by Theodore E. TePas, MD, Retired Medical Director, Comprehensive Mental Health Center, Saint Francis Hospital, Evanston, Illinois, Psychiatric Consultant at the Foster Care Services of Catholic Charities of Chicago, and member of the Association of Christian Therapists and of NOHA's Professional Advisory Board

I am writing this as an introduction to a paper that I wrote for NOHA on January 25, 2003, "Nutrition and Children's Behavior Problems Revisited Again." The reason for doing this is that the information in that original article is still basically true and the problems with you buying clean and healthy food for your family remains an issue.

So what is new in the field of nutrition and children's behavior? Since our last review of 01/25/03 not a great deal has changed in terms of policy and attitudes. There remains a prevailing position that food additives, artificial coloring and flavors approved by the FDA (Food and Drug administration) are not detrimental to children's behavior, emotions, and learning. In other words: Parents don't be so concerned about what your children eat. There is no substantial evidence that food additives, which have passed FDA standards, will harm your children or seriously affect their behavior unless, of courses, the child happens to be sensitive to these ingredients. But, that is more the exception than the rule, and, if there were a problem, you would normally consult with your pediatrician.

Where does this leave you as parents concerned about your children's health and well being? It leaves you where you have always been: in charge of what you and your family eat. A simple principle I believe in is to avoid as many additives as possible, which translates into eating fresh foods whenever available. And, fortunately, we have more choices now than we did just some ten years ago. Within a mile of where I live we have both Whole Foods and Wild Oats stores with a wide variety of organically grown foods. Some areas may not be so fortunate but generally our larger population centers have such stores available to us.

Meanwhile, there is some hope for things to improve. In fact, just yesterday, I understand that our governor, Rod Blagojevich, signed a program pushing for healthier school lunch programs.
April 20, 2006.

In preparing to write this article, I decided to do this as though I were one of you, a reader, not a practicing Child Psychiatrist. "What would I want to know that would be informative and practical?"

Attention Deficit Hyperactivity Disorder (ADHD) remains for many years now a still uncertain diagnosis with poorly understood and arguable etiology and equally contentious treatment. My own position is that ADHD is more like a symptom such as a fever with multiple potential causes and hence some of the confusion, especially when we attempt to attribute the clinical picture to the cause. Over the years we have been presented with the following possible etiologies: reduction of regional and global glucose metabolism largely in the premotor cortex and in the superior prefrontal cortex, food sensitivities both immediate and delayed, food allergies, food additives (including colorings and flavors), low levels of maternal thyroid hormone, low dietary intake of basic nutrieints and phytochemicals (these include more specifically B6, B1, Essential Fatty Acids, Omega 3 & 6 oils, Magnesium and Zinc). Additional conditions are the leaky gut syndrome, excessive use of antibiotics with subsequent intestinal dysbiosis and with yeast overgrowth, and Ileal Lymphoid Nodular Hyperplasia. There are others, but I hope you get the picture. There has been a tendency to discount much of the above and approach ADHD from a purely symptomatic point of view with medication, mostly stimulants, to control symptoms

The NIH estimates that some 3-5% of all American school children may be affected [by ADHD], amounting to some one million children and at an annual cost of 3 billion dollars.

In November of 1998 the National Institutes for Health1 called together for three days a panel of experts to explore the current state of information on the problem of Attention Deficit Hyperactivity Disorder. David J. Kupfer, MD, Professor of Psychiatry at the University of Pittsburgh, who headed the panel, stated, "There is no current validated test for the disorder. . . . Some treatments are effective in the short run—principally drugs such as Ritalin—but no studies have examined their effect on children who take them for more than 14 months." The NIH estimates that some 3-5% of all American school children may be affected, amounting to some one million children and at an annual cost of 3 billion dollars. Member Mark Vonnegut, MD, a pediatrician from Quincy, Massachusetts, stated: "The diagnosis is a mess but we all believe we are dealing with a serious core problem." Nonetheless, panel member Janis Ferre of the Utah Governor's Council for People with Disabilities said, "There's a wide inconsistency in how a diagnosis is made. This results in over diagnosis and under under diagnosis." Another panel member, Donald A. Berry, MD, of Duke University Medical Center said he thought "Ritalin and other mind-altering drugs are prescribed too often for children." He also criticized the lack of studies on the drugs' long-term side effects. Panel member Robert S. Baltimore, MD, from Yale University School of Medicine stated: "There is no gold standard for therapy, so it is difficult to look at the prescribing practice and say what is appropriate or not appropriate." Lastly, among the panel conclusions, were the following:

  1. Attention Deficit Hyperactivity Disorder or ADHD is a commonly diagnosed behavioral Disorder of Childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development, which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.
  2. Although Ritalin and other therapies may correct classroom behavior problems, there is no evidence that such correction improves a child's academic performance.
  3. Short-term trials of Ritalin and other drugs show beneficial effects on some behaviors and are superior to behavior modification training. Combining the two results in improved social skills, so parents and teachers judge this combination more favorably. Many other treatments have been tried including vitamins, herbs, and biofeedback and eliminating some foods, such as sugar. None has proved effective. Doctors and schools usually do a poor job of communicating and coordinating when treating children with ADHD and follow-up is often poor. Teachers and parents play a key role in successfully treating ADHD and fine tuning medication.

. . . panel member Donald A. Berry, MD, of Duke University Medical Center said he thought “Ritalin and other mind-altering drugs are prescribed too often for children.”  He also criticized the lack of studies on the drugs’ long term side effects.

To add to the difficulties, there are a number of conditions whose clinical picture may mimic or accompany ADHD. ADHD exists alone in only about one-third of the children. Many of these other disorders require different treatments and need to be considered separately or integrated into the treatment planning. They include Oppositional Defiant Disorder, Pervasive Developmental Disorder, Primary Disorder of Vigilance, Central Auditory Processing Disorder and Hearing Problems, Bipolar Disorder, Anxiety Disorders. There are also some medical conditions whose symptom picture can mimic ADHD: lead overload, genetic conditions, fragile "X," Tourette's, and hyperthyroidism.

Brain Structure Studies in ADHD
Brain anatomical studies were done by F. Xavier Castellanos, MD, and colleagues of the National Institute of Mental Health. In a report from October 9, 2002, in the Journal of the American Medical Association2, they found subtle structural abnormalities in the brain circuit that inhibits thoughts. On initial scan, patients with ADHD had significantly smaller brain volume in all regions, even after adjustment for significant co-variates. This global difference was reflected in the smaller total cerebral volumes (-3.2%) and in cerebellar volumes down by 3.5%. Their conclusions were "Developmental trajectories for all structures except caudate remain roughly parallel for patients and controls during childhood and adolescence, suggesting that genetic and/or early environmental influences on brain development in ADHD are fixed, nonprogressive, and unrelated to stimulant medication."

They also found that the entire right cerebral hemispheres in the boys with ADHD were on average, a statistically significant 5.2% smaller than those of the controls.

The prefrontal cortex, located in the frontal lobe just behind the forehead, is believed to serve as the brain's command center. The caudate nucleus and the global pallidus, located near the middle of the brain, translate the commands into action. Dr. Castellanos explained: "If the prefrontal cortex is the steering wheel, the caudate and the globus are the accelerator and the brakes. And it's this braking or inhibitory function that is likely impaired in ADHD. ADHD is thought to be rooted in an inability to inhibit thoughts. Finding smaller right hemisphere brain structures responsible for such 'executive' functions strengthens support for this hypothesis." They also found that the entire right cerebral hemispheres in the boys with ADHD were, on average, a statistically significant 5.2% smaller than those of the controls.

Toxins and allergens in our food
Looking back over the past some thirty years, it is clear that our food industry has yet to get the message. We continue to have additives, toxins, and allergens in many of our prepared foods. And both the food industry and government agencies continue to deny there is any harm to our bodies from these chemicals. They are also supported in this denial by my own medical profession with some dissension. The general attitude is that there is no connection between children's diets and their behavior.

A quick reading of most labels on our prepared foods will list additives including food colorings, preservatives, and flavorings. This is to help the food have a decent shelf life, as well as look, smell, and taste appealing and nourish our bodies. It doesn't hurt marketing either. We are assured by the FDA that it is safe to eat these foods. We know less about fresh food such as vegetables, fruits, and meats in terms of what has been done to them prior to our consuming them. We are supposed to assume that these foods too are safe to consume.

Some years ago in the late 1950s, when I was attending the national meeting of the American Psychiatric Association held here in Chicago, I first was exposed to Dr. Theron Randolph, who was presenting his work, by the way, in a room rather removed from most of the other presenters. Dr. Randolph was telling of his work with food testing on patients. Some had psychiatric symptoms, which Dr. Randolph suspected might be caused by the foods they were eating. He then explained that he put his patients on a water fast for some 4-5 days and then began to reintroduce them to the foods that they had been eating one at a time and then to observe them for any physical, emotional, or mental changes. And new to me was what he said about getting positive results correlating some of the foods eaten with psychiatric symptoms. I was puzzled as well as intrigued about this, never having heard anything remotely resembling this in my psychiatric residency. I dutifully reported this to one of my supervisors, a board certified psychiatrist, and was told to "Forget it." Meanwhile over many years Dr. Randolph continued his work helping literally thousands, including some of my own patients, with his methods. A founding member of the NOHA Professional Advisory Board, he was truly one of our original pioneers.

. . . most labels on our prepared foods will list additives including food colorings, preservatives, and flavorings.  This is to help the food to have a decent shelf life, as well as look, smell, and taste appealing . . . .  We are assured by the FDA that it is a safe product to eat.  We know less about fresh food such as vegetables, fruits, and meats in terms of what has been done to them prior to our consuming them.  We are supposed to assume that these foods too are safe . . .

It has been some 30 years since Dr. Benjamin Feingold3 proposed that children's behavior could be adversely affected by what they were eating. His findings have yet to be accepted by mainstream medicine. As recently as 1999, the text book Pediatrics by Nelson states: "There is no evidence that diet has a role in children's behavior problems."4

CHADD (Children and Adults with Attention Deficit Disorder), a group headed by Russell Barkley, PhD, has been very helpful to adults and parents of children with ADHD. However, their official position is that there is no real concern about food ingestion and behavior problems including ADHD5.

In 1979, a study done by J. M. Swanson, MD, at the University of Toronto6 on children, showed that the food dye tartrazine (yellow dye #5) in a test dose of 100 mg, produced a 34% drop in performance along with behavior problems and hyperactivity in the children. Prior studies had used amounts of the dye in the range of 25-50 mg and the figure was derived from the amount of the dye produced annually divided by the population, divided by 365. The Toronto study interviewed the children involved and found they were consuming in the neighborhood of 300 mgs per day. There is also evidence that the food coloring Red #5 alters neurotransmitter chemistry and not for the better. Unfortunately these problems are still with us and the evidence increases.

However, little has been done to improve matters by the food industry. There is also little support from the medical establishment to remove these chemicals from our foods. In the 1999 Nelson's Textbook of Pediatrics4 it states that there is no demonstrated relationship between behavior and diet. The same position is held by the American Association of Pediatrics (AAP). However, in a more recent 2002 edition of this same textbook (Nelson)7 a revised position is put forth:

A number of alternative treatments for ADHD have gained popularity. The support often is entirely anecdotal or theoretical, and unbiased empirical tests are either lacking or have failed to provide evidence of efficacy. Interventions of this type include the use of megavitamins, electro-encephalographic biofeedback, optometric visual training, chiropractic manipulation, and herbal remedies. Dietary management (e.g., restriction of refined sugar or food additives) has been particularly popular even though there is little evidence of clinical effect-except in very young children. However, when families feel strongly about exploring manipulation of the diet to treat ADHD, they should be allowed to see for themselves as long as other components of treatment are not neglected and the diet is not harmful.

Well, we finally got their permission to do what NOHA has been advising for years!! I welcome them to our position!

And now in more recent years we have added the problem of an increasing number of children and adolescents developing obesity with their fast food intake loaded with fat, sugar, and calories.

There are now available several non-stimulant products, one Rx, and several nutrient formulas for treating ADHD. The medication is atomotoxetine with a brand name of Straterra and two of the nutritional formulas: Attend by Vaxa that contains 12 amino acids, 20 fatty acids, herbs, and a homeopathic remedy. The other is CALM'd essentially containing phenylalanine, glutamine, vitamin B6, and Zn.

. . . groups like NOHA have been educating the public for years about the value of “eating clean” like nature intended with its related health benefits.

Fortunately for those open enough to hear it, groups like NOHA have been educating the public for years about the value of "eating clean" like nature intended with its related health benefits. We also have programs for diagnosis and treatment of chemical imbalances such as our local Pfeiffer Treatment Center, headed by NOHA Professional Advisory Board Member William Walsh, PhD, which in my opinion is one of the pioneering programs of this kind in the country.

So, over the years, I have learned to believe what my experience and that of others have shown me. I do appreciate the value of science and recognize that the double-blind, placebo-controlled study is the gold standard of science because, until something better comes along, it gives us assurance of the probable cause of what happened. It is clear that we have a lack of such studies in the field of ADHD research.

One last thing I have not mentioned and, as a psychiatrist, I would be grievously remiss to omit it, is the importance of stress on our health and the effect it has on our chemistry and overall well being. It is not the intention of this paper to get into a detailed discussion of the chemistry of stress other than to say that it has major repercussions for our overall health, physical as well as emotional.

Meanwhile my clinical experience over some 30 years tells me that there is something in food sensitivities; food colorings; excess dietary sugar; mineral deficiencies, imbalances, and toxicities; transmethylation imbalances; hypoglycemia; amino acid imbalance; and problems with essential fatty acids. It makes sense to nourish our bodies with unadulterated organically grown foods-clean of additives and pesticides and preservatives. My clinical experience also tells me that there is value in traditional medicine, integrative medicine, homeopathy, chiropractic, nutritional counseling, Chinese medicine, and the balancing of the chakra energy patterns of Ayurveda.

And a salute to our pioneers in their own fields, men and women, who honored their own observations and who have brought health and healing to those under their care: Drs. Carl Pfeiffer, Benjamin Feingold, Theron Randolph, Doris Rapp, Bill Walsh. I should actually include all of those who have presented their ideas and work to NOHA over these many years. Thanks to all of you.

1National Institutes of Health, "Consensus Statements: 110. Diagnosis and Treatment of Attention Defecit Hyperactivity Disorder." National Institutes of Health Consensus Development Statements, November 16-18, 1998.
2Castellanos, F. Xavier, et al, "Developmental Trajectories of Brain Volume Abnormalities on Children and Adolescents With Attention-Deficit/Hyperactivity Disorder," Journal of the American Medical Association, 288(14): 1740-8. October 9, 2002.
3Feingold, Benjamin, Presentation at the AMA meeting in New York City, June, 1973.
4Nelson, Waldo E., R.E. Behrman, R. Kliegman, The Nelson Textbook of Peadiatrics, 14th edition, W.B. Saunders Company, 1999.
5Barkley, Russell, PhD, Taking Charge of ADHD. The Complete Authoritive Guide for Parents, Guilford Press, (A CHADD publication),
6Swanson, J.M. amd M. Kisbourne, "Artificial food colors impair the learning of hyperactive children", Report to the Nutrition Foundation, 482 Fifth Avenue, New York, NY, 1979.
7Nelson, Waldo E., R.E. Behrman, R. Kliegman, The Nelson Textbook of Pediatrics, 15th edition, page 102, W.B. Saunders Company, 2002.

Article from NOHA NEWS, Vol. XXXI, No. 3, Summer 2006, pages 5-8.