ADD/ADHD

ADD, ADHD, AND DEFINITIONS

ADHD has been marked by an inability to concentrate and see work through to task completion. It comes in several flavors: once labeled as only Attention Deficit Disorder, it is now known as Attention Deficit Hyperactivity Disorder, and comes in at least three versions at the moment: hyperactive compulsive, inattentive, and a combined disorder of the first type.

According to the Diagnostic Statistics Manual for medical disorders known as DSM now in its 4th version, (DSM-IV) 3-7% of children currently have ADHD. This illness is especially prominent in males by a factor of 3 to 1 over females. The statistics vary for adult ADD from 1 to 10% of the population. (My clinical experience tells me it’s closer to 10%).

ADHD is frequently diagnosed with a single visit resulting in perhaps some over reporting of this disorder. Typically, a person needs to complain of problems with focus and staying on task for at least 6 months, and ideally either the person or parents have noticed these issues in early childhood, by age 6.

The formal criteria are listed below from DSM-IV

Six or more of the following must be present:

INATTENTION ADHD

1. Careless mistakes in tasks
2. Difficulty sustaining attention
3. Doesn’t seem to listen
4. Doesn’t follow through or finish
5. Difficulty organizing tasks
6. Avoids tasks which require sustained mental effort
7. Loses things
8. Easily distracted
9. Forgetful

HYPERACTIVITY ADHD

1. Fidgets
2. Difficulty remaining seated
3. Runs or climbs excessively
4. Difficulty playing quietly
5. Acts as if driven by a motor
6. Talks excessively
7. Blurts out answers before question is complete
8. Has difficulty awaiting turn
9. Interrupts others

Additionally, there may also be a history of drug addiction, alcohol abuse, or previous criminal record. People with ADD often don’t seem to have enough dopamine and it is for this reason that they try to satisfy their brain with other chemicals. Inevitably, it only makes problems worse.

There are a number of illnesses that can mask as ADD and should be ruled out if there is suspicion that they could be present. These include:

1. Dysfunctional family issues. Some children and adults are struggling from problems with their family unit. Issues range from parents fighting, sexual and mental abuse, abandonment issues and in adults marital discord and financial pressures.
2. Learning Disabilities such as dyslexia.
3. Hearing and vision disorders. I know in my own case I began having trouble seeing the chalk board in the third grade and for the longest time was afraid to say anything just hoping I’d get a front row seat. Eventually though my teacher realized I was having a problem and glasses solved my problem and my grades went up.
4. Oppositional defiant disorder and other conduct disorders.
5. Lead and other heavy metal poisoning
6. Medication issues; decongestants, antihistamines, and other medications can be associated with poor focus.
7. Tourette’s Disorder
8. Pervasive Developmental Delay
9. Absence seizures

BIOCHEMICAL BASIS OF ADHD

As I alluded to earlier, the biochemistry of ADHD seems to be tied into low neurotransmitter levels and additionally, work by Dr. Richard Deth suggests that the neurotransmitter receptors themselves are implicated in focus and attention issues.

Remember most cells communicate with each other by “reaching out and touching someone”. They do this with little leg like structures that release nerve chemicals that we call neurotransmitters. Not only are the neurotransmitters themselves important, the sites they bind to on the cells are important as well. These sites known as receptors (kind of like receptacles in the wall) can change shape depending on what’s going on with the fatty acids around them.

It turns out that one neurotransmitter in particular is very important for learning and focus. It is called dopamine. It comes from the amino acid tyrosine and is first converted to dopa then dopamine. Once it becomes dopamine, it must bind to the site on the neurons to tell them to “pay attention, this fact is important”.

Interestingly, in order to bind properly, the binding site has to relax and “open up” to allow dopamine in. What prompts it to open up? Good question. There are several things. One is the type of fatty acids that make up the wall of the cell and the rim of the receptor site. If you remember, 60% of the cell is fatty acid. The type of fat makes a difference in the flexibility of the cell and how well the cell communicates with other cells. Additionally, the fatty acids must be “methylated” properly in order to open (somewhat like a flower) to allow dopamine in. These methyl groups are one carbon with two or three hydrogen molecules attached. They come from things like folic acid. Once this methyl group binds to the fatty acid, the fat relaxes and opens up the site a bit so that dopamine can bind. This then amplifies the learning signals that the cell would typically use to create memory and focus. It is quite fascinating to read his work and realize that we have a significant measure of control over this whole issue.

The role of folic acid is crucial and without it, there would more problems than there are with ADD. Before folic acid can donate to the methylation of the dopamine receptor, it has to be altered as well. In order for this to happen, an enzyme known as MTHFR for short has to process the folic acid. This then leads to the availability of folic acid for the enzyme known as methionine synthase. This enzyme can be poisoned by mercury and the first enzyme I mentioned (MTHFR) can have genetic problems that lead to poor processing of folic acid. This would ultimately mean there is not enough folic acid around to do the job of changing the receptor sites, which means dopamine doesn’t bind properly and we are left without the proper change in shape of these binding sites for dopamine. So put another way, you can have dopamine around all day long, but if you don’t make room for it, it doesn’t help you very much.

Interestingly, the enzyme known as methionine synthase, that takes these folic acid methyl groups and uses them to neutralize more toxic amino acids like homocysteine is very sensitive to mercury. So whether the mercury came from a vaccine, a dental amalgam, the ground water, or tuna fish, it has a chance of weakening this enzyme’s ability to convert unhealthy amino acids to healthy ones. Homocysteine, at least in animal studies is an excitotoxin and can over stimulate neurons (nerve cells) . If you’ve got ADD, this is something you don’t need.

In our practice we’ve seen benefit using amino acid therapy as well to help support the production of the neurotransmitters such as dopamine, norepinephrine, serotonin, and GABA. Making neurotransmitters is in a simplistic way kind of like the Dinner Diva making dinner. You’ve got to have a recipe which includes: cofactors (vitamins and minerals especially the B vitamins), amino acids (most importantly tryptophan and tyrosine), and the right amount of fat. Does it always work? No, but it often does work especially in helping depression, insomnia, and in some cases ADD. In many cases we’ve been able to lower the dosage of medication so that there are less side effects and in some cases help people come off of medication altogether. I do NOT however recommend you do this without the guidance of a physician.

A number of studies have now been done showing support for the assessment of food allergies in all children with symptoms of ADHD although evidence is mixed. One interesting study revealed that when a multiple elimination diet (elimination of dairy, wheat, corn, yeast, soy, citrus, eggs, chocolate, peanuts, artificial colors, and preservatives) was followed for just weeks, an impressive 73% of children responded favorably as measured by the Conner Parent Rating Scale. (2) When these foods were reintroduced back into the diet, the behavior of the children was clearly aggravated with many of their symptoms returning. While foods and preservatives are not the cause of all ADHD, in this small study they were clearly implicated. Those most likely to respond positively to the elimination of foods are those with a history of asthma, eczema, seasonal rhinitis (hay fever, et al), or urticaria (allergic skin rash or hives).

In one study, 15 children underwent baseline EEGs to assess their brain wave activity. They were then challenged with their allergic foods and found to have abnormalities in their brain wave activity. This supports the possibility that children with abnormal behavior may in part be struggling with neurological manifestations of food allergy. (2)

After reviewing 13 major studies in the peer reviewed literature, Dr. Breaky in the Journal of Pediatric Child Health said in 1997 that professionals dealing with children with ADHD should be aware of dietary treatment as an option for some children. They can be supportive of parents who wish to consider diet, particularly as motivation is important in the diet implementation. Sleep and physical problems in children with ADHD, can play into this as well. They often have a history of allergic respiratory symptoms as mentioned earlier. A degree of change was noted with partial and full responses occurring rather than an all-or-nothing earlier expectation. Factors found to correlate with a beneficial response were related to allergic history–a family history of migraine, young age, and importantly, a family history of definite food reaction.

But there are other contributors to ADHD other than food that need to be looked at, especially abnormal mineral levels. In another study (3), 116 children with ADHD had their levels of magnesium, copper, zinc, calcium, and iron measured by blood and hair analysis were assessed.

The most intriguing finding was a significant difference in zinc levels in patients with ADHD and coexisting disruptive disorders. Their zinc levels were lower. Not only that, but magnesium was lower in a number of these children as well. Magnesium was then replaced in 50 of these children and was not in another 25. The 50 who had mineral replacement with magnesium had a significant decrease in hyperactivity after six months. The untreated 25 were not noted to have behavioral improvement.

Another study looking at aggressive behavior in young males, revealed that compared to “normal control males” the ratio of serum copper to plasma zinc levels was 40% higher implying that too much copper is not a positive influence for young males. (4)

Other areas of increasing interest are the fatty acid deficiencies and their impact on behavior. In my clinical experience, by measuring fatty acid levels for the Omega 3, 6 and 9s and then replenishing these fats and their cofactors, I have been able to significantly help patients with ADHD, Bipolar Disorder, and Schizophrenia.

There are some significant studies that would confirm my clinical findings, such as an article published by Burgess and Colleagues in the American Journal of Clinical Nutrition, July 2000 Supplement in which researchers found that symptoms associated with fatty acid deficiencies included dysfunction of behavior and the senses, impaired growth, dry and scaly skin, excessive thirst, excessive urination, and joint pain.

Although fatty acid deficiencies aren’t necessarily the cause of ADHD, they may be associated with this disorder. Clinically, DHA (an omega 3 fat) seems to be the most strongly linked. It is not wise however, to just begin on a single fatty acid–you could throw the others out of balance. It is important that you see your doctor for further discussion of these concepts and let him/her guide your child’s therapy.

SO WHAT TESTS ARE HELPFUL IN FIGHTING ADD/ADHD?

The following nutrients should probably be assessed:

1. RBC Magnesium level
2. RBC Zinc level
3. RBC Copper level
4. Vitamin B1, Vitamin B5, Vitamin B6, B12, and folic acid levels.
5. Fatty Acid assessment- the best test I know of is at the Kennedy Krieger Institute at Johns Hopkins. Your doctor can access this test through the Body Bio Center in New Jersey. This test comes with recommendations that we’ve seen help many children with Autistic and Attention Deficit disorders.

WHERE DO I START IN DOING THINGS TO HELP SUPPORT MY CHILD NUTRITIONALLY?

Relatively safe recommendations for children struggling with ADD/ADHD would include: evening primrose oil, ground flax seeds, Omega Nutrition Safflower Oil, Sunflower oil, sesame oil, and walnut oil. A mixture of these oils totaling one tablespoon/day would be reasonable for a child between ages 6 and 15. Efamol with DHA may also be helpful.

WHAT OTHER RESOURCES MIGHT BE HELPFUL IN LEARNING MORE ABOUT THIS SUBJECT?

While I have not covered SPECT scanning and neurological disorders, this is an exciting field and intervening with my patients based on the findings of abnormal SPECT scans has been very gratifying, with some of them experiencing significant changes (self reported) in just a very short time. Comments include things like: “better sleep”, “more focused”, “ better memory”. The majority of this research has been done at the AMEN clinics. You might find some encouraging and interesting information in Dr. Amen’s book: Healing ADD. I believe it will be an invaluable resource. SPECT scanning and the subsequent doctor visit is expensive however. As such a trial of nutritional interventions guided by blood evaluation may be less expensive and still yield very good results.

This is a rapidly expanding and exciting field. We’ll review it in more detail as time moves on. Hopefully this will get you started if you’ve not known where to go. Let me also say that we do use medication for this illness and I’ll review those at a later time. I feel that while medication can be appropriate if you can find the fundamental environmental or nutritional cause of the illness this should be dealt with first unless you are in a crisis situation in which case medication is certainly the most appropriate avenue (assuming it works).

To your health!

Dr. Neal

References

1. The Annals of Allergy, Vol 72, May 1994
2. Uhlig, et al. Eur J Pediatr. 1997 Jul;156 (7):557-61.
3. Magnesium Research, June of 1997
4. Walsh, et al, Physiology and Behavior, 1997 Vol 62, No. 2 pp 327-29

Other Resources: Richard Deth – Molecular Mechanisms of Attention