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-

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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.

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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

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