ADHD: The most common childhood disease
ADHD is the most commonly diagnosed childhood disease and is said to affect approximately 10% of the South African population. It could be present from birth (often not recognised) or early childhood and usually persists into adulthood. It is often undiagnosed in adult, which is an unfortunate oversight, since appropriate treatment helps control symptoms and improves quality of life.
The term ADHD denotes Attention Deficit Disorder with &/or without hyperactivity & has been used to describe both ADD and ADHD as well as all aspects of the condition more accurately. ADHD is a chronic condition of the brain that makes it hard for those affected to control their behaviour. According to the American National Institute of Mental Health, two to three times more boys than girls are affected by the disorder and the reason for this is uncertain.
Problems generally associated with ADHD include inattention, hyperactivity and impulsive behaviour. This can affects nearly all aspects of life.
How can I tell if my child has ADHD?
Most specialists believe that a child shouldn’t receive a diagnosis of ADHD unless the core symptoms of ADHD appear early in life and create significant problems at home and at school on an ongoing basis. Ideally ADHD should be assessed and diagnosed by a multi-disciplinary team. As there is no proven diagnostic test for ADHD at this time, a clinical diagnosis is usually made by a paediatrician based on specific criteria. It is a process that involves several steps and it requires information on behaviour. Information is required form parents, teachers, carers, health professionals for an official diagnosis to be made.
In most children with ADHD, a diagnosis are made from the age of 5 – 7 years (formative school-going age), although some of the symptoms could be present from birth. These symptoms must significantly affect a child’s ability to function in at least two areas of life – typically at school and at home. It is important that the symptoms, be present for a period of more than six months in all situations. This helps ensure that the problem isn’t with only a particular teacher or with their parents.
Most children with ADHD don’t have all the signs and symptoms of the disorder, and they may be different in boys and girls. Boys are often more likely to be hyperactive and girls tend to be inattentive. In addition, girls who have trouble paying attention often daydream, but inattentive boys are more likely to play or fiddle aimlessly. Boys also tend to be less compliant with teachers and other adults, so their behaviour is often more conspicuous.
What causes ADHD?
Parents often blame themselves when a child has been diagnosed with ADHD. However, the cause of ADHD is at present still unknown. Experts are investigating a number of genetic and environmental causative factors – some of these theories have led to dead ends, some to exciting new avenues:
- Altered brain function & anatomy: There is an imbalance of certain neurotransmitters or poor nerve communication and transport in certain parts of the brain.
- Genetics (70-80% of cases): There is great deal of evidence that ADHD runs in families and if one person in a family is diagnosed with ADHD there is a 25-35% probability that another family member also has ADHD.
- Exposure to toxins such as cigarettes and alcohol during pregnancy, high levels of lead in the bodies of children.
- Brain injury: only small percentage of children with ADHD has been found to have suffered from traumatic brain injury.
There is no clear answer! What we do know is that ADHD is a condition of the brain, likely caused by unknown factors which influence nerve communication and transport in certain parts of the brain, which has a strong genetic basis.
Food additives and sugar has long been controversial. Some research suggests that artificial colourings and preservatives may be associated with hyperactivity in children. But an association is not the same as a proven “cause-effect” relationship. There is no proof that food additives cause ADHD. Poor parenting, family problems, excessive TV watching, poor teachers and schools, food allergies or excessive sugar intake are not thought to cause ADHD. These environmental factors may contribute and worsen ADHD symptoms though but are not the cause.
How is ADHD treated?
Optimal treatment is still a matter of debate and every family wants to determine what treatments will be the most effective. It is thought that lifestyle can either reduce or strongly exaggerate symptoms of ADHD.
Clinical experience has shown that the most effective treatment for ADHD is a combination of:
- Medication, when necessary
- Dietary intervention
- The correct supplementation of vitamins and minerals
- Therapy and counselling to learn coping skills and adaptive behaviours
There is a wide range of medications available, the most common being Ritalin, Dexedrine, Adderall, Concerta. Medication does not cure ADHD. The role of medication is to control the symptoms when taken and works effectively in 70% of ADHD cases.
Each medication has its negatives. The most likely side-effects include reduced appetite, corresponding weight loss, headaches, nervousness, irritability, tummy aches, nausea & vomiting, sleep disturbances.
It is found that 30% of cases don’t respond or do not tolerate prescribed medication for ADHD. In these cases there is no other option then to opt for dietary treatment.
Diet and ADHD
Each child requires an individual approach. Helping a child with ADHD is like trying to solve a jigsaw puzzle. Puzzle pieces might include low iron status, poor diet, essential fatty acid deficiencies, magnesium deficiency, zinc deficiency, sensitivity to food stuffs such as artificial colourants, flavourants and preservatives. Remember each child is a unique puzzle with different puzzle pieces. It is therefore essential to consult a dietitian specialising in the field.
Diet in itself does not cause ADHD but can worsen the symptoms. Diet modification however does play a major role in the management of ADHD and the associated symptoms. When dietary changes are made the results could sometimes be dramatic, sometimes it can hardly be noticed – this depends upon the child and his/her own unique make-up, but it also depends upon the diet being followed 100%!
Over the years, a great deal of media attention has focused on diets and ADHD. Most common approach is by making use of Elimination diets for ADHD. This involves removing foods or ingredients that are suspected of contributing to ADHD symptoms. The assumption is that you are eating something unhealthy that triggers certain behaviours e.g. hyperactivity or makes them worse. Many children with ADHD improve when put on a diet avoiding artificial colorants, artificial flavourings & avoiding certain foods. It is impossible to predict how a child will benefit and in which area improvements will be take place, but they are often evident in improved concentration, general health and/or social interaction.
Allergies and Special Diets
Children with allergies may exhibit some behaviour seen in ADHD. Allergies to gluten, wheat and cow’s milk are often the most common amongst these children. It has also been estimated that up to 10% of primary children who suffer from allergic reactions exhibit behavioural and concentration problems in the classroom.
If you suspect that certain foods affects behaviour, your dietitian would be able to advise you on a suitable elimination diet. Do not try to do this on your own as elimination diets are nutritionally unbalanced and can cause growth stunting in children.
Food additives and preservatives
Research has shown varying degrees of hyperactivity after the consumption of food additives. Some children with ADHD improve when put on a Feingold Diet. Dr Benjamin Feingold created this diet back in 1973. This diet excludes salicylates (most fruit & vegetables), artificial colourings, preservatives and flavourings. This diet is very restrictive which means that there is the risk of nutritional deficiencies. This diet is quite controversial – very few studies have been diet on ADHD and the Feingold diet and the studies that were done report limited success.
However, research done in the UK on ADHD and food additives, showed varying degrees of hyperactivity, in children, after the consumption food additives. Additives used includes Sodium benzoate, tartrazine(E102), carmoisine(E122), sunset yellow(E110), ponceau 4R(E124), quinoline yellow(E104), allura red(E129).
Based on this and other recent studies, the American Academy of Pediatrics now agrees that eliminating preservatives and food colorings from the diet is a reasonable option for children with ADHD. Some experts recommend that people with ADHD avoid the following substances:
- Artificial colors, especially red and yellow
- Food additives such as aspartame, MSG (monosodium glutamate), and nitrites – some studies have linked hyperactivity to the intake of the preservative sodium benzoate.
Omission of sugar
Several decades ago, the opinion of some parents made headline news that sugar caused hyperactivity. Research has concluded that sugar is a not a cause of ADHD. But effects of sugar may have a role to play in 5% of children with ADHD, mostly very young children or those with food allergies. For best overall nutrition, sugary foods should be a small part of anyone’s diet, though there is probably not much harm for a child or adult with ADHD to try eliminating sugary foods to see if symptoms improve.
Essential fatty acids (EFA’s)
There is scientific evidence that individuals with ADHD are prone to essential fatty acids (EFA’s) deficiencies either due to an inability to absorb EFA’s adequately from the digestive tract or because their EFA requirements are higher than that of other people without ADHD. Several studies have indicated that some physical symptoms reported in ADHD are the same as those observed in EFA’s deficiency.
Omega-3 (compounds EPA and DHA) and Omega-6 (compound GLA) is important for the functioning and building of the cells and nerves of the brain. It also affect neural function including concentration. EPA is more active than DHA for daily brain functioning and assists in the communication between nerve ends. The ratio of EPA and DHA therefore has to be correct to have a beneficial effect.
It is known that children do not consume adequate amounts of EFA in diet due to the sources of omega-3. Omega-3 supplementation has been fund to be effective in reducing problems of attention, perception, and memory associated with ADHD and dyslexia. A Dietitian would be able to advice parents on how to increase the omega-3 content of a child’s diet and on the correct supplements for your child.
Vitamins and mineral deficiencies
Two-thirds of ADHD children studied were deficient in Magnesium and Vitamin B6. These nutrient deficiencies block the conversion process of essential fatty acids (omega-3 and 6).
- The B-group vitamins are particularly important as one of their main functions is to regulate the central nervous system. It also influences the Homocysteine levels in the body. Homocysteine provide a measure of the body’s ability to maintain chemical balance. High homocysteine levels can affect the brain contributing to depression, poor concentration, poor memory, sleeping problems, mood swings and anxiety. Homocysteine treatment requires B-vitamins that include Folic acid B3, B6, and B12.
- Magnesium is needed for growth and repair of body cells, also assist with the transmission of nerve impulses to the muscles and acts together with calcium.
- Several studies show that iron (ferritin) levels were also low in 80% of ADHD children.
- Studies show significantly lower Zinc concentrations in ADHD children. Symptoms of zinc deficiency include loss of appetite, slow growth, slow wound healing, altered taste perception.
It is therefore important to take a good multi-vitamin and mineral supplement. Your dietitian would suggest suitable vitamin and mineral supplements dependent on diet composition and underlying symptoms.
The Glyceamic Index (GI)
For a child to be able to learn 2-3 hours, the brain requires a steady stream of brain fuel (glucose) to keep concentration going. The brain can’t concentrate if the last meal provided too little glucose, but is even worse if the blood is flooded with too much glucose.
Eating a diet high in GI send blood glucose levels rocketing but in the same way that glucose levels go shooting up, they also come down and optimum concentration becomes impossible. Therefore a diet high in glyceamic index (GI) can mimic ADHD symptoms and would therefor make individuals with ADHD’s behaviour and concentration worse. This is also when a person is most likely to crave sweet things. It is therefore advised that a low glyceamic index diet is followed. This helps to control blood sugar levels which help with longer sustained concentration, being less aggressive and irritable and prevent sugar cravings.
So what do we suggest?
- Each child is different, with different growth requirements and personal problems – therefore a child needs individualised advice regarding quantity, quality, restrictions and supplementation.
- Follow a healthy, balanced diet consisting of starches, meat and meat alternatives. Dairy products, fruit and vegetables and fats. A healthy diet is very important to provide all the nutrients that the brain needs.
- Eat carbohydrates that are low in glycaemic index.
- Make sure to include protein with each meal, as this has been proven to control blood glucose levels and will sustain concentration for longer.
- Breakfast is vital: protein plus complex carbohydrate (low GI) can contribute to 3 hours of the child’s best concentration. A lesser breakfast may only help for an hour.
- ADHD children need regular snacks, every 2-3 hours to help maintain concentration.
- An elimination diet can be followed. Do not do this without medical supervision.
- If a food allergy is suspected, consult with your paediatrician or dietitian, so that the appropriate tests can be done to see if an elimination/restricted diet is required.
- Eat a diet rich in essential fatty acids (omega-3) including oily fish, seeds. Omega-3 rich eggs. It is also helpful to supplement the diet with EFA’s.
What can a Dietitian do for you?
As already mentioned, medication can influence a child’s appetite and intake that may put them at risk of malnutrition. We also know how difficult it is to get children to eat a good balanced diet at the best of times, never mind when they are restless and don’t want to sit still.
Body Mass Index (BMI) for age and gender; serve as an indication of nutritional status. Your dietitian would plot your child’s BMI to determine his or her risk of being underweight or even overweight. A dietitian can give you advice on your child’s specific dietary needs and help you to make sure that they are receiving a nutritionally adequate diet and one that is right for them.
Having ADHD is not a life sentence. When properly treated, people with ADHD can lead fulfilling, happy lives. There are many positive aspects to this condition. ADHD people may be imaginative, talented, creative, lateral thinkers and people with boundless energy.