Dr David L. J. Freed, MB, MD, MIBiol
This is a value judgement as much as a diagnosis, but few paediatricians nowadays seem to doubt that the condition exists. We owe a debt of gratitude to Professor John Soothill, formerly of Great Ormond Street Hospital, for assembling the team and the resources to do the crucial experiment on dietary management of these children (13). This pioneering work has been confirmed (14,15) and one can state with a high degree of certainty that the condition (and the related condition of delinquency) is indeed related to diet in many cases. Adults also suffer food reactions of this type but are more socially-controlled, being expressed in spouse abuse, irritability and petty crime instead.
What diet? Since the days of Feingold (16), artificial additives and fruits have been popularly held in suspicion (as for chronic urticarias see above), but the late John Soothill’s group at Gt Ormond Street showed that the classic food allergens – milk and wheat - are equally commonly implicated. Since these are daily staples, and since we are dealing with children whose dietary fads are already horrendous, I am of the view that the diet should be supervised by a dietitian unless the doctor has acquired sufficient expertise of his own in this field. In fact it is hardly ever necessary to force a child to eat, however faddy he is. If the parents ensure that no "naughty" food is available to him in the house, he will eventually eat good food. The process should be accompanied by explanation.
And yet, in spite of the pioneering and careful work noted above from Gt Ormond Street, the clinical impression remains that artificial food additives are the most likely culprits in ADHD – you merely have to stand in the supermarket watching the children after school buying tuck before going home, and seeing the difference in behaviour before and after. And these are “normal” children, not diagnosed hyperactives. Recently, Warner’s team in Southampton have confirmed this effect on normal children (17). There may be deficiencies in the classic withdrawal-and-challenge method used by Soothill’s team which challenged with single food items; it may be necessary to challenge with several ingestants simultaneously.
Afterword on the dangers of elimination diets
Although I think that the dangers have been grossly exaggerated (as compared with the dangers of
long term drug usage) it would be unfair to deny that they exist. This is especially so for children,
whose major source of protein, calcium and vitamins may be milk (the commonest food allergen).
Elimination diets are also expensive, time-consuming, irksome and socially restricting.
They may cause drastic realignments in family tensions. They may lead to isolation, introspection,
hypochondria, malnutrition and poverty.
Watch out.
References
13) Egger J, Carter CM, Graham PJ et al: Controlled trial of oligo-antigenic diet treatment in the hyper-kinetic syndrome. Lancet 1985,I: 540-5.
14) Graham P: Dietary aspects of management in childhood hyperactivity. In. Dobbing J (ed), Food Intolerance; Bailliere Tindall, Eastbourne,1987, pp 59-67.
15) Egger J, Stolla A, McEwen LM: Controlled trial of hyposensitisation in children with food-induced hyperkinetic syndrome. Lancet 1992,339: 1150-53.
16) Feingold BF: Hyperkinesis and learning disabilities linked to artificial food flavors and colors. Am J Nurs 1975, 75: 797-803.
1) Bateman B, Warner JO, Hutchinson E et al, The effects of a double-blind placebo-controlled artifician food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children. Arch Dis Child 2004, 89: 506-511
