I was reading an article on ADHD, “Who Is Diagnosing All These Kids With ADHD?” The article was commenting on a recent study into ADHD diagnosis, “Diagnostic Experiences of Children With Attention-Deficit/Hyperactivity Disorder”, which provided 2014 data on ADHD diagnosis. I was interested to read that “family members were overwhelmingly the first individuals who had been concerned about whether the child might have ADHD. However, for approximately one third of the children who received a diagnosis after age 6 years, someone at school or day care was the first to raise concern.” “Parents reported that in 89.9% of the cases, behavior rating scales or checklists were used for diagnosis.” I actually found this amazing that in this day and age we are still diagnosing children as ADHD solely based on “behaviour ratings” and “checklists”.

Even more interesting is this report: United Nations Expresses Concern Regarding Australia’s Over-Prescription of ADD and ADHD Drugs to Children. Clearly there is a concern with what is happening here in Australia. Yet we continue to write prescriptions and refuse to consider that there may be a different underlying diagnosis. Diagnosing a child from a checklist and medicating them, without a proper assessment is very wrong. After all these years of research, why are professionals and parents still not prepared to consider other underlying causes of ADHD? Even paediatricians who diagnose ADHD do not do some basic testing to ensure that there is not an underlying medical or nutritional issue that may be contributing to the child’s behaviour.

Interestingly, despite the fact that diet is always mentioned as a possible cause of ADD/ADHD, there is still a lot of opposition to trialling dietary intervention. There is no doubt that there is a subgroup of children that clearly benefit by removing certain additives or foods from their diet. In schools who have trialled removing all artificial colours and preservatives from children’s diets at school, results clearly show that the behaviour and concentration of these children improved significantly. Even in prisons where inmates’ diets were changed, the level of aggression decreased and inmates were more manageable.

If the public really knew what is in our processed foods – there would be riots in the streets. That is a whole separate article for another newsletter. So as a parent, if you have a child that has problems with concentration, hyperactivity, oppositional behaviour or conduct disorder, what are some of the questions you should be asking of professionals prior to a diagnosis? Be prepared for the usual “there is insufficient evidence”, it is “not proven” or even in some cases where dietary advice is being considered, it is “dangerous”. As always be informed, do your own research. It is your child’s future you are dealing with here.

What are the alternatives we should be checking for?

Food additives and sensitivities

Feingold first introduced the idea that many children are sensitive to dietary salicylates and artificially added food colours, flavours, and preservatives. There have been sufficient studies (requires Medscape account login) to show that eliminating reactive substances could improve learning and behavioural problems, including ADHD. The  Food Intolerance Network in Australia have a ADHD and Diet factsheet. Please follow the link as it has everything that needs to be said on the subject of food additives and intolerances. The only thing I would like to add is to be strict with the diet, otherwise it is a waste of time. For those that say that diet makes no difference, read the testimonials. For the children and families in the testimonials a change in diet has made a huge difference. Don’t dismiss it without trying it first.

IgG food sensitivity

Low allergy (IgG) restricted food diets have been investigated to see whether they may improve behaviour. A study published in the Lancet medical Journal, Restricted elimination diet for ADHD: the INCA study, demonstrated that there was a 64% improvement in symptoms of ADHD and oppositional defiant disorder. The authors also go on to say “Elimination diet studies suggest behavioural sensitivity to common salicylate and non-salicylate foods. Parents of children with ADHD should be made aware of the research about behavioural sensitivity to common foods and additives in some children.”

Fish oil

Omega-3 fatty acids have been shown to improve ADHD symptoms. One problem with fish oils may be the quality of the supplement you are giving your children. See separate article discussing quality of supplements and fish oils on the market.

Poor sleep

A recent study suggests that insufficient sleep is associated with poor concentration in ADHD. Often ADHD children have issues falling asleep. Melatonin has been used effectively to help children fall asleep. Although melatonin can help children fall asleep; it will not maintain sleep. If a child wakes at night (typically between 2-3 am), other issues need to be considered. Obstructive sleep apnoea is not an uncommon condition in children with poor quality sleep. This may be due to a number of causes that can be effectively treated. Restless legs syndrome is  another condition affecting sleep quality.  A lack of iron should be considered.

Hypoglycaemia

Low blood sugar levels can also cause hyperactive behaviour. Typically parents often report that children are quite hyperactive after picking them up after school. Not unusual for parents to give them a snack as soon as they get them in the car. As soon as blood sugar levels normalise, the children are considerably calmer.

Iron

Low iron has been shown to be an important underlying cause of ADHD. A recent study confirms the importance of having adequate iron in the brain of developing children. The levels of iron in the blood may not reflect iron levels in the brain. Low iron levels have also been shown to influence IQ levels in children. A study in 2013 has shown a link between low iron and long-term risperidone treatment. Another study that measured levels of transferrin, a protein that transports iron throughout the body and brain, in adolescents, discovered that altered transferrin levels were related to detectable differences in the brain’s structure when the adolescents reached young adulthood.

Zinc

Low zinc levels have been implicated in ADHD. A study published recently has shown that plasma zinc levels are positively associated with parent and teacher ratings of ADHD. This study is important as it has been known for some time now that a higher copper to zinc ratio contributes to ADHD and this adds to our understanding of the condition.

Lead

Lead exposure has been shown to be a risk factor for ADHD. A study of Korean children yet again confirms the link between low level lead exposure and ADHD. Where would a child be exposed to lead? There can be many environmental sources of lead exposure. Many old houses contain lead paint. Toys imported from China have been shown to contain lead paint. Testing for lead should be considered. If you don’t test you will never know.

Other possible causes

There are numerous other links to ADHD including cytomegalovirus (CMV) infection, maternal thyroid autoantibodies, the stomach hormone ghrelin, high manganese levels, also cadmium levels oxidative stress, and the list continues. This is a multifactorial disorder. Just by removing or correcting one issue does not automatically ensure that everything is right. Sometimes you need to correct multiple issues, before you see benefit.

The Questions we should be asking:

If your child has a diagnosis or is suspected as having ADD/ ADHD, exclude other causes prior to beginning medication, specifically:

If your child wasn’t checked for any of the above risk factors, then all I can say is that they have not had a comprehensive assessment. It is just lazy medicine to tick a checklist and write a script! As a parent you may be looking for an intervention that is 100% guaranteed. There is no such thing. No one intervention is appropriate for all children.

Do stimulant drugs help all children that have ADD / ADHD issues?

As with any other intervention – no, one drug does not help all children! Let’s consider yet another new drug being released to treat ADHD, methylphenidate extended-release capsules (MPH-MLR). In clinical trials, benefit was reported in up to 77% of patients. Remember these trials are run by the drug companies that are marketing their own product. Most of the clinical trials were only conducted between one and 4 weeks. The longest trial was 11 weeks where the drug was gradually increased to determine optimal dosing. All trials were short term with no long-term safety data available. The conclusion was that there “were no serious side effects”. In a study of 243 children between 6 and 17 years of age the most commonly reported adverse effects of MPH-MLR were:

• headache (10.9%)
• insomnia (9.8%)
• dizziness (2.2%
• abdominal pain (8.2%)
• nausea (3.8%)
• vomiting (3.8%)
• decreased appetite (4.9%)
• aggression in one patient and mood swings in another were reported

Remember preclinical trial side effects are the tip of the adverse effects “iceberg”. It is when the drug is released on the market that additional post-market surveillance side effects are reported. This is acknowledged by the authors “Although not observed in the clinical studies with MPH-MLR, methylphenidate and other stimulants may increase blood pressure (mean increase 2–4 mm Hg) and heart rate (mean increase 3–6 bpm). While the change is clinically insignificant in most patients, some may have a larger increase. Patients should be assessed at baseline, upon initiation and periodically during treatment. Use of stimulants in children less than 13 years of age has also been associated with a transient slowing of growth after initiation of treatment.” Preventing a misdiagnosis of any disorder is as important as making a correct diagnosis. In the case of ADHD, making the correct diagnosis is particularly important since the first line of treatment usually involves prescribing a psychostimulant. These are restricted Schedule II Controlled Substances due to their ‘high potential for abuse’. The co-morbid neurological issues, psychiatric disorders and quality of life associated with ADHD long-term is yet another story for a future newsletter.

The Importance of a Proper Assessment

A comprehensive assessment takes time to eliminate each variable. There are clues as to what may be the underlying issue. However often there may be more than one issue that needs to be addressed. As a parent you need to understand that giving a fish oil (often a gummy bear brand), trying an elimination diet half heartedly (“I did it 90% of the time” or “just a little bit wouldn’t hurt?”) is doomed to failure. It is a waste of your time and money. And so the myth is perpetuated that diet, supplements, or any other intervention does not work.

It can be hard to get family on board. I know as my partner refused to accept that our child reacted to artificial food colours for a long time. It took a can of Fanta on a long car trip home to finally convince her. A child that was well behaved all day, suddenly changed to an uncontrollable, kicking and screaming ferrel boy. Only consolation for me was that he was sitting in the car behind my partner, and she copped the brunt of it all! However it did make her sit up and notice.

This is your child’s future and at the very least they deserve a proper comprehensive evaluation. We can do this together. If you are willing I will support you through what can sometimes be a difficult time. There are many options to consider, we can prioritise and work through them all. If testing is required then we can work out what the best option may be.

From the Clinic – Parent feedback

“The doctor did not consider that she had low iron levels and dismissed the pathology results. Adding in iron to her supplements as you suggested has made a huge difference. She is no longer as tired and is able to concentrate better and her teacher reports that she is doing much better at school.”

“Strawberries make him manic!”

“P… is doing really well. Not complaining of tiredness, concentration is better, remembering words well, reading very well. Oppositional defiant symptoms are gone! I have finally got her back and it is so lovely to be around her again.” Child was already on a colour and preservative free diet. The diet was further modified by removing gluten and minimising salicylates.

“Tomatoes certainly do not agree with G…, and neither do too many high salicylate foods. Even his father has commented on how well he looks!”