By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
• This retrospective study evaluates the effectiveness of the Few-foods diet (FFD) — a restrictive, elimination diet, followed by food re-introduction, for treatment of attention deficit hyperactivity disorder (ADHD) in three general practice settings.
• Fifty-seven children diagnosed with ADHD started the FFD; 34 of 52 children remaining on the diet at the end of week 5 were “ADHD responders” and showed significant improvement in measurements of ADHD.
• For at least five weeks, 21 of 27 children successfully ceased medication for ADHD.
• At six months, 14 of the 34 ADHD responders remained on the diet.
SYNOPSIS: This Dutch study describes a six-month follow-up of children with attention deficit hyperactivity disorder (ADHD) introduced to the Few-Foods Diet. Results indicate a significant decrease in ADHD symptoms and medication in children compliant with the diet.
SOURCE: Pelsser L, Frankena K, Toorman J, Pereira RR. Retrospective outcome monitoring of ADHD and nutrition (ROMAN): The effectiveness of the Few-Foods Diet in general practice. Front Psychiatry 2020;11:96.
A 4-year-old kicked out of preschool; a 10-year-old lagging behind peers academically and socially; a quiet 15-year-old struggling to keep organized in high school. At first glance, there appears little in common among this group. However, a closer look reveals that the primary symptoms of dysfunction in each case may stem from unrecognized or untreated attention deficit hyperactivity disorder (ADHD).
Presenting with persistent inattentiveness and/or hyperactivity and impulsivity severe enough to interfere with functioning, and occurring in more than one setting, ADHD is one of the most common neurodevelopmental disorders of childhood, with a worldwide prevalence estimated between 5% to 7%.1 In the United States, these numbers trend higher. Data from a 2016 national parent survey reveals 9.4% of children between the ages of 2 and 17 years have been diagnosed with ADHD.2 Without a clear etiological basis, addressing symptoms remains the primary focus of ADHD treatment. Psychostimulants, with established but limited efficacy and duration of action, are the medication category of choice. However, concerns about use of these controlled substances in young children and teens have spurred development of alternative treatments.3,4
The Few-Foods Diet (FFD), an elimination diet, has shown promise in identifying a food-induced subtype of children with ADHD. This meal plan, also referred to as an oligoantigenic diet or restricted elimination diet, restricts foods to items with low allergic potential (e.g., rice, quinoa, turkey, some vegetables, etc.).5
In the Netherlands, since 2001, some ADHD diagnostic centers have used this diet as a tool to identify whether foods trigger ADHD symptoms. If symptoms remit after adopting the diet for five weeks, one food/week is reintroduced. Children are monitored carefully for reemergence of symptoms with a goal of eliminating the identified culprit, eventually creating an individualized diet.
Pelsser et al conducted a retrospective, multicenter effectiveness study, analyzing data from children who started the FFD in three different healthcare centers in the Netherlands from November 2012 through February 2013. Noting that in real life, ADHD often is comorbid with other psychiatric conditions, symptoms of oppositional defiant disorder (ODD) were included in the analysis. ODD is a behavioral disorder presenting with a developmentally inappropriate pattern of negativity towards authority figures.6
In this study, 57 children with significant behavioral problems began the FFD. At the start, 70% of these children had a diagnosis of ADHD, and 51% met criteria for ODD. Notably, behavioral problems were reported as severe despite 47% of the children taking psychoactive medication and 26% of them following an elimination diet. Parent and teacher rating scales were compared at the beginning of the study and at the end of a five-week FFD.
Depending on participants’ responses to the diet, medication reduction or discontinuation was periodically discussed. Of the 57 children, 14 began the study younger than 8 years of age. The centers reported mean ages from 8.6 to 10 years.6
The FFD requires commitment from the child and familial support. To this end, several weeks prior to beginning the diet, the child and family undergo assessment regarding not only the child’s behavior, but also baseline food habits, activities, and family support mechanisms. At the end of this period, parents receive feedback regarding the potential barriers in adopting this stringent diet. If all agree, the child begins a slightly modified FFD for weeks 1 and 2, with further restriction over weeks 3 through 5.
Food reintroduction may gradually begin at the end of week 5 for those recording at least a 40% symptom reduction. A gradual process, proceeding with a child’s favorite foods first and retreating if behaviors emerge, continue for some children for more than a year. For the most part, children who demonstrated less than a 40% reduction in symptoms based on parent and teacher rating scales did not continue on the diet. In this Pelsser et al study, parents and teachers used rating scales, such as the Abbreviated Connors Scale (ACS) to rate ADHD symptoms; ODD was evaluated with a structured interview based on DSM4 criteria.7
The results were:
- of the initial 57 children, five dropped out because of difficulties following the diet;
- thirty-four children showed a > 40% reduction in ADHD symptoms, thus qualifying as “ADHD responders;”
- twenty children showed a > 40% reduction in ODD symptoms, qualifying as “ODD responders,” and 80% of those were ADHD responders as well;
- of the 27 children taking medication at the start, 13 were among the responders, and 12 of those stopped medication during the study because of symptom remission;
- of the original 15 children following an elimination diet at the start, 10 were among the responders.
Among the ADHD and ODD responders, symptoms significant decreased. The decrease in rating scale criteria for the ADHD responders averaged about 72%, from 12.3 at the study’s start to 3.5 by the end of week five
(P < 0.0001). Among the ODD responders, the ODD DSM4 criteria decreased 79%, from an average of 5.2 to 1.1 (P < 0.0001). Families of ADHD responders could continue the FFD into the reintroduction phase after week 5, and 26 families chose to do so. At six months, 14 families remained as diet participants. Because family cooperation and involvement is key to maintaining this diet intervention, participants self-rated family structure as “average” or “good.” “Average” ratings implied difficulty with consistent parenting while “good” suggested consistent limit setting and parenting techniques. Of the 14 families remaining at month 6, all reported the family structure as “good,” while the nine families in a responder group reporting the family as “average” either did not start or complete the reintroduction phase.
In this work Pelsser et al show that the FFD is associated with an improvement in parent and teacher assessment of ADHD symptoms, and with a significant decrease in independently measured ODD symptoms. Notably, improvement was measured in children taking medication at baseline, allowing for medicine discontinuation. Children on an elimination diet at baseline also showed improvement, leading to a hypothesis that the FFD may have a more robust impact than generic elimination diets.
The real-world conditions are a clear strength of this study. Data was obtained retrospectively from children at three treatment centers whose families had enrolled them in the FFD protocol. One of the more striking elements of this approach is the time devoted to preparing children and families for the diet, and the need for families to support a rigid eating pattern.
Given that the children entered the study with significant behavior problems, it is likely that neither of these were trivial tasks. It may be that part of the improvement was a reflection of increased interaction between parent and child as a result of demands of the intervention. It is unclear what conclusions to draw from the self-rating of family structure, but the finding that 100% of the families continuing the diet at the six-month mark self-rated as “good” in terms of parenting consistency gives a clue to the central role of family in this intervention. Pelsser et al speculate that maintaining the FFD may require a high level of family cohesiveness and structure; the team suggests that coaching may be helpful for families implementing such a plan.
In the Netherlands, the FFD is accepted as a diagnostic tool to identify ADHD responders to diet changes. This study implies that dietary modification, and specifically the FFD, with subsequent reintroduction of food on a trial basis, has potential as a treatment for this subgroup of children. More information about the re-introduction of specific foods, and more research into this process, will be helpful in generalizing the results to clinical practice. In the United States, it is not customary to use the FFD to identify ADHD or ODD responders to food interventions. It is, however, quite common for parents of children on ADHD medication or children diagnosed with ODD to ask about diet interventions or alternatives to medication. Parents express numerous concerns about using pharmacologic agents for these disorders, including questions about the long-term effect of chronic medication use in children, implications of using controlled substances in youth, cost factors, and efficacy limitations.3,8
It is a stretch to assume that the United States’ health system, as currently designed, will allow broad-based implementation of an approach similar to that described in this study. However, it is quite likely that parents will continue to seek information regarding diet intervention for children with ADHD and comorbid disorders. Research in this field and searches for the etiologic underpinnings of the FFD should provide more answers.
The integrative provider can use information from this study to assure parents and children that food may certainly play a role in at least a subtype of behavioral and attentional disorders. Paying attention to diet and attempting to identify foods exacerbating behavioral problems is a reasonable first step. Partnership with a nutritionist may be useful to reduce risks involved in elimination diets in general, including nutritional deficiencies and parent-child conflict.9 Understanding that individualization of treatment is optimal and reaching for a comprehensive, multimodal approach is the goal in providing guidance to children with ADHD and ODD and their families.
- Polanczyk GV, Gwillcutt EG, Salum GA, et al. ADHD prevalence estimates across three decades: An updated systematic review and meta-regression analysis. Int J Epidemiol 2014;43:434-442.
- Centers for Disease Control and Prevention. Data and statistics about ADHD. Updated Oct. 15, 2019. https://www.cdc.gov/ncbddd/adhd/data.html
- Brinkman WB, Sucharew H, Majcher JH, Epstein JN. Predictors of medication continuity in children with ADHD. Pediatrics 2018;141:e20172580.
- Ahn J, Ahn HS, Cheong JH, Dela Peña I. Natural product-derived treatments for attention-deficit/hyperactivity disorder: Safety, efficacy, and therapeutic potential of combination therapy. Neural Plast 2016;2016:1320423.
- Nigg JT, Holton K. Restriction and elimination diets in ADHD treatment. Child Adolesc Psychiatr Clin N Am 2014;23:937-953.
- Riley M, Ahmed S, Locke A. Common questions about oppositional defiant disorder. Am Fam Physician 2016;93:586-591.
- Atlanta Area Family Psychiatry Clinic. Connor’s abbreviated rating scale. https://www.aafpc.net/Connor_s_Abreviated_ADHD_Rating_Scale__10_item_.pdf
- Pelsser L, Frankena K, Toorman J, Pereira RR. Diet and ADHD, reviewing the evidence: A systematic review of meta-analyses of double-blind placebo-controlled trials evaluating the efficacy of diet interventions on the behavior of children with ADHD. PLoS One 2017;12:e0169277.
- Ly V, Bottelier M, Hoekstra PJ, et al. Elimination diets’ efficacy and mechanisms in attention deficit hyperactivity disorder and autism spectrum disorder. Eur Child Adolesc Psychiatry 2017;26:1067-1079.