Diet and child behavior problems: fact or fiction?

Pediatric Nursing, March-April, 2007 by Eileen Cormier, Jennifer Harrison Elder

Case # 1

Adam, a 10-year-old boy, was diagnosed at 30 months with autism and hyperactivity. Adam has been treated with a variety of medications including mood stabilizers, psychostimulants, and anti-anxiety medications, but continues to display severe tantrums when frustrated and other behaviors his mother, Ann, describes as "unpredictable" and "almost impossible to manage, particularly in public." Along with these troubling behaviors, Adam exhibits classic autistic traits such as impaired social relatedness, delayed language development, apparent disinterest in other children, lack of imaginative play, and difficulty with changes in his environment and routine.

Like many families of children with autism, Adam's parents spend much time on the Internet searching for possible solutions and reading testimonials of individuals who have made "miraculous recoveries." Adam's mother has recently become intrigued by reports indicating positive results from diets restricted of gluten (found in wheat products) and casein (present in dairy foods). During a routine visit, Ann asked the nurse for her opinion, "What do you know about it? Should I try the diet?"

Case #2

Jimmy, a 6-year-old boy, was recently diagnosed with attention deficit hyperactivity disorder (ADHD) by a child psychiatrist and prescribed amphetamine sulphate (Adderall). His mother, Lillian, tells the psychiatric nurse practitioner, who is monitoring Jimmy's medication, that her son is lethargic, complains of stomachaches, and refuses to eat most of the day. He is also irritable in the evening and has difficulty getting to sleep. Lillian says that she has been exploring alternatives to medication for Jimmy and wants the nurse practitioner's opinion about dietary treatment for ADHD. She has with her information on dietary modifications she has downloaded from web sites on ADHD. "I really feel guilty about making Jimmy take this medication when it makes him sick. I've read that cutting down on food dyes and refined sugars can help kids with ADHD calm down and focus better at school. Why hasn't anyone mentioned this to me before?"

Introduction

For many parents and health care providers of young children with behavior or developmental problems, choosing an effective and acceptable treatment is difficult. As is often the case with chronic childhood disorders such as autism and ADHD, a broad array of treatments have been tried and continue to be used, yet only a select few have been scientifically validated as safe and effective. Despite their questionable efficacy, the use of complementary and alternative therapies, in particular dietary interventions, has become widespread in primary care settings (Chan, Rappaport, & Kemper, 2005). Concerned parents frequently approach clinicians in primary care settings with questions about the potential benefit of dietary restrictions on child behavior, and health care providers are accountable for supplying relevant, empirically sound, and helpful information. This article will review the evidence for the most common dietary modifications employed in the treatment of autism and ADHD, including historical background information regarding dietary treatment in children with behavioral disorders, the evidence-based literature published over the past two decades, limitations in the research, including challenges inherent in conducting well-controlled dietary studies, and recommendations regarding how nurses in primary care settings can assist families in making informed decisions.

Historical Background and Significance

Dietary treatment of behavioral problems in children is not new. According to clinical reports and lay media, however, it appears to be gaining in popularity. Beginning in the 1920s (Shannon, 1922), literature has included reports on restricted diets and their effect on child behavior. Most famous is Feingold's work in the 1970s, in which he noted that at least 50% of hyperactive and learning disabled children improved when placed on diets free of salicylate and additives (Feingold, 1975). Subsequent controlled studies failed to support Feingold's claims but did identify a small subset of children with true sensitivities to food additives (Connors, Goyette, Southwick, Lees, & Andrulonis, 1976; Harley, Ray, Tomasi, Eichman, Matthews, et al., 1978). In the early 1980s other researchers reported adverse effects of sugar on hyperactive and aggressive behavior (Prinz, Roberts, & Hantman, 1980; Wolraich, Stumbo, Milich, Chenard, & Shultz, 1986). Over time, most papers advocating dietary treatment have combined the recommendations of Feingold and later investigators to restrict not only food additives, preservatives and sugars, but also dairy products, wheat, corn, yeast, soy, citrus, eggs, chocolate, and nuts--foods commonly associated with allergic reactions in children (Boris & Mandel, 1994; Carter, Urbanowicz, Hemsley, Mantila, Strobel, Graham, et al., 1993; Crook, 1980; Egger, Carter, Graham, Gumley, & Soothill, 1985; Kaplan, McNicol, Conte, & Moghadam, 1989; Rapp, 1991). Others have proposed that correcting imbalances in fatty acid metabolism may resolve child behavior problems along with food and chemical sensitivities (Colquhoun & Bunday, 1981; Stevens, Zentall, Abate, Kuczek, & Burgess, 1996; Kane, 1999).