ADD and Ritalin...Is There an Alternative?

Attention Deficit Disorder (ADD) is the most common childhood psychiatric disorder. It is so common that some argue that it is a normal part of childhood. Don’t believe it. Anyone who has faced the daunting task of caring for an ADD child knows that it is a bigger-than-life problem! The child may be pleasant and well-intentioned on the surface, but inability to focus and organize tasks and settle into everyday home and social situations means that adult authority is constantly tested. Parents know that their ADD children are unable to play, study and learn independently, and the increased risk of accident and injury to themselves and friends, means that family life is fraught with stress for everyone.

Attention deficit is a symptom that interferes with learning. It is a thought disorder, not just misbehavior, and it prevents these children from succeeding at school and developing interests, skills and friendships. Motivation plays a role, of course, but there is also an organic impairment of brain function affecting both attention and memory, especially immediate short term memory, which seems to be fragmentary, disorganized, and fraught with errors, even though the total intelligence of the child measures within the normal range. ADD children often give up on learning unless it just comes all by itself. They gravitate to TV, video games, art projects, collecting things, and getting into mischief. They develop routines and resist interruptions once they are engaged. Attention is impaired, but curiosity is usually intact, and so the child is driven to explore, but taking only small ‘bites’ out of any new item. This leads to boredom, but not before family and teachers are exasperated by the constant need for supervision to cope with the hyperactivity and aggressiveness of the ADD child, and to protect his peers, and property from mindless mishaps.

ADD affects 3 to 9 percent of school-age children, the number has been increasing in the past decade. This amounts to over 2.5 million children in the United States whose educational experiences are marred by frustration and whose peer relationships are strained by conflict and misunderstanding. Eventually, such children are more likely to resort to antisocial and delinquent behaviors, including drug dependency in their teen years. Contrary to earlier opinion, children do not usually outgrow this disorder and may need lifelong medication, in order to be able to develop a skill, find a job, and maintain a stable and productive lifestyle. A follow-up study of ADD children found 80 percent still impaired after 8 years, i.e. in their late teens and early 20’s; and over half had actually worsened by becoming more defiant and unruly.[1] In the language of the professions, this is called “oppositional” and “conduct disorder” respectively. There have been no measurable differences between those treated with medication and those not. There is no doubt that the epidemic of ADD children is a major part of the epidemic of teen-age violence, suicide, drug abuse, and criminality that is having such a disturbing effect on our country.

Amphetamine-like drugs, such as Ritalin (methylphenidate), dexedrine, and desoxyn, are the medical drugs-of-choice for the ADD child. Cylert (magnesium pemoline) is a different type of amine that is also helpful. These drugs are so entrenched in medical practice and in the expectations of the education bureaucracy, that it is almost mandatory for the office-based physician to prescribe them. To not do so can be challenged as “unprofessional.” It is ironic that these same drugs are absolutely illegal when used by teen-agers as their preferred street drug. The point is that the drugs do accomplish a perceived benefit—but at some degree of risk, albeit less so under medical supervision than on the streets.

Ritalin is the least toxic of the amphetamines, but even so it does interfere with REM sleep, an essential brain repair mechanism, and it is also known to deplete the neurotransmitter, serotonin. On the other hand, research confirms that about 75 percent of hyperactive children improve, showing better attention, less impulsiveness and less over-active behavior on Ritalin. A recent study showed a significant advantage of 4 points on an IQ test measure comparing ADD children treated with Ritalin versus placebo after a year and a half of follow-up.

Research into ADD is a national priority and the search for a different and better medical approach is spurred by the increasing public dissatisfaction with the idea of treating school-children with drugs. The war on drugs has demonized almost all psychoactive substances, even those that are relatively safe and non-toxic when used in medical settings, even the likes of amphetamines and opiates. It is strange to consider that if children were getting Ritalin in the schoolyard instead of in the doctor’s office, the police would be called at once!

I am not promoting the use of drugs and amphetamines but perhaps this paradox will do some good, and get us to realize that all “drugs” have the potential for abuse and also the potential for good. It is up to patients, doctors, and our political leaders to be rational and scientific in our approach so that we don’t exclude potentially useful substances from medical practice.

There has been significant progress in our understanding of ADD but no one has yet been able to explain the apparent increase in the number of children with this behavior pattern that has caused sales of Ritalin to increase 5-fold in 7 years! Genetic factors surely play a part, for a study of identical twins found 90 percent concordance: if one twin had ADD so did the other. Environmental factors are a well-established factor. Lead and mercury are particularly damaging to brain development and activity. Lead was carefully studied in the 1960s and 70s and the consensus was that half of all cases of ADD that were not otherwise explained, were caused by lead exposure from housepaint, petrol, lead contaminated dirt—and from solder in toothpaste tubes and baby formula cans!

We know these metals are still present in home repair situations calling for the removal of old paint, but the Lead Paint Protection Act of 1976 ended the use of lead in gasoline and indoor paint in the United States and there has been a dramatic reduction in lead level in the American people. Hair levels were commonly 15 to 20 ppm in the 1970s; now it is rare to see a hair sample with more than 4 or 5 ppm (ppm is parts per million, which is the same as micrograms per gram of hair).

Mercury was not removed from paint until after 1991, when a baby died after being placed overnight in a newly-painted, poorly ventilated nursery. I have not seen a research study that estimated the frequency of ADD due to mercury from paint, or dental amalgam (silver fillings contain mercury), probably because it hasn’t been taken seriously up until now. However Drs. Marlowe, Moon and Errera measured hair mercury levels in 59 children, and found a significant correlation to IQ scores on the Wechsler Intelligence Scale. Even at very low concentration mercury had an adverse effect on brain function. Thus, though the average hair mercury was only 1.04 mcg per gram (ppm), less than half the upper limit of 2.5 ppm that the laboratory accepts as normal, the research indicated that 10 percent of the drop in IQ scores is due to mercury.

Is there sufficient evidence to ban the use of mercury-containing silver fillings in children? It is already happening in Sweden and Germany. The risk of mercury causing adverse effects is credible because mercury accumulates for the life of the filling. In the 1953 disaster at Minamata, Japan, doses of mercury that did not cause symptoms in the pregnant mothers had disastrous outcomes for the babies, which were born with permanently impaired movement, limited speech, and retarded intellect.

Another toxic agent that should be taken seriously is fluoride. There are several credible studies, in animals and humans both, that confirm the fact of brain damage from fluoride—at levels similar to those commonly experienced here in the United States. Animal studies show accumulation of fluoride in the brain, interference with enzyme activity—and direct free radical damage to nerve cells. Nerve damage from fluoride is not just a theory—it is fact. In research laboratories aluminum fluoride is routinely used to activate G-proteins, regulators of cell activity. This compound is likely to be produced when fluoridated water is heated in aluminum pots, especially in the presence of acid foods, such as tomato, fruits, and coffee.

There has been pitifully little research on the influence of fluoridation on human brain development! We should be concerned that the incidence of ADD is rising precipitously even though we have largely removed lead and mercury from contention. How to account for the fact that the number of children requiring treatment for ADD doubled between 1990 and 1993? That surely cannot be a sudden change in our gene structure. Nor is it likely to be a medical or bureaucratic fad. Have there been any large-scale changes in environment of children since the late 1980s? Yes. There has been a campaign to fluoridate the entire water supply of the United States and the number of fluoridated cities is increasing.

More pertinent, however, is the increasing popularity of vitamin supplements. The fact that you are reading this article is a direct reflection of the growing health and nutrition consciousness of Americans and the medical profession. Mothers and doctors are more likely than ever to add vitamins to infant formula in an attempt to give their child the best modern advantage. However vitamin drops are likely to be fluoridated, even in areas where the water is already fluoridated, and this becomes excessive. The fluoride burden is already too high due to fluoride residues in infant formula, baby food, and toothpaste. About the only safe haven for babies is breast milk.

In the first place, breast milk contains almost no fluoride. But it does contain nutrients essential for brain development, especially DHA and taurine. Remember, the human brain is not fully developed at birth—the EEG does not have the familiar alpha, beta, and theta wave, but only some nondescript delta activity. Even at age three the brain structure is only 90 percent developed. Babies that are fed the raw materials for human nerve cell growth and development get a tremendous advantage. In an 18 year study of 1000 New Zealand children, breast fed babies tested higher in reading, mathematics, IQ and scholastic ability—and they were 38% more likely to graduate high school. This statistic was derived after correcting for socio-economic factors and diseases of infancy.[i]

This takes on greater significance in light of research at Purdue University that found a significant deficiency of DHA in blood cells of 53 children with ADD compared to 43 children without the disorder.[ii] DHA is produced from the essential fatty acid, ALA (alpha-linolenic acid), which is commonly deficient in the American diet. This nutrient is essential for brain development and nerve cell membrane structure. Though it is readily obtained in fish oils, these are located in the skin of the fish, a part that most people don’t eat. One reason is that Americans have been strongly advised against eating fats. Even the “good fats,” like that in fish skin, are taboo. And children, even more in need than adults, lose out because DHA is not yet included in any of the commercial infant formulas sold in the USA! If you don’t add the new DHA products or the old-fashioned cod-liver oil, your child is out of luck.

Forty percent of the ADD children in the Purdue study also had symptoms of fatty acid deficiency, such as excess thirst and frequency of urination, dry hair, dandruff and dry skin (especially elbows), and bumpy hair follicles on the upper arms. This compares to only 9 percent in the control group children. However their diets were not significantly different except alpha linolenic acid was lower in the ADD group than the controls! This is the source of DHA, which is an essential component of the brain cell membranes.

DHA supplementation in adult dyslexics improves the function of nerve cells in the retina. Their dark adaptation is so improved that “experts” are considering DHA may be a dietary essential for this organ. Dyslexics have retinal and central processing defects but dark adaptation has not been reported before. Research by Dr. J. Stordy has found that DHA supplementation is associated with improved reading ability and sociable behavior.[iii]

Other comparisons are also informative: the rate of breast feeding was 81 percent in the control group, but only 45 percent in those with ADD. Recurrent ear infections (otitis) relapsing more than 10 times since birth occurred in 30 percent of the ADD children but only 9 percent of the controls. Asthma was also seen in 32 percent of the ADD kids and only 9 percent of the controls. The ADD kids also had more headaches and stomach-aches, practically non-existent in the control group.

With this in mind, it is not surprising that a double blind study found a significant gain in reading comprehension within a year of individualized nutrient supplementation for a group of 20 learning disabled children. The seventeen children who stayed on the supplement program were able to enter mainstream classes within a year and a half. A sub-group of 12 children stayed on vitamins for a full two years, during which their test scores rose 7+ points while those on placebo dropped by over 6 points. For those who stopped taking nutrients, it took almost 2 years for academic performance to decline back to baseline. The good news is the benefits are long-lasting. The bad news is that it is hard for people to appreciate just how powerful the nutrient therapy actually is.

Herbal treatments for ADD are also gaining credibility. St. John’s Wort is one of these and it probably will be scientifically proven and accepted before long. However, it also causes sunburn, an adverse effect that I think will curtail its use. Vinpocetine is another herbal brain stimulant that holds promise, based on its popularity as a “smart pill” for adults. In use for over 400 years in Europe in the form of vincamine, derived from the periwinkle plant, it has become the most popular of the smart pills in Hungary. Over 100 research studies document the claim that it increases the rate at which brain cells produce ATP, and increases the utilization of glucose and oxygen in the brain. The only adverse effect I have seen with it is headache due to dilatation of cerebral blood vessels.

Another recent study found a significant improvement in 10 of 11 ADD children treated with combination American ginseng (Panax quinquefolia) and Ginkgo biloba extracts. Over 90 percent of the subjects showed a reduction in at least 3 out of 7 ADD symptoms. The ginseng product performed as well all by itself in almost 80 percent (11 of 14) of another group of children.[iv] Ginseng works in part by increasing acetylcholine neurotransmitter production. A similar effect is associated with the use of deanol (DMAE or dimethylaminoethanol), which was first used for ADD by Dr. Leon Oettinger in 1958[v] and was confirmed in 1960 by Dr. Stanley Geller, who conducted a double-blind study in 75 children, who were given 50 mg doses, twice a day.[vi] Improved puzzle solving ability, and organization of activity were observed. Additional confirmation was provided by Coleman et al in 1976.[vii] Deanol is an important and safe orthomolecular therapy and it deserves to be used much more than it is. It is my first choice for the treatment of ADD, certainly preferred to amphetamines and Ritalin.

Other factors in ADD, such as allergy and low blood sugar remain controversial, mostly because the have been presented as causative factors. The neurologic injury that causes ADD is undoubtedly aggravated by allergy and low blood sugar and these should rightfully be treated. But they are not likely the cause of the disorder. Nevertheless, treating allergy and balancing the diet can make a huge difference. Just ask the mothers and fathers of the Feingold Association how they feel about food additives, salicylates, and allergy. The same goes for parents who find that sugar is a trigger for hyperactivity: would you have them believe an egghead statistic over their own first-hand, day-to-day experience? The New England Journal apparently would. Their recent study on the effects of sugar was thumbs down: no significant effect of sugar on child behavior! This study, by Dr. Wolraich et al, was designed so that the average dose of sugar was about 2/3 pound (300 grams) a day. There was no comparison group at a truly low sugar intake, under 100 mg per day. I wrote to them about this but my rebuttal was rejected. I called the editor; he assured me that the other critics also felt that the study should be repeated— but with a higher dose of sugar!

©2010 Richard A. Kunin, M.D.

[1] Barkley R, Fischer M, et al: The adolescent outcome of hyperactive children diagnosed by research criteria: An 8 year prospective follow-up study. J Am Acad Child Adolesc Psychiatry 29:546-556; 1990.
[i] Horwood LJ, Fergusson DM: Breastfeeding and later cognitive and academic outcomes. Pediatrics 101. 1998.
[ii] Stevens L, Zentall S, et al: Essential fatty acid metablism in boys with attention-deficit hyperctivity disorder. AJCN; 62:761-8. 1995. (unpublished)
[iii] Stordy JB: Benefit of docosoahexaenoic acid supplements to dark adaptation in dyslexics. Lancet 1995, 346:38.
[iv] Lyon MR, Cline JC et al: An open, randomized, double blind comparison of American Ginseng alone or in combination with ginkgo biloba on the symptoms of ADD in children. (unpublished 1998)
[v] Oettinger L: The use of deanol in the treatment of disorders of behavior in children. J Pediat. 53:761-765. 1958.
[vi] Geller S. Comparison of a tranquilizer and a psychic energizer. JAMA; 174:89-92. 1960.
[vii] Coleman N, Dexheimer P: Deanol in the treatment of hyperkinetic hildren. Psychosomatics; 17:68—72. 1976.