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ADHD - A look at some possible causes of ADHD-type behaviours

The fact of the matter is that some children are particularly hyperactive, impulsive and struggle to be attentive. This does not mean that these children are sick.  Sometimes this can simply be that unrealistic expectations are being made of young children. Modern day schooling methods don’t suit all children equally and a child’s difficulty in adapting to this may have more to do with societal expectations than with the child as such. Having said that, there are numerous reasons why a child might be overly active, impulsive and inattentive. As we take a look at some of these possibilities, I think you will agree that it makes little sense to reduce such diverse contributing factors to a single psychiatric disorder, commonly referred to as ADHD.

Physiological factors such as chemical imbalances, brain structure

There is no shortage of books on ADHD claiming that the main cause is a chemical imbalance in the brain that needs to be corrected by stimulant medications (such as Ritalin and Strattera).  At best this is misleading and at worst it has more to do with drug company marketeering.  As Dr Joanna Moncrieff writes:  “Although popular literature suggests that stimulants correct a chemical imbalance, there is no evidence of a specific chemical imbalance in the brains of people with attention deficit disorder…”1

Neuroimaging: The ADHD brain

Attempts have also been made to show that the brain structure of those diagnosed as ADHD is different. A closer look at these studies shows that subjects have usually been taking ADHD medications, and it is possible that any differences are due to the effects of these medications on the brain. For those interested, professors Leo and Cohen take an in-depth look at neuroimaging research and challenge some of the research findings here 2.
There are some wild genetic claims regarding the ADHD diagnosis that, with a closer look, do not live up to the media hype. We looked at an example of here, under the heading: Beware of misleading press reports making unfounded claims.

We are not saying that there is never a physiological cause (or contributory factors) to these so-called ADHD-type behaviours, even though there isn’t the evidence to say ADHD is a unitary disorder. It is possible that, in some instances, the problems are attributable to a neurological problem – this might be, for example, a brain injury as a result of a sporting accident. Hormonal disorders (such as thyroid) can also be implicated 3. There is also the possibility, in some instances, that these behaviours may be symptomatic of some genetic disorders 4. You will discover a plethora of possible links to ADHD-type behaviour as you search the internet - from breathing problems, to Streptococcal infections, through to in-utero mobile phone use by the mother 5.  I guess we need to balance a healthy scepticism with an open mind that is also willing to look at research critically.

Diet and ADHD-type behaviours

High sugar and refined carbohydrate diet
Sometimes common sense takes a holiday when it comes to mental health matters; in doing so, the basics can be missed.  One such basic, is the impact of what we eat and drink on our ability to think straight and concentrate – as well as affecting our moods and behaviour.  An easy way to make a child agitated, disruptive, over-stimulated and moody is to disrupt blood-sugar levels.

As our brains need glucose (a simple form of sugar) to be able to function, it is often said that we need balanced food every 3 or 4 hours to maintain blood-sugar levels. When I say “balanced food” I am referring to a combination of foods that include protein and slow releasing carbohydrates too – not just high sugar foods. Refined carbohydrates such as white bread and pasta are soon broken down to simple sugars, so these too can create sudden energy boosts in much the same way as sugary drinks and sugary foods.

 
 
   

High doses of simple sugars are like rocket fuel and are likely to cause some children to 'bounce off the walls'. This is then followed by an energy slump (even low mood) a few hours later.  

Not surprisingly, high sugar diets/drinks lead to hyper behaviour.  Add to this lots of white flourchild in a spin foods and this is very likely to destabilise moods and hinder concentration too. High doses of simple sugars are like rocket fuel and are likely to cause some children to 'bounce off the walls'. This is then followed by an energy slump (even low mood) a few hours later. Energy drinks, and other high sugar food and drinks can be difficult for many children to tolerate (and make them intolerable too!). Humans aren't really designed to eat refined sugar in large quantities.

Food sensitivity and allergies
Much is made these days about food sensitivities and intolerances; so much so, that many people dismiss this as a fad. Whilst this is not going to be the answer for every troubled parent desperate for a solution to their child’s behaviour, it could lead to enormous benefits for some.  A study assessing the possible impact of food sensitivity and ADHD-type behaviours reported “a significant beneficial effect on ADHD symptoms in 32 (64%) of 50 children, and reintroducing foods led to a significant behavioural relapse”. It seems that, according to this study, that for some children diagnosed as ADHD, their behaviour might be “an allergic or non-allergic hypersensitivity disorder”. Foods eliminated and then reintroduced included: chicken egg, peanut, soy, milk, fish, and wheat.

Food additives: colourings, preservatives, and flavourings
One possible trigger for overactive moods and behaviour can be food additives: colourings, preservatives, and flavourings. Here in Europe these are often referred to as specific E numbers, e.g. E110 is Sunset Yellow. Some food companies have got wise to the idea that some people read the food product labels and avoid E numbers; they therefore use the full name instead of the E number so that consumers are then much less likely to spot these.

According to a study by Southampton University, removing certain artificial colours and preservatives from the diet showed distinct benefits in reducing hyperactivity in some children 10. The study raised concerns about these food colourings in relation to hyperactivity in children: E129, E122, E124, E104, E110. In addition to these mentioned in the Southampton study, there are other colourings sometimes associated with hyperactivity: E61, E951, E211, E151, E133, E213.

In the US, extensive data has been presented to the FDA concerning food dyes (in particular one of the yellow dyes) and the impact these could have on triggering hyperactive behaviour (here). It is not that all children are adversely affected by these colourings, but some families do discover amazing differences by removing these additives from the child’s diet. Clearly some children are more sensitive to the effects of these chemicals than others. It may also be worth noting that many prescribed medicines have added food dyes, including those for paediatric use.

The flavour enhancer monosodium glutamate (MSG), E 621, is a food additive to be wary of as this too can make people hyper. It is found in numerous foods and drinks but totally avoiding it is virtually impossible as it is hidden within many different food additives. It is often associated with Chinese take away food. I am not aware of any definitive evidence, but some artificial sweeteners are associated with hyperactivity too. Some children (and adults too) are particularly sensitive to caffeine (in chocolate, colas and energy drinks etc) and soon hit the roof.

Gluten sensitivity and/or intolerance and celiac disease
As casein (milk protein) has a molecular structure similar to that of gluten, some gluten-free diets are combined with casein-free diets. This study looked at gluten and casein in relation to ADHD with autism and concluded that some children do benefit from excluding foods containing gluten and casein. According to this study, “Celiac disease is markedly overrepresented among patients presenting with ADHD. A gluten-free diet significantly improved ADHD symptoms in patients with celiac disease in this study. The results further suggest that celiac disease should be included in the ADHD symptom checklist 11.”

Vitamin and mineral deficiencies
With modern fast-food diets many children can be deficient in key vitamins and minerals. A number of emotional and behavioural issues not dissimilar to those diagnosed as ADHD are also associated with certain vitamin and mineral deficiencies, such as magnesium and the B vitamins.

Social and emotional issues

Personal and emotional concerns do of course affect the moods and behaviour of children. A child who has recently lost a parent, devoted grandparent or other loved one may well display ADHD-type behaviours as they try to cope and adapt; as with adults, their moods and ability to concentrate are affected. The same can be said in response to traumas too, such as bullying and other forms of abuse.  Children can become agitated and hyperactive in response to distress. Ongoing distress such as living with constant fear can significantly hinder a child’s ability to focus and concentrate at school. Again, these children may be diagnosed as ADHD.

Sadly, these children can become disruptive at school as they are too emotionally hurt and distracted to be able to learn at their best – so often they repeatedly get into trouble and grow up thinking they are stupid. As distressed and/or traumatised children may dissociate from the intensity of the pain, this self-protecting response can be misconstrued as an inability to focus and concentrate. It is important for teachers and carers to read the signs of distress rather than assume that these are simply symptoms of "ADHD".

Cultural preferences

I think it is important to remember that in evolutionary terms (considering our 250,000 or so years of human existence) the expectations we impose on small children are relatively recent.  It isn’t that long ago since children would have been out picking fruit with mum or hunting with dad (typical of modern day bush-people in areas where their life-styles have not yet been crushed by modern development).  It seems fair to suggest that expecting children to sit still in class rooms is not so natural for them – and we shouldn’t be too surprised if they struggle to fit this cultural mould. Children are by nature wanting to run around, explore, be impulsive and call out.  In this cultural context, maybe ADHD-type behaviours are no surprise.  But of course parents and teachers are at times facing extremes of behaviour when they refer to ADHD: that I fully appreciate.

Discussion on hyperactive children often leads to questions about parents being able (or unable) to control their children. True enough, how we reprimand and limit children does have an enormous bearing on their behaviour. There are various, and often contradictory schools of thought when it comes to training and disciplining children; consequently, it is not surprising that parents are sometimes unsure and inconsistent.  In society at large, we have moved from what was, in many ways, an authoritarian (and at times overly harsh, even brutal) approach to discipline - to placing a much greater value on being understanding and reasoning with our children - and in the extreme, permissive. Smacking and corporal punishment are in the main no longer acceptable and maybe society is struggling to find the balance between discipline and free choice with these enormous changes. 

Some children really do rule the roost at home (I see this in my work) and I find that some parents have allowed their child to become the centre of all that happens in a way that is not best for the child - rather than as an equal member of the family - each with rights and responsibilities, but functioning as a family unit.

Health and safety fears (including those of abduction and/or abuse) mean that many parents are less sure about their children playing outside these days. For many children watching TV and sitting in front of computers has replaced wildly playing near the river and climbing trees. When children grow up like this, hyperactivity is to be expected. This means that some children are not finding an outlet for their natural energy. The good news is, physical exercise is not only an outlet for their energy but it is a great leveller for emotional stress and distress too.

I wonder to what extent we train our children to be hyperactive and to require more and more stimulation. It is very natural and usual (and pleasurable to child and adults too) to frequently prompt and poke tiny babies as they giggle and gurgle. But there are times when I think we try too hard to cheer and stimulate them. Are we afraid they will not learn if we don't continually stimulate them? Or afraid they will become board? In some cultures a more laid back and passive being with babies is more the norm. I wonder if they grow up more relaxed and less hyperactive: maybe, maybe not.

Environmental factors

Environmental factors are also claimed to have links to ADHD-type behaviours. According to this study: “Exposure to organophosphates [widely used pesticides] has been associated with adverse effects on neurodevelopment, such as behavioral problems and lower cognitive function…The findings showed that children with higher urinary levels of organophosphate metabolites were more likely to meet the diagnostic criteria for ADHD 6.” According to a study on Inuit children, the exposure to prenatal levels of lead and mercury is associated with ADHD symptomatology in childhood 7.  A further study concluded “that exposure to prenatal tobacco and environmental lead are risk factors for ADHD 8”.

Clearly environmental factors will depend on a person’s locality and circumstances and is not likely to be a widespread reason for these ADHD-type behaviours.

Medication side-effects

Antidepressants can have an intensely stimulating effect, so children on antidepressants may become hyperactive. As antidepressants also can create a feeling of emotional detachment, these effects can be misread as indicative of an attention deficit hyperactivity disorder.

Sometimes medications used during pregnancy are associated with later childhood hyperactivity, attention and concentration problems. One such medication is the anticonvulsant Sodium Valproate (Epilim, Depokate). This anti-epileptic medication is often used as a “mood stabiliser”. This and similar drugs are implicated with Fetal Anticonvulsant Syndrome (more specifically, Fetal Valproate Syndrome) which is associated with a range of defects and deformities, including ADHD type behaviours 9.

The drugs prescribed as treatments of so-called ADHD create unpleasant and potentially risky side-effects. We take a look at these here.

Singulair, a drug used to help treat asthma, is sometimes reported by parents as causing hyperactive behaviour. Although there are many possible side-effects to this drug I have selected below those from the Psychiatric group here:

"Psychiatric side effects have included agitation including aggressive behavior and hostility, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor. Postmarketing reports include disorientation, insomnia, and somnambulism [sleep-walking]."

Insufficient and irregular sleep

One quick way to create an imbalance for children (and adults too) that affects moods and behaviour is too little sleep. With TVs in bedrooms and computers and mobile phones youngsters have more than enough late night distractions; these can also stimulate the brain and make falling asleep more difficult. Going to bed late is seen as being more grown up - but youngsters need considerably more sleep than adults. I take a look at sleep problems here.

 

References - Bibliography - Further reading
1 Moncrieff, J. (2009) A straight talking introduction to psychiatric drugs. PCCS Books Ltd

2 Leo, J. & Cohen, D. (2003) Broken brains or flawed studies? A critical review of ADHD neuroimaging research. The Journal of Mind & Behavior Vol 24 No 1

3 Breggin, P. (2000) What psychologists and therapists need to know about ADHD and stimulants.

4 Richardson, A. (2006) They are what you feed them. HarperThorsons London UK

5 Aldad, T. et al. (2012) Fetal Radiofrequency Radiation Exposure From 800-1900 Mhz-Rated Cellular Telephones Affects Neurodevelopment and Behavior in Mice. Scientific Reports 2 : 312 | DOI: 10.1038/srep00312. Available here.

6 Bouchard, M.F. et al (2010) Attention-Deficit/Hyperactivity Disorder and Urinary Metabolites of Organophosphate Pesticides. Pediatrics. Vol. 125 No. 6. Full text here.

See also: Polańska, K. et al (2013) Review of current evidence on the impact of pesticides, polychlorinated biphenyls and selected metals on attention deficit / hyperactivity disorder in children.  Int J Occup Med Environ Health. 2013 Mar 22. Abstract here.

7 Boucher, O. et al. (2012) Prenatal Methylmercury, Postnatal Lead Exposure, and Evidence of Attention Deficit Hyperactivity Disorder among Inuit Children in Arctic Québec. Environ Health Perspect. 120(10):1456-61. Abstract here.

8 Froehlich, T. et al. (2009) Association of Tobacco and Lead Exposures With Attention-Deficit/Hyperactivity Disorder. Pediatrics Vol. 124 No. 6. Full study available here.

9 Moore, S. et al. (2000) A clinical study of 57 children with fetal anticonvulsant syndromes. Journal Medical Genetics 37:489-497. Full study here.

10 McCann, D. et al. (2007)  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. The Lancet, Volume 370, Issue 9598, Pages 1560 – 1567. Abstract here.

11 Niederhofer, H. (2011) Association of Attention-Deficit/Hyperactivity Disorder and Celiac Disease: A Brief Report. Prim Care Companion CNS Disord. 2011; 13(3): PCC.10br01104. Available here.

 

Timimi, S. (2002) Pathological Child Psychiatry. UK: Brunner-Routledge