Dietary and nutritional treatments for attention-deficit/hyperactivity disorder: current research support and recommendations for practitioners

Systematic Review and Meta-Analysis: Do White Noise or Pink Noise Help With Task Performance in Youth With Attention-Deficit/Hyperactivity Disorder or With Elevated Attention Problems?

OBJECTIVE

Public interest in the potential benefits of white, pink, and brown noise for attention-deficit/hyperactivity disorder (ADHD) has recently mushroomed. White noise contains all frequencies of noise and sounds like static; pink or brown noise has more power in the lower frequencies and may sound, respectively, like rain or a waterfall. This meta-analysis evaluated effects on laboratory tasks in individuals with ADHD or elevated ADHD symptoms.

METHOD

Eligible studies reported on participants with diagnosis of ADHD or elevated symptoms of ADHD who were assessed in a randomized trial using laboratory tasks intended to measure aspects of attention or academic work involving attention or executive function while exposed to white, pink, and brown noise and compared with a low/no noise condition. Two authors independently reviewed and screened studies for eligibility. A random-effects meta-analysis was conducted with preplanned moderator analyses of age, diagnostic status, and task type. Publication bias was evaluated. The GRADE tool was used to assess certainty of the evidence. Sensitivity analyses were conducted to evaluate robustness.

RESULTS

Studies of children and college-age young adults with ADHD or ADHD symptoms (k = 13, N = 335) yielded a small but statistically significant benefit of white and pink noise on task performance (g = 0.249, 95% CI [0.135, 0.363], p < .0001). No studies of brown noise were identified. Heterogeneity was minimal, and moderators were nonsignificant; results survived sensitivity tests, and no publication bias was identified. In non-ADHD comparison groups (k = 11, N = 335), white and pink noise had a negative effect (g = -0.212, 95% CI [-0.355, -0.069], p = .0036).

CONCLUSION

White and pink noise provide a small benefit on laboratory attention tasks for individuals with ADHD or high ADHD symptoms, but not for non-ADHD individuals. This article addresses theoretical implications, cautions, risks, and limitations.

PLAIN LANGUAGE SUMMARY

Public interest in the potential benefits of white, pink, and brown noise exposure for enhancing task performance for individuals with attention-deficit/hyperactivity disorder (ADHD) has increased substantially. This systematic review and meta-analysis included 13 studies with 335 participants and found that white/pink noise improved cognitive performance for children and young adults with ADHD or significant ADHD symptoms. In contrast, white/pink noise impaired cognitive performance for individuals without ADHD. Positive effects of noise were small, but these results point to a possible low-cost, low-risk intervention that may benefit youth with ADHD. Additional studies are needed to confirm effects and identify safe and appropriate decibel levels. The potential detrimental effects for individuals without ADHD also requires further study.

STUDY PREREGISTRATION INFORMATION

White Noise for ADHD: A Systematic Review And Meta-analysis; https://www.crd.york.ac.uk/prospero; CRD42023393992.

Randomised controlled trial of the effects of kefir on behaviour, sleep and the microbiome in children with ADHD: a study protocol

INTRODUCTION

Current interventions for children with attention-deficit/hyperactivity disorder (ADHD) are primarily medication, behavioural therapy and parent training. However, research suggests dietary manipulations may provide therapeutic benefit for some. There is accumulating evidence that the gut microbiome may be atypical in ADHD, and therefore, manipulating gut bacteria in such individuals may help alleviate some of the symptoms of this condition. The aim of this study is to explore the effects of supplementation with kefir (a fermented dairy drink) on ADHD symptomatology, sleep, attention and the gut microbiome in children diagnosed with ADHD.

METHODS AND ANALYSIS

A 6-week randomised, double-blind, placebo-controlled trial in 70 children aged 8-13 years diagnosed with ADHD. Participants will be recruited throughout the UK, through support groups, community groups, schools, social media and word of mouth. Children will be randomised to consume daily either dairy kefir or a placebo dairy drink for 6 weeks. The primary outcome, ADHD symptomatology, will be measured by The Strengths and Weakness of ADHD-symptoms and Normal-behaviour scale. Secondary outcomes will include gut microbiota composition (using shotgun metagenomic microbiome sequencing), gut symptomatology (The Gastrointestinal Severity Index questionnaire), sleep (using 7-day actigraphy recordings, The Child's Sleep Habits Questionnaire and Sleep Self Report questionnaire), inattention and impulsivity (with a computerised Go/NoGo test). Assessments will be conducted prior to the intervention and at the end of the intervention. Interaction between time (preintervention/postintervention) and group (probiotic/placebo) is to be analysed using a Mixed Model Analysis of Variances.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by St Mary's University Ethics Committee. Results will be disseminated through peer-reviewed publications, presentations to the scientific community and support groups.

TRIAL REGISTRATION NUMBER

NCT05155696.

Skipping Breakfast and Eating Breakfast Away From Home Were Prospectively Associated With Emotional and Behavioral Problems in 115,217 Chinese Adolescents

BACKGROUND

Breakfast is deemed the most important meal of the day. We examined the prospective associations of breakfast habits with emotional/behavioral problems in adolescents and potential effect modification.

METHODS

115,217 Primary 6 students (United States Grade 6; mean age, 11.9; standard deviation [SD], 0.59 years) who attended the Student Health Service of Department of Health in Hong Kong in 2004/05, 2006/07, 2008/09 were followed till Secondary 6 (United States Grade 12). Emotional/behavioral problems were biennially examined using Youth Self-Report since Secondary 2 (United States Grade 8). Lifestyles were biennially examined using standardized questionnaires since Primary 6. Prospective associations of breakfast habit with emotional/behavioral problems and potential effect modification were examined using generalized estimating equations.

RESULTS

Compared with eating breakfast at home, eating breakfast away from home was significantly associated with total emotional/behavioral problems and seven syndromes, including withdrawal, somatic complaints, anxiety/depression, thought problems, attention problems, delinquent behaviors, and aggressive behaviors (adjusted odds ratios [AORs] 1.22-2.04), while skipping breakfast showed stronger associations with the above problems and social problems (AORs 1.34-2.29). Stronger associations were observed in younger students for total and attention problems (P < 0.03) and in those with lower weight status for delinquent behaviors (P = 0.005).

CONCLUSION

Eating breakfast away from home and especially skipping breakfast were prospectively associated with adolescent emotional/behavioral problems. The associations weakened with increasing age for total emotional/behavioral and attention problems, and weakened with higher weight status for delinquent behaviors, highlighting the vulnerability of younger and underweight children. If the associations are causal, increasing home breakfast may reduce adolescent emotional/behavioral problems and benefit psychosocial health.

Does Diet Affect the Symptoms of ADHD?

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric diagnosis in childhood and adolescence, with an estimated worldwide-pooled prevalence of 5,29%. The type of treatment depends on several factors. Psychopharmacological treatment entails undesirable side effects, with unclear long-term benefits, which has led the scientific community to investigate other therapeutic approaches, such as dietary interventions.

METHOD

The authors conducted a classical review on the current treatment recommended in individuals with ADHD diagnosis, their dietary patterns, as well as dietary factors possibly implicated in the etiology and treatment of this disorder. An extensive bibliographic research was carried out in the databases PubMed, The Cochrane Library and the National Guideline Clearinghouse.

DISCUSSION

The most common dietary interventions in the case of ADHD are food supplementation diets (e.g. PUFAs, vitamins) and elimination diets. Supplementation with omega-3 PUFAs lacks further studies that can validate them as an effective therapeutic approach in this disorder. Also, regarding vitamin supplementation, studies are not consistent as to their role in the etiology of ADHD. Elimination diets are unclear as to the benefits provided in individuals with ADHD. Children with ADHD are less likely to engage in healthy lifestyle behaviors than non-ADHD youth.

CONCLUSION

There is no clear evidence that supports dietary interventions for the treatment of ADHD. The effects of unhealthy diet patterns in ADHD individuals are not yet fully understood and, like the general population, children with ADHD may benefit from a healthy lifestyle.

Oxidative stress and immune aberrancies in attention-deficit/hyperactivity disorder (ADHD): a case-control comparison

The objective of this study is to compare oxidative stress and immune biomarkers between attention-deficit/hyperactivity disorder (ADHD) patients and controls without ADHD. A case-control comparison between 57 paediatric (6-12 years) untreated ADHD patients from the Antwerp University Hospital and 69 controls without ADHD from random schools in Flanders, Belgium, was conducted. Erythrocyte glutathione (GSH) and plasma lipid-soluble antioxidants (retinol, α-tocopherol, γ-tocopherol, retinyl palmitate, β-carotene, and co-enzyme Q10) were determined by HPLC with electrochemical detection, plasma malondialdehyde (MDA) by HPLC with fluorescence detection, plasma cytokines (interleukin (IL)-1β, IL-5, IL-6, IL-8, IL-10, tumour necrosis factor (TNF) and interferon (INF)-γ) and immunoglobulins (IgE, IgG and IgM) by flow cytometry and urinary 8-hydroxy-2'deoxyguanosine (8-OHdG) levels by ELISA assay. Dietary habits were determined by a food frequency questionnaire. Plasma MDA levels were on average 0.031 µM higher in patients than in controls (p < 0.05), and a trend for higher urinary 8-OHdG was observed. Erythrocyte GSH and plasma retinyl palmitate levels, as well as IgG and IgE levels, were higher in patients than in controls as well (on average 93.707 µg/ml, 0.006 µg/ml, 301.555 µg/ml and 125.004 µg/ml, resp., p < 0.05). Finally, a trend for lower plasma IL-5 levels was observed. After Bonferroni correction for multiple testing, the difference in GSH levels remained statistically significant (nominally significant for retinyl palmitate), while significance was lost for MDA, IgG and IgE levels. Dietary habits do not appear to cause the observed differences. These results point at the potential involvement of slight oxidative stress and immune disturbances in ADHD.

Dietary Supplements in Children

High-quality systematic reviews of use of herbal or homeopathic remedies in children often suffer from design flaws, such as not following PRISMA guidelines, inconsistent outcome measurements, and paucity of high-quality studies. Herbal remedies have modest demonstrated benefits with insufficient evidence to recommend any particular supplement. Homeopathic remedies have no role in treatment of pediatric conditions, and have been associated with great harm in infants given homeopathic teething products. Two types of herbal supplements are associated with high risk in adolescents, energy drinks and adulterated weight-loss products. Parents should be counseled about risks of these products.

No Tryptophan, Tyrosine and Phenylalanine Abnormalities in Children with Attention-Deficit/Hyperactivity Disorder

Background

The aim of the current study was to explore the role of aromatic amino acids (AAAs) in blood in relation to attention-deficit/hyperactivity disorder (ADHD). Given their impact on the synthesis of serotonin and dopamine, decreased concentrations of the AAAs tryptophan, tyrosine and phenylalanine in blood may contribute to the expression of ADHD symptoms. Decreased AAA blood concentrations, in turn, may be related to lowered dietary protein intake or to abnormal AAA catabolism, as evidenced by increased urinary AAA concentrations.

Methods

Eighty-three children with ADHD (75% males) and 72 typically developing (TD) children (51% males), aged 6 to 13 years, participated in the study. AAA concentrations were assessed in blood spots and an 18-hour urinary sample. A nutritional diary was filled out by parents to calculate dietary protein intake. Parent and teacher questionnaires assessed symptoms of ADHD, oppositional defiant disorder, conduct disorder, and autism spectrum disorder.

Results

Children with ADHD showed normal AAA concentrations in blood spots and urine, as well as normal protein intake compared to controls. No associations between AAA concentrations and symptoms of ADHD or comorbid psychiatric disorders were found.

Conclusions

This study is the first to explore AAA metabolism in children with ADHD using a well-defined and relatively large sample. We found that AAA deficiencies are not related to ADHD. The results do not support treatment with AAA supplements in children with ADHD. Future studies regarding the cause of serotonin and dopamine alterations in ADHD should focus on other explanations, such as effects of altered transport of AAAs.

Psychosocial interventions in attention-deficit/hyperactivity disorder: update

Attention-deficit/hyperactivity disorder (ADHD) is the most common reason for referral to child and adolescent psychiatry clinics. Although stimulant medications represent an evidence-based approach to managing ADHD, psychosocial interventions for child/adolescent ADHD target functional impairments as the intervention goal, and rely heavily on behavioral therapy techniques and operant conditioning principles. Evidence-based psychosocial interventions for managing pediatric ADHD include behavioral parent training, school-based interventions relying on behavioral modification, teaching skills, and operant conditioning principles, and intensive summer treatment programs. The use of conjoint psychosocial treatments with ADHD medications may enable lower doses of each form of treatment.

Diet in the treatment of ADHD in children - a systematic review of the literature

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric conditions in childhood. Dietary changes have been suggested as a way of reducing ADHD symptoms.

AIMS

To provide an overview of the evidence available on dietary interventions in children with ADHD, a systematic review was carried out of all dietary intervention studies in children with ADHD.

METHODS

Relevant databases were searched in October 2011, with an update search in March 2013. The studies included describe diet interventions in children with ADHD or equivalent diagnoses measuring possible changes in core ADHD symptoms: inattention, hyperactivity and impulsivity.

RESULTS

A total of 52 studies were identified, some investigating whether ADHD symptoms can improve by avoiding certain food elements (20 studies), and some whether certain food elements may reduce ADHD symptoms (32 studies).

CONCLUSION

Elimination diets and fish oil supplementation seem to be the most promising dietary interventions for a reduction in ADHD symptoms in children. However, the studies on both treatments have shortcomings, and more thorough investigations will be necessary to decide whether they are recommendable as part of ADHD treatment.

Promising treatments for neuropathic pain

In the last few years the understanding of mechanisms and, consequently, the diagnosis of neuropathic pain (NP) has becoming progressively clearer in clinical practice. However, the treatment of such condition remains challenging so far. One of the reasons for such difficulty is the diversity of mechanisms involved in NP generation and its persistency. In the present review we discuss several treatment modalities for NP that are scantily applied in daily clinical practice. For that, we collected positive clinical evidence of unusual and SECS (Safe, Easy, Cheap, and Sensible) approaches for NP. The aim of this review is not to establish the “state of the art” or rigid guidelines for NP treatment. In a different way, we only want bring new possibilities of treatment to the readers and also to motivate investigators to confirm those positive preliminary but promising results for NP reliev.

Nutritional Supplements for the Treatment of Attention-Deficit Hyperactivity Disorder

Polyunsaturated fatty acid supplementation appears to have modest benefit for improving ADHD symptoms. Melatonin appears to be effective in treating chronic insomnia in children with ADHD but appears to have minimal effects in reducing core ADHD symptoms. Many other natural supplements are widely used in the United States despite minimal evidence of efficacy and possible side effects. This review synthesizes and evaluates the scientific evidence regarding the potential efficacy and side effects of natural supplements and herbal remedies for ADHD. We provide clinicians with recommendations regarding their potential use and role in overall ADHD treatment.

Restriction and Elimination Diets in ADHD Treatment

Food elimination diets are defined and the history of their investigation in relation to attention-deficit/hyperactivity disorder (ADHD) is reviewed. After noting that a consensus has emerged that an elimination diet produces a small but reliable aggregate effect, the present review provides updated quantitative estimates of effect size and clinical response rates to elimination diets. It then highlights key issues that require research attention, in particular characterization of dietary responders. Finally, because some children may benefit, clinical guidelines at the present state of knowledge are summarized. It is concluded that updated trials of elimination diets are sorely needed for ADHD.

Attention deficits and hyperactivity-impulsivity: what have we learned, what next?

The domains of self-regulation, self-control, executive function, inattention, and impulsivity cut across broad swathes of normal and abnormal development. Attention-deficit/hyperactivity disorder is a common syndrome that encompasses a portion of these domains. In the past 25 years research on attention-deficit/hyperactivity disorder has been characterized by dramatic advances in genetic, neural, and neuropsychological description of the syndrome as well as clarification of its multidimensional phenotypic structure. The limited clinical applicability of these research findings poses the primary challenge for the next generation. It is likely that clinical breakthroughs will require further refinement in describing heterogeneity or clinical/biological subgroups, renewed focus on the environment in the form of etiological events as well as psychosocial contexts of development, and integration of both with biological understanding.

Research review: the role of diet in the treatment of attention-deficit/hyperactivity disorder--an appraisal of the evidence on efficacy and recommendations on the design of future studies

BACKGROUND

The efficacy of three dietary treatments for ADHD has been repeatedly tested in randomized controlled trials (RCTs). These interventions are restricted elimination diets (RED), artificial food colour elimination (AFCE) and supplementation with free fatty acids (SFFA). There have been three systematic reviews and associated meta-analyses of the RCTs for each of these treatments.

SCOPE

The aim of this review is to critically appraise the studies on the dietary treatments of ADHD, to compare the various meta-analyses of their efficacy that have been published and to identify where the design of such RCTs could be improved and where further investigations are needed.

FINDINGS

The meta-analyses differ in the inclusion and exclusion criteria applied to potentially eligible studies. The range of average effect sizes in standard deviation units is RED (0.29-1.2), AFCE (0.18-0.42) and SFFA (0.17-0.31). The methodology of many of the trials on which the meta-analyses are based is weak.

CONCLUSIONS

Nevertheless, there is evidence from well-conducted studies for a small effect of SFFA. Restricted elimination diets may be beneficial, but large-scale studies are needed on unselected children, using blind assessment and including assessment of long-term outcome. Artificial food colour elimination is a potentially valuable treatment but its effect size remains uncertain, as does the type of child for whom it is likely to be efficacious. There are additional dietary supplements that have been used with children with ADHD. A systematic search identified 11 RCTs that investigated the effects of these food supplements. Despite positive results for some individual trials, more studies are required before conclusions can be reached on the value in reducing ADHD symptoms of any of these additional supplements.

Clinical considerations for the management of pediatric patients with attention-deficit/hyperactivity disorder

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a chronic health condition presenting with symptoms of hyperactivity, impulsivity, and/or inattention in early childhood, adolescence and adulthood. Many patients will persist with associated symptoms throughout their life and may require long term treatment to maintain adequate control.

Objective: The purpose of this article is to review the current literature in regards to diagnosis, treatment, and management of ADHD in the pediatric and adolescent population.

Methods: A search was conducted using PubMed, Medline, Ovid, and CINHAL with a focus on studies and reviews in the English language from 2008 – 2013, featuring pediatric/adolescent patients across the ages of 4–17 years using the terms: “management”, “attention-deficit”, “hyperactivity”, and “treatment.” Literature referenced prior to the five-year time frame outlined herein provided foundational information on diagnostics and medications.

Discussion: Stimulants, in conjunction with behavioral therapy, are standard first line treatments used in ADHD. While stimulant medications have been shown to be effective in treating symptoms associated with ADHD, there are a variety of concerns that may prevent their use. These concerns are related to adverse consequences, many of which are not supported by concrete evidence. Other pharmacotherapy options such as norepinephrine reuptake inhibitors and selective alpha-2 adrenergic agonists are typically reserved as second line options. The use of novel and emerging complementary therapies will also be explored.

Conclusion: Patients diagnosed with ADHD must be thoroughly evaluated when making decisions regarding treatment. Many studies and reviews support the efficacy of pharmacotherapy in treatment of ADHD; however, there is insufficient evidence regarding long-term safety of the medications. Further research is warranted to evaluate current treatment options and associated risks and benefits to guide the clinician in optimal management of these patients.

Altered serum mono- and polyunsaturated fatty acid levels in adults with ADHD

Other than in children diagnosed with attention deficit hyperactivity disorder (ADHD), the connection between ADHD and lipids has not been sufficiently investigated so far in adults. Blood serum lipoproteins and fatty acids (FA) composition were measured and analyzed by colorimetry and gaschromatography in eight male and seven female adults diagnosed with ADHD as well as in 15 age- and gender-matched healthy control subjects. In ADHD patients, polyunsaturated FAs [docosahexaenoic, arachidonic and dihomogammalinolenic acid (p = 0.048; 0.003; 0.012)] showed lower concentrations, while monounsaturated acids (palmitoleic and oleic acid) as well as total and LDL cholesterol showed higher concentrations (p = 0.011; 0.005). ADHD scores positively correlated with palmitoleic (R = -0.56; p = 0.032), stearic (R = 0.53; p = 0.044), eicosapentaenoic (R = 0.62; p = 0.014), docosahexaenoic (R = 0.51; p = 0.050), gammalinolenic (R = 0.62; p = 0.018) and alphalinolenic acid (R = 0.56; p = 0.031) concentration. Even though the total and LDL cholesterol concentrations in blood serum were significantly higher among the ADHD patients than in controls, none of the ADHD symptom scores were significantly associated with any of the lipoproteine measures. We could demonstrate that a lack of polyunsaturated FAs in blood serum of subjects with ADHD persists into adulthood. Furthermore, we could show that adult ADHD symptomatology positively correlates with elevated levels of saturated stearic and monounsaturated FAs.

Complementary and alternative therapies for children and adolescents with ADHD

PURPOSE OF REVIEW

To provide a comprehensive review of complementary and alternative medicine (CAM) treatments for children and adolescents with attention deficit hyperactivity disorder (ADHD).

RECENT FINDINGS

Many parents of children with ADHD are reluctant to pursue medication options and unable to access behavioral counseling. CAM therapies are often appealing to families and studies show that a large percentage of children with ADHD are treated with one or more CAM therapy. Most research studies evaluating CAM therapies are methodologically flawed, and often times there are inconsistencies across either study design or results. Although the American Academy of Pediatrics does not recommend any CAM therapies for ADHD, essential fatty acid supplementation is likely well tolerated and modestly effective.

SUMMARY

Most complementary and alternative treatments do not have adequate research to recommend their use in children with ADHD. Physicians should be aware of the many CAM treatment options and the research surrounding them in order to provide their patients with the most current and accurate information available.