 
Nutritional Treatment for Attention Deficit Hyperactivity
Disorder
The Hype and The Hope - A Review of Current Research
James Greenblatt, M.D. and Gina
L. Nick, Ph.D., N.D.
Attention Deficit Hyperactivity Disorder (ADHD) is
the most recent name for a complex neurobiological disorder which
can occur in children, adolescents or adults. Symptoms include difficulty
with attention, concentration, memory, organization and for some
impulsivity, hyperactivity, aggressiveness and relationship problems.
A wide range of behaviors and variability of symptoms are hallmarks
of ADHD. Learning disabilities, depression, anxiety, oppositional
behaviors and other psychiatric or medical disorders may coexist
with ADHD.
The National Institute of Health sponsored a Consensus
Conference on Attention Deficit Hyperactivity Disorder (ADHD) in
November 1998.1 A panel of experts reviewed professional literature,
listened to professional and public presentations, and then prepared
a written report. This Consensus Report (available for public viewing
at www.consensus.nih.gov)
revealed that "...after years of clinical research and experience
with ADHD, our knowledge about the cause or causes of ADHD remains
speculative. Consequently we have no strategies for the prevention
of ADHD." This revelation has profound implications for psychiatry
and the treatment of ADHD. If our current knowledge of ADHD is so
limited that we are unable to develop strategies for preventing
this condition in the future, then current science is missing a
critical component in this psychiatric condition. We believe that
the missing ingredient is the notion of nutritional biochemistry
as it relates to physiologic function, and particularly neurotransmitter
function. This article explores a few aspects of this controversial
topic.
Over the past ten years, we have treated over 10,000
patients with ADHD. During this time we have shifted our practice
from primarily prescribing medications to recommending blood tests
and prescribing nutritional supplements. Our goal has always been
to try to understand the cause of ADHD. The more children we study,
the clearer it becomes that ADHD does not have a single cause. Although
genetics place children at risk, it is not the only factor. Clinical
research and oversimplified medical theories view ADHD as a single
disorder. We believe it is more accurate to view ADHD as a syndrome
with multiple environmental, genetic and metabolic causes.
In our clinic, we have found numerous nutritional
and metabolic disturbances related to the symptoms of ADHD. Some
of these have been shown to contribute to behavioral and attentional
problems - others have not. We have found food allergies, heavy
metal toxicity, fatty acid imbalances, magnesium deficiencies, iron
deficiencies, zinc deficiencies, infections, dehydration, gastrointestinal
problems and carbohydrate intolerance. Some children present with
only one of these metabolic disturbances while others may have two
or three.
Studies done by the American Dietetic Association
(1999)2, the US Department of Health and Human Services3, and the
National Cancer Institute4 , indicate that a large percentage of
children in the United States are not obtaining the RDA for nutrients
from their food. In 1997, Munoz et. al. studied 3307 children in
the U.S. (age 2-19) to determine the number of children meeting
national recommendations for food group intake and found that only
1% met all the recommendations5. Furthermore, 64% of children studied
failed to meet the minimum RDA requirements for vegetable intake,
and, of the 36% that actually met these requirements, 1/4 of all
the vegetables they consumed were in the form of French fries! This
data is startling and it is becoming more and more evident that
our children are not receiving the essential vitamins, minerals
and phytochemicals required for proper brain functioning.
Nutritional Therapy has emerged as an alternative
or complementary therapy in virtually all areas of health care.
Medical research has demonstrated that proper nutrition is critical
for the prevention of many chronic illnesses seen in this country.
Phytochemicals found in specific fruits and vegetables have been
found to have dramatic cancer preventing and/or immune strengthening
properties. Mental health research has been slow to embrace nutritional
therapies. A small number of scientists have begun publishing research
supporting the role of nutrition in psychiatric illnesses6-11. A
landmark article recently published in the Archives of Psychiatry12
demonstrated that the omega-3 fatty acids from fish oil may be beneficial
in improving symptoms in individuals with Bipolar Disorder. This
double-blind intervention trial found that depression was significantly
reduced in the experimental group.
A recent conference, "ADHD: Causes and Possible
Solutions," organized by Georgetown Medical School was held
on November 4-7, 1999. This groundbreaking medical conference supported
science which encourages the use of nutrition in treating ADHD.
Presentations by academic physicians included a diverse range of
topics including the effects of low-level exposure to chemicals,
food additives, delayed hypersensitivity reactions to foods and
the long term affects of consuming junk foods.
A month prior to this monumental event a report released
from the Center for Science in the Public Interest acknowledged
that food dyes and certain foods can adversely affect children's
behavior. The report "Diet, ADHD & Behavior, A quarter-Century
Review" sites 17 controlled studies that detail the effects
of diet on behavior. Michael F. Jacobson, the executive director
of CSPI stated "It's high time that the government - as well
as doctors - provided the public with accurate information that
might help many children." This report prompted the U.S. Department
of Health and Human Services to strongly encourage parents and professionals
to modify children's diets before resorting to any other treatment.
One area of nutrition that has received recent attention
is essential fatty acid (EFA) deficiency, faulty EFA metabolism
and hyperactivity in children13-16. Essential fatty acids are required
constituents of every membrane in the body, including neuronal cell
membranes. They serve as essential components in the biosynthesis
of eicosanoids, chemicals that effect the working of every cell
in the body17. Some of the cardinal signs of an EFA deficiency include
excessive thirst, hyperallergic responses to common foods, and skin
conditions such as eczema, clinical signs that tend to be common
in ADHD children18. Symptoms such as thirst, eczema, and allergies
are nonspecific symptoms that may have multiple etiologies unrelated
to ADHD. However, this correlation led researchers to hypothesize
that fatty acid supplementation would positively affect patients
with ADHD19-20 and most clinical research reports are confirming
their initial hypotheses21-23. Several case studies have shown that
a forced EFA deficiency will lead to neurological abnormalities,
and that these abnormalities will reverse with EFA supplementation24-25.
In 1995, Stevens et. al. studied 96 subjects to determine
whether ADHD children had a significantly different fatty acid profile
from children without ADHD26. They found that all 53 of the ADHD
children in the experimental group had significantly lower concentrations
of key fatty acids in their plasma polar lipids and in RBC total
lipids, while 100% of the 43 subjects in the control group had relatively
normal EFA profiles. Twenty-one of the subjects with ADHD also presented
with classic EFA deficiency symptoms, including excessive thirst,
dry skin, frequent urination and dry hair. The researchers also
found that only 45% of the ADHD children were breast fed (for a
significantly shorter period than control subjects - on average,
two months) as compared to 85% of the control subjects. Breast milk
contains a significant amount of DHA27, an important component of
brain and peripheral neuron structure28. It is found in high concentrations
around nerve synapses and plays a critical role in the developing
brain29-30. At least one study has suggested that children who are
breast fed are 50% less likely to manifest symptoms of ADHD than
are children who are bottle fed31. The results of this study are
consistent with other studies on EFAs and ADHD32-34.
In addition to EFA deficiencies, numerous studies
have indicated specific vitamin and mineral deficiencies in children
with ADHD35-44. For example, in 1997 Tadeusz and Starobrat-Hermelin
examined 116 children with ADHD and found that 95% of those examined
were deficient in magnesium in blood serum and hair45. Magnesium
has a profound influence in regulating the central and peripheral
nervous systems. Chronic magnesium deficiency results in hyperactivity,
impaired reaction to external stimuli, irritability, fatigue, difficulty
sleeping, and poor mental concentration46. Researchers also discovered
a positive correlation between zinc deficiency and hyperactivity47-51.
Another study found that 486 hyperactive children had significantly
reduced serum, hair and urine levels of zinc as compared to 172
age and sex-matched controls52.
While researchers assert that children with ADHD may
be deficient in fatty acids or specific vitamins and minerals, the
therapeutic implications are not as clear. It is often difficult
to interpret these research studies and apply the information clinically.
It is also difficult to successfully utilize information published
by the lay press which is mostly over-interpreted information drawn
from these research articles.
The health food industry has grossly distorted the
current literature on nutrition and behavior to sell their products.
Many companies profit on parents' fears and make preposterous claims
based on poor interpretations of scientific studies. Americans love
to take vitamins. We are caught up in a multi-billion dollar frenzy
trying to find the right vitamin or herb to cure our ills. The lay
press is popularizing the concept of fatty acid supplementation
for the treatment of ADHD. The answer is not that simple. If ADHD
is seen as a syndrome, then not every child will have the same underlying
physiology.
In our clinic, we recommend a Red Blood Cell Fatty
Acid Analysis to determine individual fatty acid requirements. After
analyzing hundreds of fatty acid test on ADHD children, we have
found the differences are as striking as the similarities. Health
food stores are filled with brochures recommending DHA and Omega-3
fatty acids. Other publications report success treating ADHD with
evening primrose oil - an omega-6 fatty acid. Increasing intake
of essential fatty acids in one's diet is a simple healthful dietary
intervention. Supplementing with large doses of one fatty acid can
be potentially dangerous and set up further metabolic imbalances.
Don't buy a supplement for your child because the company brochure
makes a connection between fatty acids and brain function. Buy a
supplement after a fatty acid analysis was completed on your child
and showed a deficiency or imbalance.
Modern psychiatry understands ADHD to be inextricably
linked with abnormal brain chemistry. No cause has been identified.
Conflicting research reports on dietary interventions are based
on oversimplified views of ADHD as a single disorder. If ADHD is
seen as a syndrome with multiple environmental, genetic and metabolic
causes it becomes clear that nutritional recommendations will need
to be based on an individuals biochemistry.
We have found individualized nutritional interventions
based on clinical history, physical symptoms and laboratory testing
can provide relief for many children with ADHD. Laboratory tests
are available for mineral deficiencies, heavy metals, food sensitivities,
yeast overgrowth, fatty acid deficiencies and many other functional
disturbances. How many physicians have looked for elevated copper
levels or recommended food allergy testing when evaluating a child
for ADHD?
The prevailing treatment approach for ADHD primarily
involves pharmacological manipulation of neurotransmitters. Medications
are routinely prescribed for reducing the symptoms of ADHD. For
a particular individual, the right choice of medication, at the
correct dosage, can be an invaluable asset in a treatment plan.
Unfortunately, over zealous psychiatrists and pharmaceutical companies
have helped create a culture of "polypharmacy," (a term
used to describe the use of multiple medications) to treat ADHD
children. Physicians are prescribing medications to wake up, medications
for school, medications for homework, and medications to fall asleep.
In 1996, researchers analyzed the prescriptions for the Michigan
Medicaid system. Physicians prescribed one or more of some 22 different
medications to 57% of ADHD children under three53. Over 33% of the
children received a combination of medications, and there was no
consistency in the combinations of drugs prescribed. In fact, the
researchers found that there were thirty different combinations
of medications prescribed to these young children54.
No scientific literature exists to support the use
of these medications in the treatment of children less than three
years of age. Furthermore, researchers have not shown if these drugs
have any long-term side effects, or if they are even helpful. The
medical profession has not really questioned the use of unapproved
psychotrophic medications for small children (under three!). What
the medical professional has consistently questioned is the understanding
of nutritional biochemistry and food sensitivities in the treatment
of ADHD.
Medicine is typically slow and cautious to accept
that nutrition may displace current theories about a medical disorder.
Should we wait for the scientific community to analyze and agree
upon this research before we act to assure that our children are
getting the essential nutrients they need for optimal brain function?
Research identified a relationship between folic acid deficiencies
and birth defects as early as 196555. It was not until 1992 that
the United States Public Health Service shared this critical knowledge
with the country and recommended that all women of childbearing
age, capable of becoming pregnant, consume 400mcg of folic acid
per day56. It took the scientific community almost 30 years to accept
that a nutrient deficiency might cause a gross distortion in human
neuronal development and to recommend supplementation. Thousands
and thousands of children were born during this time with preventable
birth defects. We don't want nutritional information concerning
ADHD to remain buried in medical dogma. The evidence warrants the
establishment of a scientific and social effort to educate physicians,
parents and caretakers on the value of optimizing brain function
with nutrition. For those patients with specific genetic vulnerabilities,
the implications are even more profound, as poor nutrition may very
well be the environmental link that accelerates a diseased state
like ADHD.
Many of our colleagues dismiss the role of nutrition
in ADHD, quoting old negative studies on food additives, sugar and
megavitamin therapy. Scientific research over the past ten years
has clearly demonstrated that nutrition plays a critical role in
brain function. Further clinical studies are desperately needed
to address the complicated role nutrition plays in this complicated
syndrome.
It is best to seek out a skilled professional to assist
in untangling the multiple factors that may contribute to ADHD.
Without treatment, ADHD can lead to profound distress at school,
work or home. Every child and parent suffering with ADHD should
be offered the opportunity to understand and treat the underlining
reasons for their behavior. Treating the underlying biochemistry
addresses the core of the problem. Although the solution is not
simple, the science is now available to develop an organized, sensible,
biochemical approach to address the metabolic imbalances of ADHD.
For More Information:
For a list of medical references for this article,
contact:
Sterling Medical Building
9 Hope Ave.
Waltham, MA 02453.
Phone (617) 332-1336
Fax (617) 332-1336
NaturalAdd.Com
is Dr. Greenblatt's website with additional information on alternative
therapies, seminar tapes available, and opportunities to reserve
a copy of his upcoming book.
Diet, ADHD and Behavior, A Quarter-Century Review
by
The Center for Science in the Public Interest
www.cspinet.org
Phone (202)
332-9110
Dr. Greenblatt is dually board certified in child
and adult psychiatry. He received his medical degree and completed
his adult psychiatry residency at George Washington University in
Washington D.C. He completed a fellowship in child and adolescent
psychiatry at Johns Hopkins Medical School.
Dr. Greenblatt is founder and Medical Director of
Comprehensive Psychiatric Resources, Inc., a multidisciplinary specialty
clinic for ADHD, and a faculty member at Harvard Medical School,
Department of Psychiatry.
Dr. Nick is a practicing Naturopathic Physician with
a Ph.D. in Nutritional Science. She is a graduate of the University
of California, Los Angeles and Southwest College of Naturopathic
Medicine and Health Sciences. She is internationally recognized
for her works in Nutritional Biochemistry and Herbal Medicine, earning
her multiple awards and grants to study in the United States, France
and Israel. She can be contacted at www.doctorgina.com.
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