Twelve-year-old Ruben is sitting on a podium in front of a room full of academics and journalists. He’s beaming, as is his mother beside him, and doesn’t seem the least intimidated by the learned audience. Ruben had attention deficit hyperactivity disorder (ADHD)—past tense. Initially, there appeared to be no solution for his symptoms other than Ritalin. “But it made me really sad,” he says, speaking candidly about the time he took the medication. “Suddenly, out of the blue, and I didn’t know why.”
Yet the solution to his hyperactivity disorder lay in a relatively simple eating regimen called an “elimination diet.” For the past year he’s been avoiding a handful of foods—tomatoes, eggplant and potatoes—and “now I feel normal,” says Ruben. “I don’t pick as many fights and my parents don’t get angry at me so much.” His mother adds: “He’s turned into a really nice, sweet kid.”
In the auditorium of the University of Nijmegen in the Netherlands, mother and son are guests at the doctoral ceremony of Lidy Pelsser. She is a scientific researcher who started her career as a veterinarian and spent 10 years studying hundreds of children to clarify the relationship between food and ADHD. “ADHD disappears among 60 percent of the children we treat with the elimination diet,” Pelsser says. “The child returns to normal; he gets his youth back.”
The first four weeks of the elimination diet involve removing all foods that are known to cause health problems. What remains is a strict but healthy diet. If the symptoms disappear, the second phase begins and foods are reintroduced step by step and then rotated. As soon as something triggers problems, it is placed on the list of “bad foods.” Following completion of the diet, the list usually contains three to six foods that cannot be eaten. The diet works for over 60 percent of children with ADHD, a result that was published last year in The Lancet.
For years, sugar and artificial additives like coloring agents were targeted as a potential cause of ADHD. The idea that it had something to do with our “unnatural” diet was popular among alternative healers. Scientists also researched this possibility, but their studies revealed no connection. Sugar temporarily makes all children a little hyperactive, and artificial colors occasionally have an effect by triggering hypersensitivity reactions, but there is no indication that they lead to ADHD. And now Pelsser’s study proves that ADHD is related to food, albeit usually normal, healthy food. “It isn’t due to ‘poison’ or ‘artificial colors,’ but normal foods, healthy foods that some children react to,” Pelsser says.
Pelsser is now busy training doctors so even more children can be helped. At the same time, she is drafting a protocol whereby ADHD is approached first as a condition that can be treated using the elimination diet. Medication should only be considered if that proves unsuccessful.
Important work, it would seem, given that the increasing numbers of adults and children with ADHD have great difficulty functioning in society. They lose things, can’t sit still, forget appointments and find even simple recordkeeping impossible. This not only makes their lives incredibly difficult, but their families also suffer from the chaos and stress associated with ADHD. The children are unmanageable and are moreover stigmatized as difficult, which seriously undermines their self-esteem.
More and more children are prescribed Ritalin because it calms them down. Like other amphetamines, Ritalin increases the dopamine levels in the brain. This, in turn, increases concentration and motivation.
In the U.S., nearly 10 percent of children between the ages of four and 17 are diagnosed with ADHD. The number of American children with the diagnosis is increasing 3 to 5 percent each year. And 2.7 million of those diagnosed with ADHD are prescribed medication, according to the Centers for Disease Control and Prevention.
Ritalin or Concerta, the more expensive alternative that is taken just once a day, only reduces symptoms. The effects of using Ritalin have not been sufficiently investigated, but it is clear that children whose brains are still developing run greater risks than adults. Addiction is a known risk. And sleeplessness, depression, high blood pressure and an accelerated heart rate are generally recognized side effects.
For Lidy Pelsser, dedicating her life to ADHD was not a foregone conclusion. But Pelsser, a friendly yet firm woman with bright eyes and loads of energy, discovered she was beginning to find people’s problems more interesting than those of animals she worked with as a veterinarian. This reinforced her interest in psychology and psychiatry.
She became fascinated by a completely different approach to mental and physical disorders. “A doctor who sees someone with a stomachache first looks to see if his patient has appendicitis or ‘just a little gas,’” she explains. If he didn’t, he would quickly be summoned to appear before the Medical Practitioners Disciplinary Tribunal. But as soon as it concerns a mental issue—like -ADHD—other standards apply. “Psychiatrists and psychologists start treating symptoms without looking for the source,” she says, adding that she could not reconcile this with her scientific background.
While researching her Ph.D, Pelsser discovered that a number of studies had been published by child psychiatrists in Germany and the UK who had successfully used the elimination diet to treat ADHD. They found that the symptoms disappeared within a few days to weeks, and the child returned to normal. “These child psychiatrists were already advising application of the elimination diet,” Pelsser says. “But nothing was done with their advice. That intrigued me. Why is this systematically ignored?”
Pelsser wondered whether the studies were flawed or something was overlooked. “I couldn’t imagine that food could have such an enormous effect on behavior. I thought it couldn’t be true and that I needed to redo the research, and do it better.”
Because the advances for children are, in Pelsser’s terms, “gigantic,” she now considers her ADHD work an integral part of her life. “It’s gut-wrenching each time I hear how a child is after the diet compared to before,” she says. “The enormous difference, the enormous impact of food!”
The truth is, no one is sure what exactly ADHD is, including the patients themselves. Neurologists can see the deviations in brain activity on scans. And parents are filling out questionnaires to help give the psychiatrist an idea of the child’s behavior. But the spectrum of concentration problems and impulsivity is very broad and impossible to define. Nor have reseachers found a clear cause of ADHD, let alone why certain foods could be a trigger for some but not for others.
In 2009, the Dutch National Institute for Public Health and the Environment said that given the results of Pelsser’s study, further research is needed into the link between food and ADHD. And yet the institute recently suggested there must be a placebo effect involved, because the study was not adequately double blind. After all, children, parents and doctors could have influenced the results because they knew about the dietary measures. In a truly double blind study, they would remain unaware of such measures.
The American ADHD expert Russell Ramsay also considers this a limitation to Pelsser’s research. “The extra attention and structure [the diet] adds in a family setting might already help improve behavioral problems, in addition to par
ents’ expectations that the child will get better.” But he adds that it is a very positive step that the link between ADHD and food is being seriously investigated. He also calls the research “an important contribution to the discussion” and hopes for a follow-up study.
Pelsser doesn’t pay much attention to the criticism. She says that within the structure of the study, she got as close as possible to the double blind ideal. “It is very distressing, particularly for children with ADHD, that people are so closed to new developments.”
Still, Pelsser is gaining increasing recognition internationally. She recently addressed a conference of 500 psychiatrists and psychologists in Copenhagen. Over half champion the idea of applying the elimination diet as a standard approach for children with ADHD and favor including “food-induced” ADHD in the Diagnostic and Statistical Manual of Mental Disorders, the classification system of psychiatric disorders. “I consider that a breakthrough,” she says.
No matter how big the breakthrough, there are disadvantages to the elimination diet. It is not easy to stick to, particularly in the early phase when the diet is very strict. Constantly focusing on what you’re eating is no fun, especially for children. However, it becomes clear within a few weeks whether food is the culprit. If not, there is always medication. But if the diet works, the child enters the phase of -adding different foods and figuring out which ones are “bad” when symptoms reappear.
Once that phase is completed, the diet becomes easier. The child only has to avoid a handful of foods that trigger symptoms. Moreover, these children experience such a big difference in how they feel that most are motivated to eliminate foods. There are, of course, children who give up and simply cannot get through the first difficult weeks.
Pelsser is eager to develop methods that can uncover more quickly which foods a child will react to so the elimination diet is no longer necessary. It is possible that ADHD is an allergic reaction. Most -children with ADHD also have physical complaints that could point to an allergy, such as -intestinal complaints or eczema. This prompted her to compare the results of the elimination diet with the outcomes of existing allergy tests. However, these comparisons revealed no connection. Pelsser thinks that in time, the immune system may prove to play a role and that there may be a way to diagnose food-induced ADHD via the blood. But that role has yet to be clarified.
Another disadvantage to the elimination diet is that there is still a shortage of physicians qualified to apply it. As a result, there are long waiting lists. But Pelsser is against the idea of quickly training a host of nutritionists, because ADHD involves child psychiatry. “If we can’t conduct a proper investigation, the results will be equally unacceptable,” she says. “That would be incredibly unfortunate for the children. At a later stage, once it’s clear which foods the child reacts to, a nutritionist can play a role in helping to guide the family.”
Unfortunately, there is also no standard list of foods that most commonly lead to symptoms. It is an individual diet. The doctor must first determine whether the child even has food-induced ADHD and, only then, which foods might be triggers. These will differ for each child, although several are nearly always involved – generally three to five. Says Pelsser: “If I say fish is usually more of a trigger than beef, everyone will start avoiding fish, perhaps unnecessarily. That wouldn’t help these children. If we came up with a random list, we’d be using them as guinea pigs. Bad foods for one child might be fish, tomatoes and oranges while for another it might be fish, strawberries and chocolate or beef and eggs.”
Ruben has been helped, along with an increasing number of children who followed the elimination diet. His diet hasn’t yet been perfected and is still sometimes challenging for him, although the list of allowed foods is growing steadily. “You can’t just eat what you want, and that’s hard, especially with friends,” Ruben explains. “If everyone around you is eating french fries or chips, you want some too, which is tough. But I know why I’m doing it so it’s ok.”
By Hanny Roskamp
Photo: flickr.com/photos/philippeleroyer/
