ADHD and the effects of
dietary/food additives on
children
Angela Eastburn
February 23, 2007
Advisor: Dr. Boissonneault,
What is ADHD
Attention deficit/hyperactivity disorder (ADHD), aka
Hyperkinesis, is the most commonly diagnosed
behavioral disorder of childhood
It is estimated to affect between 3% and 5% of schoolaged children
The key symptoms of ADHD include inattention,
hyperactivity, and impulsivity
These behaviors usually appear before age 7, and affect
boys two to three times more often than girls
Symptoms are often so significant that they can
interfere with daily life
DSM-IV Criteria for ADHD
I. Either A or B:
Six or more of the following symptoms of inattention have been
present for at least 6 months to a point that is disruptive and
inappropriate for developmental level:
Inattention
Often does not give close attention to details or makes careless
mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow instructions and fails to finish schoolwork,
chores, or duties in the workplace (not due to oppositional behavior or
failure to understand instructions).
Often has trouble organizing activities.
Often avoids, dislikes, or doesn't want to do things that take a lot of
mental effort for a long period of time (such as schoolwork or
homework).
Often loses things needed for tasks and activities (e.g. toys, school
assignments, pencils, books, or tools).
Is often easily distracted.
Is often forgetful in daily activities.
A.
B.
Six or more of the following symptoms of
hyperactivity-impulsivity have been present for at
least 6 months to an extent that is disruptive and
inappropriate for developmental level:
Hyperactivity
•
Often fidgets with hands or feet or squirms in seat.
•
Often gets up from seat when remaining in seat is expected.
•
Often runs about or climbs when and where it is not appropriate
(adolescents or adults may feel very restless).
•
Often has trouble playing or enjoying leisure activities quietly.
•
Is often "on the go" or often acts as if "driven by a motor".
•
Often talks excessively.
Impulsivity
•Often blurts out answers before questions have been finished.
•Often has trouble waiting one's turn.
•Often interrupts or intrudes on others (e.g., butts into conversations
or games).
Some symptoms that cause impairment were present before age 7
years.
Some impairment from the symptoms is present in two or more
settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment in social,
school, or work functioning.
The symptoms do not happen only during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder.
The symptoms are not better accounted for by another mental disorder
(e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a
Personality Disorder).
DSM IV Criteria Continued
I.
II.
III.
IV.
Some symptoms that cause impairment were present
before age 7 years.
Some impairment from the symptoms is present in two
or more settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment
in social, school, or work functioning.
The symptoms do not happen only during the course of
a Pervasive Developmental Disorder, Schizophrenia, or
other Psychotic Disorder. The symptoms are not better
accounted for by another mental disorder (e.g. Mood
Disorder, Anxiety Disorder, Dissociative Disorder, or a
Personality Disorder).
Based on these criteria, three types of ADHD have been identified:
ADHD DSM IV Subtypes
(1) Predominantly
Inattentive
(2) Predominantly
Hyperactive/Impulsive
(3) a Combination of
both.
The most common of
the three subtypes is
the Combined Type
Theorized Causes of ADHD
The exact cause of ADHD
is unknown
Common theories include
genetic neurobiological
causes, child-rearing
methods, environmental
agents (i.e. cigarette
smoke), and dietary
allergies from common
food additives.
Common Allopathic Treatments
Medication, behavioral therapy,
emotional counseling, and support
groups are common modalities of
treatment in ADHD
Gold Standard: stimulant drugs
The use of stimulants have been
shown to decreases the severity
of the 3 key symptoms of ADHD
These drugs have been deemed
safe for children, and are shown to
have relatively low incidence of
abuse and dependency
The most commonly used
stimulants in the treatment of
ADHD are Methylphenidate
(Ritalin), Adderall, and Concerta.
The Downside of Stimulant Therapy
Stimulants do not give the effects of a “high” however,
many children report feeling “funny” or “different”
Each child will react differently to each medication, and
one in ten will receive no benefit from the addition of
stimulants.
Side effects are usually mild but appear to be related to
medication dosages
Common side effects include: irritability, anxiety, insomnia,
decreased appetite, mild head and stomach aches
The Feingold Diet
Pediatric allergist Benjamin
F. Feingold of the KaiserPermanente Medical Center
in San Francisco
In1973, Feingold addressed
the American Medical
Association with claims that
a child’s allergies and
behavioral issues could be
alleviated when placed on
his restrictive diet
Feingold’s Research and Claims
Feingold’s diet was originally intended to help children plagued
with allergies (specifically acute urticaria or hives) that were
unresponsive to previous drug interventions and treatments. In
testing his allergy restrictive diet, he noticed that hyperactive test
subjects also benefitted from the diet; the incidence of behavioral
outbursts decreased dramatically (58-60%)
Feingold’s research showed a direct correlation between the
increasing use of artificial food additives and the increasing
incidence of hyperkinesis and learning disabilities
Feingold believed that the pharmacological characteristics of
certain food additives acted as a suppressant on a child’s ability to
learn, behave and function appropriately
Feingold’s Research and Claims
According to initial studies, Feingold noticed that children who had not
previously responded well to medications (e.g. Ritalin) dramatically
improved when subjected to a diet free of common food additives
He also noted an ability to “turn on and off” behaviors with reintroduction
of additives into the diet, further proving his hypothesis
Feingold claimed that positive behavioral changes as a result of the K-P
diet could be seen in as little as two to three days. The speed of
improvement was said to depend upon the age of the subject (the
younger the more rapid), adherence to the diet, and time needed for
clearance of pharmaceuticals from the system
At the end of five clinical studies, Feingold’s team found that 50% of
patients had a likelihood of full response, and 75% could be completely
removed from drug management
Feingold’s diet consists of eliminating
the following food additives:
Artificial (synthetic) coloring (FD&C and
D&C colors)
Artificial (synthetic) flavoring (e.g.
Glutamic acid salts, MSG)
Aspartame (Nutrasweet, and other
artificial sweeteners)
Artificial (synthetic) preservatives BHA,
BHT, TBHQ
These additives were specifically
chosen to be eliminated because many
are synthetic substances made from
petroleum refining process by-products,
and were reported to possess an
inherent potential to produce adverse
effects
Other Common Dietary Restrictions
High Fructose
Corn Syrup
Calcium Propionate
Nitrates
MSG
Elimination of Salicylates
The K-P diet, also restricts
certain salicylate containing
foods.
Salicylate can mock the
action of aspirin, and are
thought to cause adverse
reactions in allergy sensitive,
and hyperkinetic patients.
Common salicylate
containing foods included
berries, currants, apples,
oranges, tomatoes,
cucumbers, coffee, and
almonds
Problems and Controversy
The miraculous changes in ADHD children came at the high price of a
very strict, labor-intensive diet.
Locating, preparing, and affording foods free of coloring, flavorings, and
preservatives presented parents with quite a daunting task
Many common food items were eliminated, making the diet very hard to
maintain.
Many proponents of the K-P diet claim the hassle was well worth the
time and effort, and saw many significant improvement in hyperkinetic
patients.
Skeptical critics on the other side of the fence claimed followers simply
fabricated positive results for lack of better or more effective treatment
options.
Numerous studies were never able to replicate Feingold’s 58-60%
improvement statistic
Testing the Feingold Hypothesis
The first researcher to test Feingold’s hypothesis was Dr.
Keith Conners of the Children’s Hospital National Medical
Center in Washington D.C.
According to Conners, the Feingold studies contained no true
scientific methodologies in selection, inception, or data
collection, were uncontrolled, unblinded, and utilized no
objective rating scales
As a result, Conners meticulously controlled and documented
his clinical trials and data
Conners Experiment #1: control diet vs. the K-P diet in15
children determined to be hyperkinetic (based on interviews
by clinical psychologists, testings, and physical and
neurological exams, and rating scales outlined by the NIMH
standards of 1973).
Conners Clinical and Observational Results
Research data indicated that both
teachers and parents reported a
decrease in hyperactivity when on the
K-P diet vs. baseline activity.
However, it was only teachers that
noted a positive reaction to the K-P
diet over the control diet.
For Feingold’s hypothesis to be
true, behavioral differences should
be observed in both baseline and
control.
Connor concluded that hyperactivity
may be reduced in children with
ADHD when the child genuinely
possesses an allergy to additives
He goes on to state that “significant
data remained to be collected before
a recommendation could be given for
approval of the diet.”
National Advisory Committee on
Hyperkinesis and Food Additives
1.
2.
3.
4.
This committee was specifically formed to evaluate the validity of
Feingold’s clinical findings
Upon their review, they too concluded that Feingold had not
sufficiently proven his hypothesis and highlighted several other
significant shortcomings in his research:
The high number of reported favorable responses to placebo
The potential changes in family dynamic due to the strict regiment of
the diet
Possible coercion of positive results from researchers and Feingold
himself.
Lastly, due to its highly restrictive guidelines, the K-P diet may have
also substantially reduced essential nutrient and vitamin
concentrations, in turn contributing to additional behavioral changes
Feingold’s Advocates
The biggest advocates for the KP diet seem to lie in parents of
children with ADHD and hyperactivity.
Despite many negative research publications, like the ones
mentioned previously, many parents swear by the regimen and
are able to maintain it for life.
Parents are quoted as saying that they have a completely
different and manageable child after inception of the K-P
restrictive diet.
A study conducted by Dr. P.S. Cook in 1976 documented that 10
out of 15 parents enrolled in clinical trials saw substantial
behavioral improvements, and drastic relapse (in poor behavior)
upon dietary infractions
Feingold’s Advocates
A study by Dr. F. Levy in 1978, Hyperkinesis and diet: a
double-blind crossover trial with a tartrazine challenge, also
documented statistically noteworthy improvements when he
eliminated tartrazine, one of Feingold’s hypothesized
triggers, from patient’s diets.
Mothers of study participants in this study indicated a 25%
reduction in adverse behaviors when maintaining the diet free
of the artificial food coloring
A second study of tartrazine and hyperkinesis was recently
conducted by Dr. Katherine S. Rowe in 1994.
Test subjects in Rowe’s experiments showed signs of
increased irritability, restlessness, and sleep interruptions
when challenged with tartrazine, again supporting some of
Feingold’s initial claims
More of Feingold’s
Advocates
In 2004 Dr. B. Bateman conducted a double-blind, placebo
controlled coloring and preservative challenge in a large sample
of preschoolers.
In his population of 3 year old ADHD suffers, parents noticed
unpleasant behavioral effects when challenged with artificial
food colorings and benzoate preservatives.
Again, this behavioral improvement phenomenon could not be
detected in clinical data and assessments
Regardless, Bateman does suggest the findings are indeed
significant and warrant further investigation
What does this mean for the
patient and the PA?
Treatment options? Medication vs. Diet
Providers should be well versed on the benefits and
shortcomings of both pharmacological and dietary therapies
PCP should be aware of all attempted therapies and
outcomes whether beneficial or not
We need to help families realize that every child will react
differently to different treatment modalities
Discuss all options: Is an elimination diet a viable option for
the family and the child? Who will participate? When will
the diet be implemented? Who will prepare meals and
monitor changes in behaviors?
Be aware of personal judgements and biases
Conclusions
The common denominator: a healthy diet, whether restrictive of
artificial additives or not, is beneficial to the health and wellbeing
of every child
Feingold’s overarching goal was to develop a dietary plan that
assisted families in their battle with ADHD. He accomplished
this goal by providing insightful ideas and hypotheses that
sparked interest into treatments for this sometimes debilitating
disorder.
As a result he served as an advocate for hyperkinetic children
and families.
Although not all of his theories were proven clinically relevant or
reproducible, they do offer a solution to many families that had
previously been unsuccessful with behavior and pharmaceutical
treatments.
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