Many people have very strong views about the role of diet in ADD and ADHD. Some are positive and some are vehement there is no connection! It is important that whatever your interest or involvement with ADD you are well informed about where diet fits in.
People reading this may be –
- people using diet – they know diet has some role and want to manage it better;
- people who wonder if they should consider diet – they want to know how to decide; and
- those who think diet is not for them, or who have thought the diet-behaviour link was disproved years agoI will endeavour to bring all of you up to date. As well, some ideas used in diet management, such as having a detective approach to what works for your child, can be applied to other aspects of treatment of ADD. The detail of this talk is included in my book “Are you food sensitive?”
Why should anyone consider diet?
The research up until the mid 80’s refuted the “diet causes hyperactivity” hypothesis. But that did not mean diet did not have a role in some children. Different researchers around the world developed better research methods. For instance, the early workers had hid the artificial colours in chocolate biscuits. Now we know chocolate is suspect in 75% of food sensitive children. The later researchers investigated the diet question in slightly different ways Mostly they had more exclusions than Feingold had in the 70’s. These researchers published in the late 80’s and 90’s. They did find a diet-behaviour link that was statistically significant. Now we can say that those who think there is no diet-behaviour link are wrong. Those who would like the up to date research can see my review article “The role of diet and behaviour in childhood” in the J Paediatrics and Child Health, vol 33, 1997, or read my book for the interesting details.
Can diet be useful for ADD children?
The NH&MRC are right in saying diet should not be part of treatment for every ADD child. However, there are still a significant number to whom it is an important part of treatment.
Who are most likely to find diet useful? At this time this is not completely clear. It would be very useful if it was!
Diet is more likely to be useful if any of the following occur –
- The child or immediate relatives has any allergic history: someone in the family has or had eczema, asthma, hay fever, hives etc. Food does not need to be implicated.
- Different researchers report more diet responders if eczema, migraine, or irritable bowel syndrome are present in the immediate family [child, brothers, sisters, parents, uncles, aunts and grandparents but not cousins].
- The child is young. Diet may be very useful in over 5’s, but usually diet effects show more clearly in preschoolers.
- A parent can give a specific example of diet causing a definite change in the child at some time. The parent may remember examples of changes after Easter eggs or parties when young even though these no longer occur.
- All other possible medical causes for the symptom have been considered and some or all of the problem remains.
- One or two parents are motivated to investigate diet. It is wiser to run a diet trial with a dietitian than to go for years trying to exclude various foods and additives and wondering if it is necessary.
- Changes in irritability, activity, sleep, concentration or impulsivity cannot be explained by the normal ups and downs of life.
- More boys have ADHD, more girls have ADD. I believe girls are under diagnosed.
What might diet change in ADD and ADHD children?
I have a summary of the results of my research on the behaviours parents assessed diet as changing. It is published in Chapter 3 of my Masters thesis. Note that the biggest change is in mood – being less irritable, touchy, cranky. An important point is that change in mood was also found by other researchers around the world, each like me, researching diet for over 10 years. Parents use words like “easier to live with” about their children on their diet. Other symptoms that changed were – difficult to reason with, impulsive, poor concentration, demanding and argumentative, restless, difficult to control, tantrums and sleep problems.
What might diet change in physical symptoms?
Food sensitivity can affect not just the brain but adverse symptoms can be in any of the body’s systems. This is important as families or individuals with ADD children who are food sensitive may have any of these symptoms and the symptoms may decrease with dietary intervention.
Central Nervous System, CNS
– Attention Deficit Hyperactivity Disorder ADHD, Attention Deficit Disorder ADD; irritability, mood changes, tantrums, poor self-esteem, aggression, developmental delays, hypoactivity;
– headache, migraine, problems settling to sleep or sleep, night terrors, nausea, car sickness; Gastrointestinal – swelling around mouth and throat, mouth ulcers, gagging, itchy throat, retasting food, tummy aches, vomiting, looseness or diarrhoea, Irritable Bowel Syndrome, lower gut cramping, halitosis (bad breath), constipation;
Genitourinary – frequency, scalding, mucous, bed-wetting, strong smelling urine;
Respiratory – ear aches, hay fever, rhinitis, post nasal drip, constantly clearing throat, wheezing, asthma;
Skin – eczema, psoriasis, urticaria, dermatitis, strong body odour;
Systemic – limb pains, feeling faint, anaphylactic shock.
What are common problem foods?
The diet detective process is an investigation process for each child.
What are the “usual suspects” –
Those high in additives – coloured and flavoured lollies, soft drinks, ice-cream and icypoles;
Those high in suspect natural chemicals – tomato sauce, spice, fruit juice, tangy fruit, and chocolate;
Those high in added MSG – soup cubes, 2 minute noodles, some potato and corn crisps;
Some preservatives – benzoates in soft drinks, sulphites in cordials, propionates in bread.
You need to get the full detail to run a useful trial of diet.
Before you panic and wonder how you child would survive, and since we are emphasising the positive side of ADD management, let me tell you what they can still eat. Good plain food and lots of it! Cereal and milk, plain biscuits, some juice, bread with plain cheese or meat or peanut butter fillings, some fruit, meats, fish, chicken, legumes, potato, including plain hot chips, rice or pasta, vegetables, and desserts like fruit and white custard, ice-cream, or pavlova. Fortunately the number who have to completely exclude sugar is very small so there are allowed lollies, biscuits and cakes. I remind the children that this diet is not for their waistline (most food sensitive children are normal weight or lean); it is a “brain” diet!
There are two important additions to the usual suspects –
- The family sensitivity history
Most people think there is “one diet” for investigating behaviour. If fact, there is one for each family.
To work this out I take a family sensitivity history. With the parents I find out what “allergic type” symptoms are in family members and what factors make them worse. People tell me things like the example in my book…”Aunty Jane can’t eat spice; my mother and I get headaches from perfume, and Grandpa can’t eat tomatoes”. The diet detective trick here is that limitation or exclusion of whole foods is dependent on whether the food is, or was, a problem to the child or any first degree relative. If there is no family history of allergic type symptoms the child needs only consider the “usual suspects” outlined above.
- Environmental factors
These can be as big a problem as food. They can include strong smells (food sensitive children often really love or hate perfumes or petrol; and there is often one family member who gets a nickname “the smell” or one who hates walking through the perfume department in large department stores).
Environmental factors can include smells, paint, petrol, perfume, flowers, cigarettes, inhalants commonly implicated in allergy, that family members react to. The child may be worse on windy days. Other factors include increased family stress, contact dye in finger paint or coloured playdough, infections, insect bites, and seasonal factors. This “Total Body Load” is the total load of factors that may affect symptoms. Food is still an important part of this. The trick is to lower all these parts to the “Total Body Load” as much as possible. Individuals vary in which are most important in their family. Each family need only concentrate on those that affect their symptoms.
HOW do you stick to a diet?
See a dietitian, preferably one experienced in food sensitivity. If your child needs speech therapy you see a speech therapist. It is the same here. You can learn the finer points on how to be a “Diet Detective”, finding out about information on allowed and disallowed foods, what you can eat at meals every day, what commercial foods to use, and how to manage fussy eating habits. You can also get my book; you do need all the information.
Decide where you can eat out – carvery’s, grills, fish and chips with the fish crumbed, McDonalds with no Mac sauce. Ask for help at takeaways and restaurants.
Children can still have plain potato chips and crisps, allowed plain biscuits, desserts, lollies and cordial. Sometimes people feel cross about things they didn’t know. They don’t expect to know all the physiotherapy or speech therapy. Diet is a specialist area too.
“What is going on?”
The mechanism is not known, but it is certainly a pharmacological reaction – like alcohol. A good way to look at it is to consider a child who has behaviour problems, and whose parents are trying usual management and caring professionals are providing useful guidelines, but the child is accidentally being given varying amounts of alcohol. This has an add-on effect that makes everything more complex. In food sensitivity it is suspect foods and chemicals which are aggravating everything.
How do reactions show?
It is rare for people to see a reaction to a single food unless they are already on their diet, or the child is a preschooler, or they are very sensitive to that food. There are 3 types of reactions:-
- instant reactions – parents can see a change “within 10 minutes”;
- delayed reactions – when on the diet and trialing food parents often report the worst time for behaviour is 24 hours after the new food is eaten; and the third type,
- a cumulative effect. This “build-up effect” effect is the most usual. It occurs when the child eats several foods and each contributes some suspect chemicals. When the critical threshold is reached then symptoms occur. A build up effect can also occur during challenges when a not tolerated food causes a reaction after being eaten f or a few days.
To investigate whether diet affects a child, you do what I call “Diet Detective Work”
To see if diet has a role you need a baseline and you get that by lowering the Total Body Load of all suspect foods, smells etc at the same time. It often takes up to 4 weeks for any diet effect to show. Behaviour often gets worse in the first week during withdrawal. Then you challenge to find out which of the exclusions are important in your family. To do this you reintroduce everything, or groups of chemicals or single foods, for seven days or until adverse symptoms appear.
When is a reaction really a reaction to food?
When you know your baseline is right i.e. symptoms are minimal, and you bring in a test food and use it every day and you are sure the change is not due to anything else. When in doubt, double the amount of test food. If yesterday’s behaviour was due to tiredness make sure sleep is sufficient and see if problems resolve. If problems are worse food is suspect. It is not always clear. Sometimes you may take the food out and reintroduce it on another occasion.
Reactions are also dependant on how “risky” test foods are. As one child said “some foods are a little bit bad, and some foods are “werry” bad”. Several low risk foods can add up.
A good aspect of lowering the family “total body load” is that favourite foods can be reintroduced first. Since the load of suspect foods has been minimised, the favoured ones may be managed.
Some members of ADDISS have reported tolerating a glass of PepsiMax, but not Coca Cola.
Diet does interact with behaviour management.
Each child is still responsible for his or her actions.
Diet can be described to the child as being used “to see if, by using the diet, he can handle himself better”. (Read “she” for girls.)The interaction may not be clear if the child is better by the end of the diet trial. It is often as if he is handling himself as everyone knew he was capable of. It is during challenges that any diet effect is clarified. While reintroducing suspect foods the child can try to continue the new behaviour. Where the child’s bad moods, impulsivity, sleep problems, restlessness, or any other symptom return, the role of diet is shown. In over 20 years I have only had a two reports of children who were reported to improve usefully and who remained good throughout all challenges.
Many mothers report that a difficult diet is easier than a difficult child. Diet can interact in a useful way. One Mum explained the change on diet as the upward spiral effect. She had been worn down by trying management that wasn’t changing anything. After the diet she found the child was less moody and touchy, so she got the energy and motivation to do more behaviour management, that bought its own benefit and so on.
Diet and medication interact.
Medication acts as if it helps the child cope with the “total body load” much easier. Generally parents report that on the diet the main change is that the child is “easier to live with”, and that on medication school work improves.
Does diet affect girls and boys differently?
Just as new research say boys and girls brains are different, then the diet effect reflects this.
Outward directed behaviour – ADHD, hyperactivity, impulsive actions, aggression -occurs more often boys. Inward directed behaviour – ADD, daydreaming, impulsive speech, lack of self confidence – occurs more often girls. Of course there is overlap and variation along these scales. Each child is different.
Nutrition and food sensitivity.
Food sensitivity is not related to the quality of the diet. Because some food sensitive children are fussy, some may have inadequate diets. Steps you can take are:- Get diet working well first by finding enough accepted foods to run the diet trial; do the challenges so you know what are the important exclusions; help the fussy child change now that she feels better on the diet; then attend to good eating habits. If you try to do everything at once you will be overwhelmed! One of the benefits parents report is that when the child feels better on the diet the fussiness decreases!
Somehow issues of whether people believe diet has a role, and whether diet is difficult seem to be important when discussing a role for diet. However, all treatments for ADHD and ADD children are difficult in their own way. If there are indicators that you child needs speech therapy you do it because it will help your child, even if it is difficult. Diet is now one of the treatment options. Look at the indicators for whether diet should be considered. If they are there it is worth spending some time finding out how much diet can help. You can choose ‘easy’, ‘medium’, or strict levels of diet to suit your own family lifestyle. See my book “Are you food sensitive?” for details.
Links to relevant organisations
UK ADD Group: http://www.web-tv.co.uk/addnet.html
The Feingold Association of the United States: http://www.feingold.org
Dietitians Association of Australia: http://www.daa.asn.au/
Food Watch Catherine Saxelby: http://www.foodwatch.com.au
Nutition Australia: http://www.nutritionaustralia.org/
Journal of Paediatrics and Child Health:
Sabine Spiesser: http://www.users.bigpond.net.au/allergydietitian/
Food Anaphylactic Children Training & Support Assn: http://www.allergyfacts.org.au