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Are We Gender-Biased When Diagnosing & Treating ADHD?

Case Study: John, a 10-Year-Old Male with Binge Eating Disorder, Attention-Deficit/Hyperactivity Disorder, Irritability and Aggression

While all case studies are based on actual patients, significant aspects of the case have been changed to conceal the patient’s original identity.

Initial Presentation

John was brought into the clinic over concerns voiced by his parents. He had been in a treatment program for binge eating disorder (BED) and had been prescribed lisdexamfetamine and topiramate for both BED and attention-deficit/hyperactivity disorder (ADHD) with a good clinical response. His binging episodes had been significantly reduced. And while his weight was still excessive, it was starting to decrease from a previous high of around 250 pounds.

More recently, his aggressive behaviors had taken center stage. John was defiant, aggressive and disrespectful at home. He had been stealing money from his family members and was starting to self identify with gang culture. His parents were worried that if the behaviors continued, it could lead to serious criminal repercussions.

Initial Relevant Labs

  • Vitamin D low at 13 ng/mL
  • Hair copper, highly elevated at 94 µg/g
  • Hair lithium, very low at 0.004 µg/g

Working Diagnosis:

  • Binge eating disorder (BED), attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD)

Initial Treatment for BED, ADHD and OCD

  • Continue medications for BED and ADHD
  • Vitamin D 5000 IU
  • Zinc picolinate 30 mg twice daily
  • Lithium orotate 5 mg

Explanation

Patients with eating disorders and impulsive behaviors often attributed to ADHD have been found to have lower levels of vitamin D, typically under 20 ng/mL (Todisco 2020). Other research has suggested a high prevalence of vitamin D deficiency in adolescents with eating disorders (Modan-Moses 2015). Low vitamin D levels in childhood have also been associated with behavioral problems (Robinson 2020).

Copper toxicity is known to cause a host of different mental-emotional symptoms. An older study using hair mineral analysis found elevated copper to have potential links with juvenile delinquency (Rimland 1983). Copper toxicity has also been associated with irritability and antisocial behaviors (Tarnacka 2021). Zinc has been shown to help treat binge eating disorder while also providing support for depression (Sakae 2020, Donig 2022). Used in higher quantities, it can decrease copper absorption, helping to reduce excessive levels (Fischer 1981).

Pharmaceutical doses of lithium are commonly used to treat bipolar disorder. However, clinical experience has shown that lower, nutritional doses of lithium can be particularly useful for aggression and irritability in children. Generally, dosing runs between one and ten milligrams of lithium as lithium orotate.

Follow-up Presentation

Two months later, due to his improvement, John’s parents canceled his impending participation in a partial hospitalization program for binge eating disorder. John was more in control, less irritable and less oppositional. It was felt that his improvement was so significant that a higher level of care was no longer necessary. In addition to changes in behavior, John was continuing to display slow but steady weight loss.

Follow-up Treatment

Continue current treatment plan for ADHD, BED, or OCD. At three months, zinc was lowered to 30 mg once daily.

Explanation

Doses of zinc over 40 mg per day should not be continued long term as they can induce a copper deficiency.

Case Summary

John’s case showed marked improvements in behavior by treating his nutritional deficiencies identified through simple blood and hair testing. Vitamin D, zinc, copper and lithium are all factors that commonly contribute to mental health when out of balance. By measuring and addressing these and other core nutrients, mental health symptoms are often effectively reduced, helping patients with BED, ADHD, and OCD achieve a more sustainable recovery.

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References

Donig A, Hautzinger M. Zinc as an adjunct to antidepressant medication: a meta-analysis with subgroup analysis for different levels of treatment response to antidepressants. Nutr Neurosci. 2022 Sep;25(9):1785-1795. doi: 10.1080/1028415X.2021.1888205. Epub 2021 Feb 28. PMID: 33641635.

Fischer PW, Giroux A, L’Abbé MR. The effect of dietary zinc on intestinal copper absorption. Am J Clin Nutr. 1981 Sep;34(9):1670-5. doi: 10.1093/ajcn/34.9.1670. PMID: 7282591.

Modan-Moses D, Levy-Shraga Y, Pinhas-Hamiel O, Kochavi B, Enoch-Levy A, Vered I, Stein D. High prevalence of vitamin D deficiency and insufficiency in adolescent inpatients diagnosed with eating disorders. Int J Eat Disord. 2015 Sep;48(6):607-14. doi: 10.1002/eat.22347. Epub 2014 Aug 18. PMID: 25130505.

Rimland B, Larson GE. Hair mineral analysis and behavior: an analysis of 51 studies. J Learn Disabil. 1983 May;16(5):279-85. doi: 10.1177/002221948301600507. PMID: 6348191.

Robinson SL, Marín C, Oliveros H, Mora-Plazas M, Lozoff B, Villamor E. Vitamin D Deficiency in Middle Childhood Is Related to Behavior Problems in Adolescence. J Nutr. 2020 Jan 1;150(1):140-148. doi: 10.1093/jn/nxz185. PMID: 31429909.

Sakae K, Suka M, Yanagisawa H. Polaprezinc (Zinc-L-Carnosine Complex) as an Add-on Therapy for Binge Eating Disorder and Bulimia Nervosa, and the Possible Involvement of Zinc Deficiency in These Conditions: A Pilot Study. J Clin Psychopharmacol. 2020 Nov/Dec;40(6):599-606. doi: 10.1097/JCP.0000000000001284. PMID: 33044355; PMCID: PMC7643788.

Tarnacka B, Jopowicz A, Maślińska M. Copper, Iron, and Manganese Toxicity in Neuropsychiatric Conditions. Int J Mol Sci. 2021 Jul 22;22(15):7820. doi: 10.3390/ijms22157820. PMID: 34360586; PMCID: PMC8346158.

Todisco P, Meneguzzo P, Vogazianos P, Garolla A, Antoniades A, Tozzi F. Relation between vitamin D and impulse behaviours in patients with eating disorder: a pilot observational study. Eur Eat Disord Rev. 2020 Sep;28(5):587-593. doi: 10.1002/erv.2740. Epub 2020 May 5. PMID: 32372472.