Autism, ADHD And Diet: Old Lecture Notes

Autism, ADHD, and Diet

TAKE HOME IDEAS FOR VERY BUSY PEOPLE

www.maloneymedical.com

Chris Maloney, ND

4 Drew Street, Augusta ME 04330

(207) 623-1681

Three things to remember:

1)      You can make a difference

2)      You are the expert

3)      You are the heroes

Diagnosis is not your child:  The genetics of autism and ADHD overlap. [1] Testing fails to show a clear picture of where one diagnosis ends and the other begins.[2] 

Diet probably affects behavior

Watch for diet related behavior changes:  immediate, 2 hours, 12 hours, 48 hours. Gold standard is:  introduction->change, elimination, reintroduction->change

As caregivers, diet is only one issue, but you may observe. 

            Dairy-> sedation OR Dairy->manic

            Wheat-> cascade of allergic responses

What can you do? 

            GABA For AGGRESSION  (typically 500mg twice a day morning and lunch)[3]

            5 HTP for ANXIETY or DEPRESSION  (tapered up from 50mg until symptoms resolve or stomach upset occurs)  [4]

Eleven (65%) of the 17 patients who completed both test days showed a significant global worsening of behavioral symptoms with short-term tryptophan depletion, but none of the 17 patients showed any significant change in clinical status from baseline after sham depletion (P = .001). Tryptophan depletion led to a significant increase in behaviors such as whirling, flapping, pacing, banging and hitting self, rocking, and toe walking (P < .05). In addition, patients were significantly less calm and happy and more anxious. Arch Gen Psychiatry. 1996 Nov;53(11):993-1000.

Homeopathics:  The placebo effect?  I’ll take it.  (No toxicity or drug interactions)

During the screening phase, 84% (70/83) of the children responded to treatment.[5]

Stramonium (all 30c or above) – BITING (vicious)

Pulsatilla –Biting fatigued or crazy.  Normally clingy, very sweet. 

Hyoscyamus-  Need to take clothes off, display oneself. 

Chamomile- child is inconsolable, caregivers feel fed up.

Pulsatilla- child is inconsolable, caregivers just want to hold. 

Calcarea Carbonicum-  child cannot make transitions.  Fine with five minutes warning.

Tarantula- child is manic, dancing. 

Arsenicum Album- child is full of fear, up at night with terrors. 

Dr. Maloney’s Autistic Allergy Quiz

What percent of autistic children have documented allergies?

9 of 96 (9%) children with a diagnosis of autism (cases) and 41 of 449 (9%) children without autism (matched controls) had a history of gastrointestinal disorders

BMJ. 2002 Aug 24;325(7361):419-21

What percent of autistic children have undocumented allergies (estimate)?

Five times as many.  Respiratory, food, and skin allergies were reported by parents more often for children with autism, with food allergies having the strongest relative difference between the groups (odds ratio, 4.5; 95% confidence interval, 3.0-7.0).   Arch Pediatr Adolesc Med. 2006 Aug;160(8):825-30.

The consistency in estimates between the two surveys suggests high reliability for parental report of autism

MMWR Morb Mortal Wkly Rep. 2006 May 5;55(17):481-6.

What can we expect from our doctors in terms of food allergy? 

Diet and child behavior problems: fact or fiction?Cormier E, Elder JH.

Florida State University College of Nursing, Tallahassee, USA.

“Dietary treatment of children with behavioral disorders has had wide public appeal and been a source of controversy since the 1920’s. Yet, to date, there is little empirical evidence supporting the effectiveness of dietary restrictions in treating child psychiatric disorders, in particular, autism” Pediatr Nurs. 2007 Mar-Apr;33(2):138-43.

the fourth outcome, reduction in autistic traits, reported a significant beneficial treatment effect for the combined gluten- and casein- free diet.

Cochrane Database Syst Rev. 2004;(2):CD003498

Elimination diet (double-blinded) produces a 70% reduction in symptoms for ADHD.[6]

What are the most common allergies for autistic children? [7]

ASD children produced more tumor necrosis factor-alpha… irrespective of objective GI symptoms. They also produced more TNF-alpha with gliadin, which was more frequently observed in the group with loose stools

Impaired social interaction, communication and imaginative skills characterize autistic syndromes. In these syndromes urinary peptide abnormalities, derived from gluten, gliadin, and casein, are reported. They reflect processes with opioid effect. The aim of this single blind study was to evaluate effect of gluten and casein-free diet for children with autistic syndromes and urinary peptide abnormalities. A randomly selected diet and control group with 10 children in each group participated. Observations and tests were done before and after a period of 1 year. The development for the group of children on diet was significantly better than for the controls.  Nutr Neurosci. 2002 Sep;5(4):251-61.

My quick answers:

What amount is necessary to cause an allergic reaction?  2mg

What types of allergic reaction are possible? 4 types

How long is it necessary to avoid an allergen before seeing any difference?Four days

How long does a person maintain an allergic response?  Depends on immune system

What is sensitivity?  Behavioral change without allergic responses.

What is intolerance?  Physical changes without allergic responses

What about combinations?  May generate allergic, sensitivity or intolerance responses.

What else should we watch for?

Metals

Fifteen (44%) of the psychotic children (autistic and nonautistic) had blood lead levels greater than two standard deviations above the mean for normal controls

Am J Dis Child. 1976 Jan;130(1):47-8

Fifteen autistic children and four typically developing children completed the study. Three autistic subjects excreted one metal in greater quantity during the provoked excretion than baseline. Two of these were very close to the limit of detection. In the third case, the provoked excretion of mercury was between the upper limit of normal and lower limit of the potentially toxic reference range. Fish was removed from this child’s diet for greater than one month, and the provoked excretion test repeated. The repeat excretion of mercury was within the normal range. Clin Toxicol (Phila). 2007 Jun-Aug;45(5):476-81.

Magnesium

autistic children and children with other autistic spectrum disorders had significantly lower plasma concentrations of Mg than normal subjects (p=0.013 and p=0.02, respectively). Biol Trace Elem Res. 2006 Feb;109(2):97-104   

Amino Acids

However, children with autism had more essential amino acid deficiencies consistent with poor protein nutrition than an age/gender matched control group. There was a trend for children with autism who were on restricted diets to have an increased prevalence of essential amino acid deficiencies and lower plasma levels of essential acids including the neurotransmitter precursorstyrosine and tryptophan than both controls and children with autism on unrestricted diets  J Autism Dev Disord. 2003 Aug;33(4):449-54.

Iron

Seventy-seven percent had restless sleep at baseline, which improved significantly with iron therapy, suggesting a relationship between sleep disturbance and iron deficiency in children with autism spectrum disorder. Sixty-nine percent of preschoolers and 35% of school-aged children had insufficient dietary iron intake  Pediatr Neurol. 2007 Mar;36(3):152-8

Essential Fatty Acids

We observed an advantage of omega-3 fatty acids compared with placebo for hyperactivity and stereotypy, each with a large effect size. Biol Psychiatry. 2007 Feb 15;61(4):551-3

Cholesterol is essential for neuroactive steroid production, growth of myelin membranes, and normal embryonic and fetal development. It also modulates the oxytocin receptor, ligand activity and G-protein coupling of the serotonin-1A receptor. A deficit of cholesterol may perturb these biological mechanisms and thereby contribute to autism spectrum disorders (ASDs), as observed in Smith-Lemli-Opitz syndrome (SLOS) and some subjects with ASDs in the Autism Genetic Resource Exchange (AGRE). A clinical diagnosis of SLOS can be confirmed by laboratory testing with an elevated plasma 7DHC level relative to the cholesterol level and is treatable by dietary cholesterol supplementation. Individuals with SLOS who have such cholesterol treatment display fewer autistic behaviours, infections, and symptoms of irritability and hyperactivity, with improvements in physical growth, sleep and social interactions. Other behaviours shown to improve with cholesterol supplementation include aggressive behaviours, self-injury, temper outbursts and trichotillomania. Cholesterol ought to be considered as a helpful treatment approach while awaiting an improved understanding of cholesterol metabolism and ASD. There is an increasing recognition that this single-gene disorder of abnormal cholesterol synthesis may be a model for understanding genetic causes of autism and the role of cholesterol in ASD.  Int Rev Psychiatry. 2008 Apr;20(2):165-70.

In double-blind, randomized, controlled trials, DHA and EPA combinations have been shown to benefit attention deficit/hyperactivity disorder (AD/HD), autism, dyspraxia, dyslexia, and aggression.  Altern Med Rev. 2007 Sep;12(3):207-27.

Children aged 8-13 y with impaired visual sustained attention performance received placebo, 250 mg/d EPA + DHA esterified to PL-n-3 (300 mg/d phosphatidylserine), or FO for 3 mo in a randomized double-blind manner. A significant correlation between the alterations in FAs and increased TOVA scores mainly occurred in the PL-n-3 group.  Am J Clin Nutr. 2008 May;87(5):1170-80

Avoid IV treatments without research

There is no evidence that single or multiple dose intravenous secretin is effective and as such it should not currently be recommended or administered as a treatment for autism Cochrane Database Syst Rev. 2005 Jul 20;(3):CD003495

Avoid meds if possible

Some evidence of the benefits of risperidone in irritability, repetition and social withdrawal were apparent. These must however be considered against the adverse effects, the most prominent being weight gain Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005040.

Music

the findings indicate that music therapy may help children with autistic spectrum disorder to improve their communicative skills Cochrane Database Syst Rev. 2006 Apr 19;(2):CD00438

Autism, Aspergers, and ADHD

Are these separate diagnoses?

Structural brain abnormalities in adolescents with autism spectrum disorder and patients with attention deficit/hyperactivity disorder.  With regard to clinical criteria, the clinical groups did not differ with respect to ADHD symptoms; however, only patients with ASD showed deficits in social communication and interaction, according to parental rating. While the shared structural deviations in the medial temporal lobe might be attributed to an unspecific delay in brain development and might be associated with memory deficits, the structural abnormalities in the inferior parietal lobe may correspond to attentional deficits observed in both ASD and ADHD. By contrast, the autism-specific grey matter abnormalities near the right temporo-parietal junction may be associated with impaired ‘theory of mind’ abilities. These findings shed some light on both similarities and differences in the neurocognitive profiles of ADHD and ASD patients.  J Child Psychol Psychiatry. 2007 Dec;48(12):1251-8

Psychological and neurobehavioral comparisons of children with Asperger’s Disorder versus High-Functioning Autism.  There were more similarities than differences between the two clinical samples on the personality scales, although the Asperger’s group scored significantly on the two scales with anxiety components.  J Autism Dev Disord. 2007 May;37(5):847-54

The results showed that the inability to understand sarcastic situation was specific to group with AS, No To Hattatsu. 2006 May;38(3):177-81

Children with Asperger’s syndrome had better social skills and fewer autistic symptoms 2 years after study enrollment than the children with autism. The differences in outcome could not be explained by initial differences in IQ and language abilities. Children with autism who had developed verbal fluency at follow-up were very similar to the children with Asperger’s syndrome at study enrollment. Am J Psychiatry. 2000 Dec;157(12):1980-7

Outcome in high-functioning adults with autism with and without early language delays: implications for the differentiation between autism and Asperger syndrome.

Scores on tests of language comprehension and expression were also similar, but in both groups language abilities were well below chronological age level. The implications of these results with respect to the differences between Asperger syndrome and high-functioning autism are discussed. The poor performance on language tests also challenges the assumption that early language development in Asperger syndrome is essentially normal.  J Autism Dev Disord. 2003 Feb;33(1):3-13.

Regression analysis revealed that specific language impairment at time 2 (8yrs) more often accounted for the greatest variation in outcome scores in adolescence than the standard diagnosis of AS versus HFA based on history of language delay.

J Autism Dev Disord. 2008 Apr;38(4):616-25.


[1] Significant correlations were found between autistic and ADHD traits in the general population (.54 for parent data, .51 for teacher data). In the bivariate models, all genetic correlations were >.50, indicating a moderate degree of overlap in genetic influences on autistic and ADHD traits…common genetic influences operating across autistic traits and ADHD behaviours throughout normal variation and at the extreme. This is relevant for molecular genetic research, as well as for psychiatrists and psychologists, who may have assumed these two sets of behaviours are independent. J Child Psychol Psychiatry. 2008 May;49(5):535-42

[2] The goal of this study was to evaluate and compare executive functioning (EF) profiles in children with ADHD and in children with ASD with and without comorbid ADHD…Effect sizes showed clear deficits of ADHD children in inhibition and working memory tasks. Participants with ASD were impaired in planning and flexibility abilities…Nevertheless the heterogeneity of these and previous results shows that EF assessment is not useful for differential diagnosis between ADHD and ASD. It might be useful for evaluating strengths and weaknesses in individual children. Child Adolesc Psychiatry Ment Health. 2008 Jan 31;2(1):4

[3] “Multiple lines of evidence, including alterations in levels of GABA and GABA receptors in autistic patients, indicate that the GABAergic system, which is responsible for synaptic inhibition in the adult brain, may be involved in autism.”  Neurogenetics. 2006 Jul;7(3):167-74. Epub 2006 Jun 13  (DUKE)

[4] “The serotonin transporter gene (5-HTT) plays a crucial role in serotonergic neurotransmission and has been found to be associated, with varying degrees of significance, with many diseases, including autism”  Am J Med Genet B Neuropsychiatr Genet. 2008 Feb 19  (HARVARD)

[5] Homeopathy. 2007 Jan;96(1):35-41. Links

Randomised controlled trials of homeopathy in hyperactive children: treatment procedure leads to an unconventional study design. Experience with open-label homeopathic treatment preceding the Swiss ADHD placebo controlled, randomised, double-blind, cross-over trial.Frei H, Everts R, von Ammon K, Kaufmann F, Walther D, Schmitz SF, Collenberg M, Steinlin M, Lim C, Thurneysen A.

Swiss Association of Homeopathic Physicians, Lucerne, Switzerland. heiner.frei@hin.ch

BACKGROUND: Treatment of patients with attention deficit hyperactivity disorder (ADHD) with homeopathy is difficult. The Swiss randomised, placebo controlled, cross-over trial in ADHD patients (Swiss ADHD trial) was designed with an open-label screening phase prior to the randomised controlled phase. During the screening phase, the response of each child to successive homeopathic medications was observed until the optimal medication was identified. Only children who reached a predefined level of improvement participated in the randomised, cross-over phase. Although the randomised phase revealed a significant beneficial effect of homeopathy, the cross-over caused a strong carryover effect diminishing the apparent difference between placebo and verum treatment. METHODS: This retrospective analysis explores the screening phase data with respect to the risk of failure to demonstrate a specific effect of a randomised controlled trial (RCT) with randomisation at the start of the treatment. RESULTS: During the screening phase, 84% (70/83) of the children responded to treatment and reached eligibility for the randomised trial after a median time of 5 months (range 1-18), with a median of 3 different medications (range 1-9). Thirteen children (16%) did not reach eligibility. Five months after treatment start, the difference in Conners Global Index (CGI) rating between responders and non-responders became highly significant (p = 0.0006). Improvement in CGI was much greater following the identification of the optimal medication than in the preceding suboptimal treatment period (p < 0.0001). CONCLUSIONS: Because of the necessity of identifying an optimal medication before response to treatment can be expected, randomisation at the start of treatment in an RCT of homeopathy in ADHD children has a high risk of failure to demonstrate a specific treatment effect, if the observation time is shorter than 12 months.

PMID: 17227746 [PubMed – indexed for MEDLINE]

[6] Eur Child Adolesc Psychiatry. 2008 Apr 21. [Epub ahead of print] Links

A randomised controlled trial into the effects of food on ADHD.Pelsser LM, Frankena K, Toorman J, Savelkoul HF, Pereira RR, Buitelaar JK.

ADHD Research Centre, Liviuslaan 49, 5624 JE, Eindhoven, The Netherlands, lmjpelsser@worldmail.nl.

The aim of this study is to assess the efficacy of a restricted elimination diet in reducing symptoms in an unselected group of children with Attention deficit/hyperactivity disorder (ADHD). Dietary studies have already shown evidence of efficacy in selected subgroups. Twenty-seven children (mean age 6.2) who all met the DSM-IV criteria for ADHD, were assigned randomly to either an intervention group (15/27) or a waiting-list control group (12/27). Primary endpoint was the clinical response, i.e. a decrease in the symptom scores by 50% or more, at week 9 based on parent and teacher ratings on the abbreviated ten-item Conners Scale and the ADHD-DSM-IV Rating Scale. The intention-to-treat analysis showed that the number of clinical responders in the intervention group was significantly larger than that in the control group [parent ratings 11/15 (73%) versus 0/12 (0%); teacher ratings, 7/10 (70%) versus 0/7 (0%)]. The Number of ADHD criteria on the ADHD Rating Scale showed an effect size of 2.1 (cohen’s d) and a scale reduction of 69.4%. Comorbid symptoms of oppositional defiant disorder also showed a significantly greater decrease in the intervention group than it did in the control group (cohens’s d 1.1, scale reduction 45.3%). A strictly supervised elimination diet may be a valuable instrument in testing young children with ADHD on whether dietary factors may contribute to the manifestation of the disorder and may have a beneficial effect on the children’s behaviour.

PMID: 18431534 [PubMed – as supplied by publisher]

[7] Peripheral blood mononuclear cells (PBMCs) were obtained from 109 ASD children with or without GI symptoms (GI [+] ASD, N = 75 and GI (-) ASD, N = 34], from children with NFH (N = 15), and control subjects (N = 19). Diarrhea and constipation were the major GI symptoms. We measured production of type 1 T-helper cells (Th1), type 2 T-helper cells (Th2), and regulatory cytokines by PBMCs stimulated with whole cow’s milk protein (CMP), its major components (casein, beta-lactoglobulin, and alpha-lactoalbumin), gliadin, and soy. RESULTS: PBMCs obtained from GI (+) ASD children produced more tumor necrosis factor-alphairrespective of objective GI symptoms. They also produced more TNF-alpha with gliadin, which was more frequently observed in the group with loose stools.  PBMCs obtained from GI (-) ASD children produced more TNF-alpha/IL-12 with CMP than those from control subjects, but not with beta-lactoglobulin, alpha-lactoalbumin, or gliadin. Cytokine production with casein and soy were unremarkable.J Pediatr. 2005 May;146(5):605-10.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s