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Rebecca Caster Final

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Rebecca Matos

This document summarizes research on the relationship between diet and Attention Deficit Hyperactivity Disorder (ADHD). It discusses several studies that have investigated eliminating certain foods like artificial dyes, sugars, or common allergens from children's diets to see if it reduces ADHD symptoms. The research has found that diet changes can significantly improve symptoms for a small subset of children with ADHD, possibly due to food sensitivities. However, results have been inconsistent. More research is still needed to better understand how diet may help manage ADHD symptoms for some individuals.

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Rebecca Caster ADHD and Diet Empire State College August 28, 2015
ADHD and Diet Attention Deficit Hyperactivity Disorder, or ADHD, can affect up to 20 percent of all school age children (Kerig, 2014). In 2008-2009, the average size of a public school classroom was 21.2 students to every 1 teacher (U.S. Department of Education, National Center for Education Statistics 2010), meaning that on average, there can be up to 4 students in every classroom who are affected by ADHD. With numbers as high as these, it is important to really understand what ADHD is, and if diet change can help some individuals manage their ADHD symptoms. There are three main categories that Attention Deficit Hyperactivity Disorder can fall in; Inattention, Hyperactivity/Impulsivity and a combination of the two (Kerig, 2014). ADHD under the category of inattention can be seen by an inability to sustain age appropriate attention level. Children under this category are often seen moving from one project to the next without completing the previous one. They tend to be described as forgetful and disorganized, and can be prone to day dreaming and seem often distracted. Hyperactivity is often described as the child being constantly on the move, with an inability to stay in one place or on one task for very long. This is different from inattention in that it is not that they get distracted and move to the next project, but they have a physical need to move nearly constituently. A need to run, jump, or climb is often seen in children that fall into this category, and often exhibit excessive talking or an inability to stay appropriately in their seats or their own area.
With hyperactivity often comes impulsivity as well. This is seen in children who seem to ‘act without thinking’. Interrupting conversations, blurting out answers, jumping into peer games or having difficulty waiting their turn are all common symptoms of a child who exhibits this category of ADHD. The third category is a combination of these two. Children with both inattentiveness and hyperactivity/impulsivity may have the hardest time preforming in the classroom or even completing tasks at home. They can become easily distracted and then feel a need to get out of their chairs without thinking of any consequences, to go over to say something about their peer’s conversations. Diagnostic criteria for Attention Deficit Hyperactive Disorder as set forth by the Diagnostic and Statistical Manual of Mental Disorders; fifth edition (DSM-V) includes at least six criteria from the inattentive category; or six criteria from the hyperactivity/impulsivity category; or six from each to fit into a combination of the two categories (Symptoms and Diagnosis. 2015, June 26). These symptoms must also have been present before the age of twelve, and be present in more than one setting. It must be clear that the symptoms are interfering with or reducing social, educational and/or home functioning, and the symptoms must not only be present during any other psychiatric disorder. Although ADHD does not affect intelligence level, performance levels of someone with ADHD may be lowered by their inability to focus on the current task or lesson. As to not to be confused with a learning disorder, ADHD must be present in a number of settings, including school and home, as well as social settings. It is not an inability to understand or learn the
material that causes a lack in school performance, but rather an inability to focus and pay attention. There is no definitive answer as to what causes ADHD, and why some children develop it and others do not. Risk factors for developing symptoms of ADHD include some genetic factors such as family history of the disorder; an unsteady home life; and even cultural complications that seem to clash with the ‘norm’ (Kerig, 2014). There is also a well-documented difference between the prevalence of ADHD between girls and boys, with boys outnumber girls anywhere a between a 6:1 – 9:1 ratio. Some neuropsychological factors may play a role as well. Decreased blood flow to the frontal cortex and increased slow-wave activity in the frontal lobes may both play factor into ADHD development and/or the outcome and severity of the symptoms. An investigated into the relationship between diet and brain electrical activity in children with ADHD done by Uhlig, Merkenschlager, Brandmaier, and Egger (1979) found that certain food sensitivities not only influence ADHD symptomology, but may also alter brain electrical activity (Schnoll, Burshteyn, & Cea-Aravena, 2003). With the true cause unknown, and no known suitable prevention mechanism, it can be difficult to predict what styles of treatments will affect those diagnosed with ADHD. Simulants medication is often one of the first forms of treatment that is given to help sooth some of the effects of ADHD (Kerig, 2014), with Methylphenidate (Ritalin) being one of the top known stimulant medications for treatment (Ritalin 2015). Although Methylphenidate and other stimulant medication can be highly effective in treating the symptoms of ADHD, as is the case with all medications, undesirable side effects
may be seen. From dizziness to drowsiness; nervousness and insomnia; to changes in blood pressure or heart rate; as well as more serious side effects such as hallucinations, there are a number of possible unwanted effects that can be cause by this one medication. Although the more serious side effects may be rare, they are not unheard of, and every child taking the medication is at risk, and most likely experiencing, at least one of the side effects. Just as every person is different, every case of ADHD is different, and everyone diagnosed with it will be effected and react differently to treatment. While some may find all the relief they need in one medication with minimal side effects, others may seek many different treatment options in the hopes of better controlling the symptoms with less undesirable outcomes. One fairly new form of treatment that is still being researched is the use of diet changes and restrictions as a way to help control and manage the symptoms associated with ADHD. Ben F. Feingold was the first to hypothesis that a diet changes would have a positive effect on controlling symptoms of ADHD. Feingold proposed that “food additives, specifically synthetic food colors and flavors, and naturally occurring salicylates were responsible for hyperactive behavior in some children” (Schnoll, Burshteyn, & Cea-Aravena, 2003). In response to this he created the Kaiser-Permanente (K-P) diet which eliminated all artificial colors and flavors as well as all foods containing salicylates from the child’s diet. Within his own clinical experiences, Feingold reported as much as 50% of his patients having shown favorable responses to the K-P diet according to their parents (Schnoll, Burshteyn, & Cea-Aravena, 2003). There is some discussion about how reliable these results are however, as the findings did not come from a rigorous empirical study, but rather simply by what
was seen and told to him by his patients and their parents. In contrast though, it is questioned if Feingold would have a higher percentage of results if the diet was not so difficult to adhere to. Since Feingold’s first report, there has been much discussion about how effective diet really is in regards to managing symptoms of ADHD. Not only that, but there has been a number of more specific hypothesis presented in regards to which specific aspects of the diet affect ADHD and how. The majority of the studies immediately following Feingold’s reports could fall into one of two categories; those that evaluated the behaviors of hyperactive children while on the Feingold diet as compared to a placebo diet (dietary crossover designs), and those that investigated responses to specific food dye challenges (Schnoll, Burshteyn, & Cea-Aravena, 2003). Overall, the research that was conducted immediately following Feingold’s findings suggested that only a small group of children with behavioral disturbances respond positively to the Feingold diet, but in general the elimination of synthetic food color did not show any major reduction factors in hyperactivity behavior (Schnoll, Burshteyn, & Cea-Aravena, 2003). It is important to note however, that food dyes account for only 10 out of over 3,000 additives which are eliminated from Feingold’s diet plan. One study done by Swanson and Kinsbourne (1980) improved on the research that was available at the time (Schnoll, Burshteyn, & Cea-Aravena, 2003). Instead of relying on parents reports of the symptoms and on assurance that the diet was being adhered to, Swanson and Kinsboune conducted their study with participants admitted into the hospital so that the diet could be administered in a more controlled manner. They also improved upon the true daily value of food dye, and improved upon the sensitivity of the rating scale. Overall, the studies
suggest that there is a small subset of children who react highly and positively to the elimination of food dyes in their food. They also suggest that preschool age children may be more sensitive to the adding or removing of food dyes than older children would be. While there is no evidence to suggest that diet causes ADHD, there is however some reports that links junk food, fast food and an overall more ‘western diet’ as some indicators of ADHD severity and symptoms. ‘Western food’ is known for highly sweetened desserts, fried foods and high levels of salt; all of which are associated with more attention and behavioral problems over a more balanced diet, regular meals and a high intake of dairy products and vegetables (Ghanizadeh, & Haddad, 2015). There is no doubt that the prevalence of ADHD varies greatly according to region (Kerig, 2014), but there has been little evidence as to exactly why these differences are. Some theories attribute these differences to different cultural norms. A culture that values the ability to stay task orientated and focused; such as the American School Culture, may see a higher level of ‘abnormal’ behaviors which qualifies more students as ADHD. Whereas a culture that does not put as great a weight on mental work, but may value physical ability more, may not see such a high prevalence of the symptoms, as the higher exercises levels can work to mask some of inattentive and hyperactivity symptoms. There are such large variances between the prevalence of ADHD in the United States and in other countries; as low as 1.7% in Great Britain to 9.5% in Puerto Rico (Johnston, Seipp, Hommersen, Hoza, & Fine, 2005). The stark and dramatic difference between the prevalence of ADHD in other countries is another indicator that may diet affects the symptoms of ADHD. A study that was conducted in Iran with an overall of 64 children between the ages of 5 and 14
asked parents to list out ‘healthy foods’ and ‘un-favored foods’ (Ghanizadeh, & Haddad, 2015). Healthy foods included everything from fruits and vegetables, to whole grain and dairy. Un- favored foods included sugars, soft drinks, and commercially produced fruit juices and sauces. Many of the un-favorable foods that are listed in the study as recommended to intake as least as possible are common foods that are often given to children and adults on a daily basis here in the US (LOBB, 2005). Although a typical American diet may also include many of the recommended foods such as dairy, homemade fruit juices, vegetables and low fat meat (Ghanizadeh, & Haddad, 2015), it is typical for the average American to also consume many of the not so favorable diet items on a daily basis. From processed drinks to prepackaged snacks high is sugar and salt, the average American diet can differ from the average diet in other countries like Iran greatly. The study did not find any conclusive data to prove one way or another the effects of diet on the symptoms of ADHD in regards to the children who participated in the study. Neither the inattentiveness scores nor the hyperactivity/ impulsivity scores were different between the control group and the treatment group (Ghanizadeh, & Haddad, 2015). There was however a significant negative correlation seen between the inattentiveness scores at the end of the trial and the mean change of favorable/recommended diet implying that the children who markedly increased recommended foods experienced lesser inattentiveness in comparison to those with none or less increase of the favorable diet. It should be noted though that as part of the study, the children were asked to take Methylphenidate along with the diet changes. Each child in the United States is estimated to consume about two pounds of sugar every week (Schnoll, Burshteyn, & Cea-Aravena, 2003), so a look into the effects of sugar on children with ADHD as compared to their developmentally normal peers is essential. It has been shown
that for hyperactive children, the amount of sugar consumed is positively correlated with destructive–aggressive and restless behaviors shown in their everyday play. On the basis of entries in a 1-week food diary study conducted by Prinz and Riddle (1986), those children who were consuming above the 75th percentile for sugar intake (5.47 g/kg of body weight) were less able to sustain attention than those below the 25th percentile (3.23 g/kg) (Schnoll, Burshteyn, & Cea-Aravena, 2003). It is thought that about 70% of the hyperactive population suffers from some form of a food allergy (Schnoll, Burshteyn, & Cea-Aravena, 2003). In one study conducted by Hughes, Weinstein, Gott, Binggeli, and Whitaker (1982), 10 participants’ meals were replaced with a 1,800 calories hypoallergenic synthetic drink in an attempt to study the effects of food allergies on ADDH symptoms. With all possible food allergies having been removed from the diet, all 10 participants showed improvement on objective measures for ADHD (Schnoll, Burshteyn, & Cea- Aravena, 2003). Researchers note that children are allergic to some common and nutritious foods including milk, wheat, eggs, corn, as well as food additives and colorings (Schnoll, Burshteyn, & Cea-Aravena, 2003). When comparing previous mentioned research, most of the recommended diets include some form, if not all, of the most common childhood food allergies. This may work to explain why some of the children show such a higher level of improvement over others. While some children who show a higher level of improvement may not have any food allergies, and hence react positively to the elimination of many hyperactivity causing substances, others may have one or more unknown food allergies or sensitivities. Even with the removal of one food
allergies, if a participant is allergic to more than one substance, there may not be a marked improvement in their symptoms. Although most of the research is still yet inconclusive, the idea that seems to be most generally agreed upon is not whether diet affects the symptoms of ADHD or not, but that diet does affect the symptoms of ADHD in a small subsets of those who are diagnosed. With the many different forms of diet manipulation that are out there, it is not unreasonable to assume that each diet manipulation study is affecting only a small subset of the participates, because that small subset it particularly responses to that form of diet manipulation, while the other participants would be more responsive to another. An article published in the Pediatric Nursing magazine in 2007 titled “Diet and Child Behavior Problems: Fact or Fiction?” (Cormier, & Elder) outlines many of the common ADHD manipulation diets that have been tested in regards to children diagnosed with ADHD . One specific diet study that has not yet been mentioned in this paper is fatty acid supplementation. This specific study involved essential fatty acids (EFA), in particular arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexanoic acid (DHA). These specific fatty acids are especially important in the structural and functional development and maintenance of neuronal membranes. Deficiencies in these specific essential fatty acids have been implicated in a range of developmental and behavioral disorders including ADHD. “Further, studies identifying lower plasma concentration levels of certain essential fatty acids among children with ADHD have led researchers to postulate that deficiencies are responsible for key features of ADHD” (Cormier, & Elder, 2007 p 140).
Although there seem to be ample studies regarding the many ranges of ADHD and diet, the inconclusive results warrants attention to some of the short comings that may have been present in the studies causing such sporadic and inapplicable results. The previously referred to study by Cormier and Elder involving essential fatty acids presents itself with some major shortcomings as far as reliability of the data and samples tested. This study, like many of the others conducted concerning ADHD and diet were done with a fairly small sample size, and the conditions of ADHD were not always confirmed (Cormier, & Elder, 2007). There is also the issue of concurrent stimulant medication that causes any results recorded to come into question as cause and effect, mutually concurring, or simply unrelated and a conscience. When referring to the sugar elimination diets there are also some major forthcomings in the research and data conducted. Firstly, in many of the studies that were previously conducted, the chemical aspartame was used to replace sugar (Schnoll, Burshteyn, & Cea-Aravena, 2003). Where previously there was not the research to support that aspartame had any negative effects on the body, it is now believed that aspartame may not be the neutral substance it was thought to be, and that this chemical substance may lead to its own array of problems and reactions. It can also be impossible to determine a cause and effect between the relationship of sugar and the symptoms of ADHD, or just hyperactivity in general. Despite the idea that many studies support the possibility of the relationship between hyperactivity and behavior, it cannot be determined if it is a causality or not (Schnoll, Burshteyn, & Cea-Aravena, 2003). In fact, it is suggested that there is more likely a third variable such as a lack of parental discipline or the studies being conducted in an unusual environment not normal to the participates, that is causing there to appear to be a relationship between the two.
Food allergies and sensitives can be one of the hardest elimination diets to study, as each participant likely has a different allergy, if not more than one. Researchers who study food allergies do not focus on a specific food substance, but rather work with individual children to attempt to identify what substance the child may be having a negative or sensitive reaction to (Schnoll, Burshteyn, & Cea-Aravena, 2003). Thus making current research regarding one specific allergy in a group of confirmed ADHD patients all within the same range and same cultural standing extremely difficult to find or even create. Another shortcoming that is common to many of the current research on the matter is that a majority of the data collected is often from volunteers and/or self-reported. As mentioned in the article titled “Treatment choices and experiences in attention deficit and hyperactivity disorder: Relations to parents' beliefs and attributions” (Johnston, et el, 2005), many of the participates who chose to volunteer are often of a very small population, in this specific study they were predominantly Caucasian. Another major issue that is overly common in many of the non-admitted participates is that there is no way to know for sure the level of participation in regards to following the diet plans given. Researches are reliant on the self-reporting’s of the parents in most all cases, which, although may work to help lead researches in a more specialized direction, do not foster conclusive results. Researchers have also noted that creating a diet plan for a control group when conducting elimination research has also proved to be more than a little difficult (Ghanizadeh, & Haddad, 2015). In conclusion, there is far too insufficient of evidence to support a claim that diet alteration can improve the symptoms of ADHD. The current research does not necessarily
support or refute the claim that diet could prove to be useful in control symptoms, but rather does little more than warrant more research and beg more questions regarding the specifics. Many particulars should be researched further including age of participates in regards to sensitivity to diet and specifics within the diet alterations and restrictions themselves (such as sugars, fatty acids, glucose, etc..) It is too soon to say irrefutably if diet does affect or alter those who struggle with hyperactivity, impulsivity and inattention, but the data does support the awareness that there may be a link between them which may one day lead to patients being able to manage their ADHD symptoms drug free.
References Cormier, E., & Elder, J. H. (2007). Diet and Child Behavior Problems: Fact or Fiction?. Pediatric Nursing, 33(2), 138-143. Ghanizadeh, A., & Haddad, B. (2015). The effect of dietary education on ADHD, a randomized controlled clinical trial. Annals Of General Psychiatry, 14doi:10.1186/s12991-015-0050- 6 Goodday, A., Corkum, P., & Smith, I. M. (2014). Parental Acceptance of Treatments for Insomnia in Children with Attention-Deficit/Hyperactivity Disorder, Autistic Spectrum Disorder, and their Typically Developing Peers. Children's Health Care, 43(1), 54-71. doi:10.1080/02739615.2014.850879 Johnston, C., Seipp, C., Hommersen, P., Hoza, B., & Fine, S. (2005). Treatment choices and experiences in attention deficit and hyperactivity disorder: Relations to parents' beliefs and attributions. Child: Care, Health And Development, 31(6), 669-677. doi:10.1111/j.1365-2214.2005.00555.
Kerig, P. (2014). The Preschool Period: The Emergence of Attention Deficit Hyperactivity Disorder and Learning Disorder. In Developmental Psychopathology (Vol. 1). McGraw- Hill Education. LOBB, A. (2005, September 17). Eating Habits -- A Look At the Average U.S. Diet. Retrieved August 26, 2015. Pelsser, L. J., Frankena, K., Toorman, J., Savelkoul, H. J., Pereira, R. R., & Buitelaar, J. K. (2009). A randomised controlled trial into the effects of food on ADHD. European Child & Adolescent Psychiatry, 18(1), 12-19. doi:10.1007/s00787-008-0695-7 Ritalin (2015). Retrieved August 25, 2015. Schnoll, R., Burshteyn, D., & Cea-Aravena, J. (2003). Nutrition in the treatment of attention- deficit hyperactivity disorder: A neglected but important aspect. Applied Psychophysiology And Biofeedback, 28(1), 63-75. doi:10.1023/A:1022321017467
Symptoms and Diagnosis. (2015, June 26). Retrieved August 25, 2015. U.S. Department of Education, National Center for Education Statistics. (2010). Teacher Attrition and Mobility: Results from the 2008–09 Teacher Follow-up Survey (NCES 2010-353). Your Child's Diet: A Cause and a Cure of ADHD? (2011). Retrieved July 30, 2015.

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Rebecca Caster Final

  • 1. Rebecca Caster ADHD and Diet Empire State College August 28, 2015
  • 2. ADHD and Diet Attention Deficit Hyperactivity Disorder, or ADHD, can affect up to 20 percent of all school age children (Kerig, 2014). In 2008-2009, the average size of a public school classroom was 21.2 students to every 1 teacher (U.S. Department of Education, National Center for Education Statistics 2010), meaning that on average, there can be up to 4 students in every classroom who are affected by ADHD. With numbers as high as these, it is important to really understand what ADHD is, and if diet change can help some individuals manage their ADHD symptoms. There are three main categories that Attention Deficit Hyperactivity Disorder can fall in; Inattention, Hyperactivity/Impulsivity and a combination of the two (Kerig, 2014). ADHD under the category of inattention can be seen by an inability to sustain age appropriate attention level. Children under this category are often seen moving from one project to the next without completing the previous one. They tend to be described as forgetful and disorganized, and can be prone to day dreaming and seem often distracted. Hyperactivity is often described as the child being constantly on the move, with an inability to stay in one place or on one task for very long. This is different from inattention in that it is not that they get distracted and move to the next project, but they have a physical need to move nearly constituently. A need to run, jump, or climb is often seen in children that fall into this category, and often exhibit excessive talking or an inability to stay appropriately in their seats or their own area.
  • 3. With hyperactivity often comes impulsivity as well. This is seen in children who seem to ‘act without thinking’. Interrupting conversations, blurting out answers, jumping into peer games or having difficulty waiting their turn are all common symptoms of a child who exhibits this category of ADHD. The third category is a combination of these two. Children with both inattentiveness and hyperactivity/impulsivity may have the hardest time preforming in the classroom or even completing tasks at home. They can become easily distracted and then feel a need to get out of their chairs without thinking of any consequences, to go over to say something about their peer’s conversations. Diagnostic criteria for Attention Deficit Hyperactive Disorder as set forth by the Diagnostic and Statistical Manual of Mental Disorders; fifth edition (DSM-V) includes at least six criteria from the inattentive category; or six criteria from the hyperactivity/impulsivity category; or six from each to fit into a combination of the two categories (Symptoms and Diagnosis. 2015, June 26). These symptoms must also have been present before the age of twelve, and be present in more than one setting. It must be clear that the symptoms are interfering with or reducing social, educational and/or home functioning, and the symptoms must not only be present during any other psychiatric disorder. Although ADHD does not affect intelligence level, performance levels of someone with ADHD may be lowered by their inability to focus on the current task or lesson. As to not to be confused with a learning disorder, ADHD must be present in a number of settings, including school and home, as well as social settings. It is not an inability to understand or learn the
  • 4. material that causes a lack in school performance, but rather an inability to focus and pay attention. There is no definitive answer as to what causes ADHD, and why some children develop it and others do not. Risk factors for developing symptoms of ADHD include some genetic factors such as family history of the disorder; an unsteady home life; and even cultural complications that seem to clash with the ‘norm’ (Kerig, 2014). There is also a well-documented difference between the prevalence of ADHD between girls and boys, with boys outnumber girls anywhere a between a 6:1 – 9:1 ratio. Some neuropsychological factors may play a role as well. Decreased blood flow to the frontal cortex and increased slow-wave activity in the frontal lobes may both play factor into ADHD development and/or the outcome and severity of the symptoms. An investigated into the relationship between diet and brain electrical activity in children with ADHD done by Uhlig, Merkenschlager, Brandmaier, and Egger (1979) found that certain food sensitivities not only influence ADHD symptomology, but may also alter brain electrical activity (Schnoll, Burshteyn, & Cea-Aravena, 2003). With the true cause unknown, and no known suitable prevention mechanism, it can be difficult to predict what styles of treatments will affect those diagnosed with ADHD. Simulants medication is often one of the first forms of treatment that is given to help sooth some of the effects of ADHD (Kerig, 2014), with Methylphenidate (Ritalin) being one of the top known stimulant medications for treatment (Ritalin 2015). Although Methylphenidate and other stimulant medication can be highly effective in treating the symptoms of ADHD, as is the case with all medications, undesirable side effects
  • 5. may be seen. From dizziness to drowsiness; nervousness and insomnia; to changes in blood pressure or heart rate; as well as more serious side effects such as hallucinations, there are a number of possible unwanted effects that can be cause by this one medication. Although the more serious side effects may be rare, they are not unheard of, and every child taking the medication is at risk, and most likely experiencing, at least one of the side effects. Just as every person is different, every case of ADHD is different, and everyone diagnosed with it will be effected and react differently to treatment. While some may find all the relief they need in one medication with minimal side effects, others may seek many different treatment options in the hopes of better controlling the symptoms with less undesirable outcomes. One fairly new form of treatment that is still being researched is the use of diet changes and restrictions as a way to help control and manage the symptoms associated with ADHD. Ben F. Feingold was the first to hypothesis that a diet changes would have a positive effect on controlling symptoms of ADHD. Feingold proposed that “food additives, specifically synthetic food colors and flavors, and naturally occurring salicylates were responsible for hyperactive behavior in some children” (Schnoll, Burshteyn, & Cea-Aravena, 2003). In response to this he created the Kaiser-Permanente (K-P) diet which eliminated all artificial colors and flavors as well as all foods containing salicylates from the child’s diet. Within his own clinical experiences, Feingold reported as much as 50% of his patients having shown favorable responses to the K-P diet according to their parents (Schnoll, Burshteyn, & Cea-Aravena, 2003). There is some discussion about how reliable these results are however, as the findings did not come from a rigorous empirical study, but rather simply by what
  • 6. was seen and told to him by his patients and their parents. In contrast though, it is questioned if Feingold would have a higher percentage of results if the diet was not so difficult to adhere to. Since Feingold’s first report, there has been much discussion about how effective diet really is in regards to managing symptoms of ADHD. Not only that, but there has been a number of more specific hypothesis presented in regards to which specific aspects of the diet affect ADHD and how. The majority of the studies immediately following Feingold’s reports could fall into one of two categories; those that evaluated the behaviors of hyperactive children while on the Feingold diet as compared to a placebo diet (dietary crossover designs), and those that investigated responses to specific food dye challenges (Schnoll, Burshteyn, & Cea-Aravena, 2003). Overall, the research that was conducted immediately following Feingold’s findings suggested that only a small group of children with behavioral disturbances respond positively to the Feingold diet, but in general the elimination of synthetic food color did not show any major reduction factors in hyperactivity behavior (Schnoll, Burshteyn, & Cea-Aravena, 2003). It is important to note however, that food dyes account for only 10 out of over 3,000 additives which are eliminated from Feingold’s diet plan. One study done by Swanson and Kinsbourne (1980) improved on the research that was available at the time (Schnoll, Burshteyn, & Cea-Aravena, 2003). Instead of relying on parents reports of the symptoms and on assurance that the diet was being adhered to, Swanson and Kinsboune conducted their study with participants admitted into the hospital so that the diet could be administered in a more controlled manner. They also improved upon the true daily value of food dye, and improved upon the sensitivity of the rating scale. Overall, the studies
  • 7. suggest that there is a small subset of children who react highly and positively to the elimination of food dyes in their food. They also suggest that preschool age children may be more sensitive to the adding or removing of food dyes than older children would be. While there is no evidence to suggest that diet causes ADHD, there is however some reports that links junk food, fast food and an overall more ‘western diet’ as some indicators of ADHD severity and symptoms. ‘Western food’ is known for highly sweetened desserts, fried foods and high levels of salt; all of which are associated with more attention and behavioral problems over a more balanced diet, regular meals and a high intake of dairy products and vegetables (Ghanizadeh, & Haddad, 2015). There is no doubt that the prevalence of ADHD varies greatly according to region (Kerig, 2014), but there has been little evidence as to exactly why these differences are. Some theories attribute these differences to different cultural norms. A culture that values the ability to stay task orientated and focused; such as the American School Culture, may see a higher level of ‘abnormal’ behaviors which qualifies more students as ADHD. Whereas a culture that does not put as great a weight on mental work, but may value physical ability more, may not see such a high prevalence of the symptoms, as the higher exercises levels can work to mask some of inattentive and hyperactivity symptoms. There are such large variances between the prevalence of ADHD in the United States and in other countries; as low as 1.7% in Great Britain to 9.5% in Puerto Rico (Johnston, Seipp, Hommersen, Hoza, & Fine, 2005). The stark and dramatic difference between the prevalence of ADHD in other countries is another indicator that may diet affects the symptoms of ADHD. A study that was conducted in Iran with an overall of 64 children between the ages of 5 and 14
  • 8. asked parents to list out ‘healthy foods’ and ‘un-favored foods’ (Ghanizadeh, & Haddad, 2015). Healthy foods included everything from fruits and vegetables, to whole grain and dairy. Un- favored foods included sugars, soft drinks, and commercially produced fruit juices and sauces. Many of the un-favorable foods that are listed in the study as recommended to intake as least as possible are common foods that are often given to children and adults on a daily basis here in the US (LOBB, 2005). Although a typical American diet may also include many of the recommended foods such as dairy, homemade fruit juices, vegetables and low fat meat (Ghanizadeh, & Haddad, 2015), it is typical for the average American to also consume many of the not so favorable diet items on a daily basis. From processed drinks to prepackaged snacks high is sugar and salt, the average American diet can differ from the average diet in other countries like Iran greatly. The study did not find any conclusive data to prove one way or another the effects of diet on the symptoms of ADHD in regards to the children who participated in the study. Neither the inattentiveness scores nor the hyperactivity/ impulsivity scores were different between the control group and the treatment group (Ghanizadeh, & Haddad, 2015). There was however a significant negative correlation seen between the inattentiveness scores at the end of the trial and the mean change of favorable/recommended diet implying that the children who markedly increased recommended foods experienced lesser inattentiveness in comparison to those with none or less increase of the favorable diet. It should be noted though that as part of the study, the children were asked to take Methylphenidate along with the diet changes. Each child in the United States is estimated to consume about two pounds of sugar every week (Schnoll, Burshteyn, & Cea-Aravena, 2003), so a look into the effects of sugar on children with ADHD as compared to their developmentally normal peers is essential. It has been shown
  • 9. that for hyperactive children, the amount of sugar consumed is positively correlated with destructive–aggressive and restless behaviors shown in their everyday play. On the basis of entries in a 1-week food diary study conducted by Prinz and Riddle (1986), those children who were consuming above the 75th percentile for sugar intake (5.47 g/kg of body weight) were less able to sustain attention than those below the 25th percentile (3.23 g/kg) (Schnoll, Burshteyn, & Cea-Aravena, 2003). It is thought that about 70% of the hyperactive population suffers from some form of a food allergy (Schnoll, Burshteyn, & Cea-Aravena, 2003). In one study conducted by Hughes, Weinstein, Gott, Binggeli, and Whitaker (1982), 10 participants’ meals were replaced with a 1,800 calories hypoallergenic synthetic drink in an attempt to study the effects of food allergies on ADDH symptoms. With all possible food allergies having been removed from the diet, all 10 participants showed improvement on objective measures for ADHD (Schnoll, Burshteyn, & Cea- Aravena, 2003). Researchers note that children are allergic to some common and nutritious foods including milk, wheat, eggs, corn, as well as food additives and colorings (Schnoll, Burshteyn, & Cea-Aravena, 2003). When comparing previous mentioned research, most of the recommended diets include some form, if not all, of the most common childhood food allergies. This may work to explain why some of the children show such a higher level of improvement over others. While some children who show a higher level of improvement may not have any food allergies, and hence react positively to the elimination of many hyperactivity causing substances, others may have one or more unknown food allergies or sensitivities. Even with the removal of one food
  • 10. allergies, if a participant is allergic to more than one substance, there may not be a marked improvement in their symptoms. Although most of the research is still yet inconclusive, the idea that seems to be most generally agreed upon is not whether diet affects the symptoms of ADHD or not, but that diet does affect the symptoms of ADHD in a small subsets of those who are diagnosed. With the many different forms of diet manipulation that are out there, it is not unreasonable to assume that each diet manipulation study is affecting only a small subset of the participates, because that small subset it particularly responses to that form of diet manipulation, while the other participants would be more responsive to another. An article published in the Pediatric Nursing magazine in 2007 titled “Diet and Child Behavior Problems: Fact or Fiction?” (Cormier, & Elder) outlines many of the common ADHD manipulation diets that have been tested in regards to children diagnosed with ADHD . One specific diet study that has not yet been mentioned in this paper is fatty acid supplementation. This specific study involved essential fatty acids (EFA), in particular arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexanoic acid (DHA). These specific fatty acids are especially important in the structural and functional development and maintenance of neuronal membranes. Deficiencies in these specific essential fatty acids have been implicated in a range of developmental and behavioral disorders including ADHD. “Further, studies identifying lower plasma concentration levels of certain essential fatty acids among children with ADHD have led researchers to postulate that deficiencies are responsible for key features of ADHD” (Cormier, & Elder, 2007 p 140).
  • 11. Although there seem to be ample studies regarding the many ranges of ADHD and diet, the inconclusive results warrants attention to some of the short comings that may have been present in the studies causing such sporadic and inapplicable results. The previously referred to study by Cormier and Elder involving essential fatty acids presents itself with some major shortcomings as far as reliability of the data and samples tested. This study, like many of the others conducted concerning ADHD and diet were done with a fairly small sample size, and the conditions of ADHD were not always confirmed (Cormier, & Elder, 2007). There is also the issue of concurrent stimulant medication that causes any results recorded to come into question as cause and effect, mutually concurring, or simply unrelated and a conscience. When referring to the sugar elimination diets there are also some major forthcomings in the research and data conducted. Firstly, in many of the studies that were previously conducted, the chemical aspartame was used to replace sugar (Schnoll, Burshteyn, & Cea-Aravena, 2003). Where previously there was not the research to support that aspartame had any negative effects on the body, it is now believed that aspartame may not be the neutral substance it was thought to be, and that this chemical substance may lead to its own array of problems and reactions. It can also be impossible to determine a cause and effect between the relationship of sugar and the symptoms of ADHD, or just hyperactivity in general. Despite the idea that many studies support the possibility of the relationship between hyperactivity and behavior, it cannot be determined if it is a causality or not (Schnoll, Burshteyn, & Cea-Aravena, 2003). In fact, it is suggested that there is more likely a third variable such as a lack of parental discipline or the studies being conducted in an unusual environment not normal to the participates, that is causing there to appear to be a relationship between the two.
  • 12. Food allergies and sensitives can be one of the hardest elimination diets to study, as each participant likely has a different allergy, if not more than one. Researchers who study food allergies do not focus on a specific food substance, but rather work with individual children to attempt to identify what substance the child may be having a negative or sensitive reaction to (Schnoll, Burshteyn, & Cea-Aravena, 2003). Thus making current research regarding one specific allergy in a group of confirmed ADHD patients all within the same range and same cultural standing extremely difficult to find or even create. Another shortcoming that is common to many of the current research on the matter is that a majority of the data collected is often from volunteers and/or self-reported. As mentioned in the article titled “Treatment choices and experiences in attention deficit and hyperactivity disorder: Relations to parents' beliefs and attributions” (Johnston, et el, 2005), many of the participates who chose to volunteer are often of a very small population, in this specific study they were predominantly Caucasian. Another major issue that is overly common in many of the non-admitted participates is that there is no way to know for sure the level of participation in regards to following the diet plans given. Researches are reliant on the self-reporting’s of the parents in most all cases, which, although may work to help lead researches in a more specialized direction, do not foster conclusive results. Researchers have also noted that creating a diet plan for a control group when conducting elimination research has also proved to be more than a little difficult (Ghanizadeh, & Haddad, 2015). In conclusion, there is far too insufficient of evidence to support a claim that diet alteration can improve the symptoms of ADHD. The current research does not necessarily
  • 13. support or refute the claim that diet could prove to be useful in control symptoms, but rather does little more than warrant more research and beg more questions regarding the specifics. Many particulars should be researched further including age of participates in regards to sensitivity to diet and specifics within the diet alterations and restrictions themselves (such as sugars, fatty acids, glucose, etc..) It is too soon to say irrefutably if diet does affect or alter those who struggle with hyperactivity, impulsivity and inattention, but the data does support the awareness that there may be a link between them which may one day lead to patients being able to manage their ADHD symptoms drug free.
  • 14. References Cormier, E., & Elder, J. H. (2007). Diet and Child Behavior Problems: Fact or Fiction?. Pediatric Nursing, 33(2), 138-143. Ghanizadeh, A., & Haddad, B. (2015). The effect of dietary education on ADHD, a randomized controlled clinical trial. Annals Of General Psychiatry, 14doi:10.1186/s12991-015-0050- 6 Goodday, A., Corkum, P., & Smith, I. M. (2014). Parental Acceptance of Treatments for Insomnia in Children with Attention-Deficit/Hyperactivity Disorder, Autistic Spectrum Disorder, and their Typically Developing Peers. Children's Health Care, 43(1), 54-71. doi:10.1080/02739615.2014.850879 Johnston, C., Seipp, C., Hommersen, P., Hoza, B., & Fine, S. (2005). Treatment choices and experiences in attention deficit and hyperactivity disorder: Relations to parents' beliefs and attributions. Child: Care, Health And Development, 31(6), 669-677. doi:10.1111/j.1365-2214.2005.00555.
  • 15. Kerig, P. (2014). The Preschool Period: The Emergence of Attention Deficit Hyperactivity Disorder and Learning Disorder. In Developmental Psychopathology (Vol. 1). McGraw- Hill Education. LOBB, A. (2005, September 17). Eating Habits -- A Look At the Average U.S. Diet. Retrieved August 26, 2015. Pelsser, L. J., Frankena, K., Toorman, J., Savelkoul, H. J., Pereira, R. R., & Buitelaar, J. K. (2009). A randomised controlled trial into the effects of food on ADHD. European Child & Adolescent Psychiatry, 18(1), 12-19. doi:10.1007/s00787-008-0695-7 Ritalin (2015). Retrieved August 25, 2015. Schnoll, R., Burshteyn, D., & Cea-Aravena, J. (2003). Nutrition in the treatment of attention- deficit hyperactivity disorder: A neglected but important aspect. Applied Psychophysiology And Biofeedback, 28(1), 63-75. doi:10.1023/A:1022321017467
  • 16. Symptoms and Diagnosis. (2015, June 26). Retrieved August 25, 2015. U.S. Department of Education, National Center for Education Statistics. (2010). Teacher Attrition and Mobility: Results from the 2008–09 Teacher Follow-up Survey (NCES 2010-353). Your Child's Diet: A Cause and a Cure of ADHD? (2011). Retrieved July 30, 2015.