The Controversy of, and Holistic Therapies for ADHD

As a school psychologist who started his career over 30 years ago as a secondary science teacher I have always relied on research and data to support my beliefs. And when I explored the nature vs nurture (genetics vs environment) debate as it applies to mental illness I have found (based on research and data) that over 75 percent of mental illness is due to environmental factors, not genetics. This is what I believe and found to be the case with ADHD (if the “disorder” exists at all!).

Attention-Deficit/Hyperactivity Disorder (ADHD) is considered the most common childhood neurobehavioral disorder of school-aged children today. And, it is the most controversial disorder also. Controversial when we check beyond mainstream traditional Western (allopathic) diagnosis and treatment. As a school psychologist with over thirty years’ experience working with students and families from the pre-kindergarten age through grade twelve, I have rarely seen “proper” diagnosis of the disorder. What I have seen are children “drugged” in order to “do better in school.” This current trend in medicating and labeling our children can have lifelong negative effects!

Today there are many physicians, psychiatrists and psychologists that question whether such a disorder even exists. And, they refuse to recommend psycho-stimulate medication for the “disorder’s” symptoms, but seek alternative therapies.

According to the DSM-IV, children with ADHD display problematic behaviors at home and 80% are believed to display academic performance problems. Estimates range between four to twelve percent of school children have the disorder. Children that are diagnosed with ADHD usually are put on psycho-stimulate medication with what seems to be little concern of short-term or long-term side effects.

Of the five million children today with ADHD over three million take Ritalin (methylphenidate) with sometimes only cursory medical/professional diagnosis of the disorder. The medical community appears to be more concern with controlling the student’s behavior with drugs rather than trying to determine a cause of the condition. However, there are a number of theories today that address the cause and treatment of the condition’s symptoms without the use of potentially harmful medications.

Diagnosis of ADHD

The American Academy of Pediatrics (AAP) calls ADHD the most common childhood neurobehavioral disorder. Not surprisingly, the AAP questions the possible over-diagnosis of ADHD.

In their May, 2000 issue of Pediatrics the AAP calls for stricter guidelines for primary care physicians diagnosing ADHD in children age six to twelve years-old. These guidelines include: using the DSM-IV criteria, with symptoms being present in two or more settings, the symptoms adversely affecting the child’s academic or social functioning for at least six months, the assessment should include information from parents as well as classroom teachers or other school professionals, and the evaluation of ADHD should also include an assessment for co-existing conditions such as learning or language problems.

The AAP appears to be concerned that far too many physicians will place a child on psycho-stimulate medication with little or no assessment of the condition. Often they speak only to the parents or give the child a quick in-office physical before writing a prescription for Ritalin.

The National Association of School Psychologists (NASP) in their text, Best Practices in School Psychology (1995), outlines specific criteria children must meet in order to be diagnosed with ADHD. This criteria not only includes DSM-IV guidelines but meets federal requirements for evaluating a child to qualify for educational services under the Individuals with Disabilities Education Act (IDEA).

Therefore, school psychologists are often faced with the task of reconciling confused communication among parents (who believe something is not right with their child), school personnel (who have strict federal guidelines in order service students with special needs) and medical personnel (that label children ADHD and prescribe medications without any testing).

Have I seen this kind of “correct” diagnosis for ADHD? Rarely, if ever! What usually happens is that a parent brings their child to the family physician, stating that the child is having trouble paying attention in school and the physician gives an on-the-spot diagnosis of ADHD, and writes a script for a trial of an ADHD medication.

Causes of ADHD

The medical community appears to down play any one deciding factor that would cause ADHD, and would rather list several factors that may contribute to the condition. Dr. K. S. Berger, in his book, The Developing Person Through the Life Span (1998) states that current research lists factors such as genetics, prenatal damage from teratogens, or postnatal damage, such as from lead poisoning or head trauma as the cause of ADHD.

Russell Barkley, Ph.D. author of several books on ADHD such as Taking Charge of ADHD, (1995) cites recent research indicating that the areas of the brain in children with ADHD are reduced in size when compared with children without the disorder. Possible causes for the reduction could be polygenetic in nature. Specifically genes that dictate the way the brain uses a neurotransmitter called the dopamine receptor are thought to be mutated in children with ADHD. Other theories include prenatal alcohol consumption, fatty acid deficiency, faulty glucose metabolism, and thyroid abnormalities as possible causes of ADHD.

David Stein, Ph.D. questions if ADHD is a medical disorder at all. He states that there is little scientific evidence to support that it is a medical condition. Dr. Stein suggests that the environment a child is brought up in is the primary reason for ADHD behavior. In his book, Ritalin Is Not The Answer (1999), he contends lack of discipline in the home or in the classroom is the main cause of ADHD. He believes by setting consistent boundaries with behavior control interventions, ADHD symptoms can be eliminated.

Sugar appears to be highly controversial regarding its effect on children and the possibility of it causing ADHD. Depending on which study you read, you can be thoroughly confused as to its relation to children’s behavior. Dr. William Crook, a pediatrician whom had been treating hyperactive children for twenty-five years, reports in a five year study, where he interview parents of 182 hyperactive children and found the great majority of the children were adversely affected by their diet. He found their hyperactivity was definitely related to specific foods they consumed, the worst offender being sugar.

Another study by the New York Institute of Child Development in New York City involved 265 hyperactive children. They found that 74 percent of the children had an inability to properly digest and assimilate sugar and other refined carbohydrates. A study conducted by the National Institute of Mental Health showed that the rate at which the brain uses glucose, its main energy source, is lower with subjects with ADHD than with subjects without ADHD.

Mary Block, M.D., in her book, No More Ritalin, Treating ADHD Without Drugs (1996) explains how reactive hypoglycemia and adrenaline levels are related. Dr. Block states when we have too little glucose in our body (blood sugar) the body releases a backup reserve called epinephrine or adrenaline. Adrenaline is a hormone that gives the body an energy surge. The body goes into hypoglycemia (low blood sugar) by either not eating enough or paradoxically by eating too much sugar. People with reactive hypoglycemia may have a metabolism problem that causes the over secretion of adrenaline. Dr. Block cites a Yale study that tested the effects of sugar on blood glucose and adrenaline levels. The study showed the adrenaline levels of children were ten times higher than normal up to five hours after ingesting the sugar. She explains that many studies that show a poor relationship between sugar intake and behavior are usually flawed and poorly conducted. She also makes the point if any medical professionals questions the effect sugar has on behavior they should talk to a parent or teacher around Halloween.

In the 1970’s Ben Feingold, M.D., developed one of the first natural approaches to treating hyperactivity. He was a pediatrician who taught at Northwestern University and a pioneer in the fields of allergy and immunology. He also served as Chief of Allergies at the Kaiser Permanente Medical Center in San Francisco.

According to Dr. Feingold many hyperactive children are sensitive to naturally occurring salicylates and phenolic compounds. Salicylates are used as food preservatives and in the production of aspirin. Dr. Feingold determined that food additives induce hyperactivity after researching over 1,200 cases where additives were linked to behavior disorders. Dr. Feingold believes that salicylates, artificial colors, and artificial flavors in the diet are responsible for hyperactivity in children.

Dr. Weintraub reports as far back as 1940 there have been reports of sensitivities to food dyes, aspirin, and naturally occurring salicylate substances found in fruits and vegetables. Dr. Weintraub cites other studies in support of Dr. Feingold’s theory. A study published in Lancet (1985) found that 82 percent of a large group of hyperactive children responded positively to a hypoallergenic elimination diet. While on the diet many of the children’s behavior became normal. The most commonly provoking substances were artificial food colors and preservatives.

Dr. Carl Pfeiffer M.D. recommends a natural diet for hyperactive children based on the belief that food additives, artificial colors, flavors and preservatives causes hyperactivity. Another study in support of Dr. Feingold’s theories, was a study of 76 hyperactive children. When placed on a restricted diet devoid of additives 62 of the children improved and 21 realized normal behavior.

Dr. Weintraub discusses a recent study conducted at the Royal Children’s Hospital, University of Melbourne, Australia of 200 hyperactive children. In a six week trial, the children were placed on a diet free of all synthetic foods. The parents of 150 children reported significant behavioral improvements, however, they noted when artificial colors were added back into their diets their behavior worsened. The more food coloring they consumed, the longer the undesirable behavior lasted.

A 1994 study at the North Shore Hospital-Cornell Medical Center found that by eliminating reactive foods such as those with food additives and artificial colors the ADHD symptoms of irritability, restlessness, sleep disturbances and other negative behaviors were reduced.

By using PET scans of the brain scientists are able to visually observe the amount of glucose certain areas of the brain uses. In examining the brains of people with ADHD, there are certain areas of the brain that show decreased use of glucose and diminished brain metabolism. Scientists are currently searching for the cause of this decreased glucose metabolism in people with ADHD.

Another observed neurodevelopment disorder that leads to ADHD symptoms has been associated with fetal alcohol syndrome (FAS). FAS is caused by over consumption of alcohol during pregnancy, and children with FAS are characterized with low birth weight, an impaired intellect, and certain physical defects. Children born with FAS show the same hyperactivity, low impulse control, and inability to pay attention as those children diagnosed with ADHD.

A variety of recent observations have led investigators to conclude there is a relationship between thyroid dysfunction and ADHD. It has been observed that up to 70 percent of all children with a condition known as “generalized thyroid resistance” also demonstrate ADHD symptoms. Patients with thyroid resistance suffer from altered glucose uptake by cells, a feature that we now know impairs brain metabolism. Altered glucose uptake is linked to ADHD if that diminished brain activity happens to be in the brain regions responsible for our ability to pay attention and control our behavior.

Thyroid dysfunction may be caused by synthetic chemicals like PCBs, phenols, and excessive histamines. A fatty acid deficiency is also related to thyroid dysfunction. A large portion of the brain is composed of fats, called phospholipids that are derived from essential fatty acids. A number of studies have identified an essential fatty acid (EFA) deficiency in many hyperactive children. For example, a 1995 study published in The American Journal of Clinical Nutrition showed a correlation between low omega-3 blood levels and ADHD in young boys. EFAs play important roles in neurotransmitter function in communication of neurotransmitters and in proper nerve cell development.

Peter Breggin, MD, is a psychiatrist that has been specializing in ADHD treatment for over 30 years. In his books, Talking Back to Ritalin, (2001), and The Ritalin Fact Book, What Your Doctor Won’t Tell You about Stimulant Drugs, (2002) he contends that ADHD is a disorder that was fabricated by the pharmaceutical companies in order to sell their drugs. He refutes the medical evidence that ADHD is a neurological disorder by pointing out that the research that showed reduced attention centers in ADHD children was flawed.

At the National Institute of Mental Health’s Conference on ADHD (1998) Dr. Breggin was invited to speak and was one of the few critics of conventional psycho-stimulate therapy for ADHD. At that conference he pointed out that the studies on brain atrophy of ADHD children involved children that had already been on psycho-stimulate medication. And, that previous studies have shown that psycho-stimulate medications in fact, causes brain atrophy. That conference, that had thirty national experts on ADHD concluded that there is currently no conclusive evidence that suggests that ADHD is a medical disorder. In his books, Dr. Breggin presents clinical studies that show that there are little long-term educational benefits in using psycho-stimulates. And, he elaborates on the many significant harmful effects of the drugs. Dr. Breggin has also been involved several individual and class-action suits as an expert witness against the pharmaceutical companies over wrongful deaths and ill effects from the drugs prescribed for ADHD.

Traditional Treatment:

Traditional Western medicine (Allopathic) treatment for ADHD consistent primarily of prescribing psycho-stimulants to control the child’s behavior. Physicians prescribe a psycho-stimulant like Ritalin, Concerta or Adderall usually starting in a small dose (5 or 10 mg) and increase it monthly based on a reduction of the ADHD symptoms. Side-effects are monitored and medications are often switched if side-effects are too severe or if there is no noticeable difference in the child’s behavior.

The most common medication for ADHD is Ritalin (Methylphenidate hydrochloride). Or another brand name drug like Concerta which is the same chemical make-up. This drug acts a central nervous system stimulate, that also increases production of a neuro-transmitter (dopamine), the much the same way as cocaine does. Side effects can range from insomnia, nervousness, loss of appetite, abdominal pain, weight loss, abnormally fast heartbeat, blood pressure changes, dizziness, drowsiness, fever, hair loss, headache, hives, joint pain, nausea, palpitations, skin inflammation, skin rash, Tourette’s syndrome, to psychotic reactions.

Another common medication for ADHD is Adderall and Adderall XR (d-amphetamine and amphetamine mixture). This drug blocks the reuptake of neurotransmitters, thereby prolonging their actions and slows down metabolism. Common side effects could include: Irritability, nervousness, insomnia, euphoria, dry mouth, rapid heartbeat, dizziness, reduced alertness, blurred vision, headache, diarrhea or constipation, appetite loss, nausea, weight loss, seizures, and irregular heartbeat. Interestingly, the drug was taken off the market in Canada due Adderall’s connection to heart attacks in children. However, the FDA only issued a “warning” in the U.S.

Additional medications may also be prescribed like Trazadone, to help the child sleep at night, or an anti-anxiety medication if they develop twitches or tics (Paxil, Wellbutrin, Klonopin). Occasionally the ups and downs of the medications causes the child to hallucinate or have “mood swings” and they are then diagnosed with Bipolar Disorder (becoming a very popular childhood diagnosis) and anti-psychotic medication is prescribed (like Depakote or Zyprexa).

Naturopathic Treatment:

There are many factors are leading a number of doctors to question the diagnosis of ADHD. First there is the significant side-effects of the medications prescribed to children. Then there is the increasing evidence of little long-term improvement academically of students, and there is the question of the criteria that actually diagnoses the ADHD.

When looking into the DSM-IV criteria for ADHD many are struck with the realization that 9 out of 10 children could be diagnosed with the “disorder”. It appears that many normal childhood behaviors like: “fails to finish schoolwork or chores,” “often dislikes and avoids homework!” or, “has difficulty awaiting turn,” are used to determine if a child has ADHD. Then there is the realization that psycho-stimulates do not cure the cause of the behaviors, but merely supply the patient with a bandage (life-long?) for the disorder. However, many naturopathic or alternative therapies may in fact cure the “disorder.”

A recent clinical study that measured the effectiveness of nutritional interventions compared to traditional psycho-stimulant treatment. In Alternative Medicine Review (2003 Aug; 8(3):319-30) a study reported: “These findings support the effectiveness of food supplement treatment in improving attention and self-control in children with ADHD and suggest food supplement treatment of ADHD may be of equal efficacy to Ritalin treatment.”

Since Dr. Feingold pioneered his theories of diet-related causes for hyperactive behavior there have been several variations in support of a more natural diet as a cure. Dr. Feingold’s diet has been called an elimination diet due to the process he recommends of first eliminating all foods that contain natural and synthetic salicylates. Natural salicylates include fruits and vegetables such as almonds, apples, apricots, berries, cherries, grapes, raisins, oranges, peaches, plums, prunes, strawberries, pickles, tomatoes, cucumbers and vinegar.

Synthetic salicylates include all foods that contain artificial colors and artificial flavors, such as benzoic acid, BHA, BHT, MSG, butylene glycol, potassium bisulfate, potassium and sodium nitrate, sulfites, and tartrazines. Once a child’s behavior is normalized, which may take four to six weeks, food items may slowly reintroduced into their diet and monitored for their effect on the child’s behavior.

Frank Lawlis, Ph.D. in his book The ADD Answer: How to Help Your Child Now, expands Dr. Feingold’s diet and gives specific diet recommendations for the child with ADHD. He recommends the entire family follow such a diet to give the child support, as the diet can be very restrictive (see table 4-2). Dr. Lawlis states that foods that have a negative impact on children’s health include: artificial colors and preservatives, processed milk and milk products, wheat products (not whole grains), sugar, oranges, grapefruits, eggs, and MSG. He also recommends a diet rich in calcium, magnesium, zinc (important in proper neurotransmitter function), vitamins C and B6 (important in immune system and metabolism function), B12 (increases energy, lessens anxiety, increases concentration), fish oil (contains DHA important in brain health), protein (stimulates mental alertness), pycnogenol or grape seed extract (two herbs that increase blood flow in the brain) and probiotic (helps restore healthy bacteria in the intestines).

Dr. Lawlis warns that medications used for ADHD can cause severe side-effects such as psychosis, including manic and schizophrenic episodes. Often when such side-effects occur physicians do not stop medicating, they prescribe more drugs, diagnosing the child with depression or antisocial personality disorder, and they treat the child with antidepressants, mood stabilizers or narcoleptics. It is not unusual for children to be taking as many as five different medications that cause a host of side-effects. He states, “Meds upon meds is madness upon madness.”

Many researchers describe a natural therapy of increased protein in the diet to increase serotonin, which has a calming effect on children with hyperactivity. Also recommended are large amounts of B vitamins, with emphasis on B6 (pyridoxine), vitamin C, and essential fatty acids (EFA’s).

M. Salaman author of Foods That Heal (1989) cites research that used high doses of vitamin B6 (pyridoxine) to control hyperactivity. In the study, high doses of B6 were given to hyperactive children for seven weeks followed by seven weeks of Ritalin, and seven weeks of a placebo. The high dose of B6 proved to be the most effective treatment, where it raised the blood serotonin level and Ritalin did not. Dr. Salaman also recommends EFA supplementation of 1,000 to 1,500 mg capsules of evening primrose in the morning and evening. She notes some children respond better if the evening primrose oil is rubbed into their skin, as quite often children with hyperactivity may have poor intestinal tract absorption.

In Summary:

Current research does support natural treatment for ADHD, a disorder that is considered an unnatural reaction to environmental factors (if in fact such a disorder exists). There appears to be substantial evidence to support dietary factors that cause ADHD behaviors of hyperactivity and inattention, are related to sugar consumption, reaction to food additives, faulty glucose metabolism (sugar consumption), and fatty acid deficiency. Parents do in fact have a choice when it comes to treatment for their children. They no longer have to place their child on potentially harmful psycho-stimulate medications. Or, possibly risk a lifelong pattern of drug dependence for their children, as well as “labeling” them with a disorder that can have lifelong implications of them believing that there is something wrong with them.

Medications such as Ritalin, Adderall, Concerta, Strattera, Cylert, Dexedrine, Tofranil, and Norpramin have side effects that range from mild (dry mouth, nausea, headaches, dizziness, constipation, irritability) to serious (anorexia, insomnia, weight loss, depression, palpitations, blurred vision, high blood pressure), to very serious (suppressed growth, liver damage, Tourette’s syndrome, psychosis, drug dependence).

The natural approach to treatment of ADHD may require more time and effort by the family when restricting their child’s diet, but the benefits of the approach are great. The cause of the child’s behavior will have been uncovered and not just covered-up by treating the symptoms with harmful drugs.

Current research involving the use of multi-vitamin and multi-mineral supplements, herbs and eliminating toxins in the diet such as food colorings, additives and heavy metals, all appear to have a dramatic effect on a reducing a child’s ADHD symptoms without harmful side effect.

Holistic Mental Health for ADHD

Specific Recommendations:

Based on this research, treatment of ADHD should progress from the least harmful course of action. Families should try to uncover the cause of the condition, enabling treatment without harmful drugs. Causes of ADHD that can be treated without psycho-stimulate medications include food allergies, nutrient deficiencies, and diet restriction intervention. Recommended course of treatment:

• An evaluation with a naturopathic physician to determine if a food allergy exists and a dietary evaluation to determine if a nutrient deficiency exists.

• Eliminate all processed foods that contain artificial additives such as aspartame, benzoic acid, BHA, BHT, MSG, butylene glycol, potassium bisulfate, potassium and sodium nitrate, sulfites, and tartrazines from the diet.

• Eliminate natural salicylates such as almonds, apples, apricots, berries, cherries, grapes, raisins, oranges, peaches, plums, prunes, strawberries, pickles, tomatoes, cucumbers and vinegar from the diet.

• Add a vitamin/mineral supplement daily, with extra B-complex (120 to 150 mg, per day), vitamin C (1,000 to 2,000 mg, per day), calcium (1,000 to 1,500 mg, per day), magnesium (300 to 500 mg, per day), zinc (20 to 30 mg, per day) and selenium (100 to 200 mcg, per day), and an EFA supplement containing omega-3 EFAs such as in EPA fish oil capsules, or take evening primrose oil (2,000 to 3,000 mg, per day in two doses).

• Calming herbs such as St. John’s wort, valerian or skullcap can be tried to reduce symptoms of hyperactivity and irritability.