Important Nutritional Supplements for Managing ADHD
Q: My granddaughter is six years old and has been diagnosed with ADHD. Are there any alternative options using supplementation that may help improve her condition?
A: Your question is important and timely, considering that attention deficit hyperactivity disorder (ADHD) has become one of the most frequently diagnosed behavioral disorders in children today.1 To answer your specific question about nutritional alternatives to medication, it is important to understand ADHD.
An estimated 3-6% of American children carry this diagnosis, with up to 15% being affected in some cities.1,2 Rapidly growing numbers of children given this diagnosis are prescribed stimulant medications such as methylphenidate (Ritalin®) for treatment. These commonly used medications are relatively safe and effective, but they can have undesirable side effects that increase with higher doses.3 Because they also have substantial potential as drugs of abuse among young people,4,5 it is critical that the diagnosis be correct.
ADHD is classified as a mental disorder in which children (and some adults) demonstrate persistent lack of attention to tasks (attention deficit) and/or an inability to control impulses and an increase in physical activity (hyperactivity) that is not typical for people at a similar stage of development.6 I stress these two points because all children have periods of inattention, episodes of impulsive behavior, and sometimes incredible levels of energy; these are part of normal development.
For all these reasons, my first recommendation is to be certain that your granddaughter has had a thorough developmental and behavioral evaluation by a pediatrician or a specialist in development and behavior. The important thing is having someone conduct the examination and document the findings. Children should always be observed for six months and then re-evaluated before being placed on pharmaceutical treatment—there is no way to be sure of the diagnosis based on a single exam.7 Meanwhile, families can do many things to help reduce the likelihood that the child will ever require medication. ADHD is actually a spectrum of disorders. In a 2003 study, scientists listed eight general categories of possible contributors to ADHD: food and additive allergies, environmental toxicity, dietary deficiencies in proteins or excesses in simple sugars, mineral imbalances, deficiencies in cell membrane components (essential fatty acids and phospholipids), deficiencies in certain amino acids, thyroid disorders, and deficiencies in B vitamins.7
Children with ADHD have changes in brain function that may arise from abnormalities in cell membranes, blood flow, and levels of signaling chemicals (neurotransmitters) such as dopamine and norepinephrine.8-10 Stimulant drugs such as Ritalin® promote the release of such chemicals in brain tissue.
Nutritional supplementation offers a much broader and safer approach. The growing brain requires a tremendous amount of nutrition to support its structure and function. Supplements can provide components that are used in brain cell membranes and as building blocks or co-factors for neurotransmitter production. Nutritional supplementation and avoidance or elimination of toxins can produce improvements in behavior and performance in those suffering from ADHD.1,7,11
Parents should work with their children’s health care providers to ensure that any supplement or medication is provided at safe and effective doses. Many conventional physicians may not ask specifically about diet or supplements, so it is important to let them know about nutritional interventions. The following supplements have shown promise in helping children with ADHD.
Vitamins and Minerals
Multivitamin supplementation may help kids do better in school generally. One study showed that a multivitamin-mineral supplement helped reduce antisocial behavior in healthy children.12 These results suggest that multivitamins with minerals could help children with ADHD.1 High doses of vitamin A should be avoided, since excess accumulation of this fat-soluble vitamin can be dangerous.13
If a child has a known deficiency of B vitamins, supplementation may be helpful. Vitamin B6 (pyridoxine) is essential in the manufacture of many neurotransmitters that are important for healthy brain function, with potential applications for fighting ADHD. One study found that vitamin B6 supplements were as effective as Ritalin® in decreasing hyperactivity, and that the vitamin’s effects persisted even after supplementation was stopped.14
ADHD has been associated with iron deficiency,15,16 and some evidence suggests that iron supplements may reduce the severity of ADHD symptoms.17 Magnesium deficiency is found in many children with ADHD; significant decreases in hyperactivity and disruptive behavior have been found in children who received dietary magnesium supplementation.18 Some individuals with ADHD have low zinc levels, and it has been suggested that zinc supplementation may improve behavior.19 Zinc may also improve the effectiveness of drugs such as Ritalin®.20
Essential Fatty Acids
Unsaturated fatty acids, such as the omega-3 essential fatty acids, may have a useful role in the management of ADHD.1 They are critical components of cell membranes and function as the biochemical messengers that help nerve and other cells communicate. Children with ADHD appear to break down essential fatty acids faster than other children,21,22 and almost always have lower-than-normal blood levels of these important substances.
Unfortunately, most children have an excess of omega-6 fatty acids in their diet, but suffer from a severe deficiency of beneficial omega-3 fatty acids. In two recent trials, supplementation with essential fatty acids improved conduct problems as rated by parents and attention problems as rated by teachers.23,24 Essential fatty acids have been found to enhance the effect of zinc,20,25 and were found to be effective in helping control attention and movement problems.26
Because it can be difficult to obtain optimal levels of essential fatty acids—particularly omega-3 fatty acids such as EPA and DHA—through dietary sources alone, your granddaughter might benefit from supplementation with a product that provides omega-3 fatty acids.
Phosphatidylserine and Related Nutrients
Phosphatidylserine is a critical component of cell membranes and plays a role in nerve cell signaling. Phosphatidylserine has been found to improve memory and concentration in adults,27 and one report found that it significantly improved attention and learning in children with ADHD.1 In a small, controlled study, dimethylaminoethanol (DMAE), which cells convert to cell membrane constituents, was shown to reduce hyperactivity.28 Be sure to check with the child’s doctor, since DMAE can have adverse effects when used at high doses.29
Most brain neurotransmitters are manufactured from amino acids, which are protein building blocks found in the blood. Levels of the amino acids phenylalanine, glutamine, tyrosine, tryptophan, and isoleucine are often low in the blood of adults and children with ADHD.30,31 In separate trials, supplementation with tyrosine or S-adenosyl methionine (SAMe) produced improvement in adult attention,32,33 though the results may be short-lived.34 According to one study, the amino acid L-theanine, found in green tea, is more effective than a common prescription drug in promoting relaxation.35
A number of plant-derived antioxidants hold potential in the treatment of ADHD. Extracts of ginkgo biloba improve brain blood flow and can improve cognitive ability,36 though there have been no controlled trials of its use in children with ADHD. In Europe, individual reports suggest that an extract of pine bark called pycnogenol, which has antioxidant and cell-protective properties, improves cognitive function in those with ADHD.37 Grape seed extract contains many of the same compounds (proanthocyanidins) that are known to improve memory and cognition with age,38,39 suggesting that it may have applications in treating ADHD.
Sleep disorders are common in children with ADHD, especially in those taking stimulant medications.40 Melatonin, an antioxidant hormone produced in the human pineal gland, has powerful effects on sleep-wake cycles, sleep variation, and many other biological rhythms. In combination with a good “sleep hygiene” program (careful attention to bedtime, place of sleep, and bedtime rituals), melatonin may help improve insomnia in children with ADHD who are using stimulant medications.41
ADHD is a puzzling condition that has frustrated medical researchers for years. Dietary supplements clearly have a role in managing ADHD. They could reduce and may even eliminate a child’s need for pharmaceutical drugs. It is critical that a diagnosis of ADHD be made correctly. Physicians and experts in child nutrition and child development and behavior all have an important role to play in the integrative management of ADHD. Ongoing research in all of these areas is likely to provide additional insights into nutritional supplements that improve brain function and behavior.
1. Kidd PM. Attention deficit/hyperactivity disorder (ADHD) in children: rationale for its integrative management. Altern Med Rev. 2000 Oct;5(5):402-28.
2. Daley KC. Update on attention-deficit/hyperactivity disorder. Curr Opin Pediatr. 2004 Apr;16(2):217-26.
3. Klein-Schwartz W. Abuse and toxicity of methylphenidate. Curr Opin Pediatr. 2002 Apr;14(2):219-23.
4. McCabe SE, Teter CJ, Boyd CJ, Guthrie SK. Prevalence and correlates of illicit methylphenidate use among 8th, 10th, and 12th grade students in the United States, 2001. J Adolesc Health. 2004 Dec;35(6):501-4.
5. Williams RJ, Goodale LA, Shay-Fiddler MA, Gloster SP, Chang SY. Methylphenidate and dextroamphetamine abuse in substance-abusing adolescents. Am J Addict. 2004 Jul;13(4):381-9.
6. World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: WHO; 1993.
7. Harding KL, Judah RD, Gant C. Outcome-based comparison of Ritalin versus food-supplement treated children with AD/HD. Altern Med Rev. 2003 Aug;8(3):319-30.
8. Pliszka SR, McCracken JT, Maas JW. Catecholamines in attention-deficit hyperactivity disorder: current perspectives. J Am Acad Child Adolesc Psychiatry. 1996 Mar;35(3):264-72.
9. Sieg KG, Gaffney GR, Preston DF, Hellings JA. SPECT brain imaging abnormalities in attention deficit hyperactivity disorder. Clin Nucl Med. 1995 Jan;20(1):55-60.
10. Tannock R. Attention deficit hyperactivity disorder: advances in cognitive, neurobiological, and genetic research. J Child Psychol Psychiatry. 1998 Jan;39(1):65-99.
11. Ramanathan G, White GE. Attention-deficit/hyperactive disorder: making a case for multidisciplinary management. J Clin Pediatr Dent. 2001;25(3):249-53.
12. Schoenthaler SJ. Nutritional deficiencies and behavior. In: Bellanti JA, Crook WG, Layton RE., eds. Attention Deficit Hyperactivity Disorder: Causes and Possible Solutions (Proceedings of a Conference). Jackson, TN: International Health Foundation; 1999.
13. Arnold LE, Christopher J, Huestis RD, Smeltzer DJ. Megavitamins for minimal brain dysfunction. A placebo-controlled study. JAMA. 1978 Dec 8;240(24):2642-3.
14. Coleman M, Steinberg G, Tippett J, et al. A preliminary study of the effect of pyridoxine administration in a subgroup of hyperkinetic children: a double-blind crossover comparison with methylphenidate. Biol Psychiatry. 1979 Oct;14(5):741-51.
15. Konofal E, Lecendreux M, Arnulf I, Mouren MC. Iron deficiency in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2004 Dec;158(12):1113-5.
16. Starobrat-Hermelin B and Kozielec T. The effects of magnesium physiological supplementation on hyperactivity in children with attention deficit hyperactivity disorder (ADHD). Positive response to magnesium oral loading test. Magnes Res. 1997 Jun;10(2):149-56.
17. Sever Y, Ashkenazi A, Tyano S, Weizman A. Iron treatment in children with attention deficit hyperactivity disorder. A preliminary report. Neuropsychobiology. 1997;35(4):178-80.
18. Starobrat-Hermelin B. The effect of deficiency of selected bioelements on hyperactivity in children with certain specified mental disorder. Ann Acad Med Stetin. 1998;44:297-314.
19. Arnold LE. Alternative treatments for adults with attention-deficit hyperactivity disorder (ADHD). Ann NY Acad Sci. 2001 Jun;931:310-41.
20. Arnold LE, Votolato NA, Kleykamp D, Baker GB, Bornstein RA. Does hair zinc predict amphetamine improvement of ADD/hyperactivity? Int J Neurosci. 1990 Jan;50(1-2):103-7.
21. Burgess JR, Stevens L, Zhang W, Peck L. Long-chain polyunsaturated fatty acids in children with attention-deficit hyperactivity disorder. Am J Clin Nutr. 2000 Jan;71(1 Suppl):327S-30S.
22. Ross BM, McKenzie I, Glen I, Bennett CP. Increased levels of ethane, a non-invasive marker of n-3 fatty acid oxidation, in breath of children with attention deficit hyperactivity disorder. Nutr Neurosci. 2003 Oct;6(5):277-81.
23. Richardson AJ, Puri BK. A randomized double-blind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning difficulties. Prog Neuropsychopharmacol Biol Psychiatry. 2002 Feb;26(2):233-9.
24. Stevens L, Zhang W, Peck L, et al. EFA supplementation in children with inattention, hyperactivity, and other disruptive behaviors. Lipids. 2003 Oct;38(10):1007-21.
25. Bekaroglu M, Aslan Y, Gedik Y, et al. Relationships between serum free fatty acids and zinc, and attention deficit hyperactivity disorder: a research note. J Child Psychol Psychiatry. 1996 Feb;37(2):225-7.
26. Aman MG, Mitchell EA, Turbott SH. The effects of essential fatty acid supplementation by Efamol in hyperactive children. J Abnorm Child Psychol. 1987 Mar;15(1):75-90.
27. Kidd PM. A review of nutrients and botanicals in the integrative management of cognitive dysfunction. Altern Med Rev. 1999 Jun;4(3):144-61.
28. Re’ O. 2-Dimethylaminoethanol (deanol): a brief review of its clinical efficacy and postulated mechanism of action. Curr Ther Res Clin Exp. 1974 Nov;16(11):1238-42.
29. Casey DE. Mood alterations during deanol therapy. Psychopharmacology (Berl). 1979 Apr 11;62(2):187-91.
30. Bornstein RA, Baker GB, Carroll A, et al. Plasma amino acids in attention deficit disorder. Psychiatry Res. 1990 Sep;33(3):301-6.
31. Zavala M, Castejon HV, Ortega PA, et al. Imbalance of plasma amino acids in patients with autism and subjects with attention deficit/hyperactivity disorder. Rev Neurol. 2001 Sep 1;33(5):401-8.
32. Wood DR, Reimherr FW, Wender PH. Amino acid precursors for the treatment of attention deficit disorder, residual type. Psychopharmacol Bull. 1985;21(1):146-9.
33. Shekim WO, Antun F, Hanna GL, McCracken JT, Hess EB. S-adenosyl-L-methionine (SAM) in adults with ADHD, RS: preliminary results from an open trial. Psychopharmacol Bull. 1990;26(2):249-53.
34. Reimherr FW, Wender PH, Wood DR, Ward M. An open trial of L-tyrosine in the treatment of attention deficit disorder, residual type. Am J Psychiatry. 1987 Aug;144(8):1071-3.
35. Lu K, Gray MA, Oliver C, et al. The acute effects of L-theanine in comparison with alprazolam on anticipatory anxiety in humans. Hum Psychopharmacol. 2004 Oct;19(7):457-65.
36. DeFeudis FV, Drieu K. Ginkgo biloba extract (EGb 761) and CNS functions: basic studies and clinical applications. Curr Drug Targets. 2000 Jul;1(1):25-58.
37. Rohdewald P. A review of the French maritime pine bark extract (Pycnogenol), a herbal medication with a diverse clinical pharmacology. Int J Clin Pharmacol Ther. 2002 Apr;40(4):158-68.
38. Cho J, Kang JS, Long PH, et al. Antioxidant and memory enhancing effects of purple sweet potato anthocyanin and cordyceps mushroom extract. Arch Pharm Res. 2003 Oct;26(10):821-5.
39. Galli RL, Shukitt-Hale B, Youdim KA, Joseph JA. Fruit polyphenolics and brain aging: nutritional interventions targeting age-related neuronal and behavioral deficits. Ann NY Acad Sci. 2002 Apr;959:128-32.
40. Betancourt-Fursow de Jimenez YM, Jimenez-Leon JC, Jimenez-Betancourt CS. Attention deficit hyperactivity disorder and sleep disorders. Rev Neurol. 2006 Feb 13;42 Suppl 2S37-S51.
41. Weiss MD, Wasdell MB, Bomben MM, Rea KJ, Freeman RD. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry. 2006 May;45(5):512-9.
42. Mousain-Bosc M, Roche M, Rapin J, Bali JP. Magnesium VitB6 intake reduces central nervous system hyperexcitability in children. J Am Coll Nutr. 2004 Oct;23(5):545S-8S.
43. Nogovitsina OR, Levitina EV. Effect of MAGNE-B6 on the clinical and biochemical manifestations of the syndrome of attention deficit and hyperactivity in children. Eksp Klin Farmakol. 2006 Jan;69(1):74-7.
44. Bilici M, Yildirim F, Kandil S, et al. Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2004 Jan;28(1):181-90.
45. Akhondzadeh S, Mohammadi MR, Khademi M. Zinc sulfate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: a double blind and randomized trial [ISRCTN64132371]. BMC Psychiatry. 2004 Apr 8;49.
46. Joshi K, Lad S, Kale M, et al. Supplementation with flax oil and vitamin C improves the outcome of Attention Deficit Hyperactivity Disorder (ADHD). Prostaglandins Leukot Essent Fatty Acids. 2006 Jan;74(1):17-21.
47. Young GS, Conquer JA, Thomas R. Effect of randomized supplementation with high dose olive, flax or fish oil on serum phospholipid fatty acid levels in adults with attention deficit hyperactivity disorder. Reprod Nutr Dev. 2005 Sep;45(5):549-58.
48. Richardson AJ, Montgomery P. The Oxford-Durham study: a randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics. 2005 May;115(5):1360-6.
49. Lyon MR, Cline JC, Totosy de ZJ, et al. Effect of the herbal extract combination Panax quinquefolium and Ginkgo biloba on attention-deficit hyperactivity disorder: a pilot study. J Psychiatry Neurosci. 2001 May;26(3):221-8.
50. Trebaticka J, Kopasova S, Hradecna Z, et al. Treatment of ADHD with French maritime pine bark extract, Pycnogenol((R)). Eur Child Adolesc Psychiatry. 2006 May 13.