Attention deficit hyperactivity disorder (ADHD or AD/HD or ADD) is a developmental disorder. It is primarily characterised by "the co-existence of attentional problems and hyperactivity, with each behavior occurring infrequently alone" and symptoms starting before seven years of age.
ADHD management usually involves some combination of medications, behaviour modifications, lifestyle changes, and counselling. Its symptoms can be difficult to differentiate from other disorders, increasing the likelihood that the diagnosis of ADHD will be missed. Most clinicians have not received formal training in the assessment and treatment of ADHD, particularly in adult patients.
Epidemiology of ADHD
ADHD's global prevalence is estimated at 3 to 5 percent in people under the age of 19. There is, however, both geographical and local variability among studies. Geographically, children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East. The rates of diagnosis and treatment of ADHD are also much higher on the East Coast of the USA than on the West Coast.
ADHD is diagnosed two to four times more frequently in boys than in girls, though studies suggest this discrepancy may be partially due to subjective bias of referring teachers. The frequency of the diagnosis differs between male children (10%) and female children (4%) in the United States. In the UK in 2003 a prevalence of 3.6 percent is reported in male children and less than 1 percent is reported in female children.
Rates of ADHD diagnosis and treatment have increased in both the UK and the USA since the 1970s. In the UK an estimated 0.5 per 1,000 children had ADHD in the 1970s, while 3 per 1,000 received ADHD medications in the late 1990s. In the USA in the 1970s 12 per 1,000 children had the diagnosis, while in the late 1990s 34 per 1,000 had the diagnosis and the numbers continue to increase.
History of ADHD
Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An Inquiry Into the Nature and Origin of Mental Derangement written in 1798. The use of stimulants to treat ADHD was first described in 1937.
ADHD and its diagnosis and treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents and the media. Topics include the actuality of the disorder, its causes, and the use of stimulant medications in its treatment. Most healthcare providers accept that ADHD is a genuine disorder with debate in the scientific community centering mainly around how it is diagnosed and treated.
Prognosis in ADHD
Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment.In the United States, 37 percent of those with ADHD do not get a high school diploma even though many of them will receive special education services. A 1995 briefing citing a 1994 book review says the combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish high school. Also in the US, less than 5 percent of individuals with ADHD get a college degree compared to 28 percent of the general population.
Those with ADHD as children are at increased risk of a number of adverse life outcomes once they become teenagers. These include a greater risk of auto crashes, injury and higher medical expenses, earlier sexual activity, and teen pregnancy. ADHD persists into adulthood in about 30 to 50 percent of cases. Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.
ADD in adults
Researchers found that 60 percent of the children diagnosed with ADHD continue having symptoms well into adulthood. Many adults, however, remain untreated. Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized and may rely on non-prescribed drugs and alcohol to get by. They often have such associated psychiatric comorbidities as depression, anxiety disorder, bipolar disorder, substance abuse, or a learning disability. here is controversy amongst some experts on whether ADHD persists into adulthood.
Classification of ADHD
ADHD has three subtypes:
1. Attention Deficit Hyperactivity Disorder ADHD / Predominantly hyperactive-impulsive
Most symptoms (six or more) are in the hyperactivity-impulsivity categories. Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
2. Attention Deficit Disorder ADD / Predominantly inattentive
The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree. Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.
3. Combined hyperactive-impulsive and inattentive
Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present. Most children with ADHD have the combined type.
Signs and symptoms
Hyperactivity is a common symptom of ADHD. Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. The symptoms of ADHD are especially difficult to define because it is hard to draw the line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin. To be diagnosed with ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.
ADD / Predominantly inattentive type symptoms may include:
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another.
- Have difficulty maintaining focus on one task.
- Become bored with a task after only a few minutes, unless doing something enjoyable.
- Have difficulty focusing attention on organizing and completing a task or learning something new or trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities.
- Not seem to listen when spoken to.
- Daydream, become easily confused, and move slowly.
- Have difficulty processing information as quickly and accurately as others.
- Struggle to follow instructions.
ADHD / Predominantly hyperactive-impulsive type symptoms may include
- Fidget and squirm in their seats.
- Talk nonstop.
- Dash around, touching or playing with anything and everything in sight.
- Have trouble sitting still during dinner, school, and story time.
- Be constantly in motion Have difficulty doing quiet tasks or activities.
- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences.
- Have difficulty waiting for things they want or waiting their turns in games.
Other Existing disorders with ADHD
Oppositional defiant disorder (35%) and conduct disorder (26%)
Both are characterised by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, deceitfulness, lying, or stealing, inevitably linking these comorbid disorders with Antisocial Personality Disorder (ASPD). About half of those with hyperactivity and ODD or CD develop ASPD in adulthood.
Borderline personality disorder
According to a study on 120 female psychiatric patients diagnosed and treated for BPD associated with ADHD in 70 percent of those cases. Primary disorder of vigilance Characterised by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.
Boys diagnosed with the combined subtype have been shown likely to suffer from a mood disorder.
As many as 25 percent of children with ADHD have bipolar disorder. Children with this combination may demonstrate more aggression and behavioral problems than those with ADHD alone.
Found to be common in girls diagnosed with the inattentive subtype of ADHD.
OCD is believed to share a genetic component with ADHD and shares many of its characteristics.
Western medical causes of ADHD
The specific causes of ADHD are not known. There are, however, a number of factors that may contribute to, or exacerbate ADHD. They include genetics, diet and the social and physical environments.
Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases. Researchers believe that a large majority of ADHD cases arise from a combination of various genes, many of which affect dopamine transporters.
Twin studies to date have suggested that approximately 9 to 20 percent of the variance in hyperactive-impulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared environmental (nongenetic) factors. Environmental factors implicated include alcohol and tobacco smoke exposure during pregnancy and environmental exposure to lead in very early life.
The relation of smoking to ADHD could be due to nicotine causing hypoxia (lack of oxygen) to the foetus in utero. It could also be that women with ADHD are more likely to smoke and therefore, due to the strong genetic component of ADHD, are more likely to have children with ADHD.
Complications during pregnancy and birth
Complications during pregnancy and birth, including premature birth, might also play a role. ADHD patients have been observed to have higher than average rates of head injuries. Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella, enterovirus 71) and streptococcal bacterial infection.
A 2007 study linked the organophosphate insecticide chlorpyrifos, which is used on some fruits and vegetables, with delays in learning rates, reduced physical coordination, and behavioral problems in children, especially ADHD.
A 2010 study found that pesticide exposure is strongly associated with an increased risk of ADHD in children. Researchers analyzed the levels of organophosphate residues in the urine of more than 1,100 children aged 8 to 15 years old, and found that those with the highest levels of dialkyl phosphates, which are the breakdown products of organophosphate pesticides, also had the highest incidence of ADHD. Overall, they found a 35 percent increase in the odds of developing ADHD with every 10-fold increase in urinary concentration of the pesticide residues. The effect was seen even at the low end of exposure: children who had any detectable, above-average level of pesticide metabolite in their urine were twice as likely as those with undetectable levels to record symptoms of ADHD.
Three government-funded longitudinal studies from 2010 and 2011 examined environmental exposure to organophosphate pesticides between pregnancy and grade school. Although the studies varied in techniques to measure pesticide exposure, they reached similar conclusions. Children exposed to higher levels of organophosphates during pregnancy were more likely to have lower IQs and problems focusing or solving problems. One study suggested that genetics play a strong role in whether exposure to organophosphates causes damage. Two studies found higher rates of ADHD diagnosis among children exposed to higher levels of organophosphate pesticides.
Diet and ADHD
A study published in The Lancet in 2007 found a link between children’s ingestion of many commonly used artificial food colours, the preservative sodium benzoate and hyperactivity. In response to these findings, the British government took prompt action. According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers are being encouraged to voluntarily phase out the use of most artificial food colours by the end of 2009. Following the FSA’s actions, the European Commission ruled that any food products containing the “Southampton Six” (The contentious colourings are: sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124)) must display warning labels on their packaging by 2010.
The World Health Organisation states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology. Other researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities.
A study of foster children found that a high number of them had symptoms closely resembling ADHD.Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse. Furthermore, Complex Post Traumatic Stress Disorder can result in attention problems that can look like ADHD.
A 2010 article by CNN suggests that there is an increased risk for internationally adopted children to develop mental health disorders, such as ADHD and ODD. The risk may be related to the length of time the children spent in an orphanage, especially if they were neglected or abused. Many of these families who adopted the affected children feel overwhelmed and frustrated, since managing their children may entail more responsibilities than originally anticipated.
Neurodiversity theory in ADHD
Proponents of the neurodiversity theory assert that atypical (neurodivergent) neurological development is a normal human difference that is to be tolerated and respected just like any other human difference. Social critics argue that while biological factors may play a large role in difficulties with sitting still in class and/or concentrating on schoolwork in some children, these children could have failed to integrate others' social expectations of their behaviour for a variety of other reasons.
Social construct theory in ADHD
Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Physicians, parents, teachers, and others who determine which diagnostic criteria are applied therefore determine the number of people affected. Social construct theory beielieves that ADHD was “invented and not found”.
Pathophysiology of ADHD
The pathophysiology of ADHD is unclear and there are a number of competing theories.
General reduction of brain volume in certain regions
Research on children with ADHD has shown a general reduction of brain volume, but with a proportionally greater reduction in the volume of the left-sided prefrontal cortex. These findings suggest that the core ADHD features of inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction, but other brain regions particularly the cerebellum have also been implicated. Neuroimaging studies in ADHD have not always given consistent however, are only used for research and not diagnostic purposes.
A 2005 review of published studies involving neuroimaging, neuropsychological genetics, and neurochemistry found converging lines of evidence to suggest that four connected frontostriatal regions play a role in the pathophysiology of ADHD: The lateral prefrontal cortex, dorsal anterior cingulate cortex, caudate, and putamen.
Dopamine and ADHD
A laboratory found involvement of the "7-repeat" variant of the dopamine D4 receptor gene, which accounts for about 30 percent of the genetic risk for ADHD, in unusual thinness of the cortex of the right side of the brain. Additionally, SPECT scans found people with ADHD to have reduced blood circulation (indicating low neural activity) and a significantly higher concentration of dopamine transporters in the striatum which is in charge of planning ahead.
One study found that it was not the transporter levels that indicated ADHD, but the dopamine itself. ADHD subjects showed lower levels of dopamine (hypodopaminergia) across the board. They speculated that since ADHD subjects had lower levels of dopamine to begin with, the number of transporters in the brain was not the telling factor. In support of this notion, plasma homovanillic acid, an index of dopamine levels, was found to be inversely related not only to childhood ADHD symptoms in adult psychiatric patients, but to "childhood learning problems" in healthy subjects as well.
Volkow ND., at al., Brain dopamine transporter levels in treatment and drug naïve adults with ADHD.Neuroimage. 2007 Feb 1;34(3):1182-90. Epub 2006 Nov 27.
Defective glucose metabolism
A 1990 PET scan study by Alan J. Zametkin et al. found that global cerebral glucose metabolism was 8 percent lower in medication-naive adults who had been hyperactive since childhood. Further studies found that chronic stimulant treatment had little effect on global glucose metabolism, a 1993 study in girls failed to find a decreased global glucose metabolism, but found significant differences in glucose metabolism in 6 specific regions of the brains of ADHD girls as compared to control subjects. A further study in 1997 also failed to find global differences in glucose metabolism, but similarly found differences in glucose normalisation in specific regions of the brain.
Decreased thickness observed in certain brain regions
Critics, such as Jonathan Leo and David Cohen, who reject the characterisation of ADHD as a disorder, contend that the controls for stimulant medication usage were inadequate in some lobar volumetric studies which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for the decreased thickness observed in certain brain regions.
Diagnosis of ADHD
ADHD is diagnosed via a psychiatric assessment. To rule out other potential causes or comorbidities, physical examination, radiological imaging, and laboratory tests may be used.
In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD-10. If the DSM-IV criteria are used, rather than the ICD-10, a diagnosis of ADHD is 3–4 times more likely. A child's social and school environment as well as academic pressures at school are likely to be of influence.
In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified:
1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
2. ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
3. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but criterion 1A is not met for the past six months.
IA. Six or more of the following signs of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
- Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
- Often has trouble keeping attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
- Often has trouble organising activities.
- Often avoids, dislikes, or doesn't want to do things that take a lot of mental effortfor a long period of time (such as schoolwork or homework).
- Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools). Is often easily distracted.
- Often forgetful in daily activities.
IB. Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
- Often fidgets with hands or feet or squirms in seat.
- Often gets up from seat when remaining in seat is expected.
- Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
- Often has trouble playing or enjoying leisure activities quietly.
- Is often "on the go" or often acts as if "driven by a motor".
- Often talks excessively.
Often blurts out answers before questions have been finished.
Often has trouble waiting one's turn.
Often interrupts or intrudes on others (example: butts into conversations or games).
II. Some signs that cause impairment were present before age 7 years.
III. Some impairment from the signs is present in two or more settings (such as at school/work and at home).
IV. There must be clear evidence of significant impairment in social, school, or work functioning.
V. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a Personality Disorder).
In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), the signs of ADHD are given the name "Hyperkinetic disorders". When a conduct disorder (as defined by ICD-10) is present, the condition is referred to as "Hyperkinetic conduct disorder". Otherwise the disorder is classified as "Disturbance of Activity and Attention", "Other Hyperkinetic Disorders" or "Hyperkinetic Syndrome”.
Differential diagnosis in ADHD
To make the diagnosis of ADHD, a number of other possible medical and psychological conditions must be excluded.
Medical conditions that must be excluded include: hypothyroidism, anaemia, lead poisoning, chronic illness, hearing or vision impairment, substance abuse, medication side effects, sleep impairment and child abuse and cluttering (tachyphemia) among others.
A study in the Netherlands compared two groups of unmedicated 6-12-year-olds, all of them with "rigorously diagnosed ADHD". 87 of them had problems getting to sleep, 33 had no sleep problems. The larger group had a significantly later dim light melatonin onset (DLMO) than did the children with no sleep problems.
- Chronic sleep deprivation, that is insufficient sleep for physiologic sleep needs.
- Fragmented or disrupted sleep, caused by, for example, obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD).
- Primary clinical disorders of excessive daytime sleepiness, such as narcolepsy.
- Circadian rhythm disorders, such as delayed sleep phase syndrome (DSPS).
Western Medical Management of ADHD
Methods of treatment often involve some combination of behavior modification, life-style changes, counseling, and medication. A 2005 study found that medical management and behavioral treatment is the most effective ADHD management strategy, followed by medication alone, and then behavioral treatment. While medication has been shown to improve behavior when taken over the short term, they have not been shown to alter long term outcomes. Medications have at least some effect in about 80% of people.
The evidence is strong for the effectiveness of behavioral treatments in ADHD. It is recommended first line in those who have mild symptoms and in preschool aged children.
Psychological therapies used include;
- Psychoeducational input
- Behavior therapy
- Cognitive behavioral therapy (CBT)
- Interpersonal psychotherapy (IPT)
- Family therapy
- School-based interventions
- Social skills training and parent management training
Stimulant medication are the medical treatment of choice.
There are no good studies of comparative effectiveness between various medications, and there is a lack of evidence on their effects on academic performance and social behaviours. While stimulants and atomoxetine are generally safe, there are side effects and contraindications to their use. Medications are not recommended for preschool children, as their long-term effects in such young people are unknown. There is very little data on the long-term adverse effects or benefits of stimulants for ADHD.
Methylphenidate (Ritalin), dextroamphetamine (Dexedrine and Adderall), methamphetamine (Desoxyn) and pemoline (Cylert). Act on the central nervous system as dopamine agonists (chemicals that act like dopamine). Alcohol, cigarettes, caffeine, heroin, cocaine, overeating and sexual orgasms also effect dopamine activity. Dopamine, especially the D4 receptor in the brain increases alertness.
Side effects of psychostimulants
- Appetite suppression
- Sleep disturbances
- Liver damage
- Suspicious behaviour
Recent report found 200-300% increase in the amount of chromosomal damage in every one of the 12 children taking Ritalin in the study. Most of the chromosome changes have been related to increased risk of cancer. Guidelines on when to use medications vary internationally, with the UK's National Institute of Clinical Excellence, for example, only recommending use in severe cases, while most United States guidelines recommend medications in nearly all cases.
Please see also, The Drugging of our Children.
A combined dopamine and norepinephrine reuptake inhibitor. Has been associated with seizures and weight gain.
Norepinephrine Reuptake Inhibitors: Atomexetine (Strattera)
This is the class of drugs used early on for depression and it includes common names like Elavil and Tofranil. Most serious side effect of Strattera is life threatening liver failure.
Naturopathic Causes and Treatment of ADD/ADHD
- Brain damage due to hypoxia in childbirth. ADHD is twice as likely in labour > 13 hours.
- Genetic / prenatal excess alcohol
- Food allergy
- Leaky gut syndrome
- Adrenal exhaustion/ Yin xu
- Vaccinosis/Trauma of immunisation. Contain formaldehyde, mercury and aluminium.
- Low serotonin/neurochemical imbalance
- Functional hypoglycaemia
- Thyroid hormone resistance, increased / TSH decreased T4
- Environmental toxins
- Inhalants / pollutants
- Heavy metal toxicity Hg, Pb, Cd, Cu, Al
- Nutritional deficiencies Zn, Mg, vitamin B, Fe, Cr, Mn, Li, Essential fatty acid deficiency
- Poor parenting
Naturopathic Treatment Principles in ADHD
- Remove the allergen.
- Replace digestive enzymes.
- Repair gut lining.
- Reinoculate bowel flora.
- Tonify the adrenal gland.
- Chelate heavy metals.
- Correct neurochemical imbalance.
- Replace nutritional deficiencies.
- Avoid environmental toxin exposure.
- Improve thyroid hormone sensitivity.
- Tonify the nervous system.
- Avoid pesticides and insecticides, buy organic.
Naturopathic perspective of ADD and ADHD
1. Predominantly inattentive / Attention Deficit Disorder ADD
ADD without hyperactivity associated with heavy metal toxicity, otitis media. It is common in smokers. Zn, Fe and Ca deficiency common, as these nutrients are displaced by cadmium and lead.
The following mineral chelate the following heavy metals.
- Zn : Cd
- Fe : Pb
- Ca : Pb
A diet high in sea vegetables, fibre, selenium, zinc, garlic, onions, pectin as these substances chelate heavy metals and horsetail, equisetum arvense. Please see also Carahelath Heavy Metal Detox.
2. Predominantly hyperactive-impulsive / Attention Deficit Hyperactivity Disorder ADHD
ADHD with hyperactivity is associated with food allergy, sucrose sensitivity.
1. Remove the food allergen
Food allergy is the main cause of ADHD. Although I dont believe in allergy per se. allergy is merely a symptom of a sluggish liver. Please see also Sluggish Liver.
86% of hyperactive children have high eosinophil counts, suggesting allergy. The average consumption of food additives is 13-15mg. Hyperactivity is provoked through partially digested foods entering the blood stream. These food peptides act as antigens and enter the blood stream where they stimulating immune complexes. These circulation immune complexes candeposit in joints, contributing to rheumatoid arthritis, cause mucous build up and result in immediate hypersensitivity IgE mediated hay fever, asthma, and eczema and delayed hypersensitivity allergic reaction. These are IgG and IgM mediated.
Most common additives
- Anti-caking agents
- Antioxidants BHT, BHA
- Bleaching agents
- Benzyl peroxide
- Flavours, emulsifiers and mineral salts
- Preservatives, benzoates, nitrates and sulphites
- Colourings, artificial azeo dye derivatives
- Thickeners and vegetable gums.
Removing the Allergen
The only reliable way to test for food allergies is an Oligoantigenic diet and oral food challenge. There is no such thing as a machine that can test for food allergy. The only reliable way is to avoid the potential allergens for 14 days and then test foods, relying on symtoms as proof of allergy or intolernace. For information on how to conduct an oligoantigenic diet and oral food challenge please see Spring Clean.
Food Standards Australia and New Zealand (FSANZ) conducted a study into people’s diets and found that Australian pre-schoolers are consuming almost double the amount of preservatives and additives than the World Health Organisation (WHO) recommends. These are linked with asthma, eczema, hay fever and other allergic disorders and behavioural disorders such as Attention Deficit Hyperactivity Disorder (ADHD).
The following are the major offenders;
The study found that the daily intake of benzoates for pre-schoolers aged 2-5 was 40 per cent above the acceptable intake for boys and 20 per cent above the world levels for girls. The major foods containing benzoates (or additive 210-219 particularly 211) are cordial, soft drinks, fruit and vegetable juices, sauces and toppings, dairy and fat based desserts, ice creams and jams. Benzine is a well-known carcinogen linked with leukaemia.
Sulphite levels for boys aged 2-5 were 80 per cent over the acceptable daily intake. Sulphites have been linked to asthma and skin rashes. The most common foods containing sulphites are sausages, cordial, red wine and preserved fruit such as sultanas, dried apricots etc. Sulphites can be found in minced meats. Sulphur dioxide, in particular sulphites 220- 227 have been shown to induce asthma.
Avoid food colourings especially tartrazine 102 a yellow food dye and related compounds 103-155 excluding 120, 140, 141, 150, 153 and including 180. Tartrazine promotes leukotrienes which worsen allergy and asthma symptoms.
Environmental factors in ADHD
Plastic food wrap, mothballs, chlorine, glue, coloured scented paper products, oven cleaner, fabric softeners, dishwashing liquid, air fresheners, anti-bacterial; sprays, perfumes.
In the 70s Benjamin Finegold discovered that 50% of hyperactive children have food allergies to salicylates and phenolic compounds. See more on potential food allergens below.
2. Fours Rs (Reduce, Replace, Repair, Reinoculate)
Leaky Gut Syndrome (increased intestinal hyperpermeability)
Leaky Gut Syndrome is also described as increased intestinal hyperpermeability. Tight junctions (TJs) represent the major barrier between intestinal epithelial cells that line the digestion tract. Damage to the TJs leads to intestinal hyperpermeability ("leaky gut") which is part of the causes behind acute and chronic diseases such as systemic inflammatory response syndrome(SIRS), including autoimmune diseases such as inflammatory bowel diseases (IBD) including Chron’s disease and ulcerative colitis (UC), and cardiovascular disease, type 1 diabetes, allergies including eczema and asthma and even autism.
Three mechanism are proposed;
2. A "leaky" intestinal mucosal barrier
3. Altered intestinal immune responsiveness.
Dysbiosis refers to a condition with microbial flora imbalances in the digestive tract. It has been associated with different illnesses, like inflammatory bowel disease and chronic fatigue syndrome. A leaky bowel wall leads to bacteria and endotoxins building up in the bloodstream creating an immune response. This is an important stimulus for inflammatory cytokine activation.
2. A "leaky" intestinal mucosal barrier
The gastrointestinal tract is responsible for digestion and absorption of nutrients and electrolytes, and to maintain water homeostasis. Another important function is its ability to keep pathogens from the environment that enter through the gut from the host through this barrier mechanism. The intercellular tight junctions of the intestinal epithelial barrier, together with the gut-associated lymphoid tissue and the neuroendocrine network, controls the balance between tolerance and immunity to nonself-antigens. Whilst this tight junction should allow absorption of essential nutrients and ions, intestinal tight junctions that are “leaky” allow substances, which should not be absorbed into the blood stream.
Select enteric viruses, bacterial pathogens and parasites modulate intestinal tight junction structure and function and these effects may also contribute to the development of chronic intestinal disorders. Physiological, pharmacological, and pathophysiological stimuli all cause changes in the barrier properties of the tight junctions. Enteric pathogens such as E. coli, Giardia, and TNF disrupt tight junctions function of epithelial cells. Alcohol consumption induces a state of "leaky gut" increasing plasma and liver endotoxin levels, leading (in excess) to liver diseases.
3. Altered intestinal immune responsiveness
Kupffer cells are macrophages located in the liver. When Kupffer cells become activated they produce a variety of substances including cytokines, chemokines, growth factors, cyclooxygenase and lipoxygenase metabolites, and reactive oxygen species such as superoxide anion, hydrogen peroxide, and nitric oxide that damage the TJs and lead to increased intestinal hyperpermeability.
Treatment principle is the Four Rs
1.Reduce Food Antigens
Food allergy Non-IgE Mediated (Delayed) Food Allergy
These are allergic reactions that are delayed and are mediated by the cells of the immune system called immune complexes (antigen-antibody complexes), which circulate in the bloodstream. This is opposed to histamine release in immediate reaction food allergy.
These circulating antigen-antibody complexes can lodge in tissues creating all sorts of problems in particular, asthma, eczema and hayfever, but also can develop severe autoimmune disorders such as rheumatoid arthritis (children can get juvenile arthritis) and insulin dependant diabetes. There is a strong relationship between the antibody for bovine protein found in milk and the similarity of this protein to the pancreatic Islets of Langerhans for example as an immature immune system fails to recognise the difference in the cells due to the hygiene hypothesis and molecular mimicry.
For more information regarding the hygeine hypothesis and molecular mimicry, please see also Naturopathic Causes and Treatment of Autoimmune Disease.
Delayed reactions to food may take several hours or days to develop. Foods causing reactions of these types include cows’ milk, eggs, fish, wheat, other cereals, yeast, soya, pork, chocolate and citrus fruits are the main offenders. Please note the advice is to reduce and rotate your grains and milks rather than completely eliminate as complete elimination often increases sensitivity. For a full explanation of food allergy please see also Food Allergy and Intolerance Explained.
2. Replace digestive enzymes
Including saliva, stomach acid and bile flow using herbal bitters which are naturally;
- Sialogogues (promote saliva)
- Cholagogues (promotes bile)
- Orexogenics (promotes stomach acid)
Short-term use of digestive enzymes such as bromelain and papain may be advisable, alternatively eat pineapple or papaya after meals as these fruits contain the proteolytic enzymes. Chew your food 32 times. Avoid liquid with meals as this dilutes hydrochloric acid.
Herbal bitters are prescribed specifically to stimulate digestive juices. For a herbal tincture to help improve digestion, absorption and elimination please see also Carahealth Digest
3. Repair gastrointestinal lining
Nutritional supplements specifically for leaky gut
L-Glutamine for gut repair
Glutamine is important for a large number of bodily functions. It is one of the most important nutrients for healing leaky gut syndrome because it is the preferred 'fuel' for the cells lining the mucosa of the small intestine (enterocytes). Glutamine is also required for the production of both intestinal mucus and Secretary Immunoglobulin Type A (SIgA). Glutamine will help repair and maintain a healthy small intestinal lining.
An essential nutrient for the production of the GI tracts protective antibodies (SIgA). Vitamin A also helps to maintain a healthy intestinal mucosa and soothes inflammation. Vitamin A is also involved in immune function, skin and cellular health and displays antioxidant activity.
Zinc is required for growth and healing and is essential to cells with a rapid turnover. The cells of the small intestinal mucosa have an extremely rapid turnover, being replaced about every four days, so zinc is extremely important to the integrity of the intestinal lining. Small intestinal permeability is often increased in patients with Crohn's disease and may be pathogenic for clinical relapses. Clinical studies have shown zinc supplementation can resolve permeability alterations in patients with Crohn's disease in remission. Improving intestinal barrier function may contribute to reduce the risk of relapse in Crohn's disease.
Sturniolo GC., Di Leo V., Ferronato A, D'Odorico A., D'Incà R., Zinc supplementation tightens "leaky gut" in Crohn's disease. Inflamm Bowel Dis.2001 May;7(2):94-8.
Glucosamine is a precursor for glycosaminoglycans. GAGs form an important component of connective tissues and is essential for the secretion of the mucus that creates a protective lining on top the cells of the gut. For a herbal tincture to repair the gut lining please see also Carahealth Digest.
4. Re-inoculate bowel flora
Probiotics Effect of Lactobacilli on Paracellular Permeability in the Gut
The probiotic strain Lactobacillus plantarum can reduce paracellular permeability in the gut resulting from cytokines, chemicals, infections, or stress. Short-term administration of L. plantarum WCSF1 to healthy volunteers increased the relocation of occludin and ZO-1 into the tight junction area between duodenal epithelial cells.
Siv Ahrne and Marie-Louise Johansson Hagslatt Effect of Lactobacilli on Paracellular Permeability in the Gut, Nutrients 2011, 3(1), 104-117.
3. Tonify the Adrenal Gland
Adrenal Exhaustion in ADHD
Researchers compared cortisol (stress hormone) responses in children with persistent ADHD symptoms with children no longer symptomatic. They found that children with persistent ADHD symptoms had blunted cortisol responses to stressful situations, compared to children no longer symptomatic. Please see also Naturopathic Causes and Treatement of Adrenal Exhaustion.
4. Avoid Heavy Metal Exposure and Chelate Heavy Metals
Exposure of Children to Toxic Metals in ADHD
Toxic metals as the number one environmental health threat to children, adversely affecting large numbers of children. The toxic metals lead, mercury, and arsenic are having the most adverse health effects based on toxicity and current exposure levels with cadmium, chromium and nickel also highly listed. According to the American Academy of Child and Adolescent Psychiatry, an estimated one out of every 6 children in the U.S. have blood levels of lead in the toxic range, and studies estimate that over 12 million children suffer from learning, developmental, and behavioral disabilities including ADD, autism, schizophrenia, and mental retardation. One of the mechanisms documented is causing intestinal dysbiosis resulting in poor vitamin and mineral absorption and leaky gut.
The level of exposure in most infants to mercury thimerosal has been found to be many times higher than the federal limits for mercury exposure. The largest increase in neurological problems has been in infants with an increase in autism cases and similar increases in ADD. Vaccinations contain toxic metals and should be avoided.
Alpha lipoic acid is a natural chelating agent
ALA has antioxidant activity. The antioxidant effects of ALA were demonstrated when it was found to prevent the symptoms of vitamin C and vitamin E deficiency. Lipoic acid has been the subject of numerous research studies and clinical trials. ALA is particularly known for its hepatoprotective function whereby it has been found to improve liver circulation, treat chronic liver diseases including jaundice,hepatitis, cirrhosis, and hepatic coma and also in its treatment of diabetes and diabetic neuropathy.
Alpha lipoic acid has also been shown to restore intracellular glutathione. Glutathione (GSH) participates in leukotriene synthesis and is a cofactor for the enzyme glutathione peroxidase. Glutathione peroxidase is the general name of an enzyme family with peroxidase activity whose main biological role is to protect the body from oxidative damage.As a result, it may be helpful for people with Alzheimer's disease or Parkinson's disease.
ALA and heavy metal chelation
Owing to the presence of two thiol groups, dihydrolipoic acid is a chelating agent. Lipoic acid administration can significantly enhance biliary excretion of inorganic mercury. Lipoic acid is not commonly used as a first-line treatment for acute heavy-metal intoxication due the greater clinical effectiveness of the chelating agents Dimercaptosuccinic acid (DMSA) and Dimercapto-propane sulfonate (DMPS) however lipoic acid has the potential to cross the blood-brain barrier in humans, unlike DMSA and DMPS.
Food sources of lipoic acid
Lipoic acid is found in kidney, heart and liver meats as well as spinach, broccoli and potatoes. Please see also Carahealth Heavy Metal Detox.
5. Correct Brain Biochemistry Imbalance
Children demonstrating symptoms of anxiety, ADHD or ADD often have an imbalance in their brains biochemistry. A biochemical imbalance results from a deficiency of neurotransmitters.
Orthomolecular therapy corrects the brains biochemical imbalance. Numerous clinical studies established that hyperactive children often have low serotonin levels. A proper combination of tryptophan or 5-HTP and B6, elevates the serotonin level. The dosage depends on the childs age, weight, and the degree of hyperactivity.
Amino Acids are neurotransmitters
Neurotransmitters affect behaviour and learning. Apathy, lethargy, difficulty concentrating, loss of interest, and insomnia all result when the diet does not include adequate amounts of amino acids. Stress plays a major role in the depletion of neurotransmitters. Some of the major symptoms of neurotransmitter deficiencies are
- brain fog
- mood swings
- increased stress
Inhibitory neurotransmitters are the keys to behaviour, emotions, and pain and are indicated in hyperactivity. Research demonstrates a large number of children who display ADD/ADHD behaviour actually experience anxiety.
These amino acids act as inhibitory neurotransmitters;
GABA (Gamma-aminobutyric acid)
GABA, an inhibitory neurotransmitter, is found throughout the central nervous system. GABA assumes an ever-enlarging role as a significant influence on ADD, ADHD, stress, anxiety, and depression, as well as stress-induced illnesses. According to Candace Pert, a neuroscientist who discovered the GABA receptor, every cell in the body has a GABA receptor, which is one reason why GABA has such positive effects. GABA inhibits the cells from firing, diminishing anxiety-related messages. GABA, glutamine, and glycine ease anxiety, irritability, and ADD. Glutamine aids the maintenance of gut barrier function.
Glycine is an inhibitory neurotransmitter in the CNS. Glycine is a nonessential amino acid, with the simplest structure of all the amino acids resembling glucose (blood sugar) and glycogen (excess sugar converted in the liver for storage). As the third major inhibitory neurotransmitter in the brain, glycine readily passes the blood-brain barrier. Studies demonstrate glycine as an important factor in psychiatric disorders.
Glycine decreases the craving for sugar, and, in many cases, can replace sugar on foods such as cereal. Glycine calms aggression in both children and adults. When combined with GABA and glutamine, glycine influences brain function by slowing down anxiety-related messages from the limbic system. As a very nontoxic amino acid, both children and adults can use glycine.
L-Glutamine, the memory and concentration amino acid
Glutamine is the most abundant naturally occurring, non-essential amino acid in the human body. Glutamine is found in the nerves of the hippocampus, the memory centre of the brain, in the cranial nerves, and in many other areas of the brain. GABA and glutamine are not only found in the brain, but also in the receptor sites throughout the body. It also provides a major alternative fuel source for the brain when blood sugar levels are low. Glutamine functions as an inhibitory neurotransmitter, and is the precursor for GABA, the anti-anxiety amino acid. The amino acid trio of Glutamine, GABA, and Glycine plus B6 are among the major inhibitory neurotransmitters in the brain.
Dietary sources of glutamine
Dietary sources of glutamine include beef, chicken, fish, eggs, milk, yogurt, ricotta cheese, cottage cheese, dairy products, cabbage, beet root, beans, spinach and parsley. Small amounts of free L-glutamine are also found in vegetable juices and fermented foods, such as miso.
Taurine is an inhibitory neurotransmitter
Taurine is now classified as a conditionally essential amino acid in the adult. In infants and children, however, taurine is an essential amino acid. As one of the sulphur amino acids, adults synthesise taurine from cysteine and methionine, provided B6 and zinc are present.
Taurine is found abundantly throughout the body in the heart, olfactory bulb, central nervous system, and brain (hippocampus and pineal gland). As an inhibitory neurotransmitter, taurine, after GABA, is the second-most important inhibitory transmitter in the brain. Its inhibitory effect is one source of taurines anticonvulsant and anti-anxiety properties.
Tyrosine is the amino acid. As a precurser to adrenalin. nor adrenalin and dopamine, tyrosine assists the body to cope with stress and replenishes adrenal stores. Clinical studies show that tyrosine controls medication-resistant depression. Children given tyrosine supplementation demonstrate a marked improvement in mental performance and mood stability.
Most magnesium exists inside the cells where it activates enzymes necessary for the metabolism of carbohydrates and amino acids. Hyperactive or ADHD children are deficient in magnesium. Magnesium is involved in glucose metasbolism so is therefore important to fuel for the brain. Magnesium is used stress and prolonged stress can lead to deficiency. Deficiency can result in symptoms including hyperactive or ADD behaviour.
In 1988, a study published in Alternative Medicine Review linked the development of ADHD to low blood-serum magnesium levels. A group of children followed for six months were given 200 mg of magnesium a day. Researchers noted remarkably decreased hyperactivity in the children.
Calcium deficiency can also induce ADD/ADHD behaviour. A child deficient in calcium exhibits irritability, sleep disturbances, anger, and inattentiveness.
6. Improve Thyroid Hormone Sensitivity
ADHD linked to thyroid hormone resistance
Attention-deficit hyperactivity disorder (ADHD) is thought to have a biologic basis, but the precise cause is unknown. It is one of the neurodevelopmental abnormalities frequently observed in children with generalised resistance to thyroid hormone (GRTH), suggesting that thyroid abnormalities may be related to ADHD. Resistance to thyroid hormone is a thyroid disease characterised by elevated levels of serum T3 and T4, as well as inappropriately normal or high concentrations of serum TSH, evidence of a reduced response to the actions of thyroid hormones. The study concluded that the prevalence of thyroid abnormalities is higher (5.4%) in children with ADHD than in the normal population (< 1%).
Weiss RE., et al., Attention-deficit hyperactivity disorder and thyroid function. J Pediatr. 1993 Oct;123(4):539-45.
Fluoride and thyroid function
Fluoride suppresses thyroid function. Fluoride's suppressive effect on the thyroid is more severe when iodine is deficient, and fluoride is associated with lower levels of iodine.
Strunecká A, Strunecký O, Patocka J (2002). Fluoride plus aluminum: useful tools in laboratory investigations, but messengers of false information., Physiol Res 51 (6): 557–64.
Fluoride is similar in size and shape to iodine, and from a naturopathic perspective, is the main reason why thyroid disease is on the increase. The Naturopathic treatement principle is to remove fluoride. I recommend a Carahealth Gravity Fed Water Filter only for fluoride removal. Reverse osmosis is not recommended.
7. Tonify the nervous system
Herbal medicine is the best therapy to tonify the nervous system.
Carahealth Nervous System
Carahealth Nervous System contains a blend of gentle sedatives, nutritives and nervines herbs including Chamomile Matricaria recutita, Wind flower Anemone pulsatilla, Oats Avena sativa, Hyssop Hyssopus officinalis, Skullcap Scutellaria laterifolia and Lemon Verbena Aloysia triphylla, which are able to tonify and feed the nervous system and increase the ability to cope with stress. The tincture may be used in all exhausted or depressed conditions and for anxiety states and hysteria incuding ADHD.
8. Replace nutritional deficiencies
Nutritional deficiencies in ADHD
A 2002 study from the Netherlands reported that 62% of children diagnosed with ADHD showed significant improvements in behaviour over 3 weeks with dietary changes alone. Stephan Shoenthaler, Ph.D. (California criminologist) evaluated the effects of dietary changes to simply increase fruits, vegetables and whole grains and decrease fats and sugars. In this study, conducted at 12 juvenile correctional facilities and 803 public schools, there was a 47% decrease in antisocial behavior, 40% decrease in learning disabilities and 16% increase in academic performance.
Mineral Deficiencies in ADHD
William Walsh, MD from the Pfeiffer Institute reported findings on an outcome study to measure the effectiveness of biochemical therapy for 207 consecutive violent criminals. These patients presented with a diagnosed behavior disorder. 88% of patients who were compliant with treatment exhibited a reduced frequency of destructive incidents and 53% achieved elimination of the behaviour.
Carina is available to lecture for your group or organisation on this subject.
Carina Harkin BHSc.Nat.BHSc.Hom.BHSc.Acu. is a practitioner of 12 years, complementary medicine lecturer of 4 years and mother of six in Galway, Ireland who practices what she teaches.
For an appointment call Carina directly on 083 34 66 333.
All products are available through www.carahealth.ie. Remember, we are here for a good time not a long time, enjoy your food life!
Carahealth Galway Ireland. Acupuncture, Naturopathy, Homeopathy, Herbal Medicine, Nutrition, Nutritional therapy, Flower essences, Iridology, Short Courses, Cosmetic Acupuncture