AD(H)D - Attention Deficit Conditions and Enzymes
Click here for the ADHD diet (Feingold Program), and research on behavior and food
last updated 8.25.05
Nutrition and AD(H)D
Attention Deficit Disorder (ADD) and Attention Deficit with Hyperactivity (ADHD) are related. Some people feel these are cousins of other developmental delay conditions or fall on the autism spectrum, while other experts heartily say not. Whichever view you take, the diagnosis is given when someone is having a significant problem that is impacting their life.
AD(H)D is similar to several other diagnosis in that it is made based only on observable behavior. Behavior may be caused by a number of things. The diagnosis does not specific nor cover what might be causing these behaviors, just that the behaviors are there a certain percentage of the time. The diagnosis allows for flexibilty too. An individual need not fill all the criteria for a diagnosis of AD(H)D, just a certain percentage of the criteria. So different individuals may end up with the same diagnosis but they fullfill different parts of the criteria (i.e. they have different symptoms). Each person needs to be treated as the individual they are. Some therapies will work for one person but may not prove effective for another with the same diagnosis. Usually a combination of therapies is needed (reference 6 below).
Some possible choices are behavior modification or teaching new coping skills. There are some medications that can really help some (SSRIs such as Zoloft or Prozac), Risperdal, Ritalin, Concerta, etc. Over-the-counter nutritional supplements have been shown to be beneficial to some (essential fatty acids in particular: Efalex, ProEFA, omege 3, etc; magnesium). Diet and chemical sensitivities are very beneficial too. In fact, several studies show a significant improvement when certain food additives or environmental chemcials are avoided...around 50-80% of participants showed improvement! Because it is a non-invasive approach that doesn't require eliminating other approaches, it is worth considering.
see Feingold and Failsafe Programs
In addition, certain individuals with AD(H)D are related syndromes are very sensitive to various chemicals in foods as well as in the environment (multiple chemical sensitivities). You may want to look at the Research link at the following site. You can search by symptoms or chemical and see if you can find ideas for personal symptoms. Avoiding these chemicals may help reduce or alleviate some of the symptoms or behaviors associated with AD(H)D.
see Food and Chemical Research 1
see Food and Chemical Research 2
This section looks at how enzymes might be beneficial to persons that fit the profile of AD(H)D. Following the progress of a number (hundreds) of individuals with AD(H)D diagnosis, digestive enzymes do seem beneficial overall. Enzymes targeting certain compounds in fibrous foods seem the most beneficial. This may be because they target the same food compounds that are found to be problematic and avoided in the eating trials noted above. Products such as No-Fenol are particularly helpful overall. In addition, some people have general digestive problems which may or not be associated with AD(H)D. It could be a gut problem totally independent of the AD(H)D. A number of individuals see improvement when taking a broad-spectrum enzyme product, or those targeting various compounds (like Peptizyde for dairy and grains, or lactase for milk sugar, amylases for carbohydrate foods).
It is important to note that digestive enzymes work wonderfully on actual food. But several common food additives and chemical in the environment and in body care products are not actual nutritional food. These are synthetics created in labs. Thus enzymes tend to not be nearly as consistently effective on synthetic or non-food chemicals. So you might see improvement with enzymes but also need to avoid the non-food chemicals as well.
In addition, there have been a number of studies showing that certain nutrition deficiencies are relatively common in this group. This may be the result of the poor digestion. Enzyme supplements help to relieve this by improving digestion and making nutrients more available to the body. Since enzymes also help in healing an injured gut, the digestion problem may be improved overall. If you are taking a medication, note that enzymes may make the medication more available, better absorbed, and more effective as well. You might note need as much after starting enzymes to achieve the same effect.
In particular, additional magnesium can be quite beneficial for those with AD(H)D. Considering it is very safe and very inexpensive, it would be worth a trial. A number of studies have shown magnesium to help with childhood hyperactivity. Looking at the other side, magnesium deficiency is associated with many nerve disorders including ADHD, migraines, muscle spasms, pain, anxiety, irritability, poor sleep, etc.
Essential fatty acids are needed to improve nerve stability. Good results have been seen with this supplement as well.
Purdue Study: Deficiency in omega-3 fatty acids tied to ADHD in boys
Essential Fatty Acids, Diet and Developmental Disorders
A third nutrient to consider is zinc (reference 3 below). Low zinc is related to weakened intestinal integrity (might be how the gut became impaired to begin with!) and sluggish immune system. If someone is prone to illnesses, ear infections, colds, fatigue, allergies and intolerances, adding zinc may be beneficial. Please note that often mega-doses are not needed...just a good typical amount recommended, or slightly higher if your health practitioner feels it is appropriate. Mega-doses of B6 can particularly can adverse reactions for those with AD(H)D. B6 works on nerve but at times people give many more times the recommended dose. B6 is usually made from a synthetic which is hard for this group to process (just like the artificial colorings, flavorings, and other additives noted above).
see List of Abbreviations Often Used with Special Needs
Newpaper Article Synthetic Additives and Behavior
The devil in their diet - 16 August 2004
Parents have long believed that artificial food colourings could cause hyperactive behaviour in children. Now, at last, scientists seem to have proved it, writes Geoff Watts
Twelve months ago, at school and in his Glasgow home, seven-year-old Ryan Gallacher was all but uncontrollable. Then, in August last year, his father Alex changed Ryan's diet. Off the menu went anything with artificial food additives. Ryan's behaviour improved - dramatically.
Around 20,000 children have been diagnosed as having what is variously known as "hyperkinetic disorder" or "attention deficit and hyperactivity disorder"
(ADHD). But some commentators believe that the true number could be 10 times that. To Alex Gallacher, a down-to-earth Glaswegian who would normally have little time for "alternative" theories, the part that additives had played in causing Ryan's problem was blindingly obvious. But many clinicians and scientists who work on additives remain cautious if not downright dismissive about the alleged link. The woeful gap between parental conviction and scientific rigour makes a difficult problem even harder. It needs to be bridged - and the best hope of doing so lies in research at the University of Southampton. Its preliminary findings suggest that, to some degree at least, parents may have been right all along.
Ryan's problems began when he was just 18 months old. "He was excluded from his nursery for inappropriate behaviour," Alex recalls. "He was very excitable, very jumpy. Not just raucous, it was completely beyond that."
Nothing had improved by the time Ryan began school. Alex would be summoned by teachers as often as two or three times a week. "I'd get a call saying, 'Your son is running through the corridors screaming'. Or they'd say, 'You've got to come, he's hiding under a desk holding his head in his hands'."
Educational and family psychologists considered various explanations, from parental disharmony to sibling rivalry. But nothing added up. Ryan's older brother was fine. "I could let him play with the kids in the street," says Alex. "But not Ryan. I had to make excuses to him why he couldn't go out, because we knew that as soon as he did, there was going to be trouble."
Alex became increasingly frustrated and angry. He and his wife Phoebe almost split up. "There was a point at which I couldn't work properly because my mind was constantly on what was happening to Ryan. The strain was destroying us."
Salvation came from a Sunday- newspaper article on diet and behaviour. Out went all foods containing additives - and Ryan's six- year nightmare drew rapidly to a close.
The best-known treatment for ADHD is a drug called Ritalin, which first gained notoriety in the States. The number of prescriptions being issued in Britain - up from 90,000 in 1997 to well over 200,000 in 2002 - reveals its rising popularity here.
A hint of psychiatry's caution in linking the disorder to diet can be gleaned from the brevity of the relevant section in a Royal College of Psychiatrists fact sheet. "There is a small body of evidence about the effect of diet on some children," says the leaflet. "A few may be sensitive to certain foods. If parents notice that specific foods worsen hyperactivity, these may be avoided. It is best to discuss this with the specialist."
That's it. So, who is right: the doctors or the parents? Enter Professor John Warner of Southampton General Hospital, a physician with a long-established interest in additives. His team's study of their effects, published recently in the authoritative journal entitled Archives of Disease in Childhood, used methods of a kind that are standard in all careful medical research.
Among the 400 children who took part were some who showed signs of hyperactivity and some who didn't. Their parents were asked to keep them on a diet free of all additives and artificial preservatives for one month. In the second and fourth weeks, each child had to drink a daily bottle of fruit juice. During one week it was pure; during the other it was laced with a cocktail of additives. The drinks themselves were indistinguishable in taste and colour, and parents weren't told which was which.
The test drink contained four widely used food colourings: sunset yellow, tartrazine, carmoisine and ponceau 4R, and also the preservative sodium benzoate. The researchers conducting the study assessed each child at weekly intervals using tests that are routine in behaviour-disorder clinics.
Most importantly, parents, too, rated the everyday behaviour of their children. They looked for signs such as switching from one activity to another, talking or interrupting a lot, fiddling with objects, and general restlessness.
The results showed a clear distinction between the parents' assessments and those of the psychologists. The latter found no significant difference between the effect of the two drinks; the parents did.
So, what to make of the apparent contradiction? One of Warner's colleagues, the psychologist Professor James Stevenson, thinks that he can explain it.
"Children were coming along to a clinic, meeting a bright young tester who was interested in them, and they were on their best behaviour. It wasn't a context that would elicit inattention, distractability and the rest. But parents see kids when they're tired, they see them in the evening, on the bus, in the supermarket queue."
In short, in real life. This wouldn't be the first time that measurements made within the clinic have failed to detect what is more apparent outside it.
The Southampton team's conclusions are unequivocal: "The observed effect of food additives and colourings in this community sample is substantial." For Stevenson in particular, the findings prompted a change of heart. "I'd worked in hyperactivity for a number of years, and originally thought that diet was probably important only in an exceptional, odd group of children.
Having done this work, I've changed my mind."
His guess is that within the general population there's a range of behaviour that is affected by nurture as well as nature. "Additives seem to be shifting that distribution of behaviour towards the more hyperactive end."
Neither Stevenson nor Warner suggests that additives are the only factor; but their effects are large enough to take seriously. Not least, adds Stevenson, because most of them are there only for marketing purposes.
Heartened by these findings, Warner is planning a further study. This, like its predecessor, will be partly financed by the Food Standards Agency, a body that takes the issue seriously. Among parents eager to take part in the new study is Vickie Gilfillan, a single mother whose son Jacques, aged six, showed the first signs of hyperactivity when he was just eight months old. "He wouldn't sleep, he screamed all the time, he would throw things, and his temper tantrums were horrendous. As he got older, it got worse and worse."
She is enthusiastic about the new study. "I heard of the last one from a report on the TV. I e-mailed them to tell them about Jacques. I was quite lucky because my mother went through the same problem with my brother, so we managed to spot it early on. Jacques now has a largely additive-free diet.
"If Jacques goes to a birthday party, it's a nightmare. You can't stop children going to parties, but I don't know what he's eating. And you can't tell other parents what to give the children." As for young Ryan up in Glasgow, he, too, rebelled at first over the loss of sweets. But his parents' will prevailed, and the change in his behaviour has now persisted for a year. "Far from me being called up to the school," says his father, "he has even won a 'pupil of the week' award. That in itself is just mind-blowing. When people see Ryan now, they ask if it's the same boy."
Small wonder that Alex Gallacher talks about the effects of additives with a crusading zeal.
At the beginning of July, the food giant Birds Eye announced its intention to remove all additives from its products. An opportunistic gimmick? Or a sign that the food industry is finally getting the message.
Colors to Watch
* Sunset yellow (E110) is a dye used in, among other foods, orange jellies and squashes, apricot jam and packet soups. It's also in Smarties, and at least one variety of Lucozade.
* Tartrazine (E102), one of the more controversial colouring additives, is another yellow dye used in fizzy drinks, ice cream, sweets and jams. Also used in Sainsbury's processed peas and Batchelors mushy peas.
* Carmoisine (E122), a red dye, is used in jellies, sweets, blancmanges, marzipan and cheesecake mixes. You'll also find it in novelty cakes, such as the Harry Potter ones, but not, as of next month, Burtons Jammie Dodgers - it's being replaced with a natural dye.
* Ponceau 4R (E124), also red, is used in tinned fruit, jellies and salamis.
Smarties and Simpsons cakes also contain it.
Rearch on Nutrition and AD(H)D Conditions
1. Nutrition in the treatment of attention-deficit hyperactivity disorder: a neglected but important aspect.
Schnoll R, Burshteyn D, Cea-Aravena J. Department of Health and Nutrition Sciences, Brooklyn College, City University of New York
Appl Psychophysiol Biofeedback. 2003 Mar;28(1):63-75. PMID: 12737097
Attention-deficit hyperactivity disorder (ADHD) is multidetermined and complex, requiring a multifaceted treatment approach. Nutritional management is one aspect that has been relatively neglected to date. Nutritional factors such as food additives, refined sugars, food sensitivities/allergies, and fatty acid deficiencies have all been linked to ADHD. There is increasing evidence that many children with behavioral problems are sensitive to one or more food components that can negatively impact their behavior. Individual response is an important factor for determining the proper approach in treating children with ADHD. In general, diet modification plays a major role in the management of ADHD and should be considered as part of the treatment protocol.
2. Effect of docosahexaenoic acid-containing food administration on symptoms of attention-deficit/hyperactivity disorder - a placebo-controlled double-blind study.
Hirayama S, Hamazaki T, Terasawa K. Department of Early Childhood Education and Care, Kurashiki City College, Okayama, Japan
Eur J Clin Nutr. 2004 Mar;58(3):467-73. PMID: 14985685 .
OBJECTIVES: To investigate whether docosahexaenoic acid (DHA) supplementation was able to ameliorate attention-deficit/hyperactivity disorder(AD/HD) symptoms in AD/HD children.
DESIGN AND SUBJECTS: A placebo-controlled double-blind study with 40 AD/HD (including eight AD/HD-suspected) children of 6-12 y of age who were mostly without medication. Subjects of a DHA group (n=20) took active foods containing fish oil (fermented soybean milk, bread rolls and steamed bread; 3.6 g DHA/week from these foods) for 2 months, whereas those of a control group (n=20) took indistinguishable control foods without fish oil. The following items were measured at the start and end of the study: (1) attention deficit, hyperactivity and impulsivity (AD/HD-related symptoms according to DSM-IV criteria); (2) aggression assessed by both parents and teachers; (3) visual perception (finding symbols out of a table); (4) visual and auditory short-term memory; (5) development of visual-motor integration; (6) continuous performance; (7) impatience.
RESULTS: Changes in tests 1, 2, 3, 5 and 7 over time did not significantly differ between the two groups. However, visual short-term memory and errors of commission (continuous performance) significantly improved in the control group compared with the changes over time in the DHA group (P=0.02 and 0.001, respectively). Recalculation without AD/HD-suspected subjects (n=4 each group) showed similar P-values with regard to both measures.
CONCLUSION: DHA supplementation did not improve AD/HD-related symptoms. Treatment of ADHD with fatty acids deserves further investigation, but careful attention should be paid as to which fatty acid(s) is used.
3. Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder.
Bilici M, Yildirim F, Kandil S, Bekaroglu M, Yildirmis S, Deger O, Ulgen M, Yildiran A, Aksu H. Department of Psychiatry, Medical Faculty, Karadeniz Technical University, School of Medicine, Trabzon, Turkey.
Prog Neuropsychopharmacol Biol Psychiatry. 2004 Jan;28(1):181-90. PMID: 14687872
BACKGROUND: The most commonly used medications for attention deficit hyperactivity disorder (ADHD) are the psychostimulants. There is, however, considerable awareness in alternative, nonstimulant therapies, because some patients respond poorly to stimulants or are unable to tolerate them. Some studies suggest that deficiency of zinc play a substantial role in the aetiopathogenesis of ADHD. Therefore, to assess the efficacy of zinc sulfate we conducted treatment trial.
METHODS: Patients with a primary DSM-IV diagnosis of ADHD (N=400; 72 girls, 328 boys, mean age=9.61+/-1.7) were randomly assigned in a 1:1 ratio to 12 weeks of double-blind treatment with zinc sulfate (n=202) (150 mg/day) or placebo (n=198). Efficacy was assessed with the Attention Deficit Hyperactivity Disorder Scale (ADHDS), Conners Teacher Questionnaire, and DuPaul Parent Ratings of ADHD. Primary efficacy variables were differences from baseline to endpoint (last observation carried forward) in mean ADHDS and Conners Teacher Questionnaire scores between the zinc sulfate and the placebo groups. Safety evaluations included monitoring of adverse events, vital signs and clinical laboratory values.
RESULTS: Zinc sulfate was statistically superior to placebo in reducing both hyperactive, impulsive and impaired socialization symptoms, but not in reducing attention deficiency symptoms, as assessed by ADHDS. However, full therapeutic response rates of the zinc and placebo groups remained 28.7% and 20%, respectively. It was determined that the hyperactivity, impulsivity and socialization scores displayed significant decrease in patients of older age and high BMI score with low zinc and free fatty acids (FFA) levels. Zinc sulfate was well tolerated and associated with a low rate of side effect.
CONCLUSIONS: Zinc monotherapy was significantly superior to placebo in reducing symptoms of hyperactivity, impulsivity and impaired socialization in patients with ADHD. Although by themselves, these findings may not be sufficient, it may well be considered that zinc treatment appears to be an efficacious treatment for ADHD patients having older age and high BMI score with low zinc and FFA levels.
4. Outcome-based comparison of Ritalin versus food-supplement treated children with AD/HD.
Harding KL, Judah RD, Gant C. McLean Hospital, Belmont, Massachusetts, USA.
Altern Med Rev. 2003 Aug;8(3):319-30. PMID: 12946241
Twenty children with attention deficit/hyperactivity disorder (AD/HD) were treated with either Ritalin (10 children) or dietary supplements (10 children), and outcomes were compared using the Intermediate Visual and Auditory/Continuous Performance Test (IVA/CPT) and the WINKS two-way analysis of variance with repeated measures and with Tukey multiple comparisons. Subjects in both groups showed significant gains (p less than 0.01) on the IVA/CPT's Full Scale Response Control Quotient and Full Scale Attention Control Quotient (p less than 0.001). Improvements in the four sub-quotients of the IVA/CPT were also found to be significant and essentially identical in both groups: Auditory Response Control Quotient (p less than 0.001), Visual Response Control Quotient (p less than 0.05), Auditory Attention Quotient (p less than 0.001), and Visual Attention Quotient (p less than 0.001). Numerous studies suggest that biochemical heterogeneous etiologies for AD/HD cluster around at least eight risk factors: food and additive allergies, heavy metal toxicity and other environmental toxins, low-protein/high-carbohydrate diets, mineral imbalances, essential fatty acid and phospholipid deficiencies, amino acid deficiencies, thyroid disorders, and B-vitamin deficiencies. The dietary supplements used were a mix of vitamins, minerals, phytonutrients, amino acids, essential fatty acids, phospholipids, and probiotics that attempted to address the AD/HD biochemical risk factors. These findings support the effectiveness of food supplement treatment in improving attention and self-control in children with AD/HD and suggest food supplement treatment of AD/HD may be of equal efficacy to Ritalin treatment.
5. A randomized double-blind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning difficulties.
Richardso AJ, Puri BK. University Department of Physiology, Oxford, England, UK.
Prog Neuropsychopharmacol Biol Psychiatry. 2002 Feb;26(2):233-9. PMID: 11817499
(1) The authors tested the prediction that relative deficiencies in highly unsaturated fatty acids (HUFAs) may underlie some of the behavioral and learning problems associated with attention-deficit/hyperactivity disorder (ADHD) by studying the effects of HUFA supplementation on ADHD-related symptoms in children with specific learning difficulties (mainly dyslexia) who also showed ADHD features. (2) Forty-one children aged 8-12 years with both specific learning difficulties and above-average ADHD ratings were randomly allocated to HUFA supplementation or placebo for 12 weeks. (3) At both baseline and follow-up, a range of behavioral and learning problems associated with ADHD was assessed using standardized parent rating scales. (4) At baseline, the groups did not differ, but after 12 weeks mean scores for cognitive problems and general behavior problems were significantly lower for the group treated with HUFA than for the placebo group; there were significant improvements from baseline on 7 out of 14 scales for active treatment, compared with none for placebo. Group differences in change scores all favored HUFA, reaching conventional significance levels for 3 out of 14 scales. (5) HUFA supplementation appears to reduce ADHD-related symptoms in children with specific learning difficulties. Given the safety and tolerability of this simple treatment, results from this pilot study strongly support the case for further investigations.
6. Attention deficit/hyperactivity disorder (ADHD) in children: rationale for its integrative management.
Altern Med Rev. 2000 Oct;5(5):402-28. PMID: 11056411
Attention Deficit/Hyperactivity Disorder (ADHD) is the most common behavioral disorder in children. ADHD is characterized by attention deficit, impulsivity, and sometimes overactivity ("hyperactivity"). The diagnosis is empirical, with no objective confirmation available to date from laboratory measures. ADHD begins in childhood and often persists into adulthood. The exact etiology is unknown; genetics plays a role, but major etiologic contributors also include adverse responses to food additives, intolerances to foods, sensitivities to environmental chemicals, molds, and fungi, and exposures to neurodevelopmental toxins such as heavy metals and organohalide pollutants. Thyroid hypofunction may be a common denominator linking toxic insults with ADHD symptomatologies. Abnormalities in the frontostriatal brain circuitry and possible hypofunctioning of dopaminergic pathways are apparent in ADHD, and are consistent with the benefits obtained in some instances by the use of methylphenidate (Ritalin) and other potent psychostimulants. Mounting controversy over the widespread use of methylphenidate and possible life-threatening effects from its long-term use make it imperative that alternative modalities be implemented for ADHD management. Nutrient deficiencies are common in ADHD; supplementation with minerals, the B vitamins (added in singly), omega-3 and omega-6 essential fatty acids, flavonoids, and the essential phospholipid phosphatidylserine (PS) can ameliorate ADHD symptoms. When individually managed with supplementation, dietary modification, detoxification, correction of intestinal dysbiosis, and other features of a wholistic/integrative program of management, the ADHD subject can lead a normal and productive life.