MANAGING BEHAVIOURAL PROBLEMS IN CHILDREN

by Dr George Lewith MA, MRCP, MRCGP, Centre for the Study of Complementary Medicine, Southampton, Hampshire

Physical, emotional and sexual abuse, neurological damage, and food sensitivities, feature prominently as causes of severe behavioural problems in children. The author reviews the role that complementary medicine has to play in food-related behaviour problems in children.

Behavioural problems in children are often very difficult to diagnose accurately. Mothers may present with a child who apparently does not sleep, but in reality this may mean simply a first child who has a mildly disordered sleeping pattern, waking perhaps at 6 a.m. while sleeping a lot during the day. True hyperkinesis or hyperactivity is quite a specific syndrome that involves very severely disturbed sleeping patterns (often only a few hours a night) and is associated with disobedience, poor attention and concentration, irritability, aggressiveness, inability to stop talking, permanent fidgeting, and difficulty in making friends. Furthermore, these children have a very low level of tolerance and become easily frustrated, they often have an appetite disturbance and drink great quantities of liquid, and are also attention-seeking.

Three causes of behavioural problems in children have been identified:

• child abuse (physical, emotional and sexual)
• neurological damage
• food sensitivities

Child abuse

While parents are often the first to notice that their children are behaving abnormally, they may on the other hand become very tolerant of quite substantial degrees of abnormal behaviour. It can be relatives, friends or teachers who are the first to point out that a behavioural disorder is present. There may be a number of reasons for such behavioural disorders. Consider physical, emotional and sexual abuse in such children. If such abuse is suspected, appropriate referral to a social worker and management by an appropriately convened team is essential.

Neurological damage

Behavioural abnormalities may be the result of neurological damage, caused by one of the various congenital or acquired paediatric syndromes. Management of these types of behavioural dis-orders is necessarily through a whole variety of rehabilitative techniques and conventional medication as and when appropriate.

Food sensitivities

The third and probably the largest group of children suffering from behavioural disorders appear to do so as a result of food sensitivities. Hyperactivity is much more common in boys than girls, a study by the Hyperactive Children Support Group suggested that the proportion of boys to girls was approximately ten to one. A wide range of other possibly food-related symptoms were also found in these children: 78% suffered with abnormal thirst, 49% had migraine in the immediate family, 24% had eczema and 15% asthma.

The link with food

Ben Feingold, an American paediatrician, was the first to note that foods could cause hyperactivity. He suggested, in the late 1960s and mid 1970s, that diets rich in colourants, preservatives and natural salicylates were likely to result in hyperactivity. Salicylates are contained in fruits and vegetables.

While Feingold's theory was widely criticised at the time, subsequent studies have suggested that indeed there is a very powerful link between foods and behavioural disorders, and that this link is not solely confined to additives, colourants and natural salicylates.

A variety of studies have been published, probably the most thorough have been carried out at Great Ormond Street Hospital. These studies show a quite dramatic improvement in behaviour after exclusion of a wide variety of foods. High proportion of children appear to react badly to cow's milk and dairy products in general, as well as milk derived from other animals, such as goats and sheep.

Sugar appears to be a particularly common precipitator for hyperactivity, as does chocolate.

There are, undoubtedly, some children in whom the problem is primarily behavioural, and due to a distortion within the family dynamics. Toxic poisoning, such as that likely to be caused by tap water supplied through lead pipes, has also been implicated. However, the evidence available suggests that food sensitivity is a frequent and often under diagnosed cause.

Sugar and artificial sweeteners

Some authorities have argued that sugar and artificial sweeteners are quite specific triggers for antisocial behaviour in young children and adults. Schauss has suggested that reducing sugar and eliminating additives for children and young adults in detention centres reduces antisocial behaviour significantly. However, this thesis has not been uniformly supported and other studies suggest that challenge with sugar does not precipitate antisocial behaviour.

Hyperactivity and oligo-antigenic diets

A recent study published by Egger et al is probably one of the most thorough investigations of food sensitivity to date. In this study, approximately 150 children defined as hyperactive, and attending Great Ormond Street Hospital, were placed on an oligo-antigenic diet, which is a diet containing as few potential antigens such as milk, sugar, additives, salicylates, and colourants as possible. In this group of children, some 80% showed distinct behavioural improvement over a 3-month period with diet. The second phase of the study was then to re-challenge the children with foods and see whether their behaviour reverted. Of those who improved, a significant proportion deteriorated again on re-challenge. The third phase of the study was to use a desensitisation technique called enzyme potentiated desensitisation. This involved injecting the children on two occasions, intradermally, with small quantities of food antigens mixed with beta-glucuronidase. Two injections were given spaced 8 weeks apart, and those children who obviously reacted to food re-challenge were then again re-challenged after desensitisation. Subsequent re-challenge proved to provoke far fewer reactions than challenge prior to the injections. Egger et al, therefore, report a three-phase study. Firstly, they demonstrated an overall improvement in their population. Subsequently, there was a deterioration on re-challenge and, finally, they were able to test a treatment which claimed to desensitise these children, demonstrating that it did appear to be effective in diminishing food reactions in a highly reactive sub-group of hyperactive children.

Nutritional supplements

Hyperactive children have been shown to be zinc deficient and, unlike normal children, appear to excrete large quantities of zinc via their urine, following consumption of foods to which they are intolerant. Bryce-Smith has suggested that the birth weights of hyperactive children are lower than those of controls.

Many of those working within the field of food sensitivity and food intolerance frequently use zinc supplementation in children with eczema and asthma (illnesses known to be associated with food intolerance), and often find that food reactions appear to be less severe after a 2 or 3 months' course of zinc supplements. While at present the link between zinc and food intolerance in general remains unclear, there is quite obviously a link between zinc and hyperactivity.

Supplementation with evening primrose oil has also been shown to improve the behaviour of hyperactive children, and this suggests that these children may be deficient in some essential fatty acid. Zinc and vitamin B6 both act as co-factors in the metabolism of evening primrose oil. Zinc and gamma linolenic acid (GLA), a derivative of evening primrose oil, may be important in the synthesis of prostaglandin E1, which has a direct effect on the immune system, particularly in asthma.

Therefore, in severely hyperactive children it may be worthwhile considering supplementation with zinc citrate and evening primrose oil. A suggested dose is zinc citrate 15 mg to be taken in the evening along with a capsule of 500 mg evening primrose oil.

Other treatments

There is, undoubtedly, a place for the psychological management of behavioural disorders, particularly if there is a severely distorted or disturbed family environment. A number of conventional drugs have been used in hyperactivity such as ritalin (a benzodiazepine). However, before using such potentially dangerous medication, it is worthwhile considering appropriate food avoidance, particularly as there is overwhelming evidence to support the case for intolerance as being an important trigger in hyperactivity.

Diet

There is no foolproof method of testing for food intolerance, consequently many research protocols have used the very clumsy but effective approach of placing children on severely limited diets for 4 to 6 weeks and seeing if their symptoms clear. The general practitioner may not find this so easy, so probably the first step in attempting to assess whether a child has food sensitivities is to ask them to avoid all food additives, colourants and, ideally, naturally occurring salicylates for a period of 3 or 4 weeks.

If this fails, then milk and possibly sugar can be added to the exclusion list for another week or two. If again no response can be obtained, then reintroduce all the foods over the next week in order to see whether a reaction can be precipitated. The child may have been getting better slowly and food reintroduction can often produce a rapid and severe reaction, reminding all those living near to the child how bad things were prior to the food avoidance diet.

If these approaches fail to work then either food sensitivity should be rejected as a diagnosis, or the child should be referred to a specialist with particular expertise in this area.

Conclusion

While undoubtedly a small group of children with behavioural disorders do have primarily psychological problems, a much larger group have food related difficulties. While food avoidance can help a significant proportion of children with hyperactivity, many find readjustment difficult even after the food has been excluded. Severely hyperactive children are so antisocial and have learnt such difficult and confusing behaviour patterns, that even when the food ceases to make them behave abnormally, they find they need considerable help and patience in readjusting to a normal and loving series of family relationships.

For more information contact

British Society for Allergy and Environmental Medicine
66 Station Road
Fulbourn
Cambridge
CB1 5ES

Hyperactive Children's Support Group (voluntary self-help group)
59 Meadowside
Angmering
West Sussex

Key Points

• Behavioural problems need to be diagnosed accurately. This is not always easy.
• There is evidence that natural salicylates, additives, colourants, cow's milk and dairy products in general, as well as sugar and chocolate, are linked with hyperactivity.
• There are undoubtedly some children in whom the problem is primarily behavioural, as a response to disturbed family dynamics.
• In severely hyperactive children, it may well be worthwhile considering supplementation with zinc citrate (15 mg given at night) with evening primrose oil capsules (500 mg).