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problems. In some instances, it is possible to carry out double-blind chal-
lenges to establish whether a particular food really does make a difference.
Controlled evaluations do suggest that this approach can identify foods
that worsen behaviour. There is no one culprit – different individuals are
intolerant to different foods, and many are intolerant to several foods.
Artificial additives are common culprits, but so, too, are dairy products,
chocolate, wheat, oranges, tomatoes and eggs. It is unusual for an in-
dividual to react only to additives; most of those who are sensitive to
additives are also sensitive to one or more natural foods as well. Although
diet is often thought of as a treatment for ADHD, the individuals who
respond to the ‘few foods’ approach typically become less irritable and
disruptive as well as less hyperactive and inattentive. Whether the same
approach would help individuals who were irritable and oppositional but
not hyperactive is unclear.
The few foods approach is very hard work for all concerned and not
all families can see it through to completion. Cooking a special diet for
weeks on end is more than some busy parents can manage and buying
special foods can also be very expensive. Furthermore, there is little point
embarking on this approach if the child or adolescent is likely to cheat
frequently by stealing from the fridge, buying forbidden foods, or eating
other children’s school lunches! Is it possible to predict in advance who
is likely to respond to diet? Unfortunately, it is not possible to predict
from blood or skin tests (not to mention more dubious tests involving
hair analysis or dowsing). Two clinical pointers to a good response are,
first, that parents have previously noted reactions to food and, second,
that the child or adolescent has cravings for particular foods (which may
turn out to be the foods that trigger behavioural problems). Parental
observations and the child or adolescent’s cravings can be used to design
a tailor-made exclusion diet; if behaviour is improved, the excluded foods
are reintroduced one by one to identify the culprits. How this ‘short cut’
compares with the few foods approach has yet to be formally evaluated.
Other physical treatments
Electroconvulsive therapy(ECT) is rarely used for children and adolescents
and has not been adequately evaluated. It may be considered when
adequate trials of medication have not relieved severe depression or
catatonia.
Surgery. Psychosurgery is not indicated for children or adolescents, but
it is worth noting that successful epilepsy surgery may cure children or
adolescents not only of their seizures but also of associated behavioural
problems. For example, hemispherectomy for hemiplegic children and
adolescents with intractable seizures often relieves not only seizures but
hyperactivity and irritability too. It is unclear whether this behavioural
improvement stems from the abolition of seizures, the withdrawal of
antiepileptic medications, or the removal of dysfunctional brain tissue.