ATTENTION DEFICIT/HYPERACTIVITY DISORDER REVISITED
by Theodore E. TePas, MD, Medical Director of the Adult and Child Guidance Center, Saint Francis Hospital, Evanston, Illinois and member of NOHA’s Professional Advisory Board.
One of the more dramatic pieces of evidence for a biological substrate for Attention Deficit/Hyperactivity Disorder (ADHD) was published in the New England Journal of Medicine in November 19901. In the article by Alan J. Zametkin, MD, and colleagues, there is a color portrait of two dramatically different PET (Positron Emission Topography) scans of adult brains. One is normal; the other is from an adult with ADHD. The PET technique uses a radioactive glucose ([18F]fluoro-2-deoxy-D-glucose), which allows the measurement of glucose metabolism in the regions of the brain. Since the brain derives almost all of its energy from the aerobic oxidation of glucose, the end result of the PET scan is a picture that combines anatomy and biochemical functioning. This study pointed out that there was reduced global as well as regional glucose metabolism in the brains of the 25 ADHD adults compared to 50 controls. The largest reductions were in the premotor cortex and in the superior prefrontal cortex. These areas of the brain have been shown to be
involved in the control of attention and motor activity. The researchers’ conclusions were that the reduced glucose metabolism in these regions of the brain may have a role in the disordered physiologic processes that lead to hyperactivity.
In a later article2 Dr. Zametkin states that there is considerable overlap between normal and ADHD brain metabolism and cautions that individual PET scan findings need to be seen on the more complex matrix of the biological and social variables. Then he concludes, "However, when data including family studies, drug response studies, biologic studies, and ADHD’s association with other neuropsychiatric syndromes is combined, the picture of ADHD as a neurological disorder is increasingly convincing."
As exciting as these articles were when I first read them, I was perturbed by the author’s statement that "There is minimal support of a relationship, if any, that exists between diet and hyperactivity." Although the first article was published in 1990, there continues to be a prevailing opinion that there is virtually no connection between dietary intake and behavior, including hyperactivity. More recently, in the June 21, 1995 issue of the Journal of the American Medical Association3 Dr. Zametkin listed a number of ADHD myths. In myth #4 he states: "Sugar and food additives cause ADHD." Many controlled studies have failed to find any substantive link between food additives and ADHD. Support for this finding is well summarized in [Russell A.] Barkley’s definitive textbook by a number of empirical reports as well as in the1980 report of the National Advisory
Committee on Hyperkinesis and Food Additives." Russell A. Barkley, PhD, is a psychologist and one of the main figures in the ADHD field. He has consistently disavowed any significant relationship between diet and ADHD4. He essentially holds to the 1980 report. This position has been frequently stated in his writings as well as in his lectures on the subject.
In June 1973 Benjamin F. Feingold, MD, first proposed that artificial colors and flavors might affect children’s behavior5a&b. The scientific and medical community of the time did not exactly embrace this idea and a number of studies soon followed. The first to receive any significant publicity was the double-blind study done in 1978 by Harley et al.,6 supported by the University of Wisconsin’s Food Research Institute. Based on the parents’ rating, there appeared to be a significant effect in favor of the control diet and not the experimental Feingold Diet. The end result was that there was a basic lack of data to support Feingold’s hypothesis. Other studies followed, essentially coming to the same conclusion. Then in 1979 at the Hospital for Sick Children in Toronto, Drs. J. M. Swanson and M. Kinsbourne7 followed the lead of Dr. J. J. Sobotka8, who had enough sense to find out roughly what amounts of food colors children of various ages were consuming. Prior to that all of the studies had basically taken the amount of dye manufactured annually and divided by the total population and then by 365, giving an average daily consumption for one person per day. Most of the early studies were using about 25 milligrams of dye. In July 1976 Sobotka reported that the daily intake of food colors for the highest ten percent of the one-to-five-year-olds was 121.3 milligrams per day and of the six-to-twelve-year-olds 146 milligrams per day. The average intake was 75 milligrams per day and the high was 315 milligrams per day. In the Toronto study, on 100 milligrams per day of tartrazine dye (FD&C Yellow #5), there was a 34 percent drop in performance three and a half hours after challenge with active capsules. The Toronto group later found that FD&C Red #3 inhibited the uptake of all the the neurotransmitters and their precursors that they tested.
Since that time, some 17 years ago, we continue to hear from experts that parents need not be concerned about any connection between what their children eat and their behavior, as long as the children eat a balanced diet of the foods currently available in our supermarkets. The most recent article that I have reviewed from the Mayo Clinical Proceedings is by William J. Barbaresi, MD, entitled: "Primary-Care Approach to the Diagnosis and Management of
Attention-Deficit Hyperactivity Disorder."9 In most aspects, this is an excellent review of ADHD in regard to both diagnosis and treatment. The latter includes sections on Education, Special Education, Classroom Management and Other Nonmedical Intervention, Parent Training in Behavior Management, and Medical Therapy. However, in this comprehensive review of ADHD treatments, there is not one word, either positive or negative, about diet or nutrition. Fortunately, there have been studies that have addressed this issue. Here are some of them:
When I first encountered Dr. Benjamin Feingold in the middle 1970s at a NOHA sponsored lecture, I was intrigued by his thesis. At that meeting, Dr. Feingold presented his belief, based on his growing clinical experience, that certain food additives may trigger the symptoms, in susceptible persons, which we now associate with the Attention Deficit/Hyperactivity Disorder. At the present time, I have had some 20 years of clinical experience in dealing with children, and more recently adults, with the ADHD diagnosis. My experience
basically supports the Feingold thesis that indeed what a child and/or adult eats can trigger behavior that fits the ADHD criteria. However, we continue to read and hear that there is no significant connection between nutrition and ADHD. Let us go back to some of the early history.
Ever since Dr. Feingold first put forth his observations and experiences with food additives and ADHD there have been two camps on this issue. One is embodied by the Nutrition Foundation, which is a lobby representing major food, chemical, and pharmaceutical companies. (In 1992 the gross income of 17 of our largest food conglomerates was 247 billion dollars!) The Nutrition Foundation created their own National Advisory Committee on Hyperkinesis and Food Additives. In October 1980, this committee then reported to the Nutrition Foundation that there was no substantive link between food additives and ADHD. In other words: "Don’t blame our foods for ADHD!"
The other side of this picture is best represented by FAUS (The Feingold Association of the United States). Presently this is a nationwide organization promoting and supporting families: parents,
children, and now adults with ADHD. They publish an extensive food list based on the Feingold treatment program along with menus and shopping guides. Also, they publish a newsletter that keeps up with the latest professional literature supporting dietary connections to ADHD.
There is also another group CH.A.D.D. (Children and Adults with Attention Deficit Disorders). This is one of the nation’s leading organizations providing family support and advocacy, public and professional education, and encouragement of scientific and educational research. I have found CH.A.D.D. to be quite helpful in dealing with the more traditional medical and educational approaches to ADHD but of little to no support for the nutritional point of view. Their positions essentially follow those of the Nutrition Foundation and Russell A. Barkley, PhD.
On the cutting edge of treating the biological aspects of ADHD is the Pfeiffer Treatment Center here in Naperville, Illinois. This program was founded by NOHA Professional Advisory Board Member William J. Walsh, PhD, in his pioneering work with biochemical patterns and their correlations to patterns of behavior. They have by now had experience with some 6,000 children, some of whom have ADHD. It is my understanding that, when the chemistry is out of balance by their standards and treated with their biochemical program, results are forthcoming.
The Health Comm, Inc. program, well known to NOHA, was founded by NOHA Honorary Member Jeffrey Bland, PhD. They have focused on health problems, using a heavily nutritional approach. In recent years they have begun to take a look at ADHD with promising ideas and, as I understand, results.
NOHA members are familiar with the work of the late Theron G. Randolph, MD, a founding member of NOHA’s Professional Advisory Board. This creative genius, as well as courageous pioneer, founded the field of Ecologic Mental Illness and treated thousands of patients with food allergies and chemical sensitivities. Some of them had what he came to term Level Two Plus or Overcharge stage. These patients often had many of the major behavioral problems of ADHD. When their allergies and sensitivities were handled they reverted back to more normal levels of functioning. Fortunately, there are physicians who are now familiar with Dr. Randolph’s work, although still too few in number.
In the December 11, 1994 Chicago Tribune there appeared an article written about Ronald Price, PhD, a musician who found that his progressive Parkinsonian illness was held in abeyance as long as he continued to play the harp. It had something to do with the fact that he rested the harp against his clavicle and the instrument’s vibrations permeated his body through his skeletal structure. He became intrigued with the observation that if he did not play long enough daily his Parkinsonism would begin to return. Among other things he did was to conduct a study at a special education program in Joliet, Illinois with children who were considered to be
hyperactive. He taught them music with a large dose of playing the harp. He noted: "The students responded with longer attention spans. Their grades went up. Even those without an interest in music did better in their other classes." Interesting.
Acupuncture is now being used by a few practitioners of that art for ADHD and they say that they do get results. I have had no personal experience with that treatment form. There is an article in the Chicago Tribune (January 8, 1995) portraying the work of a May Loo, MD, a physician practicing in San Jose, California, who has also studied Chinese medicine in Hong Kong and who has such a practice. Again, interesting!
Lastly there are probably a number of medical conditions still unknown that are involved in ADHD. One more recently brought to light is a condition called General Resistance to Thyroid Hormone, which has an incidence for ADHD patients 15 times that for the unaffected population. Fortunately, this is not a common condition but where it exists ADHD is common.
An open mind is, in my opinion, one of the keys to wisdom. ADHD does not appear to be diminishing, although I understand that they hardly speak of it in Japan, not out of politeness, but because of its extremely low incidence by USA standards. The children and adults who have to live with ADHD have a need for the very best we in the health professions can offer them. It is my belief that they can in fact do themselves an enormous benefit by learning all they can about cleaning up their diet and getting the counsel of someone with the knowledge and experience to bring their bodies and minds into better balance in all parameters.
I would also encourage NOHA members to be willing to be advocates for their own health care needs with their health providers. I was in fact literally prodded into orthomolecular psychiatry by the parents of one of my patients in the 1970s and I continue to appreciate the push.
1Zametkin, Alan J. et al., "Cerebral Glucose Metabolism in Adults with Hyperactivity of Childhood Onset," New England Journal of Medicine, 323: 1361-6, 1990.
2Zametkin, Alan J., "The Neurobiology of Attention-Deficit Hyperactivity Disorder," CH.A.D.D.ER (A Bi-Annual Publication of CH.A.D.D. A National Support Organization for Informion on Attention Deficit Disorder), 5(1):10-1, Spring/Summer 1991.
3 Zametkin, Alan J., et al, "Attention Deficit Disorder: Born To Be Hyperactive? Selected Cases," Journal of the American Medical Association, 273:1871-4, 1995.
4Barkley, Russell A., Attention Deficit Disorder: A Handbook for Diagnosis and Treatment, New York, Guilford Press, 1990, pp. 15-6.
5aFeingold, Benjamin F., "Adverse Reactions to Food Additives with Special Reference to Hyperkinesis and Learning Difficulty," in F. Steele and A. D. Bourne, The Man/Food Equation, London, Academic Press, 1975.
5bDr. Feingold made a presentation to the American Medical Association in New York City in June 1973.
6Harley, J. P., et al., "Hyperkinesis and Food Additives: Testing the Feingold Hypothesis, Pediatrics, 61: 818-23, 1978.
7Swanson, J. M., and M. Kinsbourne, "Artificial Food Colors Impair the Learning of Hyperactive Children," Report to The Nutrition Foundation, 482 Fifth Avenue New York, NY, 1979.
8Sobatka, J. M., "Estimate of Average, 90th Percentile and Maximum Daily Intake of FD&C Artificial Colors in One Day’s Diet Among Two Age Groups of Children,"Food and Drug Administration Memorandum, July1976.
9Barbaresi, W. J., "Primary-Care Approach in the Diagnosis and Management of Attention-Deficit Hyperactivity Disorder," Mayo Clinical Proceedings, 71: 463-71,1996.
Article from NOHA NEWS, Vol. XXI, No. 4, Fall 1996, pages 3-6.