ADHD: Bringing it into Focus
by Raymond M. Lombardi, ND, DC, CCN
Exploring natural solutions for Attention Deficit Hyperactivity Disorder
Childhood should be a special time, a sojourn filled with wonder, curiosity, fun and growth. While this may be true for many, an increasing number of children are being diagnosed with a variety of behavioral problems ranging from mildly disruptive behavior to serious disorders such as autism. Of the many chronic childhood illnesses that wreak havoc on both child and family, one has reached alarming levels: attention deficit hyperactivity disorder (ADHD).
ADHD is being identified as epidemic throughout the United States. The National Institutes of Health in Washington, D.C., estimates that from 3 percent to 5 percent of all American schoolchildren have been diagnosed with the disorder. It is not uncommon to see a line of children standing outside the nurse's office at school awaiting their midday dose of Ritalin. This trend alone is reason for concern. Besides the physiological issues behind the diagnosis, the emotional consequences of ADHD — children aren't doing well in school, parents and teachers are frustrated, families are disrupted — drive the search for a cure. In the desire to solve these issues, more than 6 million American children currently diagnosed with ADHD are being treated with central nervous system stimulants — usually methylphenidate (Ritalin).
This relatively new diagnosis, as well as treatment for it, is not based on long-term studies, and parents are given few options but Ritalin. Before turning to drugs, however, there are some gentle, natural options to consider.
The American Psychiatric Association, based in Washington, D.C., describes ADHD as a disorder whose main features include "hyperactivity, impulsiveness and an inability to sustain attention or concentration." In simple terms, ADHD can be characterized by two distinct sets of symptoms — inattention and hyperactivity. ADHD is further divided into three specific diagnostic forms, each based on a specific clinical presentation that seeks to better describe a child's behaviors. These forms are ADHD-Primarily Inattentive Type (sometimes called simply ADD, attention deficit disorder); ADHD-Primarily Hyperactive/Impulsive Type; and ADHD-Combined Type (a combination of inattentive and hyperactive).
Regardless of the categories defined for ADHD, it remains an elusive and difficult disorder to diagnose. No specific medical laboratory markers exist for ADHD, and the diagnosis is usually based on behavioral assessment tests, observations from parents and teachers and clinical assessments from health care providers. Consequently, the diagnosis comes from subjective analysis.
The extreme variation in diagnosing true ADHD patterns was shown in a recent study performed by researchers at the Center for Pediatric Research at Eastern Virginia Medical School in Norfolk who evaluated the extent of ADHD medication use. Students enrolled in grades two through five in the school districts in two cities (5,767 students in district A and 23,967 students in district B) were evaluated based on nurse records of those receiving ADHD medication in school. The prevalence of ADHD was 12 percent in district A and 63 percent in district B. The researchers concluded that the criteria for ADHD diagnosis varies substantially across U.S. populations, with potential overdiagnosis and overtreatment of ADHD in some groups of children (American Journal of Public Health, 1999, vol. 89). In an attempt to provide definition for diagnosis, the American Academy of Pediatrics issued its first ADHD guidelines in May (see www.aap.org for details).
A number of primary and secondary mechanisms have been proposed as causes of or influences on ADHD. These include possible brain dysfunction (ranging from difficulties with information transfer to brain chemistry-neurotransmitter deficits); genetic influences (a family history of ADHD greatly increases the risk); environmental toxins such as lead, alcohol and cigarette smoke; food additives and coloring; food allergies; and nutrient depletions.
Traditional Western medicine utilizes stimulant and depressive medications, as well as behavioral modifications, as primary treatment modes. However, given the many potential causes of ADHD, specifically addressing the relevant probable factors can be critical to establishing an appropriate treatment regimen for an individual child. Approaches that lie outside of the traditional medical protocol include aromatherapy, biofeedback, Traditional Chinese Medicine, cranial-sacral therapy, flower essence remedies, homeopathy, hypnotherapy, massage therapy, and sound and vision therapy. However, nutritional and supplementation solutions for ADHD will be the two modalities explored here.
How important is the diet of an ADHD child? Very, according to a 1997 study published in the Journal of Pediatric Child Health. Author Jean Breakey reviewed the most important research from 1985 to 1995 on the relationship between diet and behavior. She concluded that diet definitely affects some children and that symptoms relating to ADHD, such as sleeping problems, physical symptoms and mood changes, can change with diet (Journal of Pediatric Child Health, 1997, vol. 33).
It's important to understand that the body simply acts on the information it's given; if a child is sensitive to wheat, for example, the body is going to react accordingly. We may simply see it manifest as hyperactivity or an inability to focus.
However, dealing with the diet of an ADHD child can be difficult. Plus, corrective nutritional changes made at home can be usurped if a child eats the wrong foods at school, and vice versa. Regardless, proper nutrition plays a critical role in modulating ADHD behavior.
The needed changes in diet can be addressed in a variety of ways. One way to begin nutritional changes is to institute an elimination or food-reduction diet. This type of diet, introduced in three stages, is used to reduce the number and types of food sources and can target artificial food colors and preservatives, limit foods that may be causing sensitivities and/or allergies and decrease sugar intake.
Stage 1: A food elimination program is implemented by removing many foods from the diet, such as junk foods; sugars; dairy products; whole grains like corn, barley and wheat; chocolate and other candy; citrus fruits; food colorings and additives. After elimination, unprocessed foods are reduced to basic items, such as specific fruits and vegetables only. The restricted, whole-food diet is kept in place a minimum of 8 to 12 weeks and the child's behavioral responses are observed.
Stage 2: At this point, a particular type of food — such as whole grains, citrus fruits, poultry or fish — is reintroduced. These whole foods are introduced individually and only one at a time. This "food loading" method allows observation of behavioral and personality changes in the child that can be associated with the inclusion of a specific food.
Stage 3: This final stage of the elimination diet establishes a long-term, whole food diet that is varied and tolerated by the child without causing negative physical and behavioral reactions.
In a 1999 report, the Washington, D.C.-based Center for Science in the Public Interest cited 17 controlled studies that found diet adversely affects some children's behavior, sometimes dramatically.
In 1997, researchers at Germany's Central Institute of Mental Health evaluated 49 children with hyperactive/ disruptive behavior disorder. This placebo-controlled, double-blind, crossover study comparing drugs to diet alone found "significant behavioral improvement" in 24 percent of the children who underwent dietary treatment. Although stimulant medications improved the condition in 44 percent of the children, researchers concluded that diet "cannot be neglected" in ADHD treatment (European Child and Adolescent Psychiatry, 1997, vol. 6).
Beyond the whole-food diet, a simple way of getting critical nutrients into an ADHD child is with supplements. The issues surrounding needed nutrient levels and supplementation in ADHD continues to be controversial, but research is increasing. The topic of nutritional supplementation was recently addressed by nutrition expert Leo Galland, M.D., at a 1999 conference on ADHD in Arlington, Va. Galland presented information on the types of nutritional supplements that have been used in treating children with ADHD, as reported in published studies. Some of the supplements Galland discussed include certain B vitamins, essential fatty acids, magnesium, zinc, iron, amino acids, dimethyl-aminoethanol (DMAE), phosphatidylserine (PS) and oligosaccharides. The sidebar "What Should I Take, and How Much?" lists those nutrients Galland has found, in either his clinical practice or in the literature, to be beneficial for treating ADHD patients.
Essential Fatty Acids and their effects on ADHD behavior have been the subject of much recent research (see "EFAs: The Key to LD-Free Children?"). A 1995 study evaluated essential fatty acid metabolism in 96 boys, 53 with ADHD and 43 controls. The study found the ADHD subjects had significantly lower concentrations of omega-3 and omega-6 fatty acids in their blood plasma (American Journal of Clinical Nutrition, 1995, vol. 62).
Zinc levels also strongly correlate to ADHD patients. Psychiatry department researchers at Technical University in Turkey compared 48 ADHD children to 45 non-ADHD children. While free fatty acid levels in blood serum were nearly four times lower in ADHD children, mean serum zinc levels in ADHD patients were also less than half the levels of the children in the control group (Journal of Child Psychology and Psychiatry, 1996, vol. 37).
Magnesium and ADHD is another area of increasing interest. Researchers at the Department of Family Medicine in Szczecin, Poland, studied 116 ADHD children ages 9 to 12 for blood serum levels of magnesium. Remarkably, magnesium deficiency was found in 95 percent of those examined (Magnesium Research, 1997, vol. 10).
Iron helps regulate the activity of dopamine, a neurotransmitter synthesized by the adrenal glands and implicated in some forms of psychosis. Israeli researchers at Tel Aviv University evaluated 14 ADHD boys between the ages of 7 and 11 for the effect of short-term iron administration on behavior. Each boy received 5 mg/kg body weight of iron daily for 30 days. Both parents and teachers assessed their behavior according to the Connors Rating Scale, a psychological tool used in measuring behavior. Parents felt the children improved; their ratings dropped from 17.6 to 12.7. However, there was no change in the teachers' scores (Neuropsychobiology, 1997, vol. 35). Were these simply hopeful parents, or were the parents able to see changes the teachers could not? More studies are needed to determine the benefits of iron supplementation on ADHD children.
Serotonin levels may also affect ADHD patients. Researchers at Ness Zion Mental Health Center in Israel found serotonin blood levels tended to be lower in children with more severe markers of hyperactivity, impulsiveness, aggressiveness and lack of concentration (Acta Psychiatrica Scandinavica, 1999, vol. 99). Supplementation with 5-hydroxytryptophan (5-HTP), a serotonin precursor, may consequently help those with more severe ADHD symptoms.
More studies are needed to understand why ADHD-diagnosed children are depleted of certain nutrients. Absorption problems, metabolic problems or the diet itself may prove a culprit.
ADHD is a difficult disorder for all concerned — the child, family, parents and teachers. Current treatment focuses on standard medication as its primary model. But there are other, perhaps better, ways to deal with ADHD. One component — perhaps the most critical component — to curing this nebulous malady may be nutrition: What foods do we allow our children to eat, and which supplements may ease their burden? Nutritional therapy, and a variety of other alternative care approaches, can be key to taming ADHD.
Raymond M. Lombardi, N.D., D.C., C.C.N., is a certified herbalist with an alternative care, holistic practice in Redding, Calif. He is author of Aspirin Alternatives — The Top Natural Pain-Relieving Analgesics (BL Publications).