Send letter to journal:
Re: ADHD protocol not evidence based

Dear Editor,

I write with regard to the recently published protocol for treating attention deficit/ hyperactivity disorder.[1] I would like to comment specifically on a few points.

The authors suggest a trial of an elimination diet if the history suggests that dietary factors might be significant, drawing on one paper to suggest that 'there is evidence for the effectiveness of an individually constructed elimination or oligoantigenic diet'. In fact there have been a number of good double-blind placebo-controlled trials of dietary interventions in ADHD. Changes in mood state (eg. irritability) rather than ADHD symptoms per se have been shown in response to foods in a minority of subjects. However food intolerance is very unlikely to be the sole cause and dietary intervention alone is rarely helpful and may be harmful. In any case a repeated single-blind challenge (at a minimum) is required.[2]

The assertion that intelligence testing is 'relatively straightforward' and can be carried out by non-psychologists is problematic. Cognitive functioning is extremely complex and difficult to measure reliably or meaningfully. Some paediatricians with an interest can be trained to use (and interpret) certain standardised psychometric tools, aware of their limitations. However if there is academic under-achievement the child deserves a formal psychometric assessment by an educational psychologist, including academic achievement testing, to identify strengths and weaknesses to develop an individualised program of remedial tuition.

The authors suggest trying psychological interventions before a trial of medication. This goes against the grain of published evidence.[3] If the diagnosis is clear and there is significant disability, then a trial of stimulant medication should be considered early, and instituted alongside behavioural interventions.

The suggestion to 'Check hearing clinically' runs contrary to the accepted wisdom that clinical assessment of children’s hearing is notoriously unreliable. Finally pervasive developmental disorder is listed as a co-morbidity, whereas in fact it is an exclusion criterion according to DSM-IV (the authors provide partial DSM-IV diagnostic criteria).

1. Hill P, Taylor E. An auditable protocol for treating attention deficit/ hyperactivity disorder. Arch Dis Child 2001;84:404-409 2. Breakey J. The role of diet and behaviour in childhood. [Review] Journal of Paediatrics & Child Health1997;33:190-4. 3. Arnold LE, Abikoff HB, Cantwell DP et al (MTA Co-operative Group). A 14-month randomized clinical trial of treatment strategies for attention- deficit/ hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073-86.

Send letter to journal:
Re: An auditable protocol for treating ADHD

Editor,

I read with great interest this article by P Hill and E Taylor[1]. I was perplexed to find out that the authors mentioned dietary manipulation besides behavioural management programme and medication for treating attention deficit/ hyperactivity disorder. They suggested a `few foods` approach elimination diet if psychological interventions are not effective; based on the work of Carter et al [2]. Over the years, a great deal of media attention has focused on diets for treatment of attention deficit/hyperactivity disorder in children. Most of this dietary manipulation involve eliminating additives and foods incriminated to increase hyperactivity, such as sugar, chocolate and caffeine or common food allergens such as wheat, milk and eggs. So far, however, studies have not found a consistent link between diet and improved symptoms of ADHD.

Several double-blind placebo-controlled studies have failed to support beneficial effect of dietary manipulation on the behaviour, except possibly in a very small percentage of children [3,4]. Few studies have reported behavioural improvement with hypoallergenic restriction diets [4-6]. The results of these studies require further replication before dietary intervention can be considered efficacious. A working group of the American Academy of Child and Adolescent Psychiatry has stated, `Given the minimal evidence of efficacy and extreme difficulty of inducing children and adolescents to comply with restricted diet, they should not be recommended`[7]. Current evidence suggest that `diets are arduous to implement and some may be nutritionally deficient` [8]. It seems that authors included diet and referral to dietician in the basic algorithm for the sake of completeness without realising that it may have an adverse effect on the readers especially the media, who are quick to pick up at the wrong end most of the time. Health professionals react instantaneously once parents show any concern, even very slight, about a particular food item by advising them to avoid it for a considerable period of time without realising the practical impact on the child. He is unnecessarily deprived of a particular food. It also delays proper management of behaviour with a false hope of likely improvement. In my opinion dietary manipulation and referral to a dietician is undesirable in any protocol for management of challenging behaviour until more evidence comes through in future and until then behavioural management plans and medication should be the two mainstay of treatment modalities for managing attention deficit/hyperactivity disorder.