Monday, January 16, 2012

ADHD and Food Allergies

There are a number of controversial areas in medicine when it comes to ADHD. Food allergy is certainly one of them.
The classic allergic reaction, which is classified as the type-1 hypersensitivity reaction, can be elicited by food, but this is fairly uncommon. When we discuss food sensitivities in ADHD we are discussing a different, not well-defined, mechanism.
One of the main progenitors of the food allergy/ADHD connection is Dr. Doris Rapp. Dr. Rapp was a pediatric allergist who noticed that many children in her practice had significant physical and behavioral changes when exposed to certain foods. They may have red ear lobes, dark circles under their eyes, or glazed eyes after eating certain foods. These children could have tremendous swings in behavior. They can be calm one minute and wildly hyperactive a few minutes later.
To make it more interesting, children with food allergies usually crave the food that affects them negatively. That means a child who is allergic to peanuts will demand peanut butter and jelly for lunch everyday, and for the rest of the afternoon you have to peel him off of the ceiling.
What is Food Allergy?
The classic allergic reaction operates through a very specific mechanism. The reaction is caused when a specific type of antibody, called IgE, reacts with a specific provoking substance called an allergen. The result of this interaction is an allergic response and the person is deemed allergic to that allergen.
The specific type of antibody involved in classic allergy is called IgE. The proposed antibody mechanism for this type of food allergy does not involve IgE, but a different antibody called IgG. This is significant because standard allergy testing tests only for IgE antibodies. If your child has IgG mediated sensitivity, his allergy test is going to miss it. That means that your child may have a severe allergy to a specific food, but your allergist will tell you he is not allergic to it.
Why the Controversy?
Reason 1: Diagnosis
I said this was a very controversial area of medicine and here is one of the reasons why. Food allergies are very difficult to diagnose. One reason is that the symptoms wax and wane. When a child has a classic allergy, for example to bee stings, then every time a bee stings him, he will have a reaction. Food allergies don't work that way. There seems to be a threshold that must be exceeded before there are any symptoms. In addition, this threshold seems to vary from day to day. On some days a food will affect the child, and on other days it won't. Dr. Rapp explains this phenomenon using the analogy of a barrel.
We can view each allergic child as if he has a barrel. As long as the barrel is empty or only partially full, your child will have no problems. Your child won't become hyperactive until his barrel is overflowing.
Various things will fill your child's barrel. Let's say your child is sensitive to chocolate, cats, and peanut butter. Each of these things all can partially fill his barrel. As long as he only has peanut butter or only plays with the cat, his barrel is only partially full. That means that there are no symptoms and that his behavior is fine. Then, one day he has a peanut butter and jelly sandwich, has chocolate ice cream for dessert and plays with the cat all afternoon. These things in combination make his barrel overflow, and by evening he is out of control. Your child has food allergies, but sometimes they affect him and sometimes they don't.
The barrel can change sizes. If your child has a cold or is upset his barrel gets smaller. It takes less to make it overflow. If he is happy his barrel is bigger. It takes more to make it overflow. If he isn't eating well and that day he is low on certain nutrients his barrel gets smaller.
Many traditional allergists find this barrel concept ludicrous. It doesn't fit into the pattern of how other allergies work.
Reason 2: Method of Diagnosis
The next problem is the way in which you test for food allergies. Dr. Rapp describes a technique called provocation-neutralization testing. This method works as follows: Say that a child frequently has headaches after eating eggs. The practitioner will give an intradermal injection of egg extract. If this elicits the child's headache, then the child tests positive for egg allergy. Other signs of a positive test include an increase in pulse rate of 20 points, a large skin reaction (this indicates a classic IgE reaction), a change in the child's handwriting, or some other physical or emotional complaint. This last criterion "some other physical or emotional complaint" is problematic. It is too vague. The result is that when studies compared how several physicians evaluated the same group of patients, their results didn't agree. For each patient if there were twenty different doctors with twenty different sets of findings. None of their diagnoses matched.
Reason 3: The Mechanism
As I mentioned before, the proposed mechanism is an IgG mediated response. Some food allergists diagnose specific food allergies by measuring IgG levels. This runs counter to all of modern allergy practice.
Allergists give allergy shots to treat allergy. The way this works is they give a low level of allergen, which is not enough to elicit an IgE reaction. The dose is slowly increased until eventually the patient can tolerate a significant exposure to the allergen.
This is how it works. The repeated low-level exposure to the allergen induces the body to make a different antibody to the substance. This antibody attaches to the allergen and deactivates it before IgE can cause the allergy reaction. What is this antibody that allergists try to induce to cure their patients of their allergies? You guessed it, IgG. So the very antibody the traditional allergists have been inducing for decades to successfully treat allergies, the food allergy people claim is the antibody guilty of causing allergies.
For a traditional allergist this is nothing short of heresy. IgG has been used for decades to treat allergies successfully. Comes along Rapp and her friends and they claim that IgG causes allergy? This is a little hard for some people to accept.
Just how strongly do allergists reject this idea? I once tried to contact an Israeli physician who was a food allergy specialist to discuss with him provocation-neutralization testing. I called the hospital where he is on staff and asked to speak with him. For some reason the operator instead put me through to the head of the Department of Allergy.
I began discussing with him the theory of food allergies, provocation-neutralization testing and IgG testing. He told me that he was the head of a committee of allergists who were in the process of testifying before the Israeli Knesset to get legislation passed to make IgG testing illegal in Israel.
Can you imagine? You visit a prison in Israel. In one cell there is car thief. In the next cell there is a mass murderer. And in the next cell there is a guy who tested someone for food allergies. Now that's pretty strong opposition!
Do Food Allergies Really Exist?
The formal medical societies like the AMA claim there is no such thing as food allergies. Rapp and her friends have been screaming for decades that they do exist. So, what is the bottom line? Does it really make sense that what a child eats can affect him so strongly that experts will diagnose him as having ADHD?
We know that the brain is a highly complicated and sensitive organ. We know that many foods have a physiological effect on the body without inducing a classic allergic response. For example, people who are sensitive to monosodium glutamate can have a severe reaction to eating it. The chemicals in red wine affect certain people. We also know that ingesting certain foods alters brain function. Diet has been proven to influence neurotransmitter function. Components of foods can also be used as drugs. For example, tryptophan, tyrosine, and choline have been used in the treatment of sleep disorders, pain, depression, mania, hypertension, shock, or dyskinesias.
The logic of Rapp's argument is so strong and there is enough circumstantial evidence, that I feel that the question is really the other way around. We know that the brain is intricate and has tremendous metabolic requirements. We know that some people have very strong reactions, including behavioral changes, to certain foods. These things are undisputed. If it turns out that foods do not elicit significant problems in sensitive children, in my opinion, we would need to explain why not!
Are we really seeing an allergy mechanism to food? I prefer to stay out of that debate. Rather than be ostracized by the doctors who specialize in allergy, I feel it is safer to call them food sensitivities. There are no doctors who specialize in sensitivity.
Does Your Child Have Food Sensitivities?
A large number of ADHD children may be having a negative response to food, and this response may be the primary cause of their ADHD. In what type of child should you suspect food allergies?
The following is a list of symptoms that resulted from food allergies in certain children: Hyperactivity Changes in mood Halitosis Sleep disturbances Delay in sleep onset Migraines Other headaches Abdominal pain Bedwetting Tantrums Eczema Asthma Seizures
Research shows that by treating the food allergies all of these symptoms can be relieved.
If you see your child's symptoms in this list it is possible that food allergies may be contributing to his problem. If your child also has other allergic problems, such as allergy or asthma, then food allergies are almost certainly contributing to his problems.
What Should You Do?
As I wrote in How to Help the Child You Love, there are a number of approaches to diagnosing food allergies. None of them are well substantiated and all of them have difficulties. Yet, many people find that these diagnostic techniques worked for them. Therefore, I'd suggest you could use them provided you have it on good authority that the person administering them has a strong record of success. In my experience, these techniques are more of an art than a science. They really depend upon the talent of the diagnostician.
As I said last time, the best approach to finding food allergies in your child is an elimination diet. It doesn't really matter which one you choose. I prefer the three that I outline in How to Help the Child You Love. (see
Researchers claim that the percentage of ADHD children whose behavioral symptoms are affected by foods ranges from 60% to 75%. This, however, is probably not an accurate number. Parents who consent to have their children participate in diet studies usually believe they have observed food-induced problems in their children. Therefore, children who participate in these studies are more likely to respond to foods than the general population. The truth is we do not know what percentage of ADHD children will respond to dietary changes, but it seems that the number is significant.
Treating the food sensitivities in ADHD children has a number of advantages over using medication. One major advantage all the current methods of treatment can be used to treat pre-school children. Most clinicians do not use medication on pre-school children. A more significant advantage of treating food allergy is that when it works, it works all day. In contrast, Ritalin wears off in about 4 hours.
All this, of course, is providing that food allergies really do exist.
The main thing to remember is that if you think your child has food allergies, then the biggest mistake you can make is to go to an allergist. They don't believe in food allergies. And whatever you do, do not go to an allergist and ask to have your child provocation-neutralization tested for food allergies. He is going to laugh at you.
Food allergy is an alternative medicine diagnosis. Still, there are physicians who specialize in diagnosing and treating these sensitivities, but they no longer call themselves allergists. Rapp and her group were so ostracized by the formal allergy societies that they eventually broke off and formed a new field called Environmental Medicine.
Therefore, if you want a physician to treat your child you need to find an Environmental Medicine specialist. They are not so common, but they are around.
As I mentioned before, there are a number of approaches to treating food sensitivities. The one you can do yourself is to use an elimination diet. I devoted a large section of How to Help the Child You Love describing exactly how to use elimination diets to diagnose and treat food sensitivities.
In the final analysis, I feel it is fair to say that many ADHD children have sensitivities to the foods they eat. These sensitivities may exacerbate their ADHD symptoms. I won't go so far as to say that food allergies cause ADHD. That means that if your ADHD child has severe food sensitivity, treating that sensitivity may not get rid of his ADHD. However, until you treat his food allergy, nothing else you do will really help your child's ADHD, either.
Anthony Kane, MD
ADD ADHD Advances