Attention Deficit Hyperactivity Disorder (ADHD) Case Studies

ADHD Is Associated With a “Western” Dietary Pattern in Adolescents

Amber L. Howard, Monique Robinson, Grant J. Smith, Gina L. Ambrosini,
Jan P. Piek and Wendy H. Oddy
In: Preventive Medicine 49 (2009) 39-44


To examine the relationship between dietary patterns and ADHD in a population-based cohort of adolescents.


The Raine Study is a prospective study following 2,868 live births. At the 14-year follow-up, the authors collected detailed adolescent dietary data, allowing for the determination of major dietary patterns using factor analysis. ADHD diagnoses were recorded according to International Classification of Diseases, 9th Revision coding conventions. Logistic regression was used to assess the relationship between scores for major dietary pattern and ADHD diagnoses.


Data were available for 1,799 adolescents, and a total of 115 adolescents had an ADHD diagnosis. Two major dietary patterns were identified: “Western” and “Healthy.” A higher score for the Western dietary pattern was associated with ADHD diagnosis (odds ratio = 2.21, 95% confidence interval = 1.18, 4.13) after adjusting for known confounding factors from pregnancy to 14 years. ADHD diagnosis was not associated with the “Healthy” dietary pattern.


A Western-style diet may be associated with ADHD.

The association between dietary patterns and mental health in early adolescence <h2>

Wendy H. Oddy, Monique Robinson, Gina L. Ambrosini, Therese A. OSullivan, Nicholas H. de Klerk, Lawrence J. Beilin , Sven R. Silburn , Stephen R. Zubrick , Fiona J. Stanley
In: Preventive Medicine 49 (2009) 39-44


To investigate the associations between dietary patterns and mental health in early adolescence.


The Western Australian Pregnancy Cohort (Raine) Study is a prospective study of 2900 pregnancies recruited from 1989– 1992. At 14 years of age (2003–2006; n=1324), the Child Behaviour Checklist (CBCL) was used to assess behaviour (characterising mental health status), with higher scores representing poorer behaviour. Two dietary patterns (Western and Healthy) were identified using factor analysis and food group intakes estimated by a 212-item food frequency questionnaire. Relationships between dietary patterns, food group intakes and behaviour were examined using general linear modelling following adjustment for potential confounding factors at age 14: total energy intake, body mass index, physical activity, screen use, family structure, income and functioning, gender and maternal education at pregnancy.


Higher total (b=2.20, 95% CI=1.06, 3.35), internalizing (withdrawn/depressed) (b=1.25, 95% CI=0.15, 2.35) and externalizing (delinquent/aggressive) (b=2.60, 95% CI=1.51, 3.68) CBCL scores were significantly associated with the Western dietary pattern, with increased intakes of takeaway foods, confectionary and red meat. Improved behavioural scores were significantly associated with higher intakes of leafy green vegetables and fresh fruit (components of the Healthy pattern).


These findings implicate a Western dietary pattern in poorer behavioural outcomes for adolescents. Better behavioural outcomes were associated with a higher intake of fresh fruit and leafy green vegetables.

Nutritional and dietary influences on attention deficit hyperactivity disorder <h2>

Natalie Sinn
In: Nutrition Reviews® Vol. 66(10):558–568, October 2008

An abundance of research has investigated causes and treatments for attention deficit hyperactivity disorder (ADHD). The research includes identification of suboptimal levels of nutrients and sensitivities to certain foods and food additives. This review gives an overview of this research and provides an up-to-date account of clinical trials that have been conducted with zinc, iron, magnesium, Pycnogenol, omega-3 fatty acids, and food sensitivities. A literature search was conducted using PubMed, ISIWeb of Knowledge, and Google Scholar and included studies published before April 2008. Although further research is required, the current evidence supports indications of nutritional and dietary influences on behavior and learning in these children, with the strongest support to date reported for omega-3s and behavioral food reactions.

Nutrition in the Treatment of Attention- Deficit Hyperactivity Disorder: A Neglected but Important Aspect <h2>

Roseanne Schnoll, Dmitry Burshteyn, und Juan Cea-Aravena
In: The Lancet, March 9, 1985


Attention-deficit hyperactivity disorder (ADHD) is multidetermined and complex, requiring a multifaceted treatment approach. Nutritional management is one aspect that has been relatively neglected to date. Nutritional factors such as food additives, refined sugars, food sensitivities/allergies, and fatty acid deficiencies have all been linked to ADHD. There is increasing evidence that many children with behavioural problems are sensitive to one or more food components that can negatively impact their behavior. Individual response is an important factor for determining the proper approach in treating children with ADHD. In general, diet modification plays a major role in the management of ADHD and should be considered as part of the treatment protocol.

A randomised controlled trial into the effects of food on ADHD

Lidy M.J. Pelsser, Klaas Frankena, Jan Toorman, Huub F.J. Savelkoul, Rob
Rodrigues Pereira, Jan K. Buitelaar
In: Eur Child Adolesc Psychiatry (2009),18:12–19 DOI 10.1007/s00787-008-0695-7


The aim of this study is to assess the efficacy of a restricted elimination diet in reducing symptoms in an unselected group of children with Attention deficit/hyperactivity disorder (ADHD). Dietary studies have already shown evidence of efficacy in selected subgroups. Twenty-seven children (mean age 6.2) who all met the DSM IV criteria for ADHD, were assigned randomly to either an intervention group (15/27) or a waiting-list control group (12/27). Primary endpoint was the clinical response, i.e. a decrease in the symptom scores by 50% or more, at week 9 based on parent and teacher ratings on the abbreviated ten-item Conners  Scale and the ADHD DSM-IV Rating Scale. The intentionto- treat analysis showed that the number of clinical responders in the intervention group was significantly larger than that in the control group [parent ratings 11/15 (73%) versus 0/12 (0%); teacher ratings, 7/10 (70%) versus 0/7 (0%)]. The Number of ADHD criteria on the ADHD Rating Scale showed an effect size of 2.1 (cohen’s d) and a scale reduction of 69.4%. Comorbid symptoms of oppositional defiant disorder also showed a significantly greater decrease in the intervention group than it did in the control group (cohens’s d 1.1, scale reduction 45.3%). A strictly supervised elimination diet may be a valuable instrument in testing young children with ADHD on whether dietary factors may contribute to the manifestation of the disorder and may have a beneficial effect on the children’s behaviour.

The hyperkinetic syndrome with an attention deficit disorder with a special regard to nutrition

Prof. Dr. med. Joseph Egger
In: Artikel auf den Seiten des „Bundesverband Arbeitskreis überaktives Kind e.V.“, 2003


Coherences between nutrition and behavioural disorders have been suspected since Rowe’s monograph about food allergies in 1931. Since then, the influence of nutrition on behaviour has been analysed in many reports. Nevertheless this topic remains controversial which is among other things due to inconsistent definitions and non-scientifically tested hypotheses. During the last 15 years it was possible to prove by doubled-blind, placebo controlled trials that for about 70 % of all patients with the hyperkinetic syndrome agitation, impulsiveness, capacity of memory, attention and sleep quality improved considerably and in some cases even normalised, when treated with an elimination diet (Egger et al 1985, 1992, Carter et al 1993, Boris et al 1994, Kiefer et al 1996, Uhlig et al 1997, Facaoaru et al 1994, 1998). Former hypotheses like the Feingold-hypothesis or the Phosphate-hypothesis could not persist scientifically and have become less important. Nutrition can affect behaviour in different ways. One distinguishes between the following options: • Food intolerances (that is a reproducible physical or mental reaction after taking a specific food, which appears regardless of whether the patient knows about this food or not).

  • Psychologically caused reactions to a food, which only appears when the patient knows he ate this food
  • Interaction between these two methods

Favourable effect of a standard elimination diet on the behavior of young children with attention deficit hyperactivity disorder (ADHD): a pilot study <h2>

Pelsser LM, Buitelaar JK.
In: Nederlands Tijdschrift voor Geneeskunde, 2002; 146; 2543-7


To determine whether a standard elimination diet can decrease the ADHD-symptoms in a heterogeneous group of young children with ADHD.


Open, descriptive.


40 children, 36 boys and 4 girls, aged 3-7 (average 4.8 years), who met the DSM-IV-criteria for ADHD, followed their usual diet for two weeks and thereafter for two weeks an elimination diet, based on the few foods diet (rice, turkey, pear and lettuce). The behaviour of the child was evaluated at study entry, after the baseline period and at the end of the diet. Parents completed the 10-item Conners list, the ADHD Rating Scale and a physical complaints list. The teachers completed the 10-item Conners list and the ADHD Rating Scale twice, at the beginning and at the end of the diet.


According to the parent-ratings, 25 children (62%) showed an improvement in behaviour of at least 50% on both the Conners list and the ADHD Rating Scale at the end of the elimination diet. Nine children (23%) withdrew from the study because the parents were unable to stick to the diet or because the child fell ill. Among the 15 children with both parent and teacher ratings, 10 responded both at home and in school.


In young children with ADHD an elimination diet can lead to a statistically significant decrease in symptoms.

Effects of a few food diet in attention deficit disorder

Carter CM, Urbanowicz M, Hemsley R, Mantilla L, Strobel S,
Graham PJ, Taylor E.
In: Journal of Attention Disorders OnlineFirst, published on July 14, 2010 as

Seventy-eight children, referred to a diet clinic because of hyperactive behaviour, were placed on a ‚few foods‘ elimination diet. Fifty nine improved in behaviour during this open trial. For 19 of these children it was possible to disguise foods or additives, or both, that reliably provoked behavioural problems by mixing them with other tolerated foods and to test their effect in a placebo controlled double blind challenge protocol. The results of a crossover trial on these 19 children showed a significant effect for the provoking foods to worsen ratings of behaviour and to impair psychological test performance. This study shows that observations of change in
behaviour associated with diet made by parents and other people with a role in the child‘s care can be reproduced using double blind methodology and objective assessments. Clinicians should give weight to the accounts of parents and consider this treatment in selected children with a suggestive medical history.

Controlled trial of oligoantigenic treatment in the hyperkinetic syndrome

Egger J, Carter CM, Graham PJ, Gumley D, Soothill JF.
In: The Lancet, March 9, 1985 ; 1(8428):540-5.


76 selected overactive children were treated with an oligoantigenic diet, 62 improved, and a normal range of behaviour was achieved in 21 of these. Other symptoms, such as headaches, abdominal pain, and fits, also often improved. 28 of the children who improved completed a double-blind, crossover, placebo-controlled trial in which foods thought to provoke symptoms were reintroduced. Symptoms returned or were exacerbated much more often when patients took the incriminated foods, than when they were on placebo. 48 foods were incriminated. Artificial colorants and preservatives were the commonest provoking substances, but no child was sensitive to these alone.

Gluten- and casein-free diets for autistic spectrum disorder

Millward C, Ferriter M, Calver S, Connell-Jones G
In: Cochrane Database Syst. Rev. (Update 2008, Original 2004)


It has been suggested that peptides from gluten and casein may have a role in the origins of autism and that the physiology and psychology of autism might be explained by excessive opioid activity linked to these peptides. Research has reported abnormal levels of peptides in the urine and cerebrospinal fluid of persons with autism. If this is the case, diets free of gluten and/or casein should reduce the symptoms associated with autism.


To determine the efficacy of gluten- and/or casein-free diets as an intervention to improve behaviour, cognitive and social functioning in individuals with autism.

Main results:

Reduction in autistic traits, a significant beneficial treatment effect for the combined gluten- and casein-free diet.


This is an important area of investigation and large scale, good quality randomised controlled trials are needed

Opioid Peptides Derived from Food Proteins The Exorphins

Christine Zioudrou, Richard A. Streaty, Werner A. Klee
In: The Journal of Biological Chemistry (1979)


Peptides with activity similar to that of morphine and other opioids have been isolated from the brain and other sources such as the pituitary. These peptides, the endorphins and enkephalins, may function both as hormones and neurotransmitters. An alternate source of peptides, some of which may have biological activities, is dietary protein. Because of reports linking wheat gluten with mental disorders, pepsin digests of wheat gluten were tested for opioid activity. These peptides are called exorphins because of their exogenous origin and morphine-like activity. Also present in pepsin digests of wheat gluten are stimulatory materials which exhibit activities opposed to those of the exorphins. The results have shown that peptides with morphine-like activities, exorphins, can be isolated from some food proteins after treatment with the stomach proteinase, pepsin. In all likelihood, exorphins will be produced normally in the stomach. The exorphins may be expected to survive extensive degradation, from the gastrointestinal tract into the bloodstream.
Some peptide fragments of gluten do indeed reach the brain. Finally, there is evidence that the exorphins will bind to brain opiate receptors as well as to those of peripheral organs. In summary, exorphins may normally reach opiate receptors in the central nervous system and trigger their function.

Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial

Donna McCann, Angelina Barrett, Alison Cooper, Debbie Crumpler, Lindy
Dalen, Kate Grimshaw, Elizabeth Kitchin, Kris Lok, Lucy Porteous, Emily
Prince, Edmund Sonuga-Barke, John O Warner, Jim Stevenson
In: “The Lancet“, 2007 Nov 3, 370(9598):1542


We undertook a randomised, double-blinded, placebo-controlled, crossover trial to test whether intake of artificial food colour and additives (AFCA) affected childhood behaviour.


153 3-year-old and 144 8/9-year-old children were included in the study. The challenge drink contained sodium benzoate and one of two AFCA mixes (A or B) or a placebo mix. The main outcome measure was a global hyperactivity aggregate (GHA), based on aggregated z-scores of observed behaviours and ratings by teachers and parents, plus, for 8/9-year-old children, a computerised test of attention. This clinical trial is registered with Current Controlled Trials (registration number ISRCTN74481308). Analysis was per protocol.


16 3-year-old children and 14 8/9-year-old children did not complete the study, for reasons unrelated to childhood behaviour. Mix A had a significantly adverse effect compared with placebo in GHA for all 3-year-old children but not mix B versus placebo. This result persisted when analysis was restricted to 3-year-old children who consumed more than 85% of juice and had no missing data. 8/9-year-old children showed a significantly adverse effect when given mix A or mix B when analysis was restricted to those children consuming at least 85% of drinks with no missing data.


Artificial colours or a sodium benzoate preservative (or both) in the diet result in increased hyperactivity in 3 year-old and 8/9-year-old children in the general population.

Synthetic food colouring and behaviour: A dose response effect in a double-blind, placebo controlled, repeated-measures study

Katherine S. Rowe a and Kenneth J. Rowe a
In: The Journal of Pediatrics, Volume 125, Issue 5, Pages 691-698 (November 1994)


To establish whether there is an association between the ingestion of synthetic food colourings and behavioural change in children referred for assessment of „hyperactivity.“ Participants: From approximately 800 children referred to the Royal Children‘s Hospital (Melbourne) for assessment of suspected hyperactivity, 200 were included in a 6-week open trial of a diet free of synthetic food colouring. The parents of 150 children reported behavioural improvement with the diet, and deterioration on the introduction of foods noted to contain synthetic colouring. A 30-item behavioural rating inventory was devised from an examination of the clinical histories of 50 suspected reactors. Thirty-four other children (23 suspected reactors, 11 uncertain reactors) and 20 control subjects, aged 2 to 14 years, were studied.


A 21-day, double-blind, placebo-controlled, repeated measures study used each child as his or her own control. Placebo, or one of six dose levels of tartrazine (1, 2, 5, 10, 20, 50 mg), was administered randomly each morning, and behavioural ratings were recorded by parents at the end of each 24 hours.


The study identified 24 children as clear reactors (19 of 23 suspected reactors,“ 3 of 11 „uncertain reactors,“ and 2 of 20 „control subjects“). They were irritable and restless and had sleep disturbance. Significant reactions were observed at all six dose levels. A dose response effect was obtained. With a dose increase greater than 10 mg, the duration of effect was prolonged.


Behavioural changes in irritability, restlessness, and sleep disturbance are associated with the ingestion of tartrazine in some children. A dose response effect was observed. (J P 1994;125:691-8)

Hyperkinesis and Learning Disabilities Linked to Artificial Food Flavours and Colours

Ben F. Feingold, MD
In: American Journal of Nursing, May 1975, Volume 75, Number 5

Since 1972, five separate dietary programs have been conducted with 194 H-LD children. The children were given a diet eliminating all artificial colours and flavours and all foods containing a natural salicylate radical. The experience to date indicates that approximately 50 percent of children with HLD respond to strict elimination diets. Loss of hyperactivity, aggression, and impulsiveness are the initial changes observed. This is soon followed by improvement in muscular coordination as indicated by improved writing and drawing abilities, greater facility with speech, and loss of clumsiness. Disturbances in cognition and perception are usually the last to respond. With an increased attention span which permits greater concentration, scholastic achievement improves rapidly. Age seems to be an important determining factor in the degree and speed of response to dietary management. The younger the child, the more rapid and more complete is the improvement.
Any infraction of the diet, either inadvertent or deliberate, causes a recurrence of the complete behavioural pattern within two or four hours which persists for one to four days.

Behavioral Disorders and Hyperactivity in Children and Adults

An investigation using hair analysis of the relationship between toxic load and mineral-imbalances on behavioral disorders

Philip Horsch, Hugo Schurgast
In: Schweiz. Zschr. GanzheitsMedizin Jg. 18, Heft 2, März 2006


Behavioral disorders are not only associated with psychosocial factors but also with well-documented and biochemically transparent metabolic imbalances. Ritalin and other medications may be effective for behavioral disorders and hyperactivity in the short or medium term. These medications may moderate the symptoms – however, they usually cannot correct metabolic imbalances. Aim of the study: To investigate the relationship between mineral imbalance and toxic load and hyperactivity in adults and children.


Retrospective data-analysis.


The biochemical profile, determined by a hair mineral analysis, of 1257 persons with behavioral disorders and hyperactivity, was statistically evaluated.


The study population showed a 25 % and 23 % reduced content in calcium and magnesium, respectively. Furthermore, significant amounts of the toxic elements aluminium and lead could be detected.


Further research is needed to determine the extent to which mineral imbalance and toxic load may be underlying causes of behavioral disorders. To enhance the therapeutic success of behavioral disorders, the stated metabolic imbalances as well as the body burdens have to be corrected by various interventions. The main emphasis is on a parallel application of classical methods together with nutritional interventions and a separate, individualised intake of micronutrients.

Electrophysiologic and Psycho-Acoustic Findings Following One-Year Application of a Personal Ear-Level FM Device in Children with Attention Deficit and Suspected Central Auditory Processing Disorder

Edgar Friederichs, Petra Friederichs
In: Journal of Educational Audiology 12 (2005)

This study examined whether electrophysiological and psycho- acoustic auditory measures would reflect changes following use for one year of a personal ear-level frequency-modulated (FM) device in a group of children with symptoms of central auditory processing disorder (CAPD). Subjects consisted of 10 children aged 7 to 14 years with normal hearing thresholds, suspected CAPD, and additional attention and/or learning difficulties. The children were provided with a personal ear-level FM system which was required to be used mainly during school time for one year. An age-matched control group was also followed over the time period of one year. Results indicated that the children who used the earlevel personal FM device exhibited significantly improved performance on specific tests of auditory function compared to the control group. Furthermore, electrophysiological late event-related potentials revealed significant changes in the experimental group, suggesting an accelerated neuromaturational process when using a FM-device compared to an agematched control group. Parents and teachers also reported a significant improvement in speech understanding and in overall school performance as well as accompanying conduct behaviour in the children who used the FM device. Results of this study suggest that the late auditory event-related potentials are sensitive to changes in clinical development of children using an ear-level FM device. Results also indicate that use of an ear-level FM device results in improved behavioural and electrophysiologic auditory performance.

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