Attention deficit hyperactive disorder –dietary analysis and homoeopathic approach

Dr Maherukh Siddiqui

Definition
Attention deficit hyperactivity disorder (ADHD) is defined as the combination of inattentive, hyperactive and impulsive behaviour which are severe, developmentally inappropriate, and impair function at home and in school. Common features include mood swings, anxiety, impulsivity, hostility, poor concentration and sleeping disorders, along with physical complaints such as headaches, migraines, and stomach upsets. ADHD individuals are also more likely to have been of low birth weight and to have allergies or auto-immune problems. Proportionally more males than females are affected, with inattention tending to be a more female trait and hyperactivity more common in males.

Growing children are especially vulnerable to nutritional and environmental factors that influence brain development and function, which can have either a negative or positive impact. The symptoms of this difficult condition can also significantly compromise their education, making them challenging to teach and consequently having a deleterious effect on their health.

The daily challenges of living with ADHD place a huge strain on families and reduces overall quality of life for all involved.

Origins
Back in 1981, Colquhoun and Bunday undertook a comprehensive survey of children with ADHD and discovered that many showed physical signs of essential fatty acid (EFA) deficiency, including excessive thirst, polyuria, dry hair and skin. These authors were the first to propose that fatty acid deficiency may be a factor in ADHD, and their ground-breaking work prompted more research studies and clinical trials designed to increase understanding of those nutritional factors involved in ADHD.

It has now been proposed that many developmental and psychiatric conditions, including ADHD along with dyslexia, dyspraxia, autism, depression, and schizophrenia, may involve deficiencies of certain long chained fats, especially eicosapentaenoic acid, (EPA) and docosahexaenoic acid (DHA). Both iron deficiency and zinc deficiency have also been associated with the development of ADHD.

Description

Dietary Fats
Fats have a fundamental structural and functional role in the brain and central nervous system (CNS) and are a key factor in the development ADHD. The two fats that are thought to be especially important are EPA and DHA, not only because of their role in the brain and body but because of the relative lack of them in many people’s diets. EPA is the precursor of a complex group of substances, called eicosanoids, which perform numerous regulatory functions in the brain and body. DHA is a major ‘building block’ of brain and neuronal membranes and as such has a profound influence on cell signalling. Both EPA and DHA are omega-3 fats and can be made from the omega-3 essential fatty acid, alpha linolenic acid (ALA). Dietary factors known to adversely affect this conversion include low intakes of ALA, high intakes of omega-6 fats, saturated fat, hydrogenated fat and alcohol, in addition to vitamin and mineral deficiencies, testosterone and stress hormones. Unfortunately, many dietary surveys have revealed that a typical modern-day diet is rich in omega-6 fats, saturated fats and hydrogenated fats and often low in omega-3 fats and micronutrients. ADHD children are often found to be deficient in iron and zinc and the fact that more boys than girls tend to be affected may be partly explained by the negative effect of testosterone on this conversion process.

In order to avoid a functional deficiency of these important fats, the diet should have a smaller ratio of the omega-6 essential fat, linoleic acid (LA) to omega-3 essential fat (ALA), at an ideal ratio of no more than 5:1, as well as adequate amounts of pre-formed EPA and DHA. The richest dietary sources of LA are certain vegetable and seed oils, including sunflower, safflower, soya, palm, peanut and sesame, all of which should be eaten in good amounts along with oils that are rich in ALA such as rapeseed (canola), flaxseed (linseed) and walnut oil. Olive oil is also recommended, despite having quite a low ALA content, as it is rich in beneficial monounsaturated fats. Other sources of ALA include green, leafy vegetables such as rocket, watercress and spinach as well as fresh green herbs, such as basil, coriander, mint and parsley. Consequently, the food products of animals allowed to graze on open pasture will also be rich in ALA and so organic, free-range and outdoor reared meat, milk and eggs are the best choice.

When it comes to sources of EPA and DHA, fish and seafood are the best sources with oily fish, such as salmon, trout, mackerel, sardines, herring and anchovies, being especially rich. Fresh tuna is classed as a Possible cause of ADHD-like behaviour,

• A sudden change in the child’s life—the death of a parent or grandparent; parents’ divorce; a parent’s job loss
• Undetected seizures, such as in petit mal or temporal lobe seizures
• A middle ear infection that causes intermittent hearing problems
• Vision problems
• Medical disorders that may affect brain functioning
• Underachievement caused by learning disability
• Anxiety or depression

A general recommendation of a combined daily dose of 500 mg EPA and DHA is needed to avoid functional deficiency of these important fats, although individuals with ADHD may have an even higher requirement.

For this reason, pure fish oil supplements that provide a daily standard dose of EPA and DHA are useful in addition to a diet containing fish and seafood. Increasing evidence from well-designed clinical trials have indeed shown that supplementation with EPA and DHA alleviate ADHD-related symptoms in some children.

Dietary Antioxidants
If intakes of long-chained polyunsaturated fats (PUFAs), such as EPA and DHA, increase then so does the risk of lipid peroxidation by the action of harmful free radicals, smoking, and pollutants etc; substances produced in the body by normal processes such as breathing and metabolism. PUFAs are highly susceptible to attack from these reactive substances and need the protection of antioxidants to avoid getting damaged and thus affecting the structure of the lipid membranes of the brain and CNS. When free radical production is insufficiently countered by antioxidants the resultant damage to the brain and body is termed ‘oxidative injury’. Dietary antioxidants include nutrients such as vitamin E and selenium as well as biologically active substances such as flavanols, anthocyanins and carotenoids, found in highly coloured fruits and vegetables, nuts, tea and red wine. Vitamin E is naturally found in PUFA-rich foods like oils and nuts whilst selenium is found in fish, seafood, liver, egg, Brazil nuts, mushrooms and lentils. Eating the recommended daily minimum of 5 portions of fruit and / or vegetables should provide adequate amounts of complementary dietary antioxidants, especially if a wide range of colours and varieties are chosen.

Dietary Iron
Iron deficiency has been associated with ADHD in children and tends to be worse even when compared with iron-deficient non-ADHD controls. Lower serum ferritin levels correlate with more severe ADHD symptoms and greater cognitive deficits. Dietary sources of iron include red meat, fortified breakfast cereals, pulses and dried apricots and these foods should feature regularly in the ADHD diet. Additional supplementary iron may be required in cases of proven iron deficiency.

Dietary Zinc
Zinc has a range of important functions in the body, including the metabolism of neurotransmitters and fatty acids, with zinc deficiency possibly having an effect on the development of ADHD. Children with ADHD who have been treated with supplementary zinc have exhibited reduced hyperactive, impulsive and impaired-socialisation symptoms.

Foods known to be rich in zinc include seafood, liver, pine nuts, cashew nuts and wholegrain cereals and so should be eaten regularly to help avoid deficiency.

Synthetic Food Additives
Certain synthetic food colourings, flavourings and preservatives, have been linked to increase hyperactivity in some ADHD and non-ADHD children. Many of these additives are unnecessary and are frequently used to sell poor-quality foods, that are often marketed specifically at children.

Function
The ADHD diet works by providing the right type and amount of fats needed for the brain and CNS as well as providing sufficient amounts of iron and zinc to avoid nutritional deficiencies that are known to be associated with worsening ADHD symptoms. Nutritional supplements should be taken upon the advice of a doctor or Dietitian and taken in addition to a healthy, balanced diet. Dietary provision of antioxidants is needed to protect the long-chained fats from breakdown which would affect brain structure and compromise signalling within the brain and CNS.

Finally, the ADHD diet excludes those synthetic food additives that have been identified as having the potential to adversely affect the behaviour of ADHD, and non-ADHD children alike.

Benefits
The key benefit of the ADHD diet is that it provides the correct types of foods needed to support the nutritional requirements of both the brain and body.

It provides the nutrients needed to sustain good growth and development in children, as well as general health promotion for all, whilst excluding potential antagonistic additives. The diet supports other treatment strategies, including stimulant medication, and so helps to improve the quality of life and educational possibilities of those individuals affected.

Precautions
Detailed, personalized advice should always be sought from a suitably qualified dietitian, especially when dealing with children. Any nutritional supplements should always be taken according to the manufacturer’s instructions and at the prescribed dosage. If other medication is being taken then advice should be sought from a doctor.

Risks
It has been reported that fish oil supplements when taken alongside stimulant medication can exacerbate hyperactive behaviour in some ADHD individuals. In these circumstances, the supplement should continue to be taken and the dosage of the medication be altered accordingly, under the supervision of a doctor.

Fish oil supplements can also reduce blood clotting times and so should not be used if anti-coagulant medication is already being taken.

Research and general acceptance
Among the specialists working in this particular field, there is a general consensus that ADHD is a disorder that involves a functional deficiency of the long-chained fats, EPA and DHA that frequently coexists with zinc and iron deficiencies. Among the wider community there remains a great deal of scepticism about ADHD and the role that diet has in its development or management.

In terms of supplementation, insufficient data is available to formulate a standardized treatment strategy and it is unclear whether the micronutrient deficiencies are a cause of or secondary to ADHD. Other intervention studies have looked in to carnitine supplementation and elimination diets but their findings remain inconclusive.

It is certainly well accepted that there is still very much more to be learned about ADHD and how nutrients interact to either exacerbate or improve ADHD-related symptoms. More research is planned and hopefully more useful findings will help improve the life of all those affected by this debilitating condition.

QUESTIONS TO ASK YOUR DOCTOR

Which nutritional supplements are recommended for ADHD?

What are the best food choices for ADHD?

Which food additives should be avoided?

What are the vegetarian sources of omega 3 fats?

HOMOEOPATHIC THERAPEUTICS FOR ADHD

• Indications for Calcarea carb:
  • Calcarea carb is often recommended for individuals who are generally overweight or tend to gain weight easily.
  • Children who need Calcarea carb may have a tendency to sweat excessively, particularly on the head during sleep.
  • They may also be slow to develop both physically and mentally.
  • These children often have a strong desire for eggs and indigestible things like chalk or pencils.
  • Anxiety, especially about health and well-being, can be a prominent feature in individuals who benefit from Calcarea carb.
• Behavioural and Cognitive Aspects:
  • In the context of ADHD, Calcarea carb may be considered when a child displays symptoms such as inattention, forgetfulness, and difficulty concentrating.
  • Children who need Calcarea carb may also exhibit impulsivity and restlessness, which are common features of ADHD.
• Emotional Aspects:
  • Children who are anxious, fearful, and easily overwhelmed by new situations or challenges may find relief with Calcarea carb.
  • Emotional symptoms, such as mood swings and irritability, may improve with this remedy.
• Indications for Tuberculinum:
  • Children who may benefit from Tuberculinum often have a tendency to catch colds or respiratory infections easily.
  • There may be a history of asthma, bronchitis, or other respiratory issues in the child or their family.
• Behavioural and Cognitive Aspects:
  • In the context of ADHD, Tuberculinum may be considered when the child displays symptoms of restlessness, impulsivity, and difficulty focusing.
  • These children may have a vivid and active imagination, which can sometimes lead to distractibility.
  • There may also be a sense of discontentment or dissatisfaction that is difficult to pinpoint.
• Emotional Aspects:
  • Tuberculinum may be indicated for children who are emotionally sensitive, anxious, or fearful.
  • These children may have a tendency to worry about their health or exhibit separation anxiety.
  • Emotional symptoms, such as mood swings and irritability, may be part of the picture.
• Physical Aspects:
  • The presence of specific physical symptoms, such as recurrent respiratory issues or a history of tuberculosis, is an essential consideration when prescribing Tuberculinum.
  • The remedy’s choice depends on a holistic assessment of the child’s overall health.

➢ Indications for Sulphur:

• Sulphur is often prescribed when there is a predominance of symptoms related to restlessness, impulsivity, and inattentiveness.
• Children who may benefit from Sulphur often have a restless disposition and may exhibit fidgetiness.
• These children may have a strong aversion to routine and may resist conformity or structure.
• Sulphur is also indicated when there is a tendency to be easily frustrated and irritable.

2. Behavioural and Cognitive Aspects:
   1. In the context of ADHD, Sulphur may be considered when the child displays symptoms of distractibility, difficulty concentrating, and impulsivity.
   2. There may be a creative or curious streak in these children, but it may be challenging for them to sustain focus on one task for an extended period.
3. Emotional Aspects:
   1. Sulphur may be indicated for children who are independent-minded, self-confident, and may not easily conform to authority figures or rules.
   2. Emotional symptoms, such as mood swings and irritability, may be part of the overall picture.
4. Physical Aspects:
   1. While Sulphur is primarily selected based on mental and emotional symptoms, the presence of certain physical symptoms may also guide its selection.

• Physical symptoms such as skin issues (eczema, itching), digestive complaints, and a preference for warm environments can be relevant.

➢ Indications for Nux Vomica:

Nux vomica is often prescribed when there is a combination of symptoms related to hyperactivity, irritability, and overstimulation, which are common features in some children with ADHD. Key indications for considering Nux vomica may include:

1. Irritability and Impatience: Children who may benefit from Nux vomica often display irritability, impatience, and a quick temper. They may become easily frustrated or angered.
2. Overactivity: Nux vomica is suitable for children who are hyperactive and restless. They may have difficulty sitting still or calming down.
3. Sensitivity to Stimulants: Children who are sensitive to external stimuli, including dietary factors, caffeine, or medications, may find relief with Nux vomica.
4. Digestive Issues: Nux vomica is also known for its affinity with digestive problems. Children with ADHD who experience gastrointestinal issues, constipation, or indigestion may benefit from this remedy.
5. Stress and Perfectionism: If the child with ADHD tends to be perfectionistic, stressed, or overworked, Nux vomica may be considered.
6. Overindulgence: In some cases, Nux vomica is chosen when there is a history of overindulgence in rich foods, alcohol, or stimulants in the child or the family.

Behavioural and Cognitive Aspects:
Nux vomica may be considered when the child with ADHD displays symptoms of restlessness, impulsivity, and difficulty focusing. These children may have a tendency to be overly competitive and impatient, which can interfere with their ability to concentrate on tasks.

Emotional Aspects:C
hildren who may benefit from Nux vomica may experience mood swings, irritability, and a sense of being overwhelmed by their emotions. They may be easily stressed or anxious.

Physical Aspects:
While Nux vomica is primarily selected based on mental and emotional symptoms, the presence of certain physical symptoms, particularly related to digestion, may guide its selection.

➢ Indications for Tarentula:
Tarentula is typically considered when there is a combination of symptoms related to hyperactivity, restlessness, and impulsivity. Key indications for considering Tarentula may include:

1. Hyperactivity: Children who may benefit from Tarentula often exhibit high levels of physical activity, restlessness, and a constant need to be in motion. They may have difficulty sitting still or focusing on quiet tasks.
2. Impulsivity: Tarentula is suitable for children who act on their impulses without considering the consequences. They may be quick to react and may have difficulty controlling their behaviour.
3. Aggressiveness: Children who display aggressive behaviour, including hitting, biting, or lashing out, may find relief with Tarentula.
4. Music and Dance: Tarentula is known for its connection to music and dance. Children who are drawn to music, rhythm, and dancing may be candidates for this remedy.
5. Sensitivity to Music: Some children with ADHD are particularly sensitive to music or noise, and Tarentula may be indicated if this sensitivity is prominent.
6. Restlessness and Fidgeting: Tarentula is also suitable for children who exhibit excessive fidgeting, twitching, or restlessness.

Behavioural and Cognitive Aspects:
In the context of ADHD, Tarentula may be considered when the child displays symptoms of impulsivity, inattentiveness, and difficulty focusing. These children may have a tendency to be highly active and may struggle with tasks that require sustained attention.

Emotional Aspects:
Children who may benefit from Tarentula may experience mood swings, irritability, and a sense of inner turmoil. They may have difficulty controlling their emotions and may be prone to outbursts.

Physical Aspects:
While Tarentula is primarily selected based on mental and emotional symptoms, the presence of certain physical symptoms, particularly those related to restlessness and motor coordination, may guide its selection.

➢ Indications for Belladonna:
Belladonna is typically considered when there is a combination of symptoms related to hyperactivity, impulsivity, and heightened states of excitation. Key indications for considering Belladonna may include:

1. Sudden Onset: Children who may benefit from Belladonna often have sudden and intense symptoms that appear abruptly. They may switch from a calm state to an agitated or hyperactive state rapidly.
2. Hyperactivity: Belladonna is suitable for children who exhibit extreme hyperactivity, restlessness, and an inability to sit still. These children may constantly move around and have a heightened state of alertness.
3. Impulsivity: Children who act impulsively, making hasty decisions without considering consequences, may find relief with Belladonna.
4. Sensitivity to Stimuli: Belladonna is known for its sensitivity to sensory stimuli. Children who are highly sensitive to light, noise, touch, or other sensory inputs may benefit from this remedy.
5. Violent Outbursts: Belladonna may be indicated for children who have sudden and intense fits of anger or aggression. They may become physically and verbally aggressive during these outbursts.
6. Feverishness: Belladonna is often associated with feverish states, and children who require this remedy may experience periods of high body temperature, especially during periods of excitation.

Behavioural and Cognitive Aspects:
In the context of ADHD, Belladonna may be considered when the child displays symptoms of impulsivity, inattentiveness, and an inability to focus. These children may have racing thoughts and may find it challenging to concentrate on tasks.

Emotional Aspects:
Children who may benefit from Belladonna may experience intense emotions, including anger, fear, and irritability. They may have difficulty managing and controlling these emotions.

Physical Aspects:
While Belladonna is primarily selected based on mental and emotional symptoms, the presence of certain physical symptoms, particularly those related to sudden and intense states of excitation, may guide its selection.

Resources
BOOKS
Richardson, Alex. They Are What You Feed Them Harper Thorsons 2006 Simopoulos, Artemis and Jo Robinson.
The Omega Diet Harper Collins Publishers 1999 Stevens, Laura. 12 Effective Ways to Help Your ADD / ADHD Child Penguin 2000
Stordy, Jacqueline and Malcolm Nicholl. The LCP Solution Macmillan 2002

PERIODICALS

• Akhondzadeh et al. ‘‘Zinc sulphate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: A double-blind and randomised trial’’ Bio Med Central Psychiatry 2004 4:9.
• Bateman et al. ‘‘The effects of a double-blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of pre-school children’’ Archives of Disease in Childhood 2004 89 p506-511.
• Bilici et al. ‘‘Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder’’ Progress in Neuropsychopharmacology and Biological Psychiatry 2004 28 (1) p181-190.
• Bourre. ‘‘Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain. Part 1: micronutrients’’ Journal of Nutrition, Health and Ageing 2006 10 (5) p377-385.
• Bourre. ‘‘Effects of nutrients (in food) on the structure and function of the nervous system: update on dietary requirements for brain. Part 2: macronutrients’’ Journal of Nutrition, Health and Ageing 2006 10 (5) p386-399.
• Brookes et al. ‘‘Association of fatty acid desaturase genes with attention deficit/hyperactivity disorder’’ Biological Psychiatry 2006 epub ahead of print.
• Colquhoun & Bunday. ‘‘A lack of essential fatty acids as a possible cause of hyperactivity in children.’’ Medical Hypotheses 1981 7 (5) p673-679.
• Galler et al. ‘‘Behavioural effects of childhood malnutrition’’ American Journal of Psychiatry 2005 162 p1760-1761.
• Hallahan and Garland. ‘‘Essential fatty acids and their role in the treatment of impulsivity disorders’’ Prostaglandins Leukotrienes and Essential Fatty Acids 2004 71 (4) P211-216.
• Konofal et al. ‘‘Iron-deficiency in children with attention deficit/hyperactivity disorder’’ Archives of Pediatric and Adolescent Medicine 2004 158 (12) p1113-1115.
• Richardson. ‘‘Clinical trials of fatty acid treatment in ADHD, dyslexia, dyspraxia and the autistic spectrum’’ Prostaglandins Leukotrienes and Essential Fatty Acids 2004 70 p383-390.
• Richardson. ‘‘Long-chain polyunsaturated fatty acids in childhood developmental and psychiatric disorders’’ Lipids 2004 39 p1215-1222.
• Richardson. ‘‘Omega 3 fatty acids in ADHD and related neurodevelopmental disorders’’ International Review of Psychiatry 2006 18(2) p155-172. Schab and Trinh. ‘‘Do artificial food colors promote hyperactivity in children with hyperactive syndromes?
• A meta-analysis of double-blind, placebo-controlled trials’’ Journal of Developmental and Behavioural Pediatrics 2004 25(6) p423-434.
• Stevenson. ‘‘Dietary influences on cognitive development and behaviour in children’’ Proceedings of the Nutrition Society 2006 65 94) p361-365.
• National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services.

Dr. Maherukh Siddiqui
M.D. Scholar (HOM.) Paediatrics
Government Homoeopathic Medical College & Hospital. Bhopal 462001
Under guidance of Dr. Ajay Singh Parihar
Prof. & H.O.D of Paediatrics.