ADHD Information
Last Updated 8/14/11

What is ADHD?

Attention Deficit Hyperactivity Disorder, or ADHD, is the most current name for a cluster of symptoms that generally involve behavior and concentration problems, such as hyperactivity, impulsivity, distractibility, and learning difficulties. Some of the names that have been used in the past include: Minimal Brain Damage (MBD), Minimal Brain Dysfunction (MBD), Hyperkinesis, Hyperkinesis-Learning Disability (H-LD), Hyperactivity, Attention Deficit Disorder (ADD).

ADHD affects about 3-5% of the world's population under the age of 19[1]. It typically presents itself during childhood, and is characterized by a persistent pattern of inattention and/or hyperactivity, as well as forgetfulness, poor impulse control or impulsivity, and distractibility.[2][3] ADHD is most commonly diagnosed in children and, over the past decade, has been increasingly diagnosed in adults. About 60% of children diagnosed with ADHD continue to exhibit symptoms as adults.[4]

The most common symptoms of ADHD are distractibility, difficulty with concentration and focus, short term memory difficulty, procrastination, problems organizing ideas and belongings, tardiness, impulsivity, and problems with planning and execution. Not all people with ADHD have all the symptoms, and most people do exhibit some of these symptoms, but not to the point where they seriously interfere with the person's work, schoolwork, or relationships.

The scientific consensus in the field is that ADHD impairs functioning and that many adverse life outcomes are associated with ADHD. During the elementary years an ADHD student will have more difficulties with work completion, productivity, planning, remembering things needed for school, and meeting deadlines. Oppositional and socially aggressive behavior is seen in 40%-70% of ADHD children at this age. Even ADHD kids with average to above average intelligence show "chronic and severe under achievement". Fully 46% of those with ADHD have been suspended and 11% expelled.[40] Thirty seven percent of those with ADHD do not get a high school diploma even though many of them will receive special education services.[5] Only 5% of those with ADHD will get a college degree compared to 27% of the general population. (US Census, 2003)

If this is the best that can be expected with all the expensive medical, pharmacological, and educational help available, it is a depressing prognosis. This, alone, is a good reason to try the Feingold Diet and other nutritional approaches before - or in addition to - pharmacological treatment. See our success stories.

How is ADHD usually diagnosed?

Many of the symptoms of ADHD occur from time to time in everyone. In those with ADHD, the frequency or severity of these symptoms impairs functioning both at home and at school or work. Although some computerized "tests of attention" and pen-and-paper tests for ADHD are available, no physical test exists to diagnose ADHD. Therefore, a diagnosis is generally based on the subjective reports of parents, teachers, and/or patients. In the USA, criteria for diagnosis are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ), 4th edition.

According to DSM-IV, Attention Deficit Hyperactivity Disorder (ADHD) or one of its subtypes can be diagnosed if the child shows certain characteristics for a period of six months or more, with at least some of the symptoms beginning before age seven. Symptoms must occur in more than one setting - such as at school or work and home. The symptoms are subjective, generally described by a parent, and require:

(A) Six or more symptoms of lack of attention, as paraphrased below:

  1. Fails to pay attention, makes mistakes
  2. Difficulty staying on tasks
  3. Does not seem to listen
  4. Fails to finish things
  5. Trouble organizing things
  6. Does not like homework or schoolwork
  7. Loses things
  8. Easily distracted
  9. Forgetful
~OR~

(B) Six or more symptoms of hyperactivity-impulsivity, as paraphrased below:

  1. Fidgets
  2. Leaves seat in class
  3. Runs around, is restless
  4. Difficulty playing quietly
  5. Acts like "driven by a motor"
  6. Talks too much
  7. Blurts out answers
  8. Can't wait his turn
  9. Interrupts others
For people who don't fit neatly into the categories of ADHD-attentional, ADHD-hyperactive, or ADHD-combined, there is another diagnosis called "ADHD, not otherwise specified." Diagnoses such as ODD (Oppositional Defiant Disorder), Conduct Disorder and Explosive Disorder are descriptive of their major problem symptoms; medical treatment offered is often the same as for ADHD.

Many of the symptoms listed above overlap. For example, how would you separate the symptoms "losing things," "forgetful," and "having trouble organizing?" Are they really three separate symptoms?

It is unfortunate that the DSM-IV does not appear to stress ruling out physical symptoms.

What causes ADHD?

There is no agreement on the part of doctors about the causes of ADHD. Because there is no objective test to confirm the diagnosis, practitioners rely on a checklist of behaviors, which can be very subjective. The 1998 NIH Consensus Development Conference on ADHD ended with the experts failing to reach a consensus, with one doctor telling the press, “Diagnosis is a mess!”

There is a common belief in scientific circles that ADHD is a genetic disease involving an imbalance in brain neurotransmitters. Genome wide surveys have shown linkage between ADHD and loci on chromosomes 7, 11, 12, 15, 16, and 17.[15] With so many suspected genes, however, ADHD could not follow the traditional model of a "genetic disease" and is better viewed as a complex interaction among genetic and environmental factors. To date no single gene with a major contribution to ADHD has been identified.

Measurements have shown differences in brain activity and even brain size in people with ADHD. However, these differences are subtle and not sufficient for any sort of diagnostic test. Moreover, these tests were often done on children taking stimulant medication; therefore, it is hard to know what effects are caused by ADHD and which are caused by the stimulants themselves.

Measurements have also shown that people with ADHD have differences in levels of various neurotransmitters, including dopamine and serotonin. Again, this difference is not sufficient as a diagnostic test. Moreover, although levels of the various neurotransmitters - and whether they are balanced or not - are controlled in part by your genetic makeup, it is not so simple. Neurotransmitters can also be affected by what you eat (or don't eat). For example, Vitamin B6 is a cofactor required for making dopamine so a Vitamin B6 deficiency will affect dopamine levels. On the other hand, even if you have a biological or genetic problem making enough dopamine, it can sometimes be overcome by providing extra cofactor (the Vitamin B6), thus "pushing the pathway" that is weak.

To give another example: As long ago as 1974, Stokes showed that the preservatives BHA and BHT induce changes in several neurotransmitters in the brain, including serotonin, norepinephrine, and cholinesterase.[49] In a review of the literature up to 1986, Zeisel said, "Diet clearly influences neurotransmission."[50]

In other tests using glucose and brain scans, areas of the brain required for certain tasks may not be "lit up" (using glucose) in people with an ADHD diagnosis. However, it cannot be determined whether this lower use of glucose in those areas causes the attention deficit, or whether it is the lack of attention to the task that is causing the lower use of glucose.

For some children, the symptoms can change dramatically, even from hour to hour, suggesting that the main problem is not within the child, but may have external causes. It is likely that the ADHD child has inherited a greater sensitivity to various external things, and these items can trigger the symptoms. This would explain many puzzling aspects of ADHD, including the following:

  • The incidence of ADHD symptoms has increased dramatically at the same time our food supply has changed.

  • ADHD is more commonly diagnosed in developed countries where there is a greater reliance on foods with synthetic chemical additives.

  • ADHD symptoms in most children are greatly reduced when they change their diet to remove certain food additives.

  • Even children with no prior history of ADHD have been found in double-blind studies to exhibit symptoms of hyperactivity and difficulty in paying attention when they consume food with additives like food dye.

Is ADHD inherited?

It is believed by researchers that there is a genetic factor involved since ADHD appears to run in families. As discussed above, however, the genetics involved are complex and the pattern will not be easily unraveled.

Dr. Mary Megson, in her presentation to Congress in 2000, claimed that parents with night blindness (a G protein defect) have children who are more at-risk for neurological damage by vaccines, resulting in autism, ADHD, and other disorders. Read her presentation here.

The Feingold Association has long realized that the additive-sensitive child usually has at least one parent who is also sensitive. These parents may have characteristics of ADHD, sleep disorders, migraines, etc. According to some researchers, adults usually have more symptoms of inattention and fewer of hyperactivity or impulsiveness than children do.[39] It is not known whether incarcerated adults were considered when these conclusions were drawn, however. If not, it is also possible that those adults who did not "grow out" of their hyperactivity and lack of control are simply in jail and no longer in the general population. The Feingold Association has received feedback from members who had symptoms of ADHD as children, and who suffer as adults with migraines, insomnia, or GI problems. These parents - having put their children on the Feingold diet for ADHD - report that the diet has brought relief of their own symptoms as well. When the whole family uses the Feingold Program to try to help one child, it is typical to find that the symptoms of other family members also improve.



What external factors can bring on ADHD symptoms?

ADHD has been linked with numerous external factors, including the artificial colors, flavors, preservatives and salicylates addressed by the Feingold Diet.

Some of these factors, in alphabetical order:

  • Allergies to pet, pollen, or mold
  • Allergies (other)
  • Artificial colorings and flavorings
  • Artificial (petroleum-based) preservatives BHA, BHT, and TBHQ
  • Auditory processing problems
  • Benzoate additives, naturally occurring benzoates
  • Brain damage following infection or physical trauma
  • Calcium propionate (preservative used in some bread)
  • Corn syrup, high fructose corn syrup
  • Essential fatty acid deficiency
  • Family - abusive environment or trauma[27],[28]
  • Food allergens
  • Fumes from oil heat, kerosene heaters, natural gas
  • Gluten intolerance, or unrecognized Celiac Disease
  • Head injury, especially to frontal lobes [25]
  • Hypoglycemia or reactive hypoglycemia
  • Iodine deficiency or thyroid problem
  • Iron or magnesium deficiency
  • Low birth weight, prematurity
  • Medication side effects (prescription or over-the-counter)
  • Monosodium glutamate (MSG, HVP, also found hidden in "flavoring" etc.)
  • Nitrates
  • Oxygen deprivation during birth
  • Perfumes and fragrances
  • Pesticide exposure
  • Petroleum and petroleum-derived products such as tar and asphalt
  • PKU disorder
  • Polluted air
  • Postnatal exposure to mercury, lead, or other heavy metals
  • Prenatal exposure to alcohol, tobacco smoke, heavy metals, certain medications and drugs
  • Salicylates
  • Sensory integration problems
  • Sleep deficiency or deprivation
  • Smoke from fireplace, wood stove
  • Soy formula in infancy (if child has difficulty excreting manganese which is excessive in soy formula)
  • Stress if excessive
  • Sulfation difficulty due to low or suppressed phenol sulfotransferase enzyme (salicylate suppresses this enzyme too)
  • Teething, even in older children
  • Vision deficits, including “convergence insufficiency” or subtle eye muscle imbalance
  • Vitamin B6 deficiency or inability to use it efficiently
  • Zinc deficiency or inability to retain zinc - zinc may be lost excessively upon exposure to food dyes (Ward 1990, 1997)
  • Yeast levels artificially raised by oral antibiotic use before age 2 (yeast secretes chemicals similar to those eliminated by the Feingold diet)


How is it possible to identify any of the above culprits?

A good first step in addressing ADHD symptoms is to remove items that have been shown to cause the greatest problems for the most people. The primary focus of the Feingold Program is removal of several groups of synthetic additives, many of which are made from petroleum and have been found to trigger behavior, learning, and health problems. These same chemical additives have also been shown in studies to promote a variety of cancers, so getting rid of them does not have a down side. The program also shows members how to temporarily remove “natural salicylates” to see if they may be triggering any of the symptoms of ADHD.

In most cases the first change seen is an improvement in behavior; other ADHD symptoms such as school performance might take a little longer to respond. Some people find that the Feingold Program is all they need to use, while for others, it is only one piece of the puzzle. The Program package, the newsletter (Pure Facts) and other resources included with membership discuss the types of triggers listed above and provide information on how to deal with them. Experienced parent volunteers are available to help members find additional resources and answer questions. Even in the case of a head injury, it is worthwhile trying the Feingold diet to see how much improvement may be attained by this non-invasive and healthful approach. After all - everybody has to eat anyway. More than one parent has reported to us that their child had been written off as "brain damaged" because of an earlier car accident and concussion, only to find that he was perfectly normal on the Feingold diet. In that case, at least, the damage was in the mind of the physician - not the child.



What is the Feingold Association's position on the use of drugs for ADHD?

The Feingold Association is not "for" or "against" the use of drugs for ADHD. However, we believe that they are often used inappropriately.

Drugs can save lives and can enhance the quality of one's life. They can also take lives and cause serious damage. While we believe that most people with ADHD symptoms can successfully address those symptoms without them, we recognize that drugs can provide benefits. Some parents have found that a combination of diet and stimulant medicine works well for their child, and that by using the Feingold Program they can reduce the amount of drugs needed. We offer assistance and support to people whether or not they opt for medication.

The primary criticism we have is that parents and/or patients are not given complete, accurate information on all of the options available.

We believe that parents and/or patients have the right to be told all of the potential side effects of drugs, not only their benefits, and that extreme caution should be taken when more than one drug is used, since the combination of two or more preparations can have serious consequences.

Various medicines have been used for ADHD symptoms for many years, but it is only recently that the full implications of their use have been made public.

On September 30, 2005, the New York Times reported that the Food and Drug Administration has ordered a Eli Lilly to place a prominent Black Box warning -- the FDA's most serious alert -- on the label of the drug Strattera, commonly used for ADHD as an alternative to stimulants. While not a stimulant drug, Strattera is similar to antidepressants, which have been implicated in triggering suicidal thinking in children and adults. Strattera, although not a controlled substance, carries the warnings of both the stimulants and the antidepressants.

Today, the stimulants all carry substantial Black Box Warnings. You can see the entire Ritalin monograph here, and scroll through to see the three Black Box Warnings, reprinted here from Novartis' website:

  1. Heart-related problems:
    • sudden death in patients who have heart problems or heart defects
    • stroke and heart attack in adults
    • increased blood pressure and heart rate

    Tell your doctor if you or your child have any heart problems, heart defects, high blood pressure, or a family history of these problems. Your doctor should check you or your child carefully for heart problems before starting RITALIN®.

    Your doctor should check your or your child’s blood pressure and heart rate regularly during treatment with RITALIN®.

    Call your doctor right away if you or your child has any signs of heart problems such as chest pain, shortness of breath, or fainting while taking RITALIN®.

  2. Mental (Psychiatric) problems:
    All Patients
    • new or worse behavior and thought problems
    • new or worse bipolar illness
    • new or worse aggressive behavior or hostility
    Children and Teenagers
    • new psychotic symptoms (such as hearing voices, believing things that are not true, are suspicious) or new manic symptoms

    Tell your doctor about any mental problems you or your child have, or about a family history of suicide, bipolar illness, or depression. Call your doctor right away if you or your child have any new or worsening mental symptoms or problems while taking RITALIN®, especially seeing or hearing things that are not real, believing things that are not real, or are suspicious.

and

RITALIN® is a federally controlled substance (CII) because it can be abused or lead to dependence. Keep RITALIN® in a safe place to prevent misuse and abuse. Selling or giving away RITALIN® may harm others, and is against the law.

Tell your doctor if you or your child have (or have a family history of) ever abused or been dependent on alcohol, prescription medicines or street drugs.

and

Drug Dependence

Ritalin should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Frank psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use, since severe depression may occur. Withdrawal following chronic therapeutic use may unmask symptoms of the underlying disorder that may require follow-up.

Other warnings on the Ritalin site (and other stimulat sites), besides the usual list of side effects, include the following:

  • Seizures
    There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued.

  • Visual Disturbance
    Difficulties with accommodation and blurring of vision have been reported with stimulant treatment.

  • Use in Children Under Six Years of Age
    Ritalin should not be used in children under 6 years, since safety and efficacy in this age group have not been established.

  • PRECAUTIONS
    Patients with an element of agitation may react adversely; discontinue therapy if necessary.

History of attention deficit as a recognized disorder

The clinical definition of "ADHD" dates to the mid-20th century, when physicians developed a diagnosis for a set of conditions variously referred to as "minimal brain damage", "minimal brain dysfunction", "learning/behavioral disabilities" and "hyperactivity". Researchers speculate that earlier references to the condition, as mentioned in the examples below, have been made throughout history.

In 493 BCE, physician-scientist Hippocrates described a condition that seems to be compatible with what we now know as ADHD. He described patients who had "quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression." Hippocrates attributed this condition to an "overbalance of fire over water.” His remedy for this "overbalance" was "barley rather than wheat bread, fish rather than meat, water drinks, and many natural and diverse physical activities."[44] Shakespeare made reference to a "malady of attention" in King Henry VIII, which at least "proves" that people don't pay attention when other things are on their mind.

In 1845, Dr. Heinrich Hoffmann (a German physician and poet who wrote books on medicine and psychiatry) became interested in writing for children when he couldn't find suitable materials to read to his 3-year-old son. The result was a book of poems, complete with illustrations, about children and their undesirable behaviors. One, "The Story of Fidgety Philip," was a description of a little boy who could be interpreted as having ADHD.[45] On the other hand, it could also be interpreted as merely a moral fable exaggerating children's normal "improper" behavior to amuse young children and encourage them to behave properly.

In 1902, the English pediatrician George Still gave a series of lectures to the Royal College of Physicians in England, describing a condition which some have claimed is analogous to ADHD. Dr. Still described a group of children with significant behavioral problems caused, he believed, by hereditary.[46]

In 1918–19, the world-wide influenza pandemic left many survivors with encephalitis, affecting their neurological functions. Some of these exhibited immediate behavioral problems similar to what we now call ADHD. This caused researchers and doctors to believe that the condition was the result of injury rather than heredity. Not until 1960 was the concept of hyperactivity again described as being caused by heredity (Hyperactive Child Syndrome") and not brain damage.[47])

Until the early 1990s, Europeans saw hyperkinesis as unusual and associated with retardation, brain damage, and conduct disorders; in the U.S., however, following observations in 1966 that the condition existed without any objectively observed pathological disorder or injury, researchers changed the terminology from Minimal Brain Damage to Minimal Brain Dysfunction. It may be noteworthy to mention that food additives such as flavoring and coloring were introduced into the food supply earlier in the U.S. than in Europe.

In 1968, displaying the psychoanalytical influences of that time, psychiatry officially codified a condition called “hyperkinetic reaction of childhood.” The name Attention Deficit Disorder (ADD) was first introduced in the 1980 DSM-III. Further revisions to the DSM were made in 1987 and 1994, and today's DSM-IV describes three groupings within ADHD, which can be simplified as: mainly inattentive; mainly hyperactive-impulsive; and both in combination.

In January of 1982, the National Institute of Health held a Consensus Development Conference on Defined Diets and Childhood Hyperactivity. Their conclusions were published in an NIH Consensus Statement 1982 Jan 13-15;4(3):1-11 The 1982 NIH panel's findings relating to diet therapy, was:

  • The Feingold diet is a valid option for the treatment of childhood hyperactivity.
  • While some children were clearly helped, the scientific studies did not support the clinical reports of 60 to 70% success.
  • But the studies were seriously flawed, and dealt almost exclusively with dyes, and thus were not a valid test of the Feingold diet.
Their report states:
"Controlled challenge studies have primarily involved the administration of food dyes to children, but have not included other food flavors or preservatives that are allegedly implicated in the causation of hyperactivity. Therefore, these controlled challenge studies do not appear to have addressed adequately the role of diet in hyperactivity."

Although not even named as a distinct condition until 1968, by 1996 ADHD accounted for at least 40% of child psychiatry references.[48]

In 1998, another Consensus Development Conference on stimulant drug and other treatments for ADHD was held by the NIH. They failed to reach a consensus on how to define ADHD, although calling it the "most commonly diagnosed behavioral disorder of childhood." It was reported that the disorder is more prevalent in the United States than elsewhere.

The 23 nonstimulant treatments for ADHD which were reviewed by L. Eugene Arnold were totally ignored, with diet therapy alone mentioned only in passing, with the statement that "some of the dietary elimination strategies showed intriguing results suggesting future research."

In their section on effective treatments, the panel concluded that:

  • It cannot be determined if the combination of stimulants and psychosocial treatments can improve functioning with reduced dose of stimulants;
  • there are no data on the treatment of ADHD, Inattentive type;
  • There are no conclusive data on treatment in adolescents and adults with ADHD;
  • There is no information on long-term treatment;
  • There is a need for development of methods targeted to cognitive problems such as deficiencies in working memory and language deficits.
This was the meeting at which one doctor (mentioned above under "What Causes ADHD?") complained in exasperation to the reporters that "diagnosis is a mess!!"

Dr. Arnold later published his review of the non-stimulant treatments which the panel had almost totally ignored. It can be seen here.

As the 1998 conference was being organized, and responding to the ongoing complaint that there was no long term research on the safety or efficacy of stimulant medication, a 14-month study known as the Multimodal Treatment Study of ADHD (MTA Study), had already been initiated. It involved more than 570 children with ADHD at 6 sites in the United States and Canada. Results generally showed that medication alone was more effective than psychosocial treatments alone, but that their combination was beneficial for some children. More than 40 studies have subsequently been published from this same data. [Note: Diet was not included in this study, and although this is often billed as the "largest study on ADHD ever done," the Schoenthaler study on over a million children whose diet had been changed was much larger.]

In 2004, Bateman et al did a study in England on toddlers from the general population. The children were given a modest amount of coloring (only 20 mg) plus some sodium benzoate preservative. Their reaction was sufficient for Bateman to conclude that "this suggests that benefit would accrue for all children if artificial food colours and benzoate preservatives were removed from their diet."

In 2007, a followup study (McCann 2007) was also published in England, showing that in the general population (children not diagnosed with anything), a modest amount of mixed coloring and a preservative elicited increased hyperactive symptoms and decreased attention span in both toddlers and adolescents. This study led to a radical change in the food supply of England and Europe, as supermarkets and international suppliers scrambled to replace the synthetic colorings and preservatives with safer, natural colorings and natural preservatives.

To date, the United States has not responded in any way to this development.

History of development and use of drugs for ADHD

In 1937, a Dr. Bradley in Providence, RI, reported that a group of children with behavioral problems following encephalitis improved after being treated with stimulant medication.

In 1957, the stimulant methylphenidate (Ritalin) became available. Today, under various names including Focalin, Concerta, Metadate, Methylin, and Vyvanse, it remains one of the most widely prescribed medications for ADHD. Although methylphenidate was originally used to treat narcolepsy, chronic fatigue, depression, and the sedating effects of other medications, it began to be used for ADHD in the 1960s and has steadily increased since.

In 1975, pemoline (Cylert) was approved by the FDA for use in the treatment of ADHD. While an effective agent for managing the symptoms, the development of liver failure in several children over the next 27 years resulted in the withdrawal of this medication from the market.

In 1999, new delivery systems for medications were invented to eliminated the need for taking a mid-day dose at school. These new systems include pellets of medication coated with various time-release substances to permit medications to dissolve hourly across an 8–12 hour period (Metadate CD, Adderall XR, Focalin XR) and an osmotic pump that extrudes liquid methylphenidate across an 8–12 hour period after ingestion (Concerta).

In 2003, atomoxetine (Strattera) received the first FDA approval for a nonstimulant drug to be used specifically for ADHD.

In mid-2007, a newer way of taking methylphenidate was approved. Originally called MethylPatch, it is similar to patches used for hormone replacement therapy or nicotine, and is marketed under the brand name Daytrana. The FDA approved it for use in children 6 to 12 years old, for a 9-hour period.

Most recently, in late 2007, the once-a-day stimulant lisdexamfetamine (Vyvanse) was introduced with much fanfare as the "future of ADHD treatment." It is called a "prodrug" because it has an amino acid attached to the methylphenidate, causing it to be inactive "until swallowed." As you probably know, all drugs taken by mouth are inactive until swallowed, but the main advantage of the amino acid appears to be prevention of abuse by inhalation or injection. Since this drug is so new, we refer you to the Vyvanse site itself. Note that they base their efficacy on only two (2) studies on children and one (1) study on adults. Scroll down below the box with the smiling children and read the safety information (small print) that they are required to post.

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