Gabor Szendi:
Hyperactivity and nutrition

Of course, there are annoying, fidgety, silly, inattentive, forgetful, negligent or lazy children and adults and they are easily believed by others, especially if scientists have established about them, to be suffering from a brain disease. However, it is absolutely not sure if acting based on medical opinion is the greatest help for them.

 

 

Does Attention Deficit Hyperactivity Disorder exist at all?

The entire diagnosis of Attention Deficit Hyperactivity Disorder (further referred to as ADHD) is flawed for a number of reasons. Even the diagnosis of such a disorder is absurd. As it is the case with all psychiatric diagnoses, the diagnosis of ADHD is also extremely subjective. In addition, how could you draw conclusions regarding cerebral dysfunction and its severity merely from the fact that a teacher or parent labels a child to be absent-minded, inattentive, forgetful, etc., and that this is observable rarely, frequently or very often according to them. The fact that how tolerant, easy-going or, on the contrary, diehard and perfectionistic you are, will absolutely determine what the various actions and expressions experienced on a child will mean to you. As it is the case with all psychiatric diagnoses, the diagnosis of ADHD is also extremely subjective. It is no coincidence that in some studies the incidence of ADHD is estimated to be 1%; however, in other trials, it is estimated to be 20% (Thomas et al., 2015). Namely, it depends on the investigators or the clinical trial who will receive the diagnosis of ADHD and a stimulant for treatment additionally.

ADHD is a typical 'umbrella diagnosis': each child who demonstrates some symptoms due to cultural or social reasons, disposition or even psychological trauma, will get under it. Children living in families with low socioeconomic status will receive the diagnosis of ADHD twice as more often (Russell et al., 2016). Due to cultural differences, the diagnosis of ADHD is twice more prevalent in Africa and three times more frequent in the countries of South America, whose inhabitants are more tempered, than in Europe, owing to the tests standardized in the U.S. (Polanczyk et al., 2007).

A child may become inattentive and restless if his/her parents divorce, there is serious illness in the family, the child is exposed to serial abuse by his/her environment or is starving, and the list could go on and on about the causes why a child can be unmotivated, absent-minded, negligent or excited. Norway is one of the most developed countries in the world. According to a survey, 18%, 7% and 6% of children have been abused there mentally, sexually and physically, respectively (Veldwijk et al., 2012). Children of divorced parents and physically abused children will be labelled with the diagnosis of ADHD 14 and 15 times more often, respectively (Cohen et al., 2002). 75% vs. 35% of sexually or physically abused boys and girls were diagnosed with ADHD, respectively (Ackerman et al., 1998). According to William Carey, a temperament researcher, the symptoms of ADHD overlap with the temperament features considered as normal (Carey, 2002).

From an evolutionary viewpoint, the gene responsible for widespread attention proved to be very useful and therefore spread very quickly and survived (Ding et al., 2002). This is a feature characterizing good hunters (Hartman,1993); it is therefore no coincidence that the diagnosis of ADHD is three times more frequent among boys. Also, for evolutionary reasons, boys tend to be more aggressive and impulsive with competition and impressing girls being in their nature. Modern school systems have extreme difficulties in tolerating these evolutionarily useful traits, but this is a pedagogical and educational issue rather than a psychiatric problem.

And just to avoid going from one extreme to the other, it is now no doubt that low birth weight, fetal harm including maternal smoking, alcohol use, vitamin deficiencies in the fetus, etc.; moreover, hypoxia and abnormal brain development can cause ADHD symptoms (Nigg, 2006). Nevertheless, on one hand, these cases constitute only a fraction of children diagnosed with ADHD, while on the other hand, lagging behind in brain development should be compensated with various developmental programs rather than with psychiatric medications. The reason why psychiatry is a pseudoscience is that it is not only unable to exactly define what it studies, but also unwilling to. I wonder if you could call it a scientific method when one claims about a child to have brain disorders simply based on the subjective evaluation of superficial similarities?

 

Is ADHD a brain disease?

It is no coincidence that well-paid researchers have been making efforts to confirm by researches funded with a vast amount of money for decades that ADHD is indeed associated with some pathology of the brain. If you naively think of science in a way that researchers are interested only in the truth, we must disappoint you. Given the remarkable heterogeneity of the group of children receiving the diagnosis of ADHD, how can one as a genuine professional believe that one could find brain abnormalities which are jointly characteristic to the entire group? However, not inquiring into the individual motivation of researchers, it is the results themselves that belie the initial assumptions.

It turns out one by one that the brain abnormalities reported as a great sensation are either not specific to ADHD or results cannot be reproduced; or the difference disappeared with more precise measurement techniques; or girls were compared to boys (the two sexes have different brain size); or study subjects were of different age; or the abnormalities were explained by differences in intelligence (Baumeister and Hawkins, 2001). The most gross mistake you can make in brain research is that when you compare individuals taking medications seriously affecting brain function with so-called drug-na?ve controls, meaning that the latter ones do not take such drugs at all. Jonathan Leo and David Cohen showed that in clinical trials conducted until 2004, 77% of children studied were on stimulants (Leo and Cohen, 2003; Cohen and Leo, 2004). Medications used in ADHD alter brain function and the size of specific brain regions, as this is the purpose of their administration (Ivanov et al., 2014; Nakao et al., 2011).

This year, i.e. in 2017, the media was enchanted by the fact that "it has ultimately been proven that 5 brain regions have smaller size in children with ADHD". However, workers in the media do not make efforts at all to analyze study details. In the study, 1713 children and adults diagnosed with ADHD were compared with 1529 control subjects (Hoogman et al., 2017). It was not known from 25% of children with ADHD if they were taking any drugs; however, 42% were definitely taking medications. From this point onwards, it is hard to take this study seriously any more. Yet, if you choose to immerse into it, you will find that three of the studied brain areas (thalamus, pallidum and the entire brain) were larger in children with ADHD. Despite the results, it was all over in the entire media that brain areas are smaller in children with ADHD. Actually, the authors averaged the results with data from adults diagnosed with ADHD and aged from 20 to 60. Also, the authors admitted in their paper that no significant correlation was found between the size of brain areas and ADHD symptoms either for the children or the entire sample studied. That is, the alleged differences in size have nothing to do with ADHD. Isn't it what is called deception of the general public?

Is drug treatment efficacious?

Of course, parents see their problematic children only and are not aware of the unfoundedness of ADHD as a diagnosis and the data falsifications of researches trying to prove the alleged brain abnormalities; they can only rely on the statements that treatment has fantastic effects and, on the other hand, untreated ADHD has serious negative effects with a life-long impact. Well, which parent feeling responsible for his/her child would not accept treatment? Each psychiatrist prescribing drugs to children diagnosed with ADHD should, in accordance with his/her oath, be familiar with literature data related to treatment success. The working group of Oregon State University analyzed more than 2000 studies on the drug treatment of ADHD in 2006 and concluded that "there is no good quality evidence on how the drugs used affect school performance, risky behavior, social abilities, etc." They also stated that "there is no evidence on the safety of long-term administration of drugs given in ADHD" (McDonagh et al., 2006). A study with 18 years of follow-up was published earlier this year demonstrating that children diagnosed with ADHD and treated with stimulants until adulthood maintained their symptoms even after becoming adults and had no benefit from treatment compared to children with ADHD not treated with drugs, but their ultimate height became lower owing to the medical treatment (Swanson et al., 2017).

Side effects of the "treatment"

On one hand, as you can see, ADHD is a label just as if you would call everything from TBC through asthma and bronchitis to lung cancer a 'lung disease'. It is as impossible to find an efficacious medication to such a heterogenous population as to 'patients with lung disease'. The other reason why one could oppose drug treatment in ADHD is inefficacy, i.e. drugs are not 'healing' here. When taken, stimulants enhance certain cognitive abilities both in ADHD and in children/adults with no ADHD symptoms, but they do not increase IQ nor they improve school performance (Lakhan and Kirchgessner, 2012).

The third reason is that medical treatment has no use, not to mention its damages. Between 1992 and 2005, 38 children had sudden cardiac death while taking stimulants and 7 similar deaths occurred during atomoxetine (a non-stimulant) administration in 2002-2005. These numbers are only to illustrate risk because the number of reported cases is always less than the actual rates (Vitiello, 2008). Death cases are due to cardiovascular side effects occurring very frequently. In treated subjects, there is an increase in blood pressure and heart rate of 2-4 mmHg and 5-10 bpm, respectively. The mean numbers obscure that much larger increase can be experienced in both parameters for a minority of children. Gastrointestinal symptoms (nausea, vomiting) also occur. The drugs used in ADHD result in a mean growth retardation of 1 cm/year, which is an average number, too. A case of a 10-year-old boy has been described whose growth stopped completely (Vitiello, 2008). For stimulants, loss of appetite with weight loss, irritability and sleep disorders occur in 70%, 57% and 47% of children, respectively (Khajehpiri et al., 2014). One in every 400 children treated with stimulants will develop psychosis from treatment (Ross, 2006).

Therefore, let us forget psychiatry and the diagnosis of ADHD for a moment and return to the specific symptoms of a specific child. There are several methods to treat these, e.g. neurofeedback, behavior therapy, special education as well as the nutrition approach described as follows.

ADHD and nutrition

Benjamin Feingold was born in 1899 and he turned his interest toward allergies after World War II as a practicing physician. His attention was soon caught by the fact that various allergies are somehow associated with specific personality traits and different traits are dominant depending on the severity of allergy (Feingold et al., 1962). Feingold noticed the relationship between diet and behavioral symptoms for a specific case. A 40-year-old female presented with facial edema in the Department of Allergic Diseases. Her symptoms were successfully terminated with the Kaiser-Permanente diet back then. Ten days later, the head of the Department of Psychiatry called Feingold and enquired what they had done to the woman because she had been treated for two years due to her aggressive behavior against her husband and acquaintances and now all her complaints ceased. After this, Feingold and his colleagues reviewed the medical records of adults and children treated with the Kaiser-Permanente diet and found out that, in response to the diet, behavioral disorders normalized in others as well (Feingold, 1977).

 

Owing to these recognitions, in his study conducted in 1973 he achieved marked improvement in 25 children with hyperactivity disorder from a diet later becoming known as the Feingold diet (Feingold, 1973; Feingold, 1977). The diet was free from food colorings and flavorings, artificial and natural salicylates as well as the food additives E321 and E320. In the language of food, this meant fresh meat, vegetables, milk and home-made foods. Feingold did not recommend eating fruits because of their natural salicylate (chemicals similar to aspirin) content and, due to their food additives content, he also discouraged from consuming dairy and bakery products, prepared meats, jams and soft drinks. During the diet, one could not use flavored toothpastes, scented soaps, perfumes, etc. Later, fruits excluded from the diet were gradually reintroduced to check if they provoke any negative impact (Feingold, 1976). In 1977, Feingold could provide reports from 458 children maintaining the Feingold diet and kept under observation for years. In their experience, dietary restrictions were successful in 60-70% of cases (Feingold, 1977).

Feingold's results met with a strong response since, based on estimates, 5 million American children even at that time were affected by the hyperactivity disorder, or as ADHD was then called, Minimal Brain Dysfunction. Several studies were conducted within a few years. Of course, the results were as variable as the group of children diagnosed with ADHD. It quickly became evident that it is not the diet that poses the problem for all children. Nevertheless, the fact that this phenomenon does exist was amply demonstrated in a study from 1978. Children showing improvement to the Feingold diet were included in the trial and aspirin or vitamin C was administered to them in a double-blind manner (neither the children nor the investigators knew what the tablets contained). Children receiving aspirin experienced slowing down and developed coordination and sleep disorders (Fitzsimon et al., 1978). Others focused on food colorings. Already back in 1979, the average diet contained 90 mg of food colorings but 10% of the population consumed 166 mg from it daily. James Swanson and Marcel Kinsbourne, researchers at the University of Toronto, Canada, reported two studies in 1980 in which they proved in a double-blind fashion that, after sticking to the Feingold diet for a few days, children with ADHD showed deterioration in learning tasks in response to 100-150 mg of food colorings but did not respond to placebo or a low dose (26 mg). (Stevens et al., 2011). A meta-analysis of 23 double-blind trials was published in 2004 demonstrating that food colorings may cause hyperactivity symptoms in susceptible children (Schab and Trinh, 2004).

The essence of elimination diet is that suspected allergenic food substances are eliminated from the diet for 3-4 weeks, then food substances possibly responsible for symptoms are tested one by one and, in the absence of any problems, the respective food substance will be incorporated into the child's diet. Thus, one might build up gradually what a child may and may not eat. Such studies, similar to Feingold's results, are successful in 70-80% of cases. The most problematic foods include milk, chocolate, soya, yeast, eggs, grains, corn, pulses and peanuts. Moreover, of course, food colorings, preservatives and flavor enhancers are also included. Elimination studies have demonstrated that maintenance of an additive-free diet is not sufficient to achieve symptomatic improvement (Stevens et al., 2011).

The authorities responsible for educational affairs in New York had very convincing results when they changed in several steps the composition of foods served in school meals in 803 New York state schools between 1979 and 1983. A performance test was administered every year in the U.S. schools. It is shown on the below graph how additional dietary modifications introduced year by year lead to an increase in mean performance of the 803 schools selected.

 

No changes were introduced in the first 3 years (black columns). In the school year 1979-80, the sugar content of foods was reduced, and two food colorings were omitted. In the next school year, i.e. 1980-81, the rest of the food colorings and preservatives were also sent into exile from the diet. In the subsequent academic year 1981-82, no modifications were made to the previously established diet, with no improvement in schools' performance at this time. In the academic year 1982-83, the additives E321 and E320, considered problematic by Feingold, were also eliminated. There was a rise in schools' performance in response to each modification, with an improvement in performance from the previous 41% on average to 55% (Schoenthaler et al., 1986).

This study has proven in a very large sample the significant overall impact of sugar and additives to the behavior as well as attentive and learning abilities of many children.

Conclusions

There are two important conclusions from the studies investigating the link between nutrition and hyperactivity. There was a steady deterioration in the composition and quality of foods in developed countries in the 20th century. There is a correlation with this and the increasing incidence of several diseases of civilization, obesity and, not surprisingly, certain mental health problems. The rising prevalence of hyperactivity is explained by several facts. Considerable factors in this rise include an increasing sugar and fructose content of our diet, the ever increasing number and ratio of additives (Arnold et al., 2012), qualitative starvation (that is lack of essential nutrients and vitamins) (Schoenthaler et al., 2000), a decrease in mean birth weight (Pettersson et al., 2015), the rising number of families with problems (Cunningham and Boyle, 2002) and, unfortunately, the growing appetite of the pharmaceutical industry and psychiatry. Many of these factors can be prevented and treated by returning to a healthier lifestyle. It is also important to keep in mind that bad treatment is not any better than non-treatment. It is much more important to find a career for the child matching his/her temperament and abilities rather than pushing through the parents' dreams.

 

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