Attention deficit disorder is becoming an increasingly prevalent diagnosis in children, so much so that we must often search for causes that could account for the dramatic increase. In my experience, an environmental attributing factor may be found and then controlled, or the patient's reaction to the environmental cause may be modulated and balanced to improve the overall picture. Environmental attributing factors are often sought for such patients at our clinic because we recognize that toxicity may have an effect on both neurological health and as well as the immune system. In my opinion, while toxins such as heavy metals may potentially directly affect neurological function and may attribute to symptoms, they may also negatively affect the immune system, potentially leading to an increase in allergies, that then may aggravate symptoms.
Basic neurochemistry describes the pathophysiology behind the symptoms of attention deficit disorder. Basically, our brain is composed of many individual nerve cells that make connections to each other in order to communicate. These nerve cells, or neurons, can also be grouped together into larger functional structures based on their connections and common functions. Communication between these cells is made across a very small space called the synapse, and small molecules called neurotransmitters cross the synapse from one cell to another. In many cases of ADD, there may be a deficiency of the neurotransmitters noradrenaline or dopamine in a specific area of the brain. The function of these neurotransmitters in these areas is to calm or focus the attention. It should be noted that these two neurotransmitters are most often used to further stimulate and excite the brain, but that in ADD localized deficiencies where they are used to calm and focus are important. Thus drug therapy with methylphenidate or similar drugs mainly act to increase the action of these neurotransmitters either by increasing their total number, decreasing the rate at which they are broken down or removed from the synapse, or mimicking their action by binding to the same receptors that they do.
Thus, in my opinion, to be comprehensive and provide a good biological and functional answer to this problem, a search must begin to ask the question why the symptoms of ADD become manifest and why there may be the irregularities described above.
Amino acid levels may be tested within the blood. While potentially useful and a good option for some patients in my experience, this may not be the reason why the nerve cells are malfunctioning. Balance of these chemicals may be perfectly normal in the blood and yet the nerve cells in the brain are not responding to these chemicals correctly. Thus drug therapy may overcome this non-responsiveness, but covers up the fact that there may be another potential cause, which in my opinion may be a toxicity or allergy, aggravating the nerve cell malfunctioning. Thus, for a significant portion of patients, and especially if there is a history of asthma, eczema, or hayfever in the patient or family, we want to assess for food allergies and sensitivities. Some hints for sensitivities can be from the blood, but the gold standard is elimination / rechallenge of such foods. Blood testing tests for immune proteins directed specifically against individual foods (usually 95 foods are tested but in ADD of children spices and less common foods are tested also) is more appropriate for "sensitivity" reactions that have more subtle symptoms such as fatigue, irritability, and hyperactivity. Once the results come back, an elimination / rechallenge diet may be recommended to see if symptoms are provoked by the positive foods. Temporary avoidance may be recommended for foods that elicit symptoms. Another option is to start rotation of these foods. The gastrointestinal system may be treated to help it heal, with the goal of preventing further allergies from developing.
At this second layer of assessment and treatment is to check for heavy metals. This is may or may not done by a only a simple blood draw (blood lead and/or blood mercury), as lead in the blood is only an indication of acute toxicity. There is however newer data on mortality and cardiovascular events recently published that helps to interpret even just the regular blood lead. An agent called a chelator, usually EDTA or DMSA, may be given to pull the heavy metals from tissue, and then make them safely excreted into the urine, where we can measure it. Of note, the reference ranges seen in such challenge tests must be interpreted with care, as the reference ranges for most of these labs do not have levels for the provoked levels - often the results look worse than they are.
Finally, in my opinion, nutritional recommendations should be made in order to keep two basic principles operating. One is that the sugar level in the blood should be stable throughout the day to reduce hyperactivity. Sugar in the blood spikes, either from candy, juice, or refined foods, and then drops because the hormone insulin must come out in large force to balance it. Such sugar swings may cause mood, concentration issues, and aggravate some cases of ADD / ADHD. Second is that the essential fatty acids in the diet must be balanced remember that fatty acids make up the neurological tissue.
Treatments:
- amino acid balancing
- heavy metal chelation with oral or IV agents depending on testing
- allergy management and sensitivity management
- immune system rebalancing
- dietary modifications for fatty acid balancing and especially sugar control
References ADHD & Allergies
Slim M, Rico-Villademoros F, Calandre EP. 2018. Nutrients. 2018 Jul 6;10(7). Psychiatric Comorbidity in Children and Adults with Gluten-Related Disorders: A Narrative Review.
Miłosz M, Demkow U, Wolańczyk T. 2018. Relation Between Attention-Deficit Hyperactivity Disorder and IgE-Dependent Allergy in Pediatric Patients. Adv Exp Med Biol. 2018;1096:105-109.
Jiang X, Shen C, Dai Y, Jiang F, Li S, Shen X, Hu Y, Li F. 2018. Early food allergy and respiratory allergy symptoms and attention-deficit/hyperactivity disorder in Chinese children: A cross-sectional study. Pediatr Allergy Immunol. 2018 Jun;29(4):402-409. doi: 10.1111/pai.12888. Epub 2018 Apr 15.
Miyazaki C, Koyama M, Ota E, Swa T, Mlunde LB, Amiya RM, Tachibana Y, Yamamoto-Hanada K8, Mori R1. 2017. Allergic diseases in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis. BMC Psychiatry. 2017 Mar 31;17(1):120. doi: 10.1186/s12888-017-1281-7.
Schans JV, Çiçek R, de Vries TW, Hak E, Hoekstra PJ. 2017. Neurosci Biobehav Rev. 2017 Association of atopic diseases and attention-deficit/hyperactivity disorder: A systematic review and meta-analyses. Mar;74(Pt A):139-148.
Ferro MA, Van Lieshout RJ, Ohayon J, Scott JG. 2016. Allergy. 2016 Emotional and behavioral problems in adolescents and young adults with food allergy. Apr;71(4):532-40.
Reference ADHD, Allergies, concurrent Stomach & Intestinal problems
Jameson ND, Sheppard BK, Lateef TM, Vande Voort JL, He JP, Merikangas KR. 2016. Medical Comorbidity of Attention-Deficit/Hyperactivity Disorder in US Adolescents. J Child Neurol. 2016 Oct;31(11):1282-9. (stomach & bowel problems also associated with ADHD)
References ADHD, Heavy Metals, and other Environmental Exposures
Curtis LT1, Patel K. 2008. Nutritional and environmental approaches to preventing and treating autism and attention deficit hyperactivity disorder (ADHD): a review. J Altern Complement Med. 2008 Jan-Feb;14(1):79-85. doi: 10.1089/acm.2007.0610.
Patel K1, Curtis LT. 2007. A comprehensive approach to treating autism and attention-deficit hyperactivity disorder: a prepilot study. J Altern Complement Med. 2007 Dec;13(10):1091-7. doi: 10.1089/acm.2007.0611.
Lee MJ1,2, Chou MC3,4, Chou WJ5,6, Huang CW7, Kuo HC8,9, Lee SY10,11, Wang LJ12,13. 2018. Heavy Metals' Effect on Susceptibility to Attention-Deficit/Hyperactivity Disorder: Implication of Lead, Cadmium, and Antimony. Int J Environ Res Public Health. 2018 Jun 10;15(6). pii: E1221. doi: 10.3390/ijerph15061221.
Hong SB1, Im MH, Kim JW, Park EJ, Shin MS, Kim BN, Yoo HJ, Cho IH, Bhang SY, Hong YC, Cho SC. 2015. Environmental lead exposure and attention deficit/hyperactivity disorder symptom domains in a community sample of South Korean school-age children. Environ Health Perspect. 2015 Mar;123(3):271-6. doi: 10.1289/ehp.1307420. Epub 2014 Oct 3.
Kim S1, Arora M, Fernandez C, Landero J, Caruso J, Chen A. 2013. Lead, mercury, and cadmim exposure and attention deficit hyperactivity disorder in children.
Environ Res. 2013 Oct;126:105-10. doi: 10.1016/j.envres.2013.08.008. Epub 2013 Sep 10.
Polańska K1, Jurewicz J, Hanke W. 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;26(1):16-38. doi: 10.2478/s13382-013-0073-7. Epub 2013 Mar 22.
Nicolescu R1, Petcu C, Cordeanu A, Fabritius K, Schlumpf M, Krebs R, Krämer U, Winneke G. 2010. Environmental exposure to lead, but not other neurotoxic metals, relates to core elements of ADHD in Romanian children: performance and questionnaire data. Environ Res. 2010 Jul;110(5):476-83. doi: 10.1016/j.envres.2010.04.002.
Cheuk DK1, Wong V. 2006. Attention-deficit hyperactivity disorder and blood mercury level: a case-control study in Chinese children. Neuropediatrics. 2006 Aug;37(4):234-40.