• A brain and behavioral disorder that begins in early childhood and persists into adolescence and adulthood
• Typified by one or more symptoms of disabling inattentiveness, hyperactivity, and impulsivity
• Commonly accompanied by mood disorders or learning disabilities
The term attention-deficit/hyperactivity disorder (ADHD) encompasses three separate ADHD forms: predominantly inattentive (often referred to as simply attention deficit disorder, or ADD), predominantly hyperactive, and combined type. Depending on the region and the investigator, ADHD has been found in 5 to 15% of school-age children, or about 10 million children in the United States. Clinical observation and epidemiological surveys typically report a greater incidence in boys than girls (approximately 2:1). More than 5.5 million children in the United States take amphetamine-type drugs for ADHD each day. Onset is usually by the age of three, although the diagnosis is often not made until later, when the child is in school.1
The characteristics of ADHD in order of frequency are: (1) hyperactivity, (2) emotional instability (mood swings, outbursts, etc.), (3) clumsiness, (4) disorders of attention (short attention span, distractibility, failure to finish things off, not listening, poor concentration), (5) impulsiveness (action before thought, abrupt shifts in activity, poor organizing, jumping up in class), (6) disorders of memory and thinking, (7) specific learning disabilities, (8) disorders of speech and hearing, and (9) various neurological signs and brainwave pattern irregularities.
These characteristics are frequently associated with difficulties in school, both in learning and in behavior. If not intensively managed, a child with ADHD will be likely to experience academic impairment, increased risk of injuries, and problems with self-esteem and socialization. Later in adolescence and adulthood, those with ADHD have a high risk of experiencing depression or anxiety, substance abuse and addictions, traffic accidents, financial problems, vocational underachievement, and social problems. Nevertheless, ADHD is a condition that can be transcended—many people with ADHD have achieved a high level of personal success.
There are many factors linked to ADHD, with the leading factor being diminished function of certain circuits in the executive centers of the brain responsible for impulse control and the ability to maintain sustained attention. Evidence from studies using sophisticated brain imagery techniques such as MRI, PET scanning, CT imaging, and EEGs indicates that the brains of those with ADHD exhibit differences in both structure and function compared with normal controls, particularly with regard to the executive centers.
Research into what causes these changes has focused on genetic, environmental, and nutritional factors. There is little doubt that genetics is a predisposing factor.2 However, as with most health conditions, environmental and dietary factors appear to play a significant role in whether and how these genetic factors are manifested.
The role of nutritional and environmental factors in ADHD is becoming increasingly widely recognized. Despite significant advances in the use of nutritional therapies for ADHD, however, the prevailing conventional approach to the treatment of ADHD relies almost entirely on amphetamine drugs for purely symptomatic relief. These drugs, such as Ritalin and Concerta (methylphenidate), Adderall (amphetamine), and Vyvanse (lisdexamfetamine) improve ADHD symptoms primarily by potentiating the neurotransmitter dopamine within all brain regions, including those most affected in ADHD. These medications reportedly improve behavior and cognitive functioning in approximately 75% of children in formal placebo-controlled trials. However, the success of treatment when studied in actual clinical practice may be significantly lower. Furthermore, follow-up studies have failed to demonstrate long-term benefits with these stimulant medications. Additionally, these drugs are associated with a high prevalence of adverse effects such as decreased appetite, sleep problems, anxiety, and irritability. Some of the long-term effects of these drugs could be extremely detrimental to both brain function and behavior.3–5
Nonstimulant drugs such as atomoxetine (Strattera) have been promoted as a safe alternative. However, atomoxetine has its own set of problems, including the fact that children and teenagers with ADHD who take atomoxetine are more likely to have suicidal thoughts.6
The bottom line is that every effort should be made to treat ADHD without the long-term reliance of medications.
Environmental factors that contribute to the development of ADHD may begin at or even before conception. Maternal-to-fetal transport of various neurotoxins can occur readily during pregnancy. A woman who has an ongoing exposure to or a significant body burden of neurotoxic substances (e.g., heavy metals such as lead and mercury, solvents, pesticides, PCBs, alcohol, and other drugs of abuse) may herself exhibit features consistent with ADHD and give birth to a child who manifests symptoms of ADHD. In such cases it might be assumed that ADHD is inherited when it is actually acquired. Children remain susceptible to neurotoxins following birth, and some of these agents have been shown to be common among children in North America.7,8
Maternal tobacco and drug use has been associated with a higher risk of ADHD.9–11 One study suggested that up to 25% of all behavioral disorders in children can be attributed to exposure to cigarette smoking during pregnancy.9In addition, there is an alarmingly high incidence of chronic, low-level lead intoxication in North American children.8,12 The Centers for Disease Control and Prevention estimated that about 2% of American children younger than age six currently meet the criteria for lead toxicity at a level that has been associated with cognitive deficits and behavioral disturbances (>10 mg/dl whole blood lead).12 Low-level lead intoxication has also been associated with addictive behaviors and impulsivity, suggesting neurological changes.13 Pilot studies have demonstrated improvement in ADHD behaviors in some children with moderate elevations in blood lead levels who have been treated with intravenous EDTA chelation.14
In addition to lead, other heavy metals such as mercury, cadmium, and aluminum, as well as pesticides and PCBs, are nearly ubiquitous contaminants arising from dental amalgam fillings, food, air, and drinking water, and these agents may act synergistically to impair neurological function and development in susceptible children. Consumers Union recently conducted the largest study to date looking at the level of human exposure to a wide range of pesticides in the U.S. food supply, demonstrating that human exposure to pesticides is far greater than ever previously estimated and that children are at particularly high risk for neurotoxic effects from regular inadvertent pesticide exposure from common foodstuffs.15
A recent study has shown a direct correlation between the levels of organophosphates in a child’s urine and the incidence of ADHD.16 Children eating conventionally grown foods have a level of organophosphates nine times as high as those eating organically grown foods.17 This level results in a 50% increase in ADHD—not surprisingly, as these pesticides are neurotoxins.
Food Additives, Sugar, and the Feingold Hypothesis
The hypothesis that food additives can cause ADHD in children was popularized by the research of Benjamin Feingold, M.D., and is now commonly referred to as the “Feingold hypothesis.” According to Feingold, many hyperactive children, perhaps 40 to 50%, are sensitive to artificial food colors, flavors, and preservatives.18
Feingold’s claims were based on his experience with more than 1,200 cases in which food additives were linked to learning and behavior disorders. Since Feingold’s presentation on this subject to the American Medical Association in 1973, the role of food additives as a contributing cause of hyperactivity has been hotly debated in the scientific literature. In actuality, however, researchers have focused on only 10 food dyes, though Feingold was concerned with 3,000 food additives.
At first glance, it appears that the majority of the double-blind studies designed to test the hypothesis have shown essentially negative results. However, upon closer examination of these studies and further investigation into the literature, it becomes evident that food additives do, in fact, play a major role in hyperactivity. In several of the studies, overwhelming evidence was produced.19,20
In a recent study, 153 three-year-old and 144 eight- and nine-year-old children from the general population (in other words, the study was not focused on children with a specific diagnosis of ADHD) were given either a drink that contained sodium benzoate and an artificial food coloring mix or a placebo mix. The main outcome measure was a global hyperactivity aggregate (GHA), based on observed behaviors and ratings by teachers and parents, plus, for the older children, a computerized test of attention. The results showed that the children given the artificial food coloring agents had a statistically significant adverse increase in hyperactivity.21
It is interesting to note that while U.S. studies have been largely negative, reports from the United Kingdom, Australia, and Canada have been more supportive. Feingold contended that there is a conflict of interest on the part of the Nutrition Foundation, an organization supported by major U.S. food manufacturers—Coca-Cola, Nabisco, General Foods, and others. It seems significant that the Nutrition Foundation has financed most of the negative studies. The conflict of interest arises because these companies would suffer economically if food additives were found to be harmful. Other countries have significantly restricted the use of artificial food additives because of possible harmful effects.
Virtually every study (either negative or positive) that looked at the role of food additives in ADHD demonstrated that some hyperactive children consistently react with behavioral problems when challenged by specific food additives. Critics of the hypothesis ignore the significance of these clear, reproducible individual results. The bottom line is that some children react strongly enough to food additives to warrant eliminating these compounds in the diet for at least 10 days to judge their significance in a particular child.
Sugar consumption also appears to be a factor. One study demonstrated that destructive-aggressive and restless behavior significantly correlated with the amount of sugar consumed.22 The higher the sugar intake, the worse the behavior. In another study, researchers performed five-hour oral glucose tolerance tests on 261 hyperactive children; 74% displayed abnormal glucose tolerance or hypoglycemia.23
Essential Fatty Acids
Numerous studies have now shown that children with ADHD have a measurable reduction in tissue levels of the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) when compared with age-matched controls. This should not be surprising: omega-3 fatty acids are critical in the structure and function of brain cells. Omega-3 (EPA + DHA) supplementation in ADHD has now been studied extensively and is considered a sensible intervention even by many mainstream physicians. Omega-3 fatty acid supplementation improves many symptoms of ADHD, including impulsive-oppositional behavior, a symptom not typically helped by the pharmaceutical treatment of ADHD.24 DHA deficiency has also been shown in animal studies to result in increased permeability of the blood-brain barrier, which plays a critical role in protecting the brain from an influx of neurotoxic compounds such as pesticides and mercury.25,26
Human breast milk is rich in DHA, and several studies have shown that children who are fed formula are at twice as high a risk of developing ADHD as those who are breastfed.27 The role of DHA in brain development, intelligence, and possible protection against ADHD finally led to its inclusion in many infant formulas and other foods.
Individual Nutrients and ADHD
Besides fatty acids, inadequate provision of other nutrients during fetal development and early childhood may also play a significant role in the development of ADHD.28,29 In addition, children with ADHD often show multiple nutrient deficiencies, highlighting the importance of broad-spectrum nutritional support. In particular, the following minerals are critical supplements in the management of ADHD:
• Magnesium. Magnesium levels in serum, red blood cells, and hair have all been shown to be low in the majority of children with ADHD.30 These children also demonstrated improved behavior when administered magnesium supplements.31
• Zinc. Low levels of zinc in hair and serum have both been shown to frequently accompany ADHD.32 Children with low serum zinc were also more frequently found to have lower free fatty acid levels, suggesting that abnormalities in fatty acid metabolism may result, at least in part, from zinc deficiency.33 It has also been shown that lower hair zinc levels correlate with a poorer response to treatment with amphetamines. Several clinical trials have now demonstrated positive effects of zinc supplementation in hyperactive children.34,35
• Iron. Anemia from iron deficiency is estimated to affect approximately 20% of infants, and many more are thought to suffer milder iron deficiencies without anemia, leaving them at risk for impairment of brain development.36Iron deficiency has been found to be even more common in children with ADHD. One study demonstrated that iron supplementation in non-anemic children with ADHD resulted in diminished ADHD symptoms within 30 days.37A more recent study demonstrated improvement in ADHD symptoms in children with ADHD and low iron stores.38
There is a very strong relationship between allergies, including food allergies, and ADHD.39–43 In one study demonstrable brainwave changes occurred immediately following ingestion of a previously identified food allergy.43 Food allergies and other allergic disorders have also been associated with a higher incidence of recurrent ear infections (otitis media).44 In turn, recurrent otitis media has been associated with an increased risk of ADHD.45 Both food allergy and ADHD have been associated with sleep disturbances, which may, in turn, contribute to a worsening of ADHD symptoms. Heavy snoring and sleep apnea are particularly prevalent in allergic children and may significantly contribute to ADHD symptoms.46–48 Studies have demonstrated improved sleep in children with ADHD who are on a low-allergy-potential (oligoantigenic) diet. In fact, food allergy elimination or desensitization can be as effective as drug therapy in reducing ADHD symptoms.49–52
Probiotic supplementation with active bifidobacteria and lactobacillus cultures may be helpful in the treatment of ADHD. These organisms function as part of the first line of defense in gut immunity and have been shown to counteract altered gut permeability due to food allergies.53,54
Grape Seed or Pine Bark Extract
Extracts of grape seed and the bark of the maritime pine (Pycnogenol) are rich sources of proanthocyanidins are one of the most beneficial groups of plant flavonoids. These extracts may prove useful in the treatment of ADHD due to their broad-spectrum antioxidant effects alone, as increased oxidative damage is believed to be a central factor in ADHD.
To date, four studies have been conducted on the use of Pycnogenol in children with ADHD. In two of the studies, children supplemented with Pycnogenol (1 mg/kg per day) showed improved antioxidant status.55,56 A third study not only confirmed this antioxidant effect but also demonstrated that Pycnogenol produced improvements in hyperactivity.57 In the most detailed study, which involved 61 children with ADHD supplemented with 1 mg/kg Pycnogenol or a placebo daily over a period of four weeks, the children taking Pycnogenol showed a significant reduction of hyperactivity, along with improved attention, visual-motor coordination, and concentration.58 These results point to an option to use grape seed or pine bark extract as a nutritional adjunct in ADHD.
Ginkgo Biloba Extract (GBE)
Two pilot studies, one of children (testing GBE in combination with American ginseng) and the other of adults, showed some beneficial effects attributed to supplementation with GBE.59,60 Specifically these studies showed improvements in inattentiveness, hyperactivity, and socialization.
L-theanine, an amino acid found in green tea, shows promise in improving sleep quality in children with ADHD. This amino acid is also known to reduce anxiety and increase concentration. A recently completed double-blind trial of L-theanine in ADHD showed significant improvements in sleep quality with supplementation.61 L-theanine was given at a dosage of 200 mg twice daily. These results are extremely promising, as disturbances in sleep quality are a very common occurrence in ADHD.
In biofeedback training treatment, individuals are provided with real-time feedback about their brainwave activity through electronic instrumentation. This feedback allows the subject to learn self-regulation of brainwave intensity and frequency. Biofeedback treatment is designed to train individuals with ADHD to reduce or eliminate abnormal brain wave activity (cortical slowing) and thus reduce or eliminate many symptoms associated with ADHD. Evidence supporting the use of biofeedback as an effective treatment in ADHD is accumulating; some studies show that children using biofeedback may be able to stop taking Ritalin.62–65
• More than 5.5 million children in the United States take amphetamine-type drugs for ADHD each day.
• There are many factors linked to ADHD, with the leading one being diminished function of certain circuits in the executive centers of the brain responsible for impulse control and for the ability to maintain sustained attention.
• The role of nutritional and environmental factors as the underlying cause of ADHD is increasingly being recognized.
• According to the Feingold hypothesis, many ADHD children, perhaps 40 to 50%, are sensitive to artificial food additives.
• There is growing research showing an association between the amount of organophosphate pesticides consumed and the incidence of ADHD.
• Numerous studies have now shown that children with ADHD have a measurable reduction in tissue levels of the omega-3 fatty acids EPA and DHA.
• Omega-3 fatty acid supplementation improves many symptoms of ADHD including impulsive-oppositional behavior, a symptom not typically helped by the pharmaceutical treatment of ADHD.
• Children with ADHD often show multiple nutrient deficiencies, highlighting the importance of broad-spectrum nutritional support.
• Supplementation with magnesium, zinc, or iron has shown benefit in ADHD, particularly in those subjects with confirmed deficiency.
• There is a very strong relationship between allergies, including food allergies, and ADHD.
• Food allergy elimination or desensitization can be as effective as drug therapy in reducing ADHD symptoms.
• Pycnogenol caused a significant reduction of hyperactivity while improving attention, visual-motor coordination, and concentration in children with ADHD.
• Evidence is accumulating to support the use of biofeedback as an effective treatment in ADHD.
The treatment plan for ADHD involves the detection and elimination of any heavy metal or environmental toxicity; establishment of optimal nutrition, including the use of a high-potency multiple vitamin and mineral formula and fish oil supplement; elimination of food additives and sugar from the diet; and elimination of food allergens.
An allergy elimination (oligoantigenic) diet for a period of four weeks, followed by reintroduction of (challenge with) suspected foods (full servings at least once a day, one food introduced every three to four days), is the most sensible and economical approach for identifying food allergies; for more information see the chapter “Food Allergy.” Where possible, eat only organically grown foods.
• High-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin B6: 25 to 50 mg per day
Folic acid: 400 to 800 mcg per day
Vitamin B12: 400 to 800 mcg per day
Zinc: 20 to 30 mg per day
Vitamin C: 500 to 1,000 mg per day
Vitamin E (mixed tocopherols): 100 to 200 IU per day
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
Magnesium: 5 mg/kg per day in divided doses
Iron: 30 mg per day, bound to either pyrophosphate, succinate, glycinate, or fumarate between meals (if this recommendation results in abdominal discomfort, take 30 mg with meals two times per day or use iron pyrophosphate)
• Fish oils: 1,000 to 3,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 150 to 300 mg per day
Ginkgo biloba extract (24% ginkgo flavonglycosides): 120 to 320 mg per day
L-theanine: 100 to 200 mg up to three times per day
Melatonin: 1 to 3 mg at bedtime