On November 12, the CDC reported that 10 percent of children in the U.S. have been diagnosed with attention deficit hyperactivity disorder (ADHD), an increase of almost 25 percent in just four years.
Between 2003 and 2007, a million children were given this diagnosis for the first time, raising the number of affected children to 5.54 million. Two-thirds of those children are being treated with drugs to enhance focus and concentration.
There is an effective alternative to drug therapy: nutrition.
A body of scientific research supports the importance of nutritional factors in ADHD. I have personally treated hundreds of children with ADHD over the past 30 years. Almost all have improved without the need for drug therapy. To help them and their parents I have used a series of questions that searches for the causes of ADHD in each individual child.
Parents seeking to learn more about how nutrition may impact their child's behavior can use these questions as a guide:
(1. How nutritious is the child's diet?
Over 50 percent of children with ADHD crave sweets, often at the expense of nutritious food. About 70 percent of children who crave sweets have much more control over their behavior when their food is low in added sugar. My first line of advice to parents is, keep your children away from sugary cereals, pancakes or waffles with syrup, soft drinks, candy, cakes, cookies, doughnuts, ice cream, frozen yogurt and chocolate. Every ounce of sugar reduction helps. Sugar alone does not cause hyperactivity. It reduces the nutritional quality of the diet and may aggravate other food intolerances (see below).
(2. Are there any foods or food additives to which the child is sensitive or intolerant?
During the 1960s, Dr. Benjamin Feingold, a California pediatrician, observed that many hyperactive children became excited after eating foods containing high concentrations of salicylates. These phenolic compounds occur naturally in many fruits and vegetables and are especially concentrated in raisins, nuts, apples and oranges. They are also used as preservatives (BHT and BHA, for example) or as the basis for artificial colors or flavors. Feingold developed a low salicylate diet that has helped many children overcome ADHD. Twenty-five years ago the National Institute of Mental Health convened a consensus panel which concluded that 8 to 10 percent of children with ADHD are sensitive to salicylates and benefit from the Feingold diet.
Shortly afterwards a study was done at the Hospital for Sick Children in London and published in the leading British journal, Lancet, which demonstrated that most children with severe ADHD are salicylate sensitive, but that 90 percent of these children have additional food intolerances. The conclusion is that the Feingold diet will not significantly benefit the majority of children with ADHD because they have more than one type of food sensitivity. The British researchers performed exhaustive dietary trials, closely supervised by hospital dietitians. After determining that 80 percent of the children had apparent food sensitivities as a cause of hyperactivity, they then performed double blind, placebo controlled challenges with the offending foods. Using this most rigorous clinical research method, the investigators confirmed the presence of food intolerance in the majority of children with ADHD.
Subsequent research by the leading investigator of this study suggested that these food intolerances represent true food allergy. The foods to which children with ADHD most commonly had allergic reactions were cow's milk (which included milk, cheese, yogurt and ice cream), corn (an additive in many prepared foods), wheat, soy and eggs. Altogether, 48 different foods were incriminated as triggers for hyperactivity.
In my clinical practice I have found that food allergy is especially likely to be implicated in ADHD if the answer to any of these questions is positive:
(A) Does the child have eczema, asthma, hay fever, hives or a chronic runny nose?
(B) Does either a parent or a sibling have severe allergies or migraine headaches?
(C) Does the child have a "geographical tongue"? (Irregular flattened patches that look like countries on a map.)
(D) Do the child's ears turn red for no apparent reason?
(E) Does the child seem to crave single foods (other than sweets)?
If the answer to any of these questions is positive, I recommend a trial period of two weeks in which the child totally avoids all foods containing artificial colors, artificial flavors and preservatives and the high frequency allergy foods mentioned above.
The best foods to use during this trial are meat, poultry, fish, rice and coconut milk, oats and oatmeal, fresh vegetables and fresh fruits. If this diet works, there will be not only an improvement in concentration and behavior, but other symptoms will improve, symptoms such as itching of the skin, sneezing, wheezing and the sudden red ear attacks.
The two-week trial is followed by a period in which the foods removed are added back, one food each day. If the child experiences hyperactivity, itching of the skin, wheezing, a runny nose or red ears when a particular food is reintroduced to the diet, he or she is likely to be allergic to the food.
(3. Does the child need nutritional supplements?
Hyperactive children often benefit greatly from the right supplements. To develop priorities for supplementation some further questions need to be answered:
(A) Does the child have dry skin, follicular keratoses (tiny rough bumps, usually found on the back of the arms and popularly known as chicken skin), brittle nails, dry and unruly hair or excessive thirst? If so, she or he probably needs a dietary supplement of essential fatty acids. A study done in the Department of Foods and Nutrition at Purdue University found that boys with ADHD had significantly lower concentrations of essential fatty acids in their blood than a control population. The lowest levels were found in those boys with the symptoms listed above. The deficiency of essential fatty acids probably represents a metabolic disturbance. It may be compensated for by supplementation with flax seed oil, fish oils or evening primrose oil.
There is no single supplement that will meet the needs of all children. I often use organic flax seed oil, generally one teaspoon per day. My reasons for choosing flax oil are that most Americans are deprived of alpha-linolenic acid (the leading omega-3 essential fatty acid in the diet) because of food processing and food choices. Supplying a nutritional dose of alpha linolenic acid allows the child to overcome this deficiency in the safest fashion. If there is no improvement in behavior, concentration or dryness, I may replace flax oil with fish oil, generally supplying 300 to 400 milligrams of docosahexaenoic acid (DHA) per day. DHA is the omega-3 essential fatty acid with the highest concentration in brain. If hyperactivity or dryness intensifies with omega-3 supplementation, it may indicate the need for omega-6 supplements. The leading omega-6 essential fatty acid in the diet is linoleic acid. Although deficiency of linoleic acid is extremely rare, the Purdue group found low levels of its major metabolites in the blood of children with ADHD.
For those children who do not respond well to omega-3 essential fatty acid supplements, the most effective way to increase the levels of linoleic acid metabolites (omega-6 EFAs) is to supplement with evening primrose oil or borage oil, which supply the biologically active linoleic acid derivative gamma linolenic acid (GLA). Proper EFA supplementation will improve not only behavior but also dryness of the skin and hair and brittle nails.
(B) Does the child have stomachaches, headaches or muscle pains, or has difficulty sleeping and restless? These symptoms often indicate a deficiency of magnesium or calcium. Hyperactive children become magnesium deficient for two reasons. First, like most American children, they consume far too little magnesium in the food they eat. Second, the high adrenaline levels associated with hyperactivity cause them to excrete excessive amounts of magnesium in the urine, causing magnesium deficiency by depletion.
Observational studies in Germany and in France reveal a high frequency of symptomatic magnesium deficiency in hyperactive children, especially those with headaches or abdominal pain. In my clinical practice I have found magnesium supplementation to be especially useful for sleep disturbances in children with ADHD, although the effects on hyperactive behavior are minimal.
The usual dose is 100 milligrams per day for younger children and 200 milligrams for older children, taken at bedtime. If the child's diet is low in calcium, it may be necessary to add a calcium supplement, also taken at bedtime, generally 400 milligrams for younger children and 800 milligrams for older children. There is no evidence that calcium and magnesium interfere with each other's absorption or that a fixed ratio of calcium or magnesium must be administered to a child or on adult.
A possible side effect of magnesium supplementation is diarrhea, whereas a possible side effect of calcium supplementation is constipation.
(C) Has the child taken antibiotics more than once a year? Does he or she become more hyperactive after antibiotics? If so, an overgrowth of yeast in the intestines may be contributing to hyperactivity. Yeast is a potent allergen and also ferments sugar, producing chemicals which can be toxic to the nervous system. Yeast overgrowth can be countered by avoiding sweets and supplementing the diet with probiotics like Lactobacillus or Bifidobacteria. Anti-fungal medications may also be useful if yeast overgrowth is suspected.
Other nutritional supplements demonstrated to help children with ADHD in clinical trials are zinc and pycnogenol, an extract of the French maritime pine. The benefits of these supplements may not be obvious for several weeks.
B-complex vitamins sometimes help children with ADHD, but their effect can be paradoxical. Some children with ADHD become more hyperactive when taking B-vitamins. If a hyperactive child is taking a multivitamin or any B-vitamins, I generally recommend stopping them to see if behavior improves or worsens. It's all part of individualizing treatment.
Leo Galland, MD