From The August 2000 Issue of Nutrition Science News
by Raymond M. Lombardi, N.D., D.C., C.C.N.
ADHD is being identified as epidemic throughout the United States: the National Institutes of Health in Washington, D.C., estimates that from 3 to 5 percent of all American schoolchildren have been diagnosed with the disorder. This trend alone is reason for concern, but perhaps more troubling is that more than 6 million American children currently diagnosed with ADHD are being treated with central nervous system stimulants--usually methylphenidate (Ritalin)--when more natural approaches exist. A sad commentary on the seriousness of this problem was related by a patient who recently visited his child's school and outside the nurse's office found a long line of children waiting to get their dose of Ritalin.
Learning about ADHD is important because you are certain to find parents looking to your stores for information and treatment options.
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 just ADD, attention deficit disorder), ADHD-Primarily Hyperactive/Impulsive Type, and ADHD-Combined Type (both 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.
The extreme variations 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 city A and 23,967 students in city B) were evaluated based on nurse records of those receiving ADHD medication in school. The prevalence of ADHD was 12 percent in district (city) A and 63 percent in district (city) B. The researchers concluded that the criteria for ADHD diagnosis vary substantially across U.S. populations, with potential overdiagnosis and overtreatment of ADHD in some groups of children. 
A number of primary and secondary mechanisms have been proposed as causes or influences of ADHD. These include possible brain dysfunction (ranging from information transfer problems to brain chemistry-neurotransmitter deficits); genetic influences; environmental toxins such as lead, alcohol and cigarette smoking; 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, Chinese medicine, cranial-sacral therapy, flower 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 sleep problems, physical symptoms and mood changes, can change with diet. 
A 1998 review conducted at the National Defense Medical College in Japan and published in the Journal of Gastroenter-ology Hepatology discussed dietary fat intake and its modulating effects on the intestinal immune system as it applies to Crohn's disease. The researchers found that unsaturated fatty acids, particularly at higher concentrations, suppressed cell-mediated immunity within the gut-associated lymphoid tissue. This in turn induced relapse of Crohn's disease.  Although this study focused on the effect on Crohn's disease, the study's findings may be extrapolated to ADHD and other disorders in which the gut immune system reacts with food components, food-based allergens and nutrient depletions. While clinical investigations continue, the application of these issues should be part of an integrated treatment regimen to ameliorate ADHD.
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. Regardless of the pitfalls, however, the benefits of proper nutrition are critical 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 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 the amount of sugar eaten.
A food elimination program is implemented by removing many foods from the diet such as junk foods; sugars; dairy products; whole grains such as 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 eight to 12 weeks and the child's behavioral responses are observed.
The second stage reintroduces a particular whole food, such as whole grains, citrus fruits, poultry or fish. 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. The 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.
The Washington, D.C., based Center for Science in the Public Interest (CSPI) cited 17 controlled studies in a 1999 report that found diet adversely affects some children's behavior, sometimes dramatically. Most of the studies focused on artificial colors, while some also examined the effects of milk, corn and other common foods. The percentage of children who were affected by diet and the magnitude of the effect varied widely among the studies. Six other studies did not detect any behavioral effect of diet. 
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 44 percent, researchers concluded that diet "cannot be neglected" in ADHD treatment. 
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 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.
Much of the nutrient research conducted over the years has centered on the various supplements discussed by Galland. Mineral and essential fatty acid research has been explicitly focused on ADHD, while others in his protocol are either important for basic good nutrition or carry circumstantial evidence for their use. The supplements chart on page 345 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 research during the last five years. A 1995 study by researchers in the department of foods and nutrition at Purdue University in West Lafayette, Ind., evaluated essential fatty acid metabolism in 96 boys, 53 with ADHD and 43 controls. The study found the 53 ADHD subjects had significantly lower concentrations of omega-3 and omega-6 fatty acids in their blood plasma. 
A follow-up study by this same group of researchers, which appeared in the January 2000 American Journal of Clinical Nutrition, further documented plasma deficiencies of the essential fatty acid docosahexaenoic acid (DHA) in ADHD children. 
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 controls. 
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.
Iron helps regulate the activity of dopamine, a neurotransmitter synthesized by the adrenal gland 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. In the end, the parents thought the children improved; their ratings dropped from 17.6 to 12.7. However, there was no change in the teachers' scores. 
Serotonin levels may also affect ADHD patients. Researchers at Ness Zion Mental Health Center in Israel found blood levels of serotonin tended to be lower in children with more severe markers of hyperactivity, impulsiveness, aggressiveness and lack of concentration. Supplementation with 5-hydroxytryptophan (5-HTP), a serotonin precursor, may consequently help those with more severe ADHD symptoms.
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. The key is in the foods we allow our children to eat and critical supplements that need to be utilized. Nutritional therapy, and a variety of other alternative care approaches, can be the 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, 1999).
Suggested ADHD Supplement Dosage
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