Bonus Material

An excellent case study that didn’t make it into the book:


“He was doing so well at school,” Fran said with a sigh. “That is why you had not heard from me.” I had last talked to Fran in the fall after school had started and now it was March. Harry, age 8 had finally settled in a typical classroom with a little extra help.

Harry had made significant steps considering he had spent the first few years of elementary school traveling back and forth between a special education classroom and “regular ed” activities such as art and music. Now he was in second grade with the rest of his peers and receiving just a little support. In Harry’s case, that support was a daily trip to a resource room where he got extra help in math and untimed tests. His present diagnosis was Attention Deficit Hyperactivity Disorder (ADHD).

“So, what happened?” I asked, concerned.

“I don’t know,” Fran replied throwing her hands in the air. “One minute he was doing great and then suddenly I am getting calls from school. His teacher was worried that he seemed more distracted and was no longer being cooperative. And then another day, I got a call that he hit another child. Harry is not a hitter,” Fran maintained.

I knew Harry and agreed that he did not have much of a history of aggressive behavior though as a young child he would pinch when he got frustrated. Most young children if aggravated enough will lash out. Harry’s early developmental delays made communication difficult at times and as his irritation increased so did bad behavior. But those years were behind him. I agreed with Fran that her son’s basic temperament was easy going, and that he was generally eager to please- which made this regression in behavior perplexing.

I queried Fran about the usual suspects. Had he been sick? Were there changes at the school or a new teacher? Was he being bullied in the classroom? No, no and no, Fran stated firmly. Except for a minor cold over the Christmas vacation, Harry had been healthy. He had the same teacher since the fall and they had a good relationship. Finally, the children in the classroom were friendly and he liked school.

Fran went on to describe some specifics of Harry’s school situation. Nothing sounded suspicious. Searching for inspiration, I glanced out the window. It was almost April and the cherry tree behind my office had plump little buds hours away from bursting open. I mused to myself, spring is so miraculous, momentarily distracted. I thought about a grouping of cute little crocuses I had admired earlier in the morning. Soon all the flowers will be out. Concentrate on Harry, I reprimanded myself and began to zero in on Fran, who was explaining how Harry had suddenly been having trouble memorizing his spelling words.

It seems unfair that after a long hard winter, it is finally almost spring and now Harry is falling apart, my one tract brain argued. Why are things going bad now?

“Fran,” I interrupted, “does Harry have spring allergies?”

Fran stopped for a moment unsettled by the sudden change in topic. “His father has been having a tough time for the last week or so but Harry is fine,” she said.

But I persisted, and asked her if Harry had begun any changes in behavior, such as night waking, eye rubbing or mild congestion. Harry had indeed started waking up in the middle of the night about a week ago. And while he was not rubbing his eyes, Fran had forgotten to mention that he had started chewing on his clothes.

For years, I had noticed that many children in my practice seem to develop academic or behavior problems in the spring. In addition, reports have noted that doctors write more prescription for ADHD medications such as Ritalin, Focalin and Concerta in the spring. Dr. Marvin Boris, a Long Island based allergist, looked at data from insurance company records and saw a clear pattern of increased depression, suicide and behavior problems in the spring. He suspected pollen was the culprit and he was right. His research found that two thirds of kids with ADHD had some level of behavior/academic deterioration in the spring, linking pollen reactions to the regressive behaviors.

But Boris’ most fascinating finding was that only half of the reactive children had the telltale signs of allergies. That is, only half the children with “off” behavior had red and itchy eyes or stuffy and running noses. The other half (or one third of children with ADHD) only had behaviors making it difficult for parents or teachers to consider allergies as the cause.

We now know anyone can react to allergens, such as pollen without having a histamine reaction. Traditionally, allergic reactions have been narrowly defined as histamine reactions. Histamine is a chemical produced by mast cells, a type of immune cell found in the blood. Within two hours of exposure to a problem substance, histamine causes itching, irritation and swelling.

Other messenger molecules called cytokines, may be responsible for some of the non-histamine symptoms such as tiredness, sleep disturbance or crankiness.

Cytokines are fickle little things. They are unstable and tend to disappear once their chemical messages are delivered. Consequently, they are tricky to study and not well understood. Scientists are discovering new ones everyday and believe we have not appreciated how many immune operations these molecules control.

Fran frowned and looked at me dubiously. “His nose is fine. I don’t think he has allergies,” she repeated. Fran was not convinced my theory was sound. If Harry’s behavior was a reaction to pollen, by his age, there should be a pattern.

I asked Fran if Harry had similar problems at school last year at this time. She stopped frowning and considered the question.

“It is hard to remember that long ago,” she hedged. “There is always so much going on.”

I did not want to rush her and gave her some time to think. She looked at the floor, deep in thought and suddenly, her head jerked up. Harry had indeed had some incidents at school last spring. She remembered there was even some talk about reconsidering his placement in a typical classroom but he then settled down by the end of the year.

“What about kindergarten?” I prompted.

Now that Fran was looking for a pattern, spring was clearly when Harry seemed to get in trouble. She had never thought about the timing before. The question was, what to do?

Diet sometimes affects reactions to environmental irritants like pollen. Eating a bothersome food can rev up the immune system so it reacts more easily to environmental stimulants. For example, a child who is sensitive to both dairy products and cats might be more reactive to cats if she is eating dairy products. These immune interrelationships can be complicated to unravel. Testing is sometimes required to identify the suspicious food or foods and time is needed after the food is removed to calm down the immune system. Any dietary work we did now, if relevant and successful, would more likely impact the reactions next spring. Harry needed help now.

I explained to Fran that although Harry’s symptoms were not classically classified as allergic or histamine induced, some children have responded very well to antihistamines anyway. We do not understand all the ways cytokines and histamine interact but there does appear to be some communication. I suggested she call her pediatrician and ask if he could recommend an antihistamine to try for a few days. Fran and Harry would know quickly if the medicine worked.

Fran called her doctor who was a good listener and open minded. While he thought the idea was farfetched, he agreed that a few days worth of antihistamine was safe enough to try and recommended an over the counter brand that did not cause sleepiness. The doctor told her to give the trial ten days and then stop the medicine if Fran saw no difference.

The results were fast and dramatic. Harry calmed down within a few days and his teacher called Fran to say he was back to himself again. He was more cheerful though he still tired a little faster than normal. He continued the medicine for 10 weeks until the beginning of summer and then stopped. The next spring when the behaviors started again, Fran was ready. She called just to confirm that she was seeing what she thought she was seeing.

At this point a budding nutrition detective might be thinking, hold your horses. What does this have to do with nutrition? Absolutely nothing but a good detective is curious. This was a scenario that I heard so many times I wondered what it could be. It is important to know what belongs in your realm and what belongs somewhere else.

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