Diet for ADHD Children: A Parent's Guide (page 2)
*This pamphlet is adapted from Diet, ADHD & Behavior, published by the Center for Science in the Public Interest. That report is available from CSPI or its Internet site (www.cspinet.org).
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common behavioral problems in children. It not only bedevils children, but also affects their siblings and parents. It can be treated, but not cured. A key question for parents is how to treat their children.
ADHD—also called hyperactivity or attention-deficit disorder—has been diagnosed in millions of American children and adults. The main symptoms in children are reduced attentiveness and concentration, excessive levels of activity, distractibility, and impulsiveness. Before concluding that your child has ADHD, consult a doctor or psychologist who is qualified to make the diagnosis. Many children whose parents think they have ADHD are merely very active or spirited. Besides ADHD, some children exhibit other types and degrees of inappropriate behavior.
Exactly how many children suffer from ADHD is not known. The usual estimates are 3 to 5 percent of school-age children. Using broader diagnostic definitions, some surveys find that the percentage is as high as 20 percent in certain subgroups of the population. ADHD is two or three times more common in boys than in girls. On average, at least one child in every classroom in the United States needs help for ADHD.
Researchers generally agree that ADHD has genetic roots. Thus, if one child has the syndrome, his or her siblings have a greater risk of developing it. Because doctors cannot yet diagnose ADHD by using blood analyses, brain scans, or other laboratory tests, ADHD is usually diagnosed by observing a child’s behavior, interviewing parents and teachers, and by using a checklist of behaviors, such as those included in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV published by the American Psychiatric Association. (See box on next page.) Researchers are working hard to develop more reliable diagnostic tools and have found subtle differences in brain structure and metabolism between children with and without ADHD.
ADHD takes an enormous toll on children and their families. The child falls behind in school, loses self-esteem, and needs extra help. A family must cope daily with the need to focus the child’s attention on essential activities or restrain his or her impulsive behavior, while dealing with the unsettling fact that the child is not always welcome in other people’s homes, in play groups, or on teams. Siblings may suffer because their needs are not as acute, and many marriages suffer from the constant stress of dealing with an affected child.
Signposts of ADHD
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders describes three patterns of behavior that indicate ADHD. People with ADHD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive. Or they may show all three types of behavior.
Signs of inattention include:
- becoming easily distracted by irrelevant sights and sounds
- failing to pay attention to details and making careless mistakes
- rarely following instructions carefully and completely
- losing or forgetting things like toys, or pencils, books, and tools needed for a task
- avoiding tasks that require sustained mental effort
Signs of hyperactivity and impulsivity include:
- feeling restless, often fidgeting with hands or feet, or squirming
- running, climbing, or leaving a seat, in situations where sitting or quiet behavior is expected
- acting as if driven by a motor
- blurting out answers before hearing the whole question
- having difficulty waiting in line or for a turn
Because everyone shows some of those behaviors at times, the DSM contains specific guidelines for determining when they indicate ADHD. The behaviors must appear early in life, before age seven, and continue for at least six months. In children, they must be more frequent or severe than in others the same age. Above all, the behaviors must create a real handicap in at least two areas of a person’s life, such as school, home, work, or social settings. So someone whose work or friendships are not impaired by those behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active at school but functions well elsewhere.
(Adapted from Attention Deficit Hyperactivity Disorder, National Institute of Mental Health, 1994.)
Many children outgrow or learn how to control their symptoms. But symptoms sometimes persist into adulthood, making it more difficult to succeed in careers, to start and maintain families, and to become involved in community activities. Adults with ADHD have higher rates of alcoholism, drug use, and imprisonment. Thus, early treatment is crucial.
The Feingold Diet
In the early 1970s, Dr. Benjamin Feingold generated a firestorm of excitement and controversy by asserting that certain foods and food additives could trigger ADHD. Feingold, who was Chief Emeritus of the Department of Allergy at the Kaiser Foundation Hospital and Permanente Medical Group in San Francisco, reported that when he prescribed dietary changes for patients with hives, asthma, or other allergic reactions, their behavioral problems (if present) sometimes diminished. He claimed that 30 percent to 50 percent of his hyperactive patients benefited from diets free of artificial colorings and flavorings and certain natural chemicals (salicylates in apricots, berries, tomatoes, and other foods).
Thousands of beleaguered families, eager for drug-free relief for their hyperactive children, tried Feingold’s diet. Many reported improvement in their children’s behavior. That spurred the formation of Feingold-diet support groups throughout the country to share information and provide assistance to families. For more information contact the Feingold Association of the United States (P.O. Box 6550, Alexandria, VA 22306; 800-321-3287; www.feingold.org).
But not everyone was impressed by Feingold’s claim. The processed-food industry, many child-behavior experts, and many pediatricians reacted to Feingold’s claim with skepticism bordering on derision, pointing out that it was based solely on his and parental observations and was not backed by any controlled studies. The reported successes of his diet could be due to something else the families were doing or simply to their wishful thinking, they said, and not necessarily to the absence of certain chemicals in the food.
Slowly, researchers began testing Feingold’s claim. The first study, conducted by C. Keith Conners and his colleagues at the University of Pittsburgh and published in 1976, found that at least four of 15 children diagnosed with ADHD improved on a diet free of artificial colors and flavors. Over the next two decades, almost two dozen more controlled trials followed, most of which focused on food dyes. In some cases, children were put on a diet that lacked many food additives and then “challenged” with dyes. In other cases, the behavior of children was monitored after they were switched to a diet free of foods that might cause a reaction (dyes, wheat, egg, chocolate, and others) and then challenged with those foods. Most—but not all—of those studies found that some—but not all—children were affected by diet. Some of those “responders” were affected by diet slightly, others dramatically.
In 1982 the National Institutes of Health (NIH) convened a “consensus development conference” on diets and hyperactivity to review the early scientific research and advise health professionals and the public. That NIH panel concluded that food additives and certain foods do, indeed, affect a small proportion of children with behavioral problems. In addition to noting that anecdotal reports claimed “dramatic improvements” in some hyperactive children, the panel concluded that controlled studies “did indicate a limited positive association between defined [Feingold-type] diets and a decrease in hyperactivity.” It pointed out that a major limitation of the research was that most studies tested the effect only of dyes and not of other additives and foods that also might promote hyperactivity. It recognized “that initiation of a trial of dietary treatment . . . may be warranted” for hyperactive children. The conference recommended that additional research on diet and behavior be conducted, but over the next decade and a half only scattered research was done. The failure to conduct a broad range of research means that little is known about the percentage of children who respond to dietary therapy, to what degree they respond, which children are likeliest to be affected, the additives and foods that cause problems, and the best ways to use diet therapy.
Concerns About Stimulant Drugs
Once pediatricians, psychologists, and psychiatrists have concluded that a child has ADHD, they usually prescribe parenting-skills training for parents and behavioral counseling and stimulant drugs for the child. The drug most frequently prescribed is methylphenidate, the most popular brand of which is Ritalin. Other behavioral problems may be treated with other drugs.
Ritalin is often highly effective in reducing the symptoms of ADHD, and millions of children have been treated with it. In recent years, Ritalin’s use has increased greatly, with a 2.5-fold increase occurring just between 1990 and 1995.
One reason to consider alternatives to Ritalin is that it and other drugs have troubling side effects. Ritalin and amphetamines (Adderall, Dexedrine) may cause reduced appetite and weight loss, stomachaches, and insomnia. More seriously, those drugs occasionally may cause or exacerbate tics and Tourette’s syndrome. Another drug, pemoline (Cylert), has been associated with fatal liver failure, and the Food and Drug Administration (FDA) urges doctors not to use it to treat ADHD. Furthermore, until long-term studies are done, it will not be known whether years-long treatment in childhood (or adulthood) with stimulant drugs affects the nervous system or other parts of the body later in life.
Adding to the concern about Ritalin is that a study conducted by the federal government’s National Toxicology Program (NTP) found that methylphenidate caused liver tumors in mice. Unlike studies in which animals developed tumors only after being fed extraordinarily high dosages of a chemical, the dose of methylphenidate that caused tumors was only several times higher than the maximum recommended dose in humans. (In a separate study, amphetamines did not cause cancer.)
Samuel Epstein, a cancer expert at the School of Public Health at the University of Illinois, says, “The NTP study sends a powerful warning that Ritalin may cause cancer—in the liver or other organs—in humans. Millions of young children take Ritalin for years on end, and children may be especially susceptible to a carcinogen’s effects.”
The FDA acknowledges that the NTP study indicates “a weak signal of carcinogenic potential,” but still considers the drug to be safe. The FDA noted that it did not cause cancer in rats and that the strain of mouse used was especially susceptible to developing liver tumors. There is no evidence that Ritalin causes cancer in humans, but no studies have followed large numbers of Ritalin-users for four or five decades. After all, large numbers of children have been consuming Ritalin for only the past one or two decades, and cancer might not occur until the children reach their 60s or 70s.
Reprinted with the permission of the Center for Science in the Public Interest.