The Role of Nutritional Supplements in the Treatment of ADHD: What the Evidence Says

Association between infant feeding and ADHD development in childhood: a birth cohort study in Taiwan

BACKGROUND

Infant feeding plays a vital role in neurodevelopment, and a lack of breastfeeding and complementary feeding may increase the risk of developing attention-deficit/hyperactivity disorder (ADHD). However, empirical evidence on this relationship remains uncertain, as most studies are based on cross-sectional designs. Therefore, this study aimed to examine this temporal relationship using longitudinal data from a birth cohort.

METHODS

A retrospective cohort study was conducted using data from Wave I (starting at 6 months old, 2005-2006) to Wave IV (up to 5 years old, 2010-2011) of the Taiwan Birth Cohort Study. A total of 19,721 pairs completed the four-wave interviews and provided information on infant feeding, medical history, ADHD occurrence, and sociodemographic characteristics. An extended Cox model with time-dependent covariates was used to examine this association.

RESULTS

In total, 207 infants developed ADHD during the 54-month observational period, with an estimated cumulative incidence of 5.56 per 1,000 person-years. The average breastfeeding duration was approximately 2 months. With complementary feeding, rice solid food (HR = 0.73) was found to be a protective factor against developing ADHD. Significantly associated factors for increasing ADHD risk included males, lower family income, low birth weight, maternal weight, advanced maternal age, child gastrointestinal disease, child seizures, maternal heart disease, and paternal diabetes mellitus.

CONCLUSIONS

Complementary feeding within 6 months is important to protect infants from developing ADHD. The beneficial effect of breastfeeding within 6 months was not observed while controlling for other risk factors. However, owing to the limitation of a smaller number of ADHD cases, further studies should rely on larger observational periods.

Behavioural, cognitive, and neurophysiological effects of a synbiotic supplementation enriched with pigmented corn extract or cornstarch in drug-naïve children with attention-deficit hyperactivity disorder: A randomised, double-blind, comparison-controlled clinical trial

BACKGROUND & AIMS

Considerable interest has been recently given to the potential role of the gut-brain axis (GBA) -a two-way communication network between the gut microbiota and the central nervous system- in the pathogenesis of attention-deficit hyperactivity disorder (ADHD), suggesting the potential usefulness of probiotic and synbiotic supplementations. In light of the limited available evidence, synbiotic efficacy in ADHD children not taking medications should be clarified. This study aimed to investigate the efficacy of a synbiotic dietary supplementation on fatty acids levels as well as on microbiota composition, behaviour, cognition, and brain function in children with ADHD.

METHODS

A total of 41 drug-naïve school-aged children diagnosed with ADHD were enrolled in a 3-month randomised, double-blind, comparison-controlled clinical trial, receiving either a synbiotic mix (COMP group) or the same synbiotic mix enriched with an additional extract from pigmented corn (EXP group). Changes in levels of some specific short-chain and branched-chain fatty acids were considered as primary outcomes. Secondary outcome measures included gut microbiota profiling, Child Behaviour Checklist, Conners Parent Rating Scale-revised, computerised cognitive tasks, and haemodynamic response to a Go-NoGo task measured by fNIRS.

RESULTS

No superiority of the EXP synbiotic mix was observed. Analysis of fatty acids did not reveal any significant difference between groups. Children in the COMP group reported a slightly greater improvement than those in the EXP group in focused attention and in the haemodynamic response to a cognitive task.

CONCLUSIONS

This study shows that pigmented corn extract does not enhance the effects of the synbiotic supplementation in ADHD children in terms of fatty acid production, microbiota composition, clinical, cognitive and neurophysiological measures. However, a synbiotic mix of probiotics plus prebiotic acacia fibre and cornstarch could have some promising effects on ADHD symptoms, which warrants further research. Future studies should also continue to explore the potential of fNIRS for monitoring the effects of interventions that target the GBA.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06005506.

Plasma fatty acids and attention deficit hyperactivity disorder: a Mendelian randomization investigation

Background

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood, and pathogenesis is not fully understood. Observational studies suggest an association between fatty acids abnormalities and ADHD, but there are contradictions and differences between these findings. To address this uncertainty, we employed a two-sample bidirectional Mendelian Randomization (MR) analysis to investigate the causal relationship between fatty acids and ADHD.

Methods

We conducted a two-sample Mendelian Randomization (MR) study, selecting single nucleotide polymorphisms (SNPs) highly correlated with fatty acid levels from the CHARGE Consortium as our instruments. The outcome data were sourced from the Psychiatric Genomics Consortium (PGC) dataset on ADHD, comprising 225,534 individuals, with 162,384 cases and 65,693 controls. Inverse variance weighting, MR-Egger, and weighted median methods were employed to estimate the causal relationship between fatty acids and ADHD. Cochran's Q-test was used to quantify heterogeneity of instrumental variables. Sensitivity analyses included MR-Egger intercept tests, leave-one-out analyses, and funnel plots.

Results

The MR analysis revealed no significant associations between genetically predicted levels of various saturated, monounsaturated, and polyunsaturated fatty acids (including omega-3 and omega-6) and ADHD risk in the CHARGE and PGC cohorts. Notably, an initial association with Dihomo-gamma-linolenic acid (DGLA) (OR = 1.009, p = 0.032 by IVW) did not persist after correction for multiple testing (adjusted p-value = 0.286). Sensitivity analysis supported our findings, indicating robustness. Moreover, there was a lack of evidence supporting a causal link from ADHD to fatty acids.

Conclusion

While our study on the basis of genetic data does not provide evidence to support the causal role of fatty acids in ADHD, it does not preclude their potential involvement in reducing the risk of ADHD. Further research is needed to explore this possibility.

Micronutrients for ADHD in youth (MADDY) study: comparison of results from RCT and open label extension

BACKGROUND

The Micronutrients for Attention-Deficit/Hyperactivity Disorder in Youth (MADDY) study evaluated the efficacy and safety of a multinutrient formula for children with ADHD and emotional dysregulation. The post-RCT open-label extension (OLE) compared the effect of treatment duration (8 weeks vs 16 weeks) on ADHD symptoms, height velocity, and adverse events (AEs).

METHODS

Children aged 6-12 years randomized to multinutrients vs. placebo for 8 weeks (RCT), received an 8-week OLE for a total of 16 weeks. Assessments included the Clinical Global Impression-Improvement (CGI-I), Child and Adolescent Symptom Inventory-5 (CASI-5), Pediatric Adverse Events Rating Scale (PAERS), and anthropometric measures (height and weight).

RESULTS

Of the 126 in the RCT, 103 (81%) continued in the OLE. For those initially assigned to placebo, CGI-I responders increased from 23% in the RCT to 64% in the OLE; those who took multinutrients for 16 weeks increased from 53% (RCT) to 66% responders (OLE). Both groups improved on the CASI-5 composite score and subscales from week 8 to week 16 (all p-values < 0.01). The group taking 16 weeks of multinutrients had marginally greater height growth (2.3 cm) than those with 8 weeks (1.8 cm) (p = 0.07). No difference in AEs between groups was found.

CONCLUSION

The response rate to multinutrients by blinded clinician ratings at 8 weeks was maintained to 16 weeks; the response rate in the group initially assigned to placebo improved significantly with 8 weeks of multinutrients and almost caught up with 16 weeks. Longer time on multinutrients did not result in greater AEs, confirming an acceptable safety profile.

Treatment response to supplemental nutrients for ADHD is independent of diet quality: the MADDY Study RCT

OBJECTIVES

The 8-week Micronutrients for ADHD in Youth (MADDY) randomized controlled trial (N = 126, age 6-12) of broad-spectrum multinutrients for ADHD with emotional dysregulation found 3 times as many responders with multinutrients (54%) compared to placebo (18%) by Clinical Global Impression-Improvement (CGI-I). Our primary aim for this analysis tests the hypothesis that those with poor overall diet quality at baseline benefit more. The second aim is to explore whether specific components of diet quality moderate treatment response.

METHODS

124 children (69 multinutrients, 55 placebo) had diet quality assessed using the Healthy Eating Index-2015 (HEI-2015). For each potential moderator, the outcome CGI-I at week 8 (RCT-end), was modeled two ways: (1) as a dichotomous variable: responder/non-responder, with responders defined by a rating of 1 or 2 'very much' or 'much improved,' all else equals non-responder using logistic regression, and (2) as a dimensional improvement outcome from 1 = very much improved to 7 = very much worse, using linear regression.

RESULTS

HEI-2015 total score did not moderate treatment response [odds ratio = 1.00 (95% CI: 0.90,1.10), p = 0.984] or improvement [β = -0.01 (95% CI: -0.06,0.04), p = 0.648]. However, total vegetable intake moderated level of improvement in exploratory analysis [β = -0.48 (95% CI: -0.82, -0.13), p = 0.007]: those with higher baseline vegetable intake showed greater benefit from multinutrients compared to placebo.

CONCLUSIONS

Multinutrients may benefit children with ADHD and irritability regardless of overall diet quality. The finding that higher baseline vegetable intake may improve response to multinutrients deserves further exploration, including dietary effect on gut microbiota and absorption of multinutrients and parental factors.

Nutrition in the Management of ADHD: A Review of Recent Research

PURPOSE OF REVIEW

Various nutrients and diet quality have been suggested to be involved in the pathophysiology of ADHD. The purpose of this review was to examine data from recent cohort studies and dietary interventions to determine whether nutrition may play a role in the management of ADHD.

RECENT FINDINGS

Preliminary evidence suggests that minerals might have beneficial effects on ADHD symptomatology. Probiotics might offer novel strategies to prevent or treat ADHD. Inverse associations between adherence to "healthy" diets and ADHD symptoms have been observed. Children with ADHD responding to the few-foods diet (or oligoantigenic diet) with an elimination of individually identified food items show substantially improved behavior and cognitive functioning. Evidence from recent research does not allow any recommendations regarding the use of micronutrients or probiotics in the management of ADHD. The few-foods diet may become an additional therapeutic option for children with ADHD.

Fruit and vegetable intake is inversely associated with severity of inattention in a pediatric population with ADHD symptoms: the MADDY Study

OBJECTIVES

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with a U.S. pediatric prevalence of 8-10%. It presents with inattention and hyperactivity/impulsivity; frequently associated with emotional dysregulation (ED) symptoms common in Oppositional Defiant Disorder and Disruptive Mood Dysregulation Disorder. The etiology of ADHD is multi-factorial; symptom severity is associated with diet. This study examines the association of diet quality with ADHD and ED symptoms within a pediatric research cohort.

METHODS

Baseline data were analyzed for 134 children aged 6-12 years with symptoms of ADHD and ED enrolled in an RCT of multinutrient supplementation. Diet quality was based on Healthy Eating Index-2015 (HEI-2015). ADHD and ED symptoms were assessed using Child and Adolescent Symptom Inventory-5 and Strengths and Difficulties Questionnaire. Linear regression models, adjusting for covariates when necessary, determined association.

RESULTS

The mean HEI Total Score of 63.4 (SD = 8.8) was not significantly associated with any outcome symptoms. However, after adjusting for covariates, HEI component scores for total fruit intake (β =  -0.158, p = .037) and total vegetable intake (β =  -0.118, p = .004) were negatively associated with inattention.

CONCLUSIONS

The lack of association with total diet quality could be explained by the relatively good baseline diet quality and mild symptom severity in this sample, along with measurement error from dietary intake estimates and relatively small sample size. These findings suggest that dietary intake may impact inattention in children with ADHD and ED: those eating less fruits and vegetables were likely to have more severe symptoms of inattention. Causality is not established by this cross-sectional analysis.

Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a major problem in children and adolescents, characterised by age-inappropriate levels of inattention, hyperactivity, and impulsivity, and is associated with long-term social, academic, and mental health problems. The stimulant medications methylphenidate and amphetamine are the most frequently used treatments for ADHD, but these are not always effective and can be associated with side effects. Clinical and biochemical evidence suggests that deficiencies of polyunsaturated fatty acids (PUFA) could be related to ADHD. Research has shown that children and adolescents with ADHD have significantly lower plasma and blood concentrations of PUFA and, in particular, lower levels of omega-3 PUFA. These findings suggest that PUFA supplementation may reduce the attention and behaviour problems associated with ADHD. This review is an update of a previously published Cochrane Review. Overall, there was little evidence that PUFA supplementation improved symptoms of ADHD in children and adolescents.

OBJECTIVES

To compare the efficacy of PUFA to other forms of treatment or placebo in treating the symptoms of ADHD in children and adolescents.

SEARCH METHODS

We searched 13 databases and two trials registers up to October 2021. We also checked the reference lists of relevant studies and reviews for additional references.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared PUFA with placebo or PUFA plus alternative therapy (medication, behavioural therapy, or psychotherapy) with the same alternative therapy alone in children and adolescents (aged 18 years and under) diagnosed with ADHD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was severity or improvement of ADHD symptoms. Our secondary outcomes were severity or incidence of behavioural problems; quality of life; severity or incidence of depressive symptoms; severity or incidence of anxiety symptoms; side effects; loss to follow-up; and cost. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 37 trials with more than 2374 participants, of which 24 trials were new to this update. Five trials (seven reports) used a cross-over design, while the remaining 32 trials (52 reports) used a parallel design. Seven trials were conducted in Iran, four each in the USA and Israel, and two each in Australia, Canada, New Zealand, Sweden, and the UK. Single studies were conducted in Brazil, France, Germany, India, Italy, Japan, Mexico, the Netherlands, Singapore, Spain, Sri Lanka, and Taiwan. Of the 36 trials that compared a PUFA to placebo, 19 used an omega-3 PUFA, six used a combined omega-3/omega-6 supplement, and two used an omega-6 PUFA. The nine remaining trials were included in the comparison of PUFA to placebo, but also had the same co-intervention in the PUFA and placebo groups. Of these, four trials compared a combination of omega-3 PUFA plus methylphenidate to methylphenidate. One trial each compared omega-3 PUFA plus atomoxetine to atomoxetine; omega-3 PUFA plus physical training to physical training; and an omega-3 or omega-6 supplement plus methylphenidate to methylphenidate; and two trials compared omega-3 PUFA plus dietary supplement to dietary supplement. Supplements were given for a period of between two weeks and six months. Although we found low-certainty evidence that PUFA compared to placebo may improve ADHD symptoms in the medium term (risk ratio (RR) 1.95, 95% confidence interval (CI) 1.47 to 2.60; 3 studies, 191 participants), there was high-certainty evidence that PUFA had no effect on parent-rated total ADHD symptoms compared to placebo in the medium term (standardised mean difference (SMD) -0.08, 95% CI -0.24 to 0.07; 16 studies, 1166 participants). There was also high-certainty evidence that parent-rated inattention (medium-term: SMD -0.01, 95% CI -0.20 to 0.17; 12 studies, 960 participants) and hyperactivity/impulsivity (medium-term: SMD 0.09, 95% CI -0.04 to 0.23; 10 studies, 869 participants) scores were no different compared to placebo. There was moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups (RR 1.02, 95% CI 0.69 to 1.52; 8 studies, 591 participants). There was also moderate-certainty evidence that medium-term loss to follow-up was likely similar between groups (RR 1.03, 95% CI 0.77 to 1.37; 13 studies, 1121 participants).

AUTHORS' CONCLUSIONS

Although we found low-certainty evidence that children and adolescents receiving PUFA may be more likely to improve compared to those receiving placebo, there was high-certainty evidence that PUFA had no effect on total parent-rated ADHD symptoms. There was also high-certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups. We found moderate-certainty evidence that overall side effects likely did not differ between PUFA and placebo groups. There was also moderate-certainty evidence that follow-up was similar between groups. It is important that future research addresses the current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, and short follow-up times.

Long-Term Effects of an Oligoantigenic Diet in Children with Attention-Deficit/Hyperactivity Disorder (ADHD) on Core Symptomatology

In the early 1920s, it was discovered that nutrition is associated with what is known today as Attention-Deficit/Hyperactivity Disorder (ADHD) and that certain foods can worsen the symptoms. In previous studies, approximately 60% of the participants experience at least a 40% reduction in ADHD symptoms after an oligoantigenic diet (OD). The purpose of this study was to evaluate ADHD symptoms in children approximately 3.5 years after completing a 4-week oligoantigenic diet. Among 28 participants who completed the 4-week diet, 21 were re-assessed for this study after 3.5 years. The severity of ADHD symptoms was assessed with the ADHD-Rating-Scale-IV (ARS). Of 21 participants, 14 fulfilled the responder criterion, whereas 7 did not. At follow-up, 28% of the participants were taking medication. The mean ARS total score improved significantly from T1: M = 29.62 (SD = 9.80) to T2: M = 15.86 (SD = 8.56) between the time points before and after the diet (d = -1.91). There was also a lower ARS total score at the follow-up T5: M = 16.00 (SD = 10.52) compared to before the diet (d = -1.17). This study shows that individually adjusted nutrition significantly improved the ADHD symptomatology of the participants long-term. This suggests that an oligoantigenic diet with subsequent individual nutritional recommendations could become an additional treatment option for children with ADHD.

Targeting PI3K by Natural Products: A Potential Therapeutic Strategy for Attention-deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is a highly prevalent childhood psychiatric disorder. In general, a child with ADHD has significant attention problems with difficulty concentrating on a subject and is generally associated with impulsivity and excessive activity. The etiology of ADHD in most patients is unknown, although it is considered to be a multifactorial disease caused by a combination of genetics and environmental factors. Diverse factors, such as the existence of mental, nutritional, or general health problems during childhood, as well as smoking and alcohol drinking during pregnancy, are related to an increased risk of ADHD. Behavioral and psychological characteristics of ADHD include anxiety, mood disorders, behavioral disorders, language disorders, and learning disabilities. These symptoms affect individuals, families, and communities, negatively altering educational and social results, strained parent-child relationships, and increased use of health services. ADHD may be associated with deficits in inhibitory frontostriatal noradrenergic neurons on lower striatal structures that are predominantly driven by dopaminergic neurons. Phosphoinositide 3-kinases (PI3Ks) are a conserved family of lipid kinases that control a number of cellular processes, including cell proliferation, differentiation, migration, insulin metabolism, and apoptosis. Since PI3K plays an important role in controlling the noradrenergic neuron, it opens up new insights into research on ADHD and other developmental brain diseases. This review presents evidence for the potential usefulness of PI3K and its modulators as a potential treatment for ADHD.

Biological Potential, Gastrointestinal Digestion, Absorption, and Bioavailability of Algae-Derived Compounds with Neuroprotective Activity: A Comprehensive Review

Currently, there is no known cure for neurodegenerative disease. However, the available therapies aim to manage some of the symptoms of the disease. Human neurodegenerative diseases are a heterogeneous group of illnesses characterized by progressive loss of neuronal cells and nervous system dysfunction related to several mechanisms such as protein aggregation, neuroinflammation, oxidative stress, and neurotransmission dysfunction. Neuroprotective compounds are essential in the prevention and management of neurodegenerative diseases. This review will focus on the neurodegeneration mechanisms and the compounds (proteins, polyunsaturated fatty acids (PUFAs), polysaccharides, carotenoids, phycobiliproteins, phenolic compounds, among others) present in seaweeds that have shown in vivo and in vitro neuroprotective activity. Additionally, it will cover the recent findings on the neuroprotective effects of bioactive compounds from macroalgae, with a focus on their biological potential and possible mechanism of action, including microbiota modulation. Furthermore, gastrointestinal digestion, absorption, and bioavailability will be discussed. Moreover, the clinical trials using seaweed-based drugs or extracts to treat neurodegenerative disorders will be presented, showing the real potential and limitations that a specific metabolite or extract may have as a new therapeutic agent considering the recent approval of a seaweed-based drug to treat Alzheimer’s disease.

Dietary Micronutrients from Zygote to Senility: Updated Review of Minerals' Role and Orchestration in Human Nutrition throughout Life Cycle with Sex Differences

Micronutrients such as selenium, fluoride, zinc, iron, and manganese are minerals that are crucial for many body homeostatic processes supplied at low levels. The importance of these micronutrients starts early in the human life cycle and continues across its different stages. Several studies have emphasized the critical role of a well-balanced micronutrient intake. However, the majority of studies looked into or examined such issues in relation to a specific element or life stage, with the majority merely reporting the effect of either excess or deficiency. Herein, in this review, we will look in depth at the orchestration of the main element requirements across the human life cycle beginning from fertility and pregnancy, passing through infancy, childhood, adolescence, and reaching adulthood and senility, with insight on the interactions among them and underlying action mechanisms. Emphasis is given towards approaches to the role of the different minerals in the life cycle, associated symptoms for under- or overdoses, and typical management for each element, with future perspectives. The effect of sex is also discussed for each micronutrient for each life stage as literature suffice to highlight the different daily requirements and or effects.

Efficacy and Safety of Polyunsaturated Fatty Acids Supplementation in the Treatment of Attention Deficit Hyperactivity Disorder (ADHD) in Children and Adolescents: A Systematic Review and Meta-Analysis of Clinical Trials

Based on epidemiological and animal studies, the rationale for using polyunsaturated fatty acids (PUFAs) as a treatment for Attention Deficit Hyperactivity Disorder (ADHD) seems promising. Here, the objective was to systematically identify and critically assess the evidence from clinical trials. The primary outcome was ADHD core symptoms. The secondary outcomes were behavioral difficulties, quality of life, and side effects. We performed a systematic search in Medline, Embase, Cinahl, PsycInfo, and the Cochrane Library up to June 2020. The overall certainty of evidence was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). We identified 31 relevant randomized controlled trials including 1755 patients. The results showed no effect on ADHD core symptoms rated by parents (k = 23; SMD: -0.17; 95% CI: -0.32, -0.02) or teachers (k = 10; SMD: -0.06; 95% CI: -0.31, 0.19). There was no effect on behavioral difficulties, rated by parents (k = 7; SMD: -0.02; 95% CI: -0.17, 0.14) or teachers (k = 5; SMD: -0.04; 95% CI: -0.35, 0.26). There was no effect on quality of life (SMD: 0.01; 95% CI: -0.29, 0.31). PUFA did not increase the occurrence of side effects. For now, there seems to be no benefit of PUFA in ADHD treatment; however, the certainty of evidence is questionable, and thus no conclusive guidance can be made. The protocol is registered in PROSPERO ID: CRD42020158453.

Magnesium, Iron, Zinc, Copper and Selenium Status in Attention-Deficit/Hyperactivity Disorder (ADHD)

In this study, we critically review the literature concerning the relation of Mg, Fe, Zn, Cu and Se and attention-deficit/hyperactivity disorder (ADHD). Elemental status is estimated using peripheral blood parameters, hair, urine, daily intake and response to supplementation. The observed associations between concentration levels of the elements Mg, Fe, Zn, Cu and Se and ADHD symptoms are contradictory. This is partly due to the heterogeneity and complexity of the disorder. As a trend, lower ferritin and zinc levels can be observed. However, this correlation is not causative, as illustrated by placebo-controlled trials reporting conflicting evidence on the efficacy of supplementation. Well-defined studies on changes in concentration levels of the elements in relation to ADHD symptoms before and after treatment with therapeutics it will be possible to shed more light on the significance of these elements in this behavioral disorder. The discussion on whether a change in concentration of an element is cause or consequence of ADHD is not within the scope of this article.

Serum zinc, copper, zinc-to-copper ratio, and other essential elements and minerals in children with attention deficit/hyperactivity disorder (ADHD)

BACKGROUND

Essential trace elements and minerals play a significant role in neurodevelopment. Although certain studies demonstrated impaired essential trace element and mineral status in children with ADHD, the existing data are insufficient. The objective of the present study was to assess serum trace element and mineral levels in children with ADHD.

METHODS

Serum trace element and mineral levels in 68 children with ADHD and 68 neurotypical controls were assessed using ICP-MS at NexION 300D (PerkinElmer Inc., USA) equipped with ESI SC-2 DX4 autosampler (Elemental Scientific Inc., USA).

RESULTS

Serum Cr, Mg, and Zn levels in children with ADHD were 21 % (p = 0.010), 4 % (p = 0.005), and 7 % (p = 0. 001) lower as compared to the healthy controls, respectively. In turn, serum Cu/Zn values were 11 % higher than those in the control group. Age and gender had a significant impact on serum element levels in ADHD. Particularly, preschool children were characterized by significantly increased Cu (+8 %; p = 0.034), and Cu/Zn (+19 %; p < 0.001) values, whereas serum Zn (-9 %; p = 0.004) level was decreased. In primary school-aged children only 6 % (p = 0.007) lower Mg levels were observed. Both boys and girls with ADHD were characterized by 8 % (p = 0.016) lower serum Zn levels and 10 % (p = 0.049) higher Cu/Zn values when compared to neurotypical girls. Boys with ADHD also had significantly higher Cu/Zn, exceeding the respective control values by 12 % (p = 0.021), predominantly due to a 7 % (p = 0.035) decrease in serum Zn. Serum Mg levels were also found to be significantly lower than those in neurotypical children by 5 % (p = 0.007). In adjusted regression models serum Cr (β=-0.234; p = 0.009) and Cu/Zn (β = 0.245; p = 0.029) values were significantly associated with ADHD, respectively. Two-way ANOVA revealed a significant impact of ADHD on Cr, Mg, Zn, and Cu/Zn, whereas age was associated with Cu, I, Mg, Mo, and Cu/Zn, whereas gender accounted only for variability in serum Mn levels. Principal component analysis (PCA) also revealed significant contributions of Mg, Zn, and Cu/Zn values to ADHD variability.

CONCLUSIONS

Hypothetically, the observed decrease of essential trace elements, namely Mg and Zn, and elevation of Cu/Zn may significantly contribute to the risk of ADHD or its severity and/or comorbidity.

Blood and hair zinc levels in children with attention deficit hyperactivity disorder: A meta-analysis

We summarized the observational studies on the correlation between zinc and attention deficit hyperactivity disorder (ADHD) since 1986, extracted relevant data for meta-analysis to determine the relationship between zinc and ADHD. We searched PubMed, Scopus, Cochrane Library, EMBASE (included EMBASE and Medline), Web of Science and Clinical Trials.gov databases from inception to April 8, 2019. We assessed the blood zinc, hair zinc and ADHD by combined the standardized mean difference (SMD) and 95% confidence interval (CI). Statistical analysis was performed using Stata 14.0. We included 11 studies for meta-analysis. Of these, 8 studies comprising 1311 participants reported blood zinc and 3 studies comprising 206 participants reported hair zinc. The zinc levels in blood (SMD: -0.91, 95% CI: -1.88-0.07, P(SMD) < 0.068), and hair (SMD: 1.42, 95% CI: -4.49-7.33, P(SMD) = 0.638) not significantly compare ADHD with controls. Nevertheless, high heterogeneity (I² > 97.3%) emerged among the included studies. The subgroup analysis showed that the heterogeneity of samples >100 group was significantly reduced. The sensitivity analysis found that the results changed significantly after excluding the only cross-sectional study. In conclusion, our meta-analysis showed that there was no statistically significant difference in blood zinc and hair zinc levels between ADHD children and adolescents compared with healthy children and adolescents.

The Blood Levels of Trace Elements Are Lower in Children With Tic Disorder: Results From a Retrospective Study

Background: Tic disorders (TD) are common neuropsychiatric disorders among children and adolescents. It is controversial that trace elements may participate in the pathogenesis of TD. Our study aimed to investigate the trace elements status of zinc (Zn), copper (Cu), iron (Fe), and magnesium (Mg) in children with TD, in comparison to healthy controls.

Methods: The medical records of eligible TD children and normal healthy children from January 1 to December 31, 2018 in the outpatient clinic were retrospectively reviewed. The clinical information of all subjects were collected including age, gender, diagnosis, previous health records, and serum trace elements level (Cu, Zn, Fe, Mg) at the time of diagnosis before initiating treatment.

Results: In total, 1204 TD children (7.63 ± 2.45 years) and 1,220 healthy children (7.27 ± 3.15 years) who were divided into two gender and three age groups (2–4years, 5–9years, ≥10 years) were reviewed in our study. Our study showed that TD children generally had lower whole blood levels of Zn, Cu, Fe than the normal controls (P < 0.01). No significant difference was observed in whole blood levels of Mg. After adjusting for gender, the trends still remained. Further analysis was performed according to age, the trends still remained in Zn and Fe in all age groups (P < 0.05). However, we observed an almost significantly (P = 0.055) lower level of Cu in TD of 2–4 years group while significant differences in other two groups (P < 0.01). Further multiple linear regression and point biserial correlation showed that the lower blood levels of Zn, Cu, and Fe were correlated with the incidence of TD.

Conclusion: The present results indicated that lower blood levels of zinc, iron, copper were associated with TD. Trace elements may be used as an auxiliary treatment for TD and need to be further explored.

Omega-3 Long-Chain Polyunsaturated Fatty Acids Intake in Children with Attention Deficit and Hyperactivity Disorder

Omega-3 long-chain polyunsaturated fatty acids (LC-PUFA) play a central role in neuronal growth and in the development of the human brain, and a deficiency of these substances has been reported in children with attention deficit hyperactive disorder (ADHD). In this regard, supplementation with omega-3 polyunsaturated fatty acids is used as adjuvant therapy in ADHD. Seafood, particularly fish, and some types of nuts are the main dietary sources of such fatty acids in the Spanish diet. In order to assess the effect of the intake of common foods containing high amounts of omega-3 polyunsaturated fatty acids, a food frequency questionnaire was administered to parents of children with ADHD (N = 48) and to parents of normally developing children (control group) (N = 87), and the intake of dietary omega-3 LC-PUFA, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), was estimated. Children with ADHD consumed fatty fish, lean fish, mollusks, crustaceans, and chicken eggs significantly less often (p < 0.05) than children in the control group. The estimated daily omega-3 LC-PUFA intake (EPA + DHA) was significantly below that recommended by the public health agencies in both groups, and was significantly lower in children with ADHD (p < 0.05, Cohen’s d = 0.45) compared to normally developing children. Dietary intervention to increase the consumption of fish and seafood is strongly advised and it is especially warranted in children with ADHD, since it could contribute to improve the symptoms of ADHD.

Magnesium status and attention deficit hyperactivity disorder (ADHD): A meta-analysis

Current research suggests conflicting evidence surrounding the association between serum magnesium levels and the diagnosis of attention deficit hyperactivity disorder (ADHD). This systematic review and meta-analysis aims to explore, summarize and quantify the published literature addressing this topic. We conducted an exhaustive literature search on Scopus and PubMed for all the relevant observational studies published up to August 2018. A meta-analysis using a random-effects model was used to summarize the overall association between serum magnesium level and ADHD from the available data. We identified seven studies which reported the mean and standard deviation (SD) of magnesium concentration in both ADHD and control groups. The random-effects meta-analysis showed that subjects with ADHD had 0.105 mmol/l (95% CI: -0.188, -0.022; P < 0.013) lower serum magnesium levels compared with to their healthy controls. Moreover, we observed striking and statistically significant heterogeneity among the included studies (I² = 96.2%, P = 0.0103). The evidence from this meta-analysis supports the theory that an inverse relationship between serum magnesium deficiency and ADHD exists. High heterogeneity amongst the included studies suggests that there is a residual need for observational and community-based studies to further investigate this issue.

Use of Nutritional Supplements in Youth with Medicated and Unmedicated Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To find out whether use of nutritional supplements (NUS) differs between children and adolescents with attention-deficit/hyperactivity disorder (ADHD; medicated or unmedicated), compared with those without the disorder.

METHODS

We used cross-sectional data from the population-based I.Family study conducted between 2013 and 2014 in eight European countries. Parents completed questionnaires and participated in interviews, for example, on health and medical history of their child. Data from 5067 children and adolescents aged 5-17 years were included. Exposures were medicated (with ADHD-approved medication) and unmedicated ADHD. The outcome was the use of NUS, measured by use of any or multiple different NUS. Multivariable logistic regression adjusted for sociodemographics and health determinants was used to find ADHD-depending differences.

RESULTS

The study sample comprised 4490 children and adolescents without ADHD and 51 medicated and 76 unmedicated subjects with ADHD. Regarding the use of any NUS, no statistically significant differences were found between children and adolescents without ADHD (18%) and those with medicated (18%) or unmedicated ADHD (22%). However, discrepancies appear when considering multiple use of NUS, not reported for any medicated ADHD subject but remarkably often for unmedicated ADHD subjects (13%), resulting in an adjusted odds ratio of 2.6 (95% confidence interval, 1.2-5.6) when compared with those without ADHD (5%).

CONCLUSION

Children and adolescents who were not using medication for treating ADHD potentially took NUS as oral remedies. Given the potential for a delay of indicated treatments and for use of those NUS which have no proven effectiveness, pediatricians should actively explore whether NUS have been used to treat ADHD core symptoms, and families should be informed that the average effect size has to be considered small.

Dietary Acid Load and Mental Health Outcomes in Children and Adolescents: Results from the GINIplus and LISA Birth Cohort Studies

High dietary acid load may have detrimental effects on mental health during childhood and adolescence. We examined cross-sectional and prospective associations of dietary acid load and mental health problems in a population-based sample, using data from the German birth cohort studies GINIplus (German Infant Nutritional Intervention plus environmental and genetic influences on allergy development) and LISA (Influences of lifestyle-related factors on the immune system and the development of allergies in childhood). These studies included detailed assessments of dietary intake through a food frequency questionnaire (FFQ), mental health outcomes measured through the Strengths and Difficulties Questionnaire (SDQ), and covariates. Using logistic regression, cross-sectional associations between dietary acid load measured as potential renal acid load (PRAL) and SDQ subscales were assessed at age 10 years (N = 2350) and 15 years (N = 2061). Prospective associations were assessed, considering PRAL at 10 years as exposure and SDQ subscales at 15 years as outcome (N = 1685). Results indicate that children with a diet higher in PRAL have more emotional problems (OR = 1.33 (95% CI = 1.15; 1.54); p < 0.001), and show hyperactivity more often (1.22 (1.04; 1.43); p = 0.014) at 10 years. No significant associations were present either cross-sectionally at age 15 years, nor prospectively. Results were confirmed in sensitivity analyses. These findings reveal first evidence for potential relationships between PRAL and mental health in childhood, although we cannot exclude reverse causality, i.e., that dietary behavior and PRAL are influenced by mental status. Future studies should address confirmation and identify biological mechanisms.

A double-blind placebo-controlled randomised trial of omega-3 supplementation in children with moderate ADHD symptoms

OBJECTIVE

Clinical trials and inconclusive meta-analyses have investigated the effects of omega-3 supplements in children with Attention-Deficit Hyperactivity Disorder (ADHD). We performed a randomised placebo-controlled trial to evaluate the efficacy of omega-3 fatty acids.

METHODS

Children aged 6-15 years with established diagnosis of ADHD were randomised 1:1 to receive either supplements containing docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) or a placebo for 3 months. Psychotropic or omega-3-containing treatments were not authorised during the study. The primary outcome was the change in the Attention-Deficit Hyperactivity Disorder Rating Scale version 4 (ADHD-RS-IV). Other outcomes included safety, lexical level (Alouette test), attention (Test of Attentional Performance for Children-KiTAP), anxiety (48-item Conners Parent Rating Scale-Revised-CPRS-R), and depression (Children's Depression Inventory-CDI).

RESULTS

Between 2009 and 2011, 162 children were included in five French child psychiatry centres. The mean age was 9.90 (SD 2.62) years and 78.4% were boys. The inclusion ADHD-RS-IV at was 37.31 (SD 8.40). The total ADHD-RS-IV score reduction was greater in the placebo group than in the DHA-EPA group: -19 (-26, -12)  % and -9.7 (-16.6, -2.9) %, respectively, p = 0.039. The other components of the Conners score had a similar variation but the differences between groups were not significant. Two patients in the DHA-EPA group and none in the placebo group experienced a severe adverse event (hospitalisation for worsening ADHD symptoms).

CONCLUSION

This study did not show any beneficial effect of omega-3 supplement in children with mild ADHD symptoms.

Dietary factors in the etiology and therapy of attention deficit/hyperactivity disorder

PURPOSE OF REVIEW

The purpose of this study is to discuss the role of dietary factors in the etiology and therapy of attention deficit/hyperactivity disorder (ADHD). Relevant literature published from January 2016 to January 2017 was included in this review.

RECENT FINDINGS

Unhealthy prenatal diet may be associated with ADHD in the offspring through an increase in epigenetic changes. The few-foods diet may have some efficacy, but requires further investigation before firm conclusions can be drawn. The efficacy of the supplementation of polyunsaturated fatty acids in the therapy of ADHD is probably small and may be confined to patient subgroups. It is unclear whether vitamin deficiency plays a role in the etiology of ADHD.

SUMMARY

There is no clear evidence supporting a role of food or nutrient-based intervention strategies in the etiology and therapy of ADHD. The investigation of the inter-relationship between diet and other lifestyle interventions may be a promising approach.