greenblatt:  Yeah. For depression, even though exercise helps, it’s hard to get our depressed patients [to exercise]. But yeah, absolutely for ADHD. Any form of movement and exercise, both helps, whether it’s martial arts or aerobics or even yoga, we have good research. And it’s a very powerful intervention that can be used with any of the other interventions.

Chris Kresser:  Are there any particular types of exercise that are better than others, or exercise where you’re really using your cognitive function, as well? Something like martial arts, where you’re learning routines, or perhaps certain sports or exercises where there’s maybe contact or there’s more exertion, is there anything specific that people should be aware of? Or is it just movement or, and depending on people’s preference and what they enjoy doing?

Jim Greenblatt:  Well, I think it’s really preference for most of the exercise. So your kids who,  baseball might be boring for one child, but it’s very exciting for another child [with ADHD]. And so it’s picking this sport that they like. But you mentioned at first, and to me, it’s been amazing over the years how many parents have shared with me a martial arts program has made a huge dent permanently. So I would say this research on all the exercise, both from yoga and martial arts, but clinically, what I’ve heard over the years is parents who didn’t think that the kid would be able to stand there for two minutes has progressed and been able to take the training from simple martial arts into the real world.

Chris Kresser:  If I was to think of another intervention, behavioral intervention, that was similar to exercise and that you could research benefits for X and pretty much substitute any condition for X, mindfulness and meditation is right up there at the top of the list. And you discuss this in your book, as well. Although I imagine that mindfulness to someone with ADHD might be kind of like exercise to someone with depression where it’s maybe not the easiest thing for someone who has ADHD to sit down and commit to. So tell us a little bit about your experience with mindfulness as an intervention and then any tips or ideas for how to get kids involved, in particular with mindfulness, and what age you start to consider that for kids?

Jim Greenblatt:  Yeah, I mean, I think, again, the nice thing about mindfulness is there are academic psychiatrists looking at it. So we have research and books on mindfulness with ADHD. And it’s kind of not intuitive because you’re going to naturally think of a hyperactive child and you’re going to ask them to take a few deep breaths and focus.

Chris Kresser:  Stare at a wall for 10 minutes. Yeah.

Jim Greenblatt:  So the only, as the consultant, I’m really following kids long term with time. But I just help parents and kids think of kind of an active walking mindfulness. And it really is just helping them understand the concepts of mindfulness and awareness. But movement is, unless you’re working with a therapist, are the ones that are the easiest. So it’s usually a walking awareness and mindfulness and breathing. And the younger kids love it and the older kids really notice a difference. Particularly, I think I might have included the research now just being in nature affecting attention symptoms, of taking inner city kids and putting them in nature, and some of the effects were sustained over time.

Chris Kresser:  Yeah, I mean, there’s so much good research on that now with nature deficit disorder, having been loosely defined and studies of kids who are, with ADHD who go out camping in some of these programs where they don’t have screens available and even just after three or four days of camping, their behavior is completely different. And even if they resisted initially, the kids, by the time, by the end, they don’t want to come back. They feel the difference themselves.

Jim Greenblatt:  Yes.

Chris Kresser:  So there are a couple, just while we’re on this topic, I want to offer a couple of resources to parents out there. I’ve been a longtime meditator, almost 30 years now, and it’s something I tend to talk a lot about with my patients. And there are a couple of books for mindfulness and meditation for kids. One’s called Sitting Still Like a Frog, and the other is called Mindful Monkey, Happy Panda. So those are a couple of books that can be helpful in introducing the concepts of mindfulness and meditation to kids, even fairly young kids.

And I’ve seen fairly young kids, of course, they’re not going to sit there for 30 minutes, but they will sometimes sit for periods of time. And even when I’m doing my sitting practice, sometimes my daughter will just come over and sit with me and join me for a period of time. I never try to force her to do it, and just always leave it up to her. But that can be one way of introducing it.

Jim, I want to ask you a little bit about while we’re on the topic of other interventions like non-pharmaceutical and even non-nutritional interventions, if a parent with a kid with ADHD goes online and starts researching different options, there are so many different approaches, whether it’s parenting and different parenting styles for kids with ADHD, or cognitive behavioral therapy I know has some solid research behind it, I think. There’s Stephen Porges’ polyvagal theory and his Safe and Sound Protocol and Focus Program there. There’s the Brain Balance program, which I think is available nationally. Which of these, if any, have you found to be most helpful? Or have you heard from the people that you’ve worked with are most helpful?

Jim Greenblatt:  Yeah, I mean, I think if we put, if we emphasize the word most helpful, I would say things like the neurofeedback, good research, and I did it in my office for a number of years, and it helps. So neurofeedback and I think parent education, because so many of the parents wonder, two spouses have different opinions about what to do if a child knocks this over or fails a test. So parent education and training to me always turns out to be the most important. Then all the other things you mentioned, that cognitive behavioral therapy, it helps. It really depends on what the issues are for a child.

But what I found, struggled with, is some of these kids [have] real difficulty with impulse control or motor activity or can’t concentrate. So seeing that as a biological problem, and then asking them to sit in therapy, one on one, why are you not getting an A, it seems to be both a waste of time [and] money, and makes these kids feel worse. So to me, it’s something looking at how to control the behavior like neurofeedback and then helping to change the environment, which is parental education and training. And then some of the CBT [cognitive behavioral therapy] work can be really focused on specific symptoms that linger after the biological approach has been addressed.

Chris Kresser:  That makes a lot of sense. It’s if, going back to the depression comparison, like sometimes the antidepressant can help people get to the place where they can start exercising and getting more engaged in things that affect their mood and eating better. And just telling them to do those things over and over, before they have any support that can help them to do those things, is maybe not very productive.

You use an acronym in your book, talk about an approach to parenting kids with ADHD, which is SAIL. S-A-I-L. Tell us a little bit about this.

How “SAIL” Can Help Parents Understand Kids with ADHD

Jim Greenblatt:  Well, I mean, I think it’s really important, again, that parents understand their child and respect the child. So I just use that acronym as an image or a metaphor about being a little free. But the S is for understand their symptoms, and it’s not again, that willful behavior. The A is in ADHD. And probably the most important line in the book is that it’s okay, the I. And then listening. Many of these kids that I’ve talked to over the years are just so appreciative of being asked the question about being bored, about trying. So it’s kind of that respect and listening. So SAIL is that concept of understanding these symptoms, or ADHD, it’s okay, and try to understand what it’s like for your child or your spouse. And that’s the listening part.

Chris Kresser:  So it seems like the biggest shift is what you’ve mentioned a few times, but I think it doesn’t hurt to clarify because there’s so much misconception around ADHD in general. And then for a parent [of] a child with ADHD, it can be so challenging. Not to assume that the behavior is. As adults, ideally, we’re making rational choices about how we behave. Although, of course, we know that’s not always the case. And we have, our frontal cortex is a lot more developed. And we’re presumably making decisions from that place. And if we assume, which is easy to do, that kids are making, the kids’ behaviors are a result of the same kind of calculated process, then we’re kind of setting these kids up to fail. Because what you’re saying is that the behaviors are often a symptom of an underlying process that not only are they not aware of, in many cases, they have no control over in many cases.

Jim Greenblatt:  Yes. And there are going to be times where a willful behavior is mixed in there. And I think as parents, it’s always challenging. But that’s part of being a child and development.

Chris Kresser:  Right.

Jim Greenblatt:  But giving the kid the benefit of the doubt, certainly, when you try to shift, what could be years, if not decades, of just low self-esteem, because individuals feel that they’ve never been able to kind of even work or live up to their potential. And that’s kind of the underlying theme, I think, for many with ADHD. Because it’s not a, it’s got nothing to do with intelligence. It’s really just performance. And that’s something that we can address.

Chris Kresser:  Great. Well, this has been really fascinating and I imagine so helpful for the listeners. I know given the size of our audience and given the statistics of prevalence of ADHD, there are thousands of people listening to this that will be able to relate and get something really practical and useful out of this. If a parent or an adult, for that matter, with ADHD is listening and wants to approach their treatment from this kind of perspective, this more holistic, functional, integrative perspective, how do they find a practitioner that is looking at things through this lens? Because they’re not necessarily going to be successful just going to their primary care doctor or their pediatrician.

How to Find a Functional Medicine Practitioner and Get Help with ADHD

Jim Greenblatt:  Yeah, I think there are good integrative doctors, and there’s more and more pediatric practices. And on our website, we now have a list of, I think about 20 docs who kind of went through a training on this kind of Functional Medicine approach for ADHD.

Chris Kresser:  And what’s that link, Jim?

Jim Greenblatt:  So it’s psychiatryredefined.org.

Chris Kresser:  Okay, psychiatryredefined.org and you’ve got about 20 practitioners that have been through your training. And tell us a little more about the training, too, because we have a lot of clinicians and practitioners of all types who are listening to the podcast and may want to integrate this into their own work.

Jim Greenblatt:  Sure. I mean, we have, the Psychiatry Redefined is my attempt to kind of shift the model of psychiatry and we have courses on most major psychiatric illness, depression, anxiety. Many of them have CME-approved credit. And there’s a three-hour course for professionals on ADHD.

And then we have a fellowship, a year-long fellowship on Functional Medicine for psychiatry, which covers everything. And by the summer, we’ll have just a specialty ADHD fellowship, which is hours of the coursework, and then more individual supervision and mentoring. Because it takes some time working with these cases to really kind of get a feel for the individual program for Functional Medicine for kids.

Chris Kresser:  So how do the fellowships work? Are they virtual at a distance? Is there an in-person component? I’m sure all the COVID-19-aware folks out there want to know.

Jim Greenblatt:  Yeah, the good news is it’s been virtual, so we can maintain. So it’s all online courses. And then the fellowships are group supervision, presenting cases among a group of colleagues through Zoom or GoToMeeting.

Chris Kresser:  That’s great.

Jim Greenblatt:  It’s a virtual program.

Chris Kresser:  Is this available to mental health professionals only or occupational therapists? Or who do you accept in the courses and in the fellowship?

Jim Greenblatt:  Yeah, we’ve had a wide range. I’d say the majority have been nurse practitioners and psychiatrists, psychologists. But we’ve had acupuncturists. And so any clinician in a number of specialties. Folks on mental health, the vast majority of the courses are similar to the book focused on this Functional Medicine, nutritional model. And we’re slowly developing our kind of lifestyle adjunct, but we wanted to focus first on the Functional Medicine approach.

Chris Kresser:  Great, so necessary, and I’m so grateful that you’re doing this and now we have somewhere to send. We have many clinicians coming through our training programs, and we don’t cover these subjects in any detail. That’s not my background or expertise. But we’ll be excited to send people your way who want to get further training in these areas. Because when I think of some, it’s hard to think of something that’s much more important than this. Making sure our kids are set up to thrive and succeed in the world they’re entering into. And as [is] so often the case, they don’t necessarily get that support that they need.

And it’s not from the lack of care or concern usually by, on the part of their doctors. It’s just a lack of awareness about how to approach it from this perspective. So kudos to you for setting up this program and doing this work. I know it’s going to make a big impact.

Jim Greenblatt:  Great. No, looking forward to educating some of the younger clinicians who are really motivated to see the field of mental health change.

Chris Kresser:  Great. Dr. Jim Greenblatt, thank you so much for joining us again, and the website is psychiatryredefined.org. The book is Finally Focused, which I highly recommend. I read it I think in two sittings. You can get it on Amazon. And thanks for listening, everybody. Keep sending your questions in to ChrisKresser.com/podcastquestion and we’ll see you next time.