ADHD & Autism

While general statements can be made, the best way to treat children with mood and regulation problems is based on biomedical testing and observations.

 Start with the Basics

Complete blood count (CBC) and comprehensive metabolic panel (CMP): Here I’m checking for iron deficiency anemia, inflammation, low cholesterol, and basic liver and kidney function.

Cholesterol less than 145 mg/dl in neurotypical children has been shown to increase defiance and irritability and increase the chances of school suspension three-fold. Supplementing children can be helpful with similar symptoms/behaviors.

*Zhang,J., et al., Association of serum cholesterol and history of school suspension among school-age children and adolescents in the United States. Am J Epidemiol, 2005. 161(7): p. 691-9.
*Aneja, A. and E. Tierney, Autism: the role of cholesterol in treatment. Int Rev Psychiatry, 2008. 20(2): p. 165-70.

Iron deficiency has been associated with inattention and lower IQ. Iron supplementation in children found to be low with deficit hyperactivity disorder (ADHD) leads to improvements compared to placebo. Iron supplementation in children found to be low with autism leads to improvements in sleep.

*Konofal, E., et al., Iron deficiency in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med, 2004. 158(12): p. 1113-5.
*Lozoff, B., et al., Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev, 2006. 64(5 Pt 2): p. S34-43; discussion S72-91.
*Konofal, E., et al., Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol, 2008. 38(1): p. 20-6.
*Dosman, C.F., et al., Children with autism: effect of iron supplementation on sleep and ferritin. Pediatr Neurol, 2007. 36(3): p. 152-8.

Thyroid function tests: Many children with autism have clinical hypothyroidism, which can be the reason for some of the symptoms.

Ammonia and lactic acid: Here I’m looking for mitochondrial dysfunction, especially if there is evidence of low muscle tone. In such cases, symptoms can improve with supplements such as Coenzyme Q10/Ubiquinone, L-carnitine, etc.

Cysteine: A marker of impaired glutathione productions or excessive oxidative stress/toxicity

Lead: Can cause autistic-type behaviors in some children and may prompt an intensive study of the child’s environment (home, daycare, outdoor areas)

Magnesium (RBC): Low levels have been noted in some children with ADHD and autism. Aggressive supplementation can be helpful to improve sleep, reduce autistic behaviors, decrease hyperactivity, and improve constipation.

*Mousain-Bosc, M., et al., Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6. II. Pervasive developmental disorder-autism. Magnes Res, 2006. 19(1): p. 53-62.
*Starobrat-Hermelin, B. and T. Kozielec, The effects of magnesium physiological supplementation on hyperactivity in children with attention deficit hyperactivity disorder (ADHD). Positive response to magnesium oral loading test. Magnes Res, 1997. 10(2): p. 149-56.

Serum testosterone: A small percentage of children with autism have elevated testosterone, which has been associated with aggressive behaviors.

*Geier, D.A. and M.R. Geier, A clinical trial of combined anti-androgen and anti-heavy metal therapy in autistic disorders. Neuro Endocrinol Lett, 2006. 27(6): p. 833-8.

Specialty Functional Tests 

• Urine organic acid test (OAT):Especially with extensive gastrointestinal symptoms, this assays examines the urine for evidence of yeast, Clostridia bacteria, and other important factors like indirect nutritional factors and mitochondrial function.
• Heavy metals and organic chemicals:Provides direction for detoxification
• Urine neopterin:Provides a marker of inflammation and provides rationale for anti-inflammatory treatments
• Urine nucleic acid/isoprostane:Provides marker of oxidative stress inside/outside the cell; helpful for guiding antioxidant treatments

Gastrointestinal tests, if warranted, may include:

• Comprehensive 3-day stool analysis:A comprehensive, noninvasive diagnostic evaluation of the GI system looking at gut ecology; potential pathogens such as opportunistic bacteria, invasive yeast, and parasites; inflammation; and ability to digest and absorb nutrients
• Intestinal permeability/absorption tests:The GI system is the rate-limiting step to convert all food into the products the body needs in order to be healthy, detox, and achieve optimal functionality. This test can help guide treatment when indicated.
• Bacterial overgrowth breath test:Analyzes the fermentation products of bacteria in the small intestine. Helps to identify if populations of bacteria have become excessive in the upper GI tract, which may contribute to immune hyper-reactivity, nutritional deficiencies, and digestive problems often seen in children with ASD.

While many tests can be ordered without a physician, it is in your child’s best interest to work with a biomedical clinician who specializes in a biomedical approach. Regarding nutritional supplementation, it’s difficult to design a reasonable, cost-effective biomedical protocol without proper observation.

Most parents are confused by side effects versus adjustment reactions that go along with the use of nutraceuticals, and they lack the needed background to have confidence their child is “a ship sailing in the right direction.” The end result is that unneeded supplements are given in happenstance fashion or the strategy is abandoned altogether and no improvements are realized.

The biomedical process takes time and commitment and often leads to fundamental improvements. Even complete resolution of symptoms can be achieved in some cases.

Multivitamin has been shown to improve sleep problems and gastrointestinal symptoms in children with ASD when compared to a placebo.

*Adams, J.B. and C. Holloway, Pilot study of a moderate dose multivitamin/mineral supplement for children with autistic spectrum disorder. J Altern Complement Med, 2004. 10(6): p. 1033-9.

Vitamin C has been shown to reduce stereotypical autistic behaviors (such as stimming) compared to a placebo.

*Dolske, M.C., et al., A preliminary trial of ascorbic acid as supplemental therapy for autism. Prog Neuropsychopharmacol Biol Psychiatry, 1993. 17(5): p. 765-74.

Vitamin B12 and folic acid have been shown to lead to improvements in certain autistic behaviors.

*James, S.J., et al., Metabolic biomarkers of increased oxidative stress and impaired methylation capacity in children with autism. Am J Clin Nutr, 2004. 80(6): p. 1611-7.
*James, S.J., et al., Efficacy of methylcobalamin and folinic acid treatment on glutathione redox status in children with autism. Am J Clin Nutr, 2009. 89: p. 1-6. 

Zinc has been shown to improve symptoms compared to a placebo.

*Yorbik, O., et al., Zinc status in autistic children. J Trace Elem Exp Med, 2004. 17(2): p. 101-107.
*Bilici, M., et al., Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol

 Magnesium and B6, when taken together, have been shown to improve autistic behaviors, social interaction, communication, stereotypia, hyperactivity and

*Mousain-Bosc, M.,et al.,Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6. II. Pervasive developmental disorder-autism. Magnes Res, 2006. 19(1): p. 53-62.
*Starobrat-Hermelin, B. and T. Kozielec, The effects of magnesium physiological supplementation on hyperactivity in children with attention deficit hyperactivity disorder (ADHD). Positive response to magnesium oral loading test. Magnes Res, 1997. 10(2): p. 149-56.
*Mousain-Bosc,M., et al.,Magnesium Vit B6 intake reduces central nervous system hyperexcitability in children. J Am Coll Nutr, 2004. 23(5): p. 545S-548S. 

Pycnogenol has been shown to increase glutathione levels, decrease oxidative stress, and improve attention, coordination, and concentration compared to placebo.

*Dvorakova, M., et al., The effect of polyphenolic extract from pine bark, Pycnogenol on the level of glutathione in children suffering from attention deficit hyperactivity disorder (ADHD). Redox Rep, 2006. 11(4): p. 163-72.
*Chovanova,Z., et al.,Effect of polyphenolic extract, Pycnogenol, on the level of 8-oxoguanine in children suffering from attention deficit/hyperactivity disorder. Free Radic Res, 2006. 40(9): p. 1003-10.
*Trebaticka, J., et al., Treatment of ADHD with French maritime pine bark extract, Pycnogenol. Eur Child Adolesc Psychiatry, 2006. 15(6): p. 329-35.

L-Carnitine has been shown to be an effective treatment for Rett syndrome and has been shown to improve sleep efficiency, attention, and aggression and lessen hyperactivity in children with ADHD.

*Filipek, P.A., et al., Relative carnitine deficiency in autism. J Autism Dev Disord, 2004. 34(6): p. 615-23.
*Rossignol, D.A. and J.J. Bradstreet, Evidence of mitochondrial dysfunction in autism and implications for treatment. American Journal of Biochemistry and Biotechnology, 2008. 4(2): p. 208-217.
*Ellaway, C.J., et al., Medium-term open label trial of L-carnitine in Rett syndrome. Brain Dev, 2001. 23 Suppl 1: p. S85-9.
*Van Oudheusden, L.J. and H.R. Scholte, Efficacy of carnitine in the treatment of children with attention- deficit hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids, 2002. 67(1): p. 33-8.
*Torrioli, M.G., et al., A double-blind, parallel, multicenter comparison of L-acetylcarnitine with placebo on the attention deficit hyperactivity disorder in fragile X syndrome boys. Am J Med Genet A, 2008. 146(7): p. 803-12.

Carnosine has been shown to decrease seizure activity and improve speech and social behavior compared in children with autism compared to a placebo.

*Chez, M.G., et al., Double-blind, placebo-controlled study of L-carnosine supplementation in children with autistic spectrum disorders. J Child Neurol, 2002. 1(11): p. 833-7.

Omega-3 fatty acids have been shown that children with fatty acid deficiency are more likely to be hyperactive, have conduct problems, anxiety, and tantrums, and that infants lacking omega-3 fatty acid supplementation in breast milk or infant formula are about up to 4 times more likely to develop autism.

Many studies have demonstrated improvements with supplementation in children with developmental disorders, ADHD, and autism.

*Stevens, L.J., et al., Omega-3 fatty acids in boys with behavior, learning, and health problems. Physiol Behav, 1996. 59(4-5): p. 915-20.
*Schultz, S.T., et al., Breastfeeding, infant formula supplementation, and Autistic Disorder: the results of a parent survey. Int Breastfeed J, 2006. 1: p. 16.
*Richardson, A.J. and P. Montgomery, The Oxford- Durham study: a randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics, 2005. 115(5): p. 1360-6.
*Sinn, N., J. Bryan, and C. Wilson, Cognitive effects of polyunsaturated fatty acids in children with attention deficit hyperactivity disorder symptoms: a randomized controlled trial. Prostaglandins Leukot Essent Fatty Acids, 2008. 78(4-5): p. 311-26.
*Meguid, N.A., et al., Role of polyunsaturated fatty acids in the management of Egyptian children with autism. Clin Biochem, 2008.
*Amminger, G.P., et al., Omega-3 fatty acids supplementation in children with autism: a double- blind randomized, placebo-controlled pilot study. Biol Psychiatry, 2007. 61(4): p. 551-3.
*Schlanger, S., M. Shinitzky, and D. Yam, Diet enriched with omega-3 fatty acids alleviates convulsion symptoms in epilepsy patients. Epilepsia, 2002. 43(1): p. 103 

Melatonin: Several studies have shown improvement in sleep with the use of melatonin in ADHD and autism. My preference is to give along with 5HTP in order to support serotonin pathways and improve mood.

*Schreck, K.A., J.A. Mulick, and A.F. Smith, Sleep problems as possible predictors of intensified symptoms of autism. Res Dev Disabil, 2004. 25(1): p. 57-66.
*Melke, J., et al., Abnormal melatonin synthesis in autism spectrum disorders. Mol Psychiatry, 2008. 13(1): p. 90-8.
*Andersen, I.M., et al., Melatonin for insomnia in children with autism spectrum disorders. J Child Neurol, 2008. 23(5): p. 482-5.
*Garstang, J. and M. Wallis, Randomized controlled trial of melatonin for children with autistic spectrum disorders and sleep problems. Child Care Health Dev, 2006. 32(5): p. 585-9.
*VanderHeijden, K.B., et al., Effect of melatonin on sleep, behavior, and cognition in ADHD and chronic sleep-onset insomnia. J Am Acad Child Adolesc Psychiatry, 2007. 46(2): p. 233-41.

While many supplements can be found in your local health-food store (even Walmart); efficacy, quality and dosing matters. It is in your child’s best interest to work with a biomedical clinician who specializes in monitoring and prescribing nutraceuticals and restrictive diets. What’s more, it’s difficult to design a reasonable, cost effective biomedical protocol without proper observation.

Most parents are confused by side effects versus adjustment reactions that goes along with the use of nutraceuticals and lack the needed background to have confidence their child is “a ship sailing in the right direction.” The end result being that too many unneeded supplements are given in happenstance fashion or the strategy is abandoned altogether and no improvements are realized. 

A couple of analogies:

• You have to dig deep to find the water. Digging many superficial holes in the ground just messes up the landscape.
• You have to build the dam brick-by-brick to hold back the water efficiently.

The biomedical process takes time and commitment and often leads to fundamental improvements, even complete resolution of symptoms can be achieved in some cases.

Getting Children to take Supplements

Oftentimes, younger children have a hard time swallowing pills or adjusting to new tastes.  But that’s when we have to put on our thinking caps and come up with fun and creative ways to ensure our children get what they need.

 Basic Ideas:

• Mix it in pudding or yogurt (unless reactive to casein)
• Stir it into applesauce (unless reactive on Feingold diet)
• Mix with orange juice or any other strongly flavored juices
• Stir it into a smoothie
• Mix into coconut milk

More Creative Ideas: 

• Squeeze in into a waffle and cover with syrup
• Mix with a teaspoon of spaghetti sauce (or other strong flavored sauces)
• Mix into a bite of strawberry ice-cream (or coconut based ice-cream if reactive to casein)
• Inject into a slightly warm hot dog
• Follow with a reward treat (something rarely given otherwise)
• Stir into “blueberry pudding”- (a mixture of blueberries, avocado, and honey)
• Add pumpkin spice to milk, coconut milk, or almond milk) and blend with medicine

Non-food Ideas:

• Slowly squirt into mouth using a syringe placed on the inside of the cheek to avoid most taste buds
• Bite capsule and spit out the gel cap. Follow with liquid or food.

Many specialized diets have been shown to be helpful. These may include:

• Gluten-Casein-Soy-Free Diet
• Specific-Carbohydrate Diet
• Low-Phenol Diet
• Ketogenic Diet
• Salicylate-Free Diet
• Low-Oxalate Diet

All such diets have been shown to be helpful in reducing autistic behaviors, improving mood, and/or reducing impulsivity. There is also some value to testing and eliminating any foods that aggravate IgG immunoglobulin (this does not necessarily indicate food allergy, but improvements have been noted nonetheless.)

Also, eating organic foods can help to reduce exposure to agrichemicals, and limiting sugars and improving protein intake can be beneficial as well.

The “key” is rational testing and observation.

As examples: A child who displays characteristic symptoms such as dark circles under their eyes, or flushing ears and cheeks when exposed to red food coloring, who responds well to Epsom salt baths and other “sulfation” supplements will likely further improve with a Low-Phenol diet.

A child found to have GI permeability problems, excessive cravings for gluten and dairy, gastrointestinal symptoms, and symptoms of silliness and giddiness after eating will likely further improve with a Gluten-Casein-Soy-Free Diet.

Similar reasoning can be applied to most specialized diets, but it is important to undergo restricted diets only under supervision of a physician or nutritionist who is familiar with them.

List of references:

*Whiteley, P., et al., A gluten-free diet as an intervention for autism and associated spectrum disorders: preliminary findings. Autism, 1999. 3(1): p. 45.
*Knivsberg, A.M., et al., A randomized, controlled study of dietary intervention in autistic syndromes. Nutr Neurosci, 2002. 5(4): p. 251-61.
*Millward, C., et al., Gluten-and casein-free diets for autistic spectrum disorder. Cochrane Database Syst Rev, 2008(2): p. CD003498.
*McCann, D., et al., Food additives and hyperactive behavior in 3-year-old and 8/9-year-old children in the community: a randomized, double-blinded, placebo- controlled trial. The Lancet, 2007. 370(9598): p. 1560-7.
*Lucarelli, S., et al., Food allergy and infantile autism. Panminerva Med, 1995. 37(3): p. 137-41.
*Lu, C., et al., Organic diets significantly lower children’s dietary exposure to organophosphorus pesticides. Environ Health Perspect, 2006. 114(2): p. 260-3.
*Evangeliou, A., et al., Application of a ketogenic diet in children with autistic behavior: pilot study. J Child Neurol, 2003. 18(2): p. 113-8.

While many restrictive diets can be tried without clinical supervision, it is in your child’s best interest to work with a biomedical clinician who specializes in a biomedical approach. Again, it is difficult to design a reasonable, cost-effective biomedical protocol without proper observation.

Most parents are confused by side effects versus adjustment reactions that go along with initiating a restrictive diet, and they lack the needed background to have confidence their child is “a ship sailing in the right direction.”

The end result is that diets are tried in happenstance fashion or the strategy is abandoned altogether and no improvements are realized.

The biomedical process takes time and commitment and often leads to fundamental improvements. Even complete resolution of symptoms can be achieved in some cases.