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reducing the ingestion of additives and the burden of heavy metals sive effect on levels of norepinephrine, serotonin and acetyl- (e.g., lead, cadmium, mercury) in reducing ADHD symptoms. choline (Ward, 1990, op. cit.). Early work found that zinc deficiency caused hyperactivity syn- Moderate zinc deprivation in prepubertal monkeys has been drome in rats (Pediatr. Res. 1975;9:94-7). Further studies (Arch. found to adversely affect their performance in visual attention and Gen. Psychiatr. 1981;38:714-8; J. Pediatr. 1994;125:691-8) short-term memory tasks, without affecting growth rate and with- showed that additives such as tartrazine (E102), one of the 15 azo out any overt signs of zinc deficiency (Golub et al., Am. J. Clin. dyes permitted in food, can trigger Nutr. 1994;60:238-43). Zinc deficiency hyperactive behaviour in some chil- can cause a hyperadrenal condition dren. One double-blind, placebo-con- (Physiol. Behay. 1979;22:211-5), and trolled study by Ward and co-workers adrenergic and dopaminergic system showed that in hyperactive (HA) chil- i dysfunction have been implicated in dren tartrazine could induce a reduc- Environmental factors, ADHD (Kaplan, H. et al., Synopsis of tion in blood serum and saliva zinc such as fluorescent lighting, Psychiatry, 7th ed., Williams & levels, with an associated increase in H Wilkins, Baltimore, pp. 1063-8). It urinary zinc output (J. Nutr. Med. should also first be may also be associated with a reduction 1990;10:415-31). This change was eliminated. in melatonin secretion (Int. J. Neurosci. related to deterioration in behaviour 1990;52:239-41), which, in turn, would and emotional expression. lead to a reduction in serotonin secre- In a further study of HA children, tion, which is known to be linked to Ward confirmed that the former had aggressive behaviour. statistically lower zinc and iron levels In his most recent paper (Nutrition compared to controls for blood, urine and washed scalp hair (all p Practit. 2000;2(2):43-5), Ward summarises the evidence for the < 0.001) (J. Nutr. Environ. Med. 1997;7:333-42). HA children benefits of diet and trace elements and reports a study of supple- known to react to synthetic colouring showed a significant reduc- mentation on ADHD children. Of those given either dietary mod- tion in their blood serum zinc levels and an increase in urinary ification involving elimination, trace elements (zinc, iron and zinc output in response to ingesting either tartrazine or sunset yel- selenium) or EFA, or a combination of trace elements and EFA, low (E119). Many HA children also showed significantly high the "most dramatic improvement" occurred in those on the combi- levels of aluminium, cadmium and/or lead in their urine or hair. nation, in terms of blood serum and hair levels and reduction in Raised aluminium levels are associated with antisocial behaviour behavioural problems over a 10-week period. In a further, as yet in children (Biol. Trace Elem. Res. 1986;11:5), while cadmium unpublished, study, he found a progressive decline in blood zinc has an adverse effect on brain metabolism, particularly a depres- levels in four children using Ritalin over a 12-month period. Given that zinc is an essential co-factor . . in over 100 enzymes and particularly in the Diagnosing ADHD conversion of EFAs to LCPUFAs, zine sta- DHD is defined by the "core" signs of inattention, hyperactivity and impul- tus and appropriate supplementation, plus siveness, according to the American Psychiatric Association's Diagnostic | assessment of synthetic food additives and and Statistical Manual of Mental Disorders (DSM, 4th edition, 1994), and is | heavy metals, would seem of primary known as "hyperkinetic disorder" in the 10th revision of the International | importance in treating ADHD children. Classification of Diseases (WHO, Geneva, 1992). There are three subtypes of ADHD: CONCLUSION = combined type, with signs of inattention and hyperactivity/impulsivity; The work of researchers like Dr + predominantly inattentive type, with inattention but not Alexandra Richardson and Dr Neil Ward hyperactivity/impulsivity; and point irrefutably to two prime causes of the + predominantly hyperactive/impulsive type, with hyperactivity/impulsivity symptoms associated with ADHD. Given but not inattention. the paucity of evidence for any long-term The diagnostic criteria further require that: benefit from MPH, its primary toxic effects the signs have persisted for at least six months to a degree that is maladap- and the first report that early MPH treat- tive and inconsistent with the developmental level of the child; ment in minors does correlate with later - there must be clear evidence of clinically significant impairment in social or stimulant abuse in adulthood (Lambert, N., academic functioning; Hartsough, C., J. Learn. Disabil. = some impairment is present in two or more settings (usually at home and at 1998;31:533-44), it seems only common school); sense first to assess the nutritional status = some of the signs that caused impairment were present before the age of and heavy metal burden of any presenting seven; and child, correct it and observe any improve- the signs do not occur exclusively during the course of a pervasive develop- ments in behaviour before considering any mental disorder, schizophrenia or other psychotic disorder and are not better highly potent drug therapy. Environmental accounted for by other mental disorders (such as depression or anxiety). factors, such as fluorescent lighting, should The diagnosis of hyperkinetic disorder (HKD), sometimes used by UK clini- also first be eliminated. cians, defines a subgroup of ADHD. HKD requires the presence of all three Let the advocates of MPH remember core signs: inattention, hyperactivity and impulsiveness. It also requires that all | Hippocrates’ primary command: "First, do of the core symptoms were present before the age of seven years, are pervasive | no harm." He might have added, "especially (present in two or more settings) and cause impairment. HKD is broadly similar | to children". oo to severe combined-type ADHD. . Continued on page 81 Environmental factors, such as fluorescent lighting, should also first be eliminated. 24 = NEXUS Continued on page 81 www.nexusmagazine.com OCTOBER — NOVEMBER 2001