by Leo Galland, M.D.
Attention deficit hyperactivity disorder has reached epidemic proportions among U.S. school children. The primary medical treatment for ADHD is the stimulant drug, Ritalin, the use of which has increased by 700 percent over the past five years. Although Ritalin can control some symptoms of ADHD, its long-term risks or benefits are not known and the drug does not get to the root of the problem. A body of scientific research supports the importance of nutritional factors in ADHD and permits alternatives to Ritalin in the treatment of this disorder. I have personally treated hundreds of children with ADHD over the past twenty years. Almost all have improved without the need for Ritalin. To help them and their parents I have used a series of questions that searches for the causes of ADHD in each individual child.
The first question is: how effective are the parents at parenting? All children, especially those with behavioral problems, needed affection, consistency and the clear setting of limits. A corollary question is: how appropriate is the educational setting for this child? Some children need to work consistently with their hands and need to keep physically active. These children will become restless and inattentive when deprived of physical work. Their problem is not a medical disorder but inappropriate schooling or ineffective parenting. Fortunately, most of the parents whose children I see in my medical practice understand these principles well. They are consulting me for nutritional advice; I ask the following questions to get the nutritional answers I need and I recommend that pharmacists being asked by parents about alternatives to Ritalin use these questions as a guide.
(1) How nutritious is the child's diet? Over half 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 waffle's with syrup, soft drinks, candy, cakes, cookies, doughnuts, ice cream, frozen yogurt, and chocolate. Every ounce of sure reduction helps. Sugar alone does not cause hyper activity. 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. Thirteen 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 hyper activity, 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 hyper activity. In my clinical practice I have found that food allergy is especially likely to be implicated in ADHD if the answer to any other following 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 looked 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 rice 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 hyper activity, itching of the skin, wheezing, a runny nose or red ears when a particular food is re-introduced to the diet, he or she is likely to be allergic to the food. If allergies are found, the pharmacist should be prepared to offer further nutritional guidance so that the child can follow a balanced diet while avoiding the triggering foods.
(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 nail us, 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 certain long chain essential fatty acids in plasma phospholipids that a control population. The lowest levels were found in those boys with the symptoms listed above. The deficiency of long chain 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 initiate treatment with organic flax seed oil, five grams 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 replace flax oil with concentrated fish oil, 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 hyper activity or dryness intensifies with omega-3 supplementation, it indicates 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). The dose of GLA needed is 135 to 270 milligrams per day, with older larger children needing the higher doses. Proper EFA supplementation will improve not only behavior but also dryness of the skin and hair and brittle nails.
(B) Does the child of stomach aches, headaches or muscle pains, or is sleep difficult 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 less than the RDA of magnesium. 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 dose needed 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, 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 over growth of yeast in the intestines may be contributing to hyper activity. Yeast is a potent allergen and also ferments sugar, producing chemicals which can be toxic to the nervous system. Yeast over growth can be countered by avoiding sweets and supplementing the diet with probiotics like Lactobacillus or Bifidobacteria. The dose needed is one billion to five billion organisms per day. Anti-fungal medications may also be useful if yeast over growth is suspected.
Other nutritional supplements that may help children with ADHD include B-complex vitamins, zinc, dimethylaminoethanol (DMAE) and phosphatidyl serine. These are most useful for children who have learning difficulties in addition to hyperactivity. The dose of zinc needed is 10 milligrams per day for younger children, 20 milligrams per day for teens; for DMAE the necessary dose is 600 to 1200 milligrams per day and for phosphatidyl serine it is 200 to 300 milligrams per day. The benefits of these supplements may not be obvious for several weeks. The effect of B-complex vitamins can be paradoxical. Some children with ADHD become more hyperactive when taking B-vitamins. If this occurs each of the B-vitamins should be administered individually, starting with vitamin B6 (pyridoxine, 10 milligrams per day), then vitamin B1 (thiamine, 20 milligrams per day), then folic acid, 400 micrograms per day.
Over the past twenty years, I have consistently found that the questions listed above permit me to administer nutritional therapies to children with ADHD in a systematic, personalized and highly effective fashion.
1. Egger J, Carter CM, Graham PJ et,al., Controlled trial of oligoantigenic treatment in the hyper kinetic syndrome, Lancet 1985 volume 1 pp. 540 ? 545.
2. Galland L., Magnesium, stress and neuropsychiatric disorders, Magnesium and Trace Elements, 1991, volume 10, pp. 287 ? 301 .
3. Stevens L. J.,Zentall SS, Deck JL, et al, Essential fatty acid metabolism in boys with attention deficit hyper activity disorder, American Journal of Clinical Nutrition, 1995, volume 62, pp. 761 ? 768.
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