Supplementation with flax oil and vitamin C improves the outcome of Attention Deficit Hyperactivity Disorder (ADHD)

Metabolomic Insights into Attention Deficit Hyperactivity Disorder: A Scoping Review

Background /Objectives Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental condition, and symptoms persist into adulthood. Its etiology, though recognized as multifactorial, is still under discussion. Metabolomics helps us to identify pathways associated with functional and structural changes that may be related to symptomatology. This study aimed to characterize potentially altered metabolic pathways and associated biochemical reactions in ADHD. Methods: A scoping review of experimental research was conducted using PubMed, Web of Science, and Scopus using PRISMA ScR. Fifty-five studies were eligible for data extraction, of which fifteen met the criteria for inclusion in the review. Subsequently, the identified metabolites were analyzed in the context of the literature to recognize possible discordant pathways in the disorder. Results: Two groups of relevant neuromodulators of ADHD were found: precursors of monoamines and polyunsaturated fatty acids. The literature was reviewed to discover potential implicated pathways and new metabolites of interest. Conclusions: The study of ADHD biomarkers should focus on measuring precursor, intermediate, and final metabolites of polyunsaturated fatty acids and monoamines in panels or through untargeted analysis to improve the understanding of the pathology and individualization of treatments.

Diet and special educational needs (SENs) among children and adolescents: a systematic review

Special educational needs (SENs) refer to children and adolescents needing additional educational support. Diet during pregnancy and pediatric age can influence the prevalence/severity of symptoms in SEN-related conditions/disabilities. This review aims to summarize associations between (i) pregnant women's diet and the prevalence of SEN-related conditions/disabilities among children/adolescents and (ii) the diet of children/adolescents with SEN-related conditions/disabilities and their symptomatology/well-being. A literature search was performed on Medline and Scopus, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following inclusion criteria were considered, for each aim: (i) children/adolescents aged 19 years and younger, pregnant women's diet/nutrition, and diagnosis of SEN-related conditions/disabilities in children/adolescents; (ii) children/adolescents aged 19 years and younger, children/adolescents' diet/nutrition, and symptomatology/well-being of children/adolescents with SEN-related conditions/disabilities. 87 articles were included, referring to 10 different SEN-related conditions/disabilities, from which attention-deficit/hyperactivity disorder (ADHD) (41 articles) and autism spectrum disorder (ASD) (34 articles) stand out. Noteworthy results were seen regarding maternal caffeine consumption; pregnant woman multivitamin supplementation, high-sugar foods, and beverage intake during childhood/adolescence; maternal breastfeeding; and vitamin D supplementation. Despite the notable associations, further research using more standardized and homogeneous methodologies is needed to strengthen these findings. PROSPERO registration number: CRD42022313235.

Nutrient intake and food selectivity in children with Tourette syndrome

Objectives: Children with Tourette syndrome (TS) have been shown to exhibit high levels of food selectivity; however, its association with nutritional status has yet to be explored. The current study explored macro and micronutrient intake and food selectivity among children with and without TS, using 24-hour dietary recall and the Child Eating Behaviour Questionnaire.Method: Parents of 43 children diagnosed with TS and 38 age-matched children without a clinical diagnosis completed an online 24-hour food diary.Results: Fifty-eight per cent of children with TS were identified as falling outside of the healthy BMI range (underweight = 24.2%; overweight = 27.3%; obese = 6.1%). Children with TS also consumed fewer portions of fruit and vegetables along with meeting the daily reference nutrient intake guidelines significantly less often for vitamins B3, B6 and C, selenium and phosphorus compared to children without TS.Conclusions: Understanding the nutritional risk of children with TS relative to other children is important to clinicians and health care professionals who oversee nutritional inspection in primary care, and caregivers who are worried about the impact of limited or restricted diets.

Investigating the Impact of Nutrition and Oxidative Stress on Attention Deficit Hyperactivity Disorder

Background/Objectives: Attention deficit hyperactivity disorder (ADHD) is the most common childhood-onset neurodevelopmental disorder, characterized by difficulty maintaining attention, impulsivity, and hyperactivity. While the cause of this disorder is still unclear, recent studies have stated that heredity is important in the development of ADHD. This is linked to a few comorbidities, including depression, criminal behavior, and anxiety. Although genetic factors influence ADHD symptoms, there are also non-genetic factors, one of which is oxidative stress (OS), which plays a role in the pathogenesis and symptoms of ADHD. This review aims to explore the role of OS in ADHD and its connection to antioxidant enzyme levels, as well as the gut-brain axis (GBA), focusing on diet and its influence on ADHD symptoms, particularly in adults with comorbid conditions. Methods: The literature search included the main available databases (e.g., Science Direct, PubMed, and Google Scholar). Articles in the English language were taken into consideration and our screening was conducted based on several words such as "ADHD", "oxidative stress", "diet", "gut-brain axis", and "gut microbiota." The review focused on studies examining the link between oxidative stress and ADHD, the role of the gut-brain axis, and the potential impact of dietary interventions. Results: Oxidative stress plays a critical role in the development and manifestation of ADHD symptoms. Studies have shown that individuals with ADHD exhibit reduced levels of key antioxidant enzymes, including glutathione peroxidase (GPx), catalase (CAT), and superoxide dismutase (SOD), as well as a diminished total antioxidant status (TOS) compared to healthy controls. Additionally, there is evidence of a close bidirectional interaction between the nervous system and gut microbiota, mediated by the gut-brain axis. This relationship suggests that dietary interventions targeting gut health may influence ADHD symptoms and related comorbidities. Conclusions: Oxidative stress and the gut-brain axis are key factors in the pathogenesis of ADHD, particularly in adults with comorbid conditions. A better understanding of these mechanisms could lead to more targeted treatments, including dietary interventions, to mitigate ADHD symptoms. Further research is required to explore the therapeutic potential of modulating oxidative stress and gut microbiota in the management of ADHD.

Ascorbate and its transporter SVCT2: The dynamic duo's integrated roles in CNS neurobiology and pathophysiology

Ascorbate is a small antioxidant molecule essential for the proper development and function of the brain. Ascorbate is transported into the brain and between brain cells via the Sodium vitamin C co-transporter 2 (SVCT2). This review provides an in-depth analysis of ascorbate's physiology, including how ascorbate is absorbed from food into the CNS, emphasizing cellular mechanisms of ascorbate recycling and release in different CNS compartments. Additionally, the review delves into the various functions of ascorbate in the CNS, including its impact on epigenetic modulation, synaptic plasticity, and neurotransmission. It also emphasizes ascorbate's role on neuromodulation and its involvement in neurodevelopmental processes and disorders. Furthermore, it analyzes the relationship between the duo ascorbate/SVCT2 in neuroinflammation, particularly its effects on microglial activation, cytokine release, and oxidative stress responses, highlighting its association with neurodegenerative diseases, such as Alzheimer's disease (AD). Overall, this review emphasizes the crucial role of the dynamic duo ascorbate/SVCT2 in CNS physiology and pathology and the need for further research to fully comprehend its significance in a neurobiological context and its potential therapeutic applications.

1H NMR-based metabolomics study of the lipid profile of omega-3 fatty acid supplements and some vegetable oils

Omega-3 fatty acids, which consist of alpha-linolenic acid (ALA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA), are a type of polyunsaturated fatty acids that are crucial for enhancing human health. These three omega-3s are regarded as vital dietary nutrients because it cannot synthesize them on its own. Therefore, they must be obtained through dietary sources. On the other hands, there are concerns regarding the quality and quantity of omega-3 in dietary sources and supplements. In this study, 1H NMR spectroscopy and multivariate analysis were harnessed for non-destructive profiling of fatty acids in commercially available omega-3 supplements and plant-based oils. Results disclosed substantial disparities in omega-3 content from 8 to over 50 %, with some revealing unexpected adulteration. Notably, in one fish oil sample DHA could not be detected indicating the possibility of adulteration. Additionally, the research delineated the fatty acid composition of plant-based oils, emphasizing variations in alpha-linolenic acid (ALA) and linoleic acid (LA) content among flaxseed, chia seed, and walnut oils. Chia seeds emerged as a rich source of ALA (57-65 %mol), while walnuts contained considerable LA (44-53 % mol). The findings emphasize the power of metabolomics as a rapid and affordable tool for finding omega-3 fatty acids content and adulteration in commercial dietary products.

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.

Mitochondrial dysfunction in cognitive neurodevelopmental disorders: Cause or effect?

Mitochondria have a crucial role in brain development and neurogenesis, both in embryonic and adult brains. Since the brain is the highest energy consuming organ, it is highly vulnerable to mitochondrial dysfunction. This has been implicated in a range of brain disorders including, neurodevelopmental conditions, psychiatric illnesses, and neurodegenerative diseases. Genetic variations in mitochondrial DNA (mtDNA), and nuclear DNA encoding mitochondrial proteins, have been associated with several cognitive disorders. However, it is not yet clear whether mitochondrial dysfunction is a primary cause of these conditions or a secondary effect. Our review article deals with this topic, and brings out recent advances in mitochondria-oriented therapies. Mitochondrial dysfunction could be involved in the pathogenesis of a subset of disorders involving cognitive impairment. In these patients, mitochondrial dysfunction could be the cause of the condition, rather than the consequence. There are vast areas in this topic that remains to be explored and elucidated.

The Effect of Drug Use, Body Mass Index and Blood Pressure on Oxidative Stress Levels in Children and Adolescents with Attention Deficit and Hyperactivity Disorder

Objective

The aim of this study was to determine the correlation between clinical variables such as body mass index, blood pressure, drug use and oxidative stress level in children and adolescents with attention deficit and hyperactivity disorder (ADHD).

Methods

Total oxidant status (TOS), total antioxidant status (TAS), oxidative stress index (OSI), malondialdehyde (MDA) and superoxide dismutase (SOD) activity were measured in the serum of 51 patients (38 male, 13 female) diagnosed with ADHD according to DSM-5 diagnostic criteria and 32 control subjects (12 male, 20 female). The Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version was applied to all participants.

Results

The mean TOS, OSI, MDA values were determined to be significantly higher (p < 0.001) and the mean SOD value was lower in the ADHD group (p < 0.001). Multivariate regression analysis indicated significantly lower SOD and diastolic blood pressure values and significantly higher MDA in the ADHD group compared to the control group (p < 0.01). Low SOD (sensitivity 90.2%, specificity 78.0%) and high MDA (sensitivity 86.3%, specificity 81.2%) were determined to be predictive parameters for diagnosing ADHD. In univariate analysis, the mean TOS, OSI and SOD values were higher in ADHD patients under medication, while the mean TAS was higher in patients not using medication (p < 0.01). Only TOS was significant in multivariate logistic regression analysis (p < 0.01).

Conclusion

The results of this study demonstrate that impaired oxidative balance may play a role in the etiology of ADHD.

The effect of dietary approaches to stop hypertension (DASH) diet on attention-deficit hyperactivity disorder (ADHD) symptoms: a randomized controlled clinical trial

BACKGROUND

The dietary approaches to stop hypertension (DASH) diet have several components like high amounts of fruits, vegetables, low-fat dairy products, and vitamin C and low amounts of simple sugars that might improve attention-deficit hyperactivity disorder (ADHD) symptoms. We aimed to investigate the effect of a DASH diet on children (aged 6-12 years) with ADHD, for the first time.

METHODS

Participants were randomized to receive a DASH or a control diet for 12 weeks. The severity of ADHD symptoms [determined by abbreviated 10-item Conner's scale (ACS), 18-item Swanson, Nolan and Pelham (SNAP-IV) scale and strengths and difficulties questionnaire (SDQ)] were assessed every four weeks.

RESULTS

Eighty children completed the study. After adjustment for confounders, parent (- 4.71 for the DASH group vs. - 3 for the control group) and teacher-reported (- 5.35 vs. - 1.87) ACS scores, parent-, teacher-, child-reported hyperactivity (- 1.40 vs. - 0.66, - 1.95 vs. -0.63, - 1.60 vs. - 0.43, respectively), emotional symptoms (- 1.50 vs. - 0.45, - 1.42 vs. - 0.63, and - 1.09 vs. - 0.61, respectively), and total SDQ scores (- 3.81 vs. - 1.65, - 4.11 vs. - 1.23, - 4.44 vs. - 1.26, respectively), teacher-reported of conduct problems (- 1.42 vs. - 0.63), peer relationship problems (- 0.87 vs. - 0.07), and prosocial behaviors (1.36 vs. 0.08) assessed by the SDQ were significantly improved in the DASH group compared with the control group (P < 0.05).

CONCLUSION

Adherence to a DASH-style diet might improve ADHD symptoms. Further RCTs which include participants from both sexes and with longer follow-up periods are needed to warrant current findings (The trial registration code: IRCT20130223012571N6; http://irct.ir/trial/12623 ). Trial registration Trial registration number: The trial was registered in the Iranian registry of clinical trials (registration code: IRCT20130223012571N6), URL: http://irct.ir/trial/12623 .

Effects of agmatine, glutamate, arginine, and nitric oxide on executive functions in children with attention deficit hyperactivity disorder

In this study, we aimed to investigate the effects of agmatine, nitric oxide (NO), arginine, and glutamate, which are the metabolites in the polyamine pathway,  on the performance of executive functions (EF) in attention deficit hyperactivity disorder (ADHD). The ADHD group included 35 treatment-naive children (6-14 years old) who were ewly diagnosed with ADHD. The control group consisted of 35 healthy children with the same age and sex, having no previous psychiatric disorders. In the study groups, Stroop test (ST) and trail making test (TMT) were used to monitor EF, and blood samples were collected to measure agmatine with ultra-high-performance liquid chromatography and NO, glutamate, and arginine with enzyme-linked immunosorbent assay (ELISA). The EFs were significantly impaired in the ADHD group. The agmatine and arginine levels of the ADHD group were significantly higher than their peers. The NO and glutamate levels were also higher in the ADHD group compared to the control group, but these differences did not reach statistical significance. Children with ADHD had more difficulties during EF tasks compared to healthy children. The elevated NO and glutamate levels may be related with the impairment during EF tasks. Therefore, agmatine and arginine may increase to improve EF tasks through its inhibitory effect on the synthesis of NO and glutamate. Further studies are needed about polyamine pathway molecules to shed light on the pathophysiology of ADHD.

Flaxseed for Health and Disease: Review of Clinical Trials

BACKGROUND

Flaxseed (Linum usitatissimum) is an oil-based seed that contains high amounts of alpha-linolenic acid, linoleic acid, lignans, fiber and many other bioactive components which is suggested for a healthier life. Nowadays, flaxseed is known as a remarkable functional food with different health benefits for humans and protects against cardiovascular disease, diabetes, dyslipidemia, obesity and altogether metabolic syndrome.

METHODS

To review the bioactive components of flaxseed and their potential health effects, PubMed and Scopus were searched from commencement to July 2019. Keywords including: "flaxseed", "Linum usitatissimum", "metabolic syndrome", "obesity", "inflammation", "insulin resistance", "diabetes", "hyperlipidemia" and "menopause" were searched in the databases with varying combinations.

CONCLUSION

Consumption of flaxseed in different forms has valuable effects and protects against cardiovascular disease, hypertension, diabetes, dyslipidemia, inflammation and some other complications. Flaxseed can serve as a promising candidate for the management of metabolic syndrome to control blood lipid levels, fasting blood sugar, insulin resistance, body weight, waist circumference, body mass and blood pressure.

Antioxidants as a Potential Target against Inflammation and Oxidative Stress in Attention-Deficit/Hyperactivity Disorder

Psychostimulants and non-psychostimulants are the medications prescribed for the treatment of attention-deficit/hyperactivity disorder (ADHD). However, several adverse results have been linked with an increased risk of substance use and side effects. The pathophysiology of ADHD is not completely known, although it has been associated with an increase in inflammation and oxidative stress. This review presents an overview of findings following antioxidant treatment for ADHD and describes the potential amelioration of inflammation and oxidative stress using antioxidants that might have a future as multi-target adjuvant therapy in ADHD. The use of antioxidants against inflammation and oxidative conditions is an emerging field in the management of several neurodegenerative and neuropsychiatric disorders. Thus, antioxidants could be promising as an adjuvant ADHD therapy.

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.

Relationship between Antioxidant Status and Attention Deficit Hyperactivity Disorder Among Children

Background:

Attention deficit hyperactivity disorder (ADHD) is one of the prevalent neuropsychiatric disorders in childhood. In general, diagnoses of ADHD include inattention, hyperactivity, and impulsivity. Recent studies have reported increased oxidative stress in psychiatric disorders such as ADHD, but the results are conflicting. This research aimed to study the relationship between antioxidant status and ADHD in children of 6–13 years old.

Methods:

From schools, 32 ADHD students whose diseases were diagnosed by child and adolescence psychiatrist based on Diagnostic and Statistical Manual of Mental Disorders-IV index were recruited; moreover, 32 healthy subjects, which according to the medical history questionnaire of psychiatric disorder had not had chronic disease, were selected. Total antioxidant capacity (TAC), catalase (CAT), glutathione (GSH), and malondiadehyde (MDA) were measured. General information, health history, and medication history were collected. All participants completed a 168-item food frequency questionnaire. Dietary intakes of antioxidants were obtained through this questionnaire.

Results:

There was no significant difference between mean of energy intake and Zn, Se, vitamin E, C, and β-carotene as antioxidants between the two groups. The mean of serum TAC, GSH level, and CAT level in the patients were significantly lower than the healthy group (P < 0.001), but the mean of MDA was not significantly different between the two groups (P = 0.18).

Conclusions:

The result of this study indicates that, in ADHD, the serum levels of GSH, CAT, and TAC decrease; the level of antioxidant in the serum has been compromised to fight oxidative stress. More perspective studies with large sample sizes are essential to confirm these findings.

Understanding the impact of diet and nutrition on symptoms of Tourette syndrome: A scoping review

Anecdotal reports frequently suggest some dietary involvement in the maintenance of tics in children with Tourette syndrome (TS). This scoping review aimed to (1) understand the possible influence of diet as a trigger of tics and (2) map out the existing studies documenting dietary interventions in children with TS. Current evidence suggests no single diet to benefit individuals with TS. However, reports from parents of children with TS suggest that certain allergens in food may exacerbate tic-related symptoms. For example, an increase in tics has been related to the consumption of caffeine and refined sugar. Moreover, oligoantigenic diets and sugar-free diets have been identified as significantly reducing tics. More research is urgently needed to develop more accurate guidance for parents and children with TS, as many have reported using dietary and nutritional supplements, despite the lack of evidence detailing any benefits, side effects and recommended doses.

ADHD research in India: A narrative review

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with no clear etiopathogenesis. Owing to unique socio cultural milieu of India, it is worthwhile reviewing research on ADHD from India and comparing findings with global research. Thereby, we attempted to provide a comprehensive overview of research on ADHD from India.

METHODS

A boolean search of articles published in English from September 1966 to January 2017 on electronic search engines Google Scholar, PubMed, IndMED, MedIND, using the search terms "ADHD", "Attention Deficit and Hyperactivity Disorder", "Hyperactivity" ,"Child psychiatry", "Hyperkinetic disorder", "Attention Deficit Disorder", "India"was carried out and peer - reviewed studies conducted among human subjects in India were included for review. Case reports, animal studies, previous reviews were excluded from the current review.

RESULTS

Results of 73 studies found eligible for the review were organized into broad themes such as epidemiology, etiology, course and follow up, clinical profile and comorbidity, assessment /biomarkers, intervention/treatment parameters, pathways to care and knowledge and attitude towards ADHD.

DISCUSSION

There was a gap noted in research from India in the domains of biomarkers, course and follow up and non-pharmacological intervention. The prevalence of ADHD as well as comorbidity of Bipolar Disorder was comparatively lower compared to western studies. The studies found unique to India include comparing the effect of allopathic intervention with Ayurvedic intervention, yoga as a non pharmacological intervention. There is a need for studies from India on biomarkers, studies with prospective research design, larger sample size and with matched controls.

The potential relevance of docosahexaenoic acid and eicosapentaenoic acid to the etiopathogenesis of childhood neuropsychiatric disorders

Over the last 15 years, considerable interest has been given to the potential role of omega-3 polyunsaturated fatty acids (PUFAs) for understanding pathogenesis and treatment of neurodevelopmental and psychiatric disorders. This review aims to systematically investigate the scientific evidence supporting the hypothesis on the omega-3 PUFAs deficit as a risk factor shared by different pediatric neuropsychiatric disorders. Medline PubMed database was searched for studies examining blood docosahexaenoic acid (DHA) or eicosapentaenoic acid (EPA) status in children with neuropsychiatric disorders. Forty-one published manuscripts were compatible with the search criteria. The majority of studies on attention-deficit/hyperactivity disorder (ADHD) and autism found a significant decrease in DHA levels in patients versus healthy controls. For the other conditions examined-depression, juvenile bipolar disorder, intellectual disabilities, learning difficulties, and eating disorders (EDs)-the literature was too limited to draw any stable conclusions. However, except EDs, findings in these conditions were in line with results from ADHD and autism studies. Results about EPA levels were too inconsistent to conclude that EPA could be associated with any of the conditions examined. Finally, correlational data provided, on one hand, evidence for a negative association between DHA and symptomatology, whereas on the other hand, evidence for a positive association between EPA and emotional well-being. Although the present review underlines the potential involvement of omega-3 PUFAs in the predisposition to childhood neuropsychiatric disorders, more observational and intervention studies across different diagnoses are needed, which should integrate the collection of baseline PUFA levels with their potential genetic and environmental influencing factors.

Efficacy of Polyunsaturated Fatty Acids (PUFA) in the Treatment of Attention Deficit Hyperactivity Disorder

OBJECTIVE

We aimed to investigate the efficacy of polyunsaturated fatty acids (PUFAs) as an adjuvant treatment in patients with ADHD receiving methylphenidate as well as its side effects.

METHOD

This randomized clinical trial was conducted on 40 ADHD patients aged between 6 and 12 years. Both treatment and placebo groups received methylphenidate. Treatment arm also received omega-6 once daily. The Parent ADHD Rating Scale was used to evaluate disease improvement.

RESULTS

The Parent ADHD Rating Scale scores of the two groups were similar at baseline. Although total score and scores of three categories decreased significantly in both groups, total score and scores of inattention, hyperactivity, and impulsivity were not significantly different between the groups.

CONCLUSION

The results did not support the efficacy of PUFA in the treatment of ADHD, and adding PUFAs to the therapeutic regimen of ADHD is not recommended at the moment.

Sugar-Sweetened Beverage Consumption Is Adversely Associated with Childhood Attention Deficit/Hyperactivity Disorder

Attention deficit/hyperactivity disorder (ADHD) is one of the most common childhood neurobehavioral conditions. Evidence of the negative effects of sugar-sweetened beverages (SSBs) on mental health has not been convincing, although a few studies have found an association between high SSB levels and attention problems in children. This study aimed to test the hypothesis that SSB consumption is associated with ADHD among children. Doctor-diagnosed ADHD cases (n = 173) and non-ADHD controls (n = 159) between age 4 to 15 were recruited. SSB consumption, socio-demographic and lifestyle characteristics of the children, as well as of their mothers' characteristics during pregnancy, were collected using a questionnaire. Blood lead levels and polymorphisms of two commonly verified dopaminergic-related genes (the D4 dopamine receptor gene DRD4 and the dopamine transporter gene DAT1) were also analyzed. There was a dose-response relationship between SSB consumption and ADHD. After covariates were adjusted, children who consumed SSBs at moderate levels and high levels had 1.36 and 3.69 odds, respectively, of having ADHD, compared with those who did not consume SSBs (p for trend < 0.05). Similar results were obtained when females were excluded. Our findings highlighted the adverse correlation between SSB consumption and ADHD and indicated a dose-response effect even after covariates were adjusted.

Omega-3 and Omega-6 Polyunsaturated Fatty Acid Levels and Correlations with Symptoms in Children with Attention Deficit Hyperactivity Disorder, Autistic Spectrum Disorder and Typically Developing Controls

Background

There is evidence that children with Attention Deficit Hyperactivity Disorder (ADHD) and Autistic Spectrum Disorder (ASD) have lower omega-3 polyunsaturated fatty acid (n-3 PUFA) levels compared with controls and conflicting evidence regarding omega-6 (n-6) PUFA levels.

Objectives

This study investigated whether erythrocyte n-3 PUFAs eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were lower and n-6 PUFA arachidonic acid (AA) higher in children with ADHD, ASD and controls, and whether lower n-3 and higher n-6 PUFAs correlated with poorer scores on the Australian Twin Behaviour Rating Scale (ATBRS; ADHD symptoms) and Test of Variable Attention (TOVA) in children with ADHD, and Childhood Autism Rating Scale (CARS) in children with ASD.

Methods

Assessments and blood samples of 565 children aged 3–17 years with ADHD (n = 401), ASD (n = 85) or controls (n = 79) were analysed. One-way ANOVAs with Tukey’s post-hoc analysis investigated differences in PUFA levels between groups and Pearson’s correlations investigated correlations between PUFA levels and ATBRS, TOVA and CARS scores.

Results

Children with ADHD and ASD had lower DHA, EPA and AA, higher AA/EPA ratio and lower n-3/n-6 than controls (P<0.001 except AA between ADHD and controls: P = 0.047). Children with ASD had lower DHA, EPA and AA than children with ADHD (P<0.001 for all comparisons). ATBRS scores correlated negatively with EPA (r = -.294, P<0.001), DHA (r = -.424, P<0.001), n-3/n-6 (r = -.477, P<0.001) and positively with AA/EPA (r = .222, P <.01). TOVA scores correlated positively with DHA (r = .610, P<0.001), EPA (r = .418, P<0.001) AA (r = .199, P<0.001), and n-3/n-6 (r = .509, P<0.001) and negatively with AA/EPA (r = -.243, P<0.001). CARS scores correlated significantly with DHA (r = .328, P = 0.002), EPA (r = -.225, P = 0.038) and AA (r = .251, P = 0.021).

Conclusions

Children with ADHD and ASD had low levels of EPA, DHA and AA and high ratio of n-6/n-3 PUFAs and these correlated significantly with symptoms. Future research should further investigate abnormal fatty acid metabolism in these disorders.

Natural Product-Derived Treatments for Attention-Deficit/Hyperactivity Disorder: Safety, Efficacy, and Therapeutic Potential of Combination Therapy

Typical treatment plans for attention-deficit/hyperactivity disorder (ADHD) utilize nonpharmacological (behavioral/psychosocial) and/or pharmacological interventions. Limited accessibility to behavioral therapies and concerns over adverse effects of pharmacological treatments prompted research for alternative ADHD therapies such as natural product-derived treatments and nutritional supplements. In this study, we reviewed the herbal preparations and nutritional supplements evaluated in clinical studies as potential ADHD treatments and discussed their performance with regard to safety and efficacy in clinical trials. We also discussed some evidence suggesting that adjunct treatment of these agents (with another botanical agent or pharmacological ADHD treatments) may be a promising approach to treat ADHD. The analysis indicated mixed findings with regard to efficacy of natural product-derived ADHD interventions. Nevertheless, these treatments were considered as a “safer” approach than conventional ADHD medications. More comprehensive and appropriately controlled clinical studies are required to fully ascertain efficacy and safety of natural product-derived ADHD treatments. Studies that replicate encouraging findings on the efficacy of combining botanical agents and nutritional supplements with other natural product-derived therapies and widely used ADHD medications are also warranted. In conclusion, the risk-benefit balance of natural product-derived ADHD treatments should be carefully monitored when used as standalone treatment or when combined with other conventional ADHD treatments.

Critical appraisal of omega-3 fatty acids in attention-deficit/hyperactivity disorder treatment

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder. The classical treatment of ADHD where stimulant medication is used has revealed severe side effects and intolerance. Consequently, the demand to search for alternative treatment has increased rapidly. When comparing levels of omega-3 polyunsaturated fatty acids (ω-3 PUFAs) in ADHD patients with those in age-matching controls, lower levels are found in ADHD patients' blood. ω-3 PUFAs are essential nutrients and necessary for a proper brain function and development. Additionally, there are strong indications that ω-3 PUFA supplements could have beneficial effects on ADHD. However, the results of ω-3 PUFA supplementation studies show a high variability. Therefore, we reviewed recent studies published between 2000 and 2015 to identify effective treatment combinations, the quality of design, and safety and tolerability of ω-3-containing food supplements. We searched the databases MEDLINE, PubMed, and Web of Science with keywords such as "ADHD" and "ω-3/6 PUFA" and identified 25 studies that met the inclusion and exclusion criteria. The results of these ω-3 PUFA studies are contradictory but, overall, show evidence for a successful treatment of ADHD symptoms. Tolerability of the given supplements was high, and only mild side effects were reported. In conclusion, there is evidence that a ω-3 PUFA treatment has a positive effect on ADHD. It should be added that treatment could be more effective in patients with mild forms of ADHD. Moreover, the dosage of stimulant medication could be reduced when used in combination with ω-3 PUFA supplements. Further studies are necessary to investigate underlying mechanisms that can lead to a reduction of ADHD symptoms due to ω-3 PUFA treatments and also to determine the optimal concentrations of ω-3 PUFAs, whether used as single treatment or in combination with other medication.

VI. The role of physical activity in reducing barriers to learning in children with developmental disorders

Emerging research suggests that physical activity may be an effective non-pharmaceutical intervention approach for childhood developmental disorders. Findings indicate that both single bouts of activity and chronic physical activity associate with improved mental health and classroom performance in children with attention-deficit/hyperactivity disorder and children with autism spectrum disorders. This review describes the research in this area and identifies limitations and challenges to the translation of these findings to promote physical activity in clinical practice and educational policy.

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.

The effect of alpha-linolenic acid supplementation on ADHD symptoms in children: a randomized controlled double-blind study

Background: Attention deficit-hyperactivity disorder (ADHD) is the most common neuro-developmental disorder in childhood. Its pharmacologic treatment mostly includes methylphenidate, yet many parents seek alternative, “natural,” therapeutic options, commonly omega-3 fatty acids. Previous studies of supplementation with fish oil or long-chain omega-3 fatty acids to children with ADHD yielded mixed results. The use of alpha-linolenic acid (ALA), a medium-chained, plant-based omega-3 fatty acid (18:3 n-3), has not been sufficiently examined in this population.

Methods: Forty untreated children with ADHD, aged 6–16 years, were randomized to receive either 2 g/day of oil containing 1 g ALA or placebo, for 8 weeks. Before and after supplementation, the children underwent a physician assessment of ADHD symptoms and a computerized continuous performance functions test. The children’s parents and teachers filled out Conners’ and DSM questionnaires.

Results: Seventeen (42.5%) children completed the study, eight in the supplementation group, nine in the placebo group. Main drop-out reasons were capsule size, poor compliance, and a sense of lack of effect. No significant difference was found in any of the measured variables tested before and after supplementation, in both study groups. No between-group difference was found in the changes of the various measures of ADHD symptoms throughout the study period.

Conclusion: Supplementation of 2 g/day of oil containing 1 g ALA did not significantly reduce symptoms in children with ADHD. Future studies in this field should consider an alternative method to deliver the oil, a higher dose, and a larger sample size.

Docosahexaenoic acid content is significantly higher in ghrita prepared by traditional Ayurvedic method

BACKGROUND

Ghee (clarified butter) also known as ghrita, has been utilized for thousands of years in Ayurveda. Ghee is mostly prepared by traditional method in Indian households or by direct cream method at industry level. Ayurvedic classics mention that ghrita made from cow milk is superior. However, there is no scientific comparison available on preparation methods and essential fatty acids content of ghrita.

OBJECTIVE

To investigate fatty acid composition of ghrita prepared by traditional/Ayurvedic method and commercial method (direct cream method).

MATERIALS AND METHODS

Fatty Acid Methyl Esters (FAME) extracted from ghrita samples were analysed on Gas Chromatography (GC) Shimadzu B using capillary column BPX70 (0.32 mm*60 m, ID of 0.25 mm). The fatty acids in the samples were identified by comparing peaks with the external standard 68A (Nu-Chek-Prep, Inc.USA). Significant differences between the experimental groups were assessed by analysis of variance.

RESULTS

Distribution of fatty acids was compared in ghrita samples prepared by traditional method and direct cream method which is commercially used. Saturated fatty acids were predominant in both the groups. Mono unsaturated fatty acids and poly unsaturated fatty acids were in the range of 17-18% and 3-6% respectively. DHA content was significantly higher in ghee prepared by traditional method using curd starter fermentation.

CONCLUSION

The findings suggested that ghrita prepared by traditional ayurvedic methods contains higher amount of DHA; Omega-3 long-chain polyunsaturated fatty acids, which is a major component of retinal and brain tissues and remains important in prevention of various diseases.

Omega-3 fatty acid and ADHD: blood level analysis and meta-analytic extension of supplementation trials

Interest in the value of omega-3 (n-3) fatty acid supplementation for treatment of ADHD remains high. No prior meta-analysis has examined whether ADHD is associated with alterations in blood lipid levels and meta-analyses of supplementation have reached conflicting conclusions.

METHODS

We report two new meta-analyses. Study 1 examined blood levels of omega-3 fatty acids in relation to ADHD. Study 2 examined a larger sample of randomized intervention trials than previously reported.

RESULTS

Study 1 included 9 studies (n=586) and found lower overall blood levels of n-3 in individuals with ADHD versus controls (g=0.42, 95% CI=0.26-0.59; p<.001). Study 2 included 16 studies (n=1408) and found that n-3 supplementation improved ADHD composite symptoms; using the best available rating and reporter (g=0.26, 95% CI=0.15-0.37; p<.001). Supplementation showed reliable effects on hyperactivity by parent and teacher report, but reliable effects for inattention only by parent report.

CONCLUSIONS

Omega-3 levels are reduced in children with ADHD. Dietary supplementation appears to create modest improvements in symptoms. There is sufficient evidence to consider omega-3 fatty acids as a possible supplement to established therapies. However it remains unclear whether such intervention should be confined to children with below normal blood levels.

Which polyunsaturated fatty acids are active in children with attention-deficit hyperactivity disorder receiving PUFA supplementation? A fatty acid validated meta-regression analysis of randomized controlled trials

Concerns about growth retardation and unknown effects on long-term brain development with stimulants have prompted interest in polyunsaturated fatty acid supplementation (PUFA) as an alternative treatment. However, randomized controlled trials (RCTs) and meta-analyses of PUFA supplementation in ADHD have shown marginal benefit, and uncertainty exists as to which, if any, PUFA might be effective in alleviating symptoms of ADHD. We conducted an updated meta-analysis of RCTs in ADHD together with multivariable meta-regression analyses using data on PUFA content obtained from independent fatty acid methyl ester analyses of each study PUFA regimen. The PubMed, Embase and PsycINFO databases were searched with no start date and up to 28th July 2013. Study inclusion criteria were: randomized design, placebo controlled, PUFA preparation as active intervention, reporting change scores on ADHD rating-scale measures. Rating-scale measures of inattention and hyperactive-impulsive symptoms were extracted, study authors were contacted to obtain missing data, studies not reporting negative findings had these data imputed, and study quality was assessed using the Jadad system plus other indicators. Random-effects models were used for pooled effects and for meta-regression analyses. Standardized mean differences (SMD) in inattention, hyperactive-impulsive and combined symptoms were assessed as rated by parents, teachers or all raters. The influence of study characteristics and PUFA regimen content was explored in multivariable meta-regression analyses. The overall pooled estimate from 18 studies showed that combined ADHD symptoms rated by all raters decreased with PUFA supplementation; SMD -0.192 (95% CI: -0.297, -0.086; P<0.001). However, when analyzed by rater, only parent-rated symptoms decreased significantly. Multivariable meta-regression showed that longer study duration, γ-linolenic acid (GLA), and the interaction between GLA and eicosapentaenoic acid (EPA) were associated with significant decreases in inattention; however, PUFA regimen content was unrelated to changes in hyperactive-impulsive symptoms. Certain fatty acids present in placebo preparations may potentially have been psychoactive. This meta-analysis provides modest evidence of PUFA effectiveness in ADHD, especially GLA and EPA for inattention symptoms; however, evidence of reporting bias, publication bias, variable methodological quality, and use of potentially psychoactive placebos limit the generalizability of these findings.

Differential transcriptional activity of SAD, FAD2 and FAD3 desaturase genes in developing seeds of linseed contributes to varietal variation in α-linolenic acid content

Linseed or flax (Linum usitatissimum L.) varieties differ markedly in their seed α-linolenic acid (ALA) levels. Fatty acid desaturases play a key role in accumulating ALA in seed. We performed fatty acid (FA) profiling of various seed developmental stages of ten Indian linseed varieties including one mutant variety. Depending on their ALA contents, these varieties were grouped under high ALA and low ALA groups. Transcript profiling of six microsomal desaturase genes (SAD1, SAD2, FAD2, FAD2-2, FAD3A and FAD3B), which act sequentially in the fatty acid desaturation pathway, was performed using real-time PCR. We observed gene specific as well as temporal expression pattern for all the desaturases and their differential expression profiles corresponded well with the variation in FA accumulation in the two groups. Our study points to efficient conversion of intermediate FAs [stearic (SA), oleic (OA) and linoleic acids (LA)] to the final product, ALA, due to efficient action of all the desaturases in high ALA group. While in the low ALA group, even though the initial conversion up to OA was efficient, later conversions up to ALA seemed to be inefficient, leading to higher accumulation of OA and LA instead of ALA. We sequenced the six desaturase genes from the ten varieties and observed that variation in the amino acid (AA) sequences of desaturases was not responsible for differential ALA accumulation, except in the mutant variety TL23 with very low (<2%) ALA content. In TL23, a point mutation in the FAD3A gene resulted into a premature stop codon generating a truncated protein with 291 AA.

ROS and brain diseases: the good, the bad, and the ugly

The brain is a major metabolizer of oxygen and yet has relatively feeble protective antioxidant mechanisms. This paper reviews the Janus-faced properties of reactive oxygen species. It will describe the positive aspects of moderately induced ROS but it will also outline recent research findings concerning the impact of oxidative and nitrooxidative stress on neuronal structure and function in neuropsychiatric diseases, including major depression. A common denominator of all neuropsychiatric diseases including schizophrenia and ADHD is an increased inflammatory response of the brain caused either by an exposure to proinflammatory agents during development or an accumulation of degenerated neurons, oxidized proteins, glycated products, or lipid peroxidation in the adult brain. Therefore, modulation of the prooxidant-antioxidant balance provides a therapeutic option which can be used to improve neuroprotection in response to oxidative stress. We also discuss the neuroprotective role of the nuclear factor erythroid 2-related factor (Nrf2) in the aged brain in response to oxidative stressors and nanoparticle-mediated delivery of ROS-scavenging drugs. The antioxidant therapy is a novel therapeutic strategy. However, the available drugs have pleiotropic actions and are not fully characterized in the clinic. Additional clinical trials are needed to assess the risks and benefits of antioxidant therapies for neuropsychiatric disorders.

The pilot study: sphingomyelin-fortified milk has a positive association with the neurobehavioural development of very low birth weight infants during infancy, randomized control trial

AIM

This study was a randomised control trial to examine the effects of sphingomyelin (SM), on the mental, motor and behavioural development of premature infants.

PATIENTS AND METHODS

Randomised, double-blind controlled trial, enroling infants born with a birth weight of less than 1500 g between January 2004 and October 2007 at Juntendo University Hospital, with follow-up to 18 months. Twenty-four preterm babies were randomly assigned; 12 were assigned to a test group and fed SM-fortified milk (SM 20% of all phospholipids in milk) and 12 were assigned to a control group (SM 13% of all phospholipids in milk). We analysed the composition of the plasma phospholipids and red-cell-membrane fatty acids, after which VEP, Fagan, BSID-II, attention and memory tests were performed.

RESULTS

The percentage of SM in the total phospholipids was significantly higher in the trial group than in the control group at 4, 6 and 8 weeks. The Behaviour Rating Scale of the BSID-II, the Fagan test scores, the latency of VEP, and sustained attention test scores at 18 months were all significantly better in the trial group than in the control group.

CONCLUSION

This study is the first to report that nutritional intervention via administration of SM-fortified milk has a positive association with the neurobehavioural development of low-birth-weight infants. However, detailed studies on the effects of SM on longer-term development are required.

Supplementierung inklusive therapeutische Formelnahrung

Einer der Unterschiede in der Zusammensetzung von Muttermilch und künstlichen Säuglingsnahrungen auf Kuhmilchbasis besteht im Gehalt an langkettigen mehrfach ungesättigten Fettsäuren („long chain polyunsaturated fatty acids“, LCPUFA). Die Zugabe von Nervon-, Docosapentaen- und Docosahexaensäure zu Formulamilchen wurde empfohlen (Sala-Vila et al. 2004) und inzwischen teilweise von den Herstellern umgesetzt, obwohl auch festgestellt wurde, dass dies keinen Vorteil erbringt, wenn bereits 10 % der Energie als Linolensäure und 1 % als α-Linolensäure zugeführt werden (Auestad et al. 2004).

Biomarkers and attention-deficit/hyperactivity disorder: a systematic review and meta-analyses

OBJECTIVE

To determine whether peripheral biochemical markers (biomarkers) might differentiate patients with attention-deficit/hyperactivity disorder (ADHD) from non-ADHD individuals.

METHOD

We conducted a systematic search and a series of meta-analyses of case-control studies comprising studies from 1969 to 2011.

RESULTS

We identified 210 studies in the following categories: 71 studies of the main metabolites and metabolism enzymes of monoaminergic neurotransmission pathway; 87 studies of environmental risk factors divided into heavy metals (18 studies), substance/chemical exposures (16 studies), and nutritional factors (trace elements: 29 studies; essential fatty acids: 24 studies); 22 studies of the hypothalamic-pituitary-adrenal axis (HPA) pathway; 31 studies indicated with "other". After screening for the availability for meta-analyses of drug naïve/free case-control studies and Bonferroni correction, five comparisons were statistically significant (Norepinephrine [NE], 3-Methoxy-4-hydroxyphenylethylene glycol [MHPG], monoamine oxidase [MAO], Zinc [Zn], cortisol), five of the significant findings found support in studies of response to ADHD medications (NE, MHPG, MAO, b-phenylethylamine [PEA], cortisol), six in studies of symptoms severity (NE, MHPG, MAO, ferritin, Zn, cortisol) and three in studies of neurophysiological or cognitive functioning (lead-ferritin-Zn). No evidence of publication bias was found, whereas significant heterogeneity of effect sizes across studies was found for three of the five biomarkers that differentiated ADHD from control subjects. Suggestive associations were evidenced for neuropeptide Y (NPY), manganese, and dehydroepiandrosterone (DHEA).

CONCLUSIONS

This study provides evidence for several peripheral biomarkers as being associated with ADHD both in diagnosis and in treatment efficacy. Further studies are warranted to replicate these findings, to assess their specificity for ADHD, and to quantify the degree to which they are sufficiently precise to be useful in clinical settings.

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. Children and adolescents with ADHD have been shown to 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.

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 the following databases in August 2011: CENTRAL (The Cochrane Library 2011, Issue 2), MEDLINE (1948 to July Week 3, 2011), EMBASE (1980 to 2011 Week 29), PsycINFO (1806 to current), CINAHL (1937 to current), BIOSIS (1969 to 30 July 2011), Science Citation Index (1970 to 30 July 2011), Social Science Citation Index (1970 to 30 July 2011), Conference Proceedings Citation Index - Science (1990 to 30 July 2011), Conference Proceedings Citation Index - Social Science and Humanities (1990 to 30 July 2011), Cochrane Database of Systematic Reviews (2011, Issue 7), DARE (2011 Issue 2), Dissertation Abstracts (via Dissertation Express) and the metaRegister of Controlled Trials (mRCT). In addition, we searched the following repositories for theses on 2 August 2011: DART, NTLTD and TROVE. We also checked reference lists of relevant studies and reviews for additional references.

SELECTION CRITERIA

Two review authors independently assessed the results of the database searches. We resolved any disagreements regarding the selection of studies through consensus or, if necessary, by consultation with a third member of the review team.

DATA COLLECTION AND ANALYSIS

Two members of the review team independently extracted details of participants and setting, interventions, methodology and outcome data. If differences were identified, we resolved them by consensus or referral to a third member of the team. We made all reasonable attempts to contact the authors where further clarification or missing data were needed.

MAIN RESULTS

We included 13 trials with 1011 participants in the review. After screening 366 references, we considered 23 relevant and obtained the full text for consideration. We excluded five papers and included 18 papers describing the 13 trials. Eight of the included trials had a parallel design: five compared an omega-3 PUFA supplement to placebo; two compared a combined omega-3 and omega-6 supplement to placebo, and one compared an omega-3 PUFA to a dietary supplement. Five of the included trials had a cross-over design: two compared combined omega-3/6 PUFA to placebo; two compared omega-6 PUFA with placebo; one compared omega-3 to omega-6 PUFA, and one compared omega-6 PUFA to dexamphetamine. Supplements were given for a period of between four and 16 weeks.There was a significantly higher likelihood of improvement in the group receiving omega-3/6 PUFA compared to placebo (two trials, 97 participants; risk ratio (RR) 2.19, 95% confidence interval (CI) 1.04 to 4.62). However, there were no statistically significant differences in parent-rated ADHD symptoms (five trials, 413 participants; standardised mean difference (SMD) -0.17, 95% CI -0.38 to 0.03); inattention (six trials, 469 participants; SMD -0.04, 95% CI -0.29 to 0.21) or hyperactivity/impulsivity (five trials, 416 participants; SMD -0.04, 95% CI -0.25 to 0.16) when all participants receiving PUFA supplements were compared to those receiving placebo.There were no statistically significant differences in teacher ratings of overall ADHD symptoms (four trials, 324 participants; SMD 0.05, 95% CI -0.18 to 0.27); inattention (three trials, 260 participants; SMD 0.26, 95% CI -0.22 to 0.74) or hyperactivity/impulsivity (three trials, 259 participants; SMD 0.10, 95% CI -0.16 to 0.35).There were also no differences between groups in behaviour, side effects or loss to follow-up.Overall, there were no other differences between groups for any other comparison.

AUTHORS' CONCLUSIONS

Overall, there is little evidence that PUFA supplementation provides any benefit for the symptoms of ADHD in children and adolescents. The majority of data showed no benefit of PUFA supplementation, although there were some limited data that did show an improvement with combined omega-3 and omega-6 supplementation.It is important that future research addresses current weaknesses in this area, which include small sample sizes, variability of selection criteria, variability of the type and dosage of supplementation, short follow-up times and other methodological weaknesses.

Polyunsaturated fatty acids, cognition and literacy in children with ADHD with and without learning difficulties

Suboptimal omega-3 polyunsaturated fatty acid (n-3 PUFA) levels may contribute to attention deficit hyperactivity disorder (ADHD) and related developmental problems. Associations between n-3 and omega-6 (n-6) PUFA levels in red blood cells (erythrocytes) and learning and behaviour were investigated in 75 children aged 7-12 with ADHD. Children provided blood samples and underwent cognitive assessments. Parents completed questionnaires and Conners' Rating Scales. Controlling for covariates, higher n-3 PUFA predicted lower anxiety/shyness (β = -.27), higher docosahexaenoic acid (DHA) better word reading (β = .22), and higher n-6 PUFA poorer reading (β = -.34), vocabulary (β = .-.26), spelling (β = -.30) and attention (β = -.30). Thirty-six per cent of the sample with learning difficulties had lower DHA than those without (M = 3.26 ± 0.54 vs M = 3.68 ± 0.76, p = .02). This study is the first to compare erythrocyte PUFAs (a measure of PUFA status) in children who have ADHD with and without learning difficulties, and supports emerging indications that the former may be more likely responders to n-3 PUFAs.

Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis

OBJECTIVE

Several studies have demonstrated differences in omega-3 fatty acid composition in plasma and in erythrocyte membranes in patients with attention-deficit/hyperactivity disorder (ADHD) compared with unaffected controls. Omega-3 fatty acids have anti-inflammatory properties and can alter central nervous system cell membrane fluidity and phospholipid composition. Cell membrane fluidity can alter serotonin and dopamine neurotransmission. The goal of this meta-analysis was to examine the efficacy of omega-3 fatty acid supplementation in children with ADHD.

METHOD

PubMed was searched for randomized placebo-controlled trials examining omega-3 fatty acid supplementation in children with ADHD symptomatology. The primary outcome measurement was standardized mean difference in rating scales of ADHD severity. Secondary analyses were conducted to determine the effects of dosing of different omega-3 fatty acids in supplements.

RESULTS

Ten trials involving 699 children were included in this meta-analysis. Omega-3 fatty acid supplementation demonstrated a small but significant effect in improving ADHD symptoms. Eicosapentaenoic acid dose within supplements was significantly correlated with supplement efficacy. No evidence of publication bias or heterogeneity between trials was found.

CONCLUSION

Omega-3 fatty acid supplementation, particularly with higher doses of eicosapentaenoic acid, was modestly effective in the treatment of ADHD. The relative efficacy of omega-3 fatty acid supplementation was modest compared with currently available pharmacotherapies for ADHD such as psychostimulants, atomoxetine, or α(2) agonists. However, given its relatively benign side-effect profile and evidence of modest efficacy, it may be reasonable to use omega-3 fatty supplementation to augment traditional pharmacologic interventions or for families who decline other psychopharmacologic options.

A randomized targeted amino acid therapy with behaviourally at-risk adopted children

BACKGROUND

Increasing numbers of children are at-risk for behavioural and emotional disorders, a phenomenon contributing to increased use of pharmacological interventions for paediatric clients. Adverse side effects and other risks associated with pharmacological approaches have helped fuel interest in nutritional interventions for behaviourally at-risk children.

METHODS

The current randomized clinical trial evaluates the efficacy of a neurochemical intervention involving the glutamine and glutamate analogue L-theanine and 5-hydroxytryptophan, the precursor for serotonin, with children adopted from traumatic backgrounds.

RESULTS

Results include significant increases in urinary levels of the biomarkers for serotonin and gamma-aminobutyric acid, coupled with significant decreases in parent reports of the children's behaviour problems.

CONCLUSIONS

While further research is needed, these initial findings are encouraging and are consistent with a growing number of studies indicating the efficacy of nutritional approaches to help behaviourally at-risk children.

Omega-3 fatty acid treatment of children with attention-deficit hyperactivity disorder: A randomized, double-blind, placebo-controlled study

BACKGROUND

Although several clinical trials have evaluated the impact of n-3 polyunsaturated fatty acid (PUFA) on patients with attention-deficit hyperactivity disorder (ADHD), changes in plasma PUFA composition were not always assessed following n-3 supplementation. Furthermore, no reports are available on the efficacy of n-3 PUFA in Canadian youth with ADHD.

OBJECTIVES

To determine fatty acid (FA) composition, and the efficacy and safety of n-3 PUFA supplementation on ADHD clinical symptoms in French Canadian primary school children.

PATIENTS AND METHODS

The Strengths and Weaknesses in ADHD and Normal Behaviors (SWAN) and Conners' questionnaires were used to assess changes in ADHD symptoms in 37 children (only 26 children completed the study from zero to 16 weeks). They were divided into two groups (A and B), and participated in a 16-week, double-blind, one-way, crossover randomized study. In the first phase, group A received the n-3 PUFA supplement and group B received n-6 PUFA (sunflower oil) as a placebo. During the second phase, group B received the active n-3 PUFA supplement that was continued in group A. FA composition and lipid profile were assessed during the phases of the study.

RESULTS

FA differences between groups were observed in the 26 patients. Supplementation with n-3 PUFA resulted in significant increases in eicosapentaenoic and docosahexaenoic acids in group A, while group B was enriched with alpha-linolenic, gamma-linolenic and homo-gamma-linolenic acids. The n-3 PUFA supplement was tolerated without any adverse effects. A statistically significant improvement in symptoms was noted based on the parent version of the Conners' questionnaire from baseline to the end of phase 1, and this amelioration continued from phases 1 to 2, although the latter changes from phases 1 and 2 were not statistically significant in any of the subscales except for the subscale measuring inattention in group B. The improvement was greater in patients from group A in phase 1 and in patients from group B in phase 2. A subgroup of eight patients (four in each group) displayed a statistically significant clinical improvement following the administration of the n-3 PUFA supplement, particularly for the inattention and global Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, total Conners' subscales.

CONCLUSIONS

A subgroup of children with ADHD who used n-3 PUFA supplements achieved and maintained symptom control. The data of the present study also supported n-3 PUFA safety and tolerability, but limited changes were noted in the FA profile in French Canadians with ADHD.

Wound healing activity of topical application forms based on ayurveda

The traditional Indian medicine-Ayurveda, describes various herbs, fats, oils and minerals with anti-aging as well as wound healing properties. With aging, numerous changes occur in skin, including decrease in tissue cell regeneration, decrease in collagen content, loss of skin elasticity and mechanical strength. We prepared five topical anti-aging formulations using cow ghee, flax seed oil, Phyllanthus emblica fruits, Shorea robusta resin, Yashada bhasma as study materials. For preliminary efficacy evaluation of the anti-aging activity we chose excision and incision wound healing animal models and studied the parameters including wound contraction, collagen content and skin breaking strength which in turn is indicative of the tissue cell regeneration capacity, collagenation capacity and mechanical strength of skin. The group treated with the formulations containing Yashada bhasma along with Shorea robusta resin and flax seed oil showed significantly better wound contraction (P < .01), higher collagen content (P < .05) and better skin breaking strength (P < .01) as compared to control group; thus proposing them to be effective prospective anti-aging formulations.

Impact of plant extracts tested in attention-deficit/hyperactivity disorder treatment on cell survival and energy metabolism in human neuroblastoma SH-SY5Y cells

Plant extracts such as Hypericum perforatum and Pycnogenol have been tested as alternatives to the classical ADHD drugs. It has been possible to describe neuroprotective effects of such plant extracts. A reduction of ADHD symptoms could be shown in clinical studies after the application of Pycnogenol, which is a pine bark extract. The impacts of the standardized herbal extracts Hypericum perforatum, Pycnogenol and Enzogenol up to a concentration of 5000 ng/mL on cell survival and energy metabolism in human SH-SY5Y neuroblastoma cells has been investigated in the present examination. Hypericum perforatum significantly decreased the survival of cells after treatment with a concentration of 5000 ng/mL, whereas lower concentrations exerted no significant effects. Pycnogenol( induced a significant increase of cell survival after incubation with a concentration of 32.25 ng/mL and a concentration of 250 ng/mL. Other applied concentrations of Pycnogenol failed to exert significant effects. Treatment with Enzogenol did not lead to significant changes in cell survival.Concerning energy metabolism, the treatment of cells with a concentration of 5000 ng/mL Hypericum perforatum led to a significant increase of ATP levels, whereas treatment with a concentration of 500 ng/mL had no significant effect. Incubation of cells with Pycnogenol and Enzogenol exerted no significant effects.None of the tested substances caused any cytotoxic effect when used in therapeutically relevant concentrations.

Oxidative imbalance in child and adolescent patients with attention-deficit/hyperactivity disorder

Various psychological, social, genetic, and biochemical factors are thought to be involved in the aetiology of attention-deficit/hyperactivity disorder (ADHD). However, few studies have evaluated the biochemical basis of ADHD. In the present study, we evaluate whether levels of nitric oxide pool (NO+NO(2)(-)) and malondialdehyde (MDA) oxidants as well as superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) antioxidant enzyme activities are associated with ADHD. The sample population consisted of thirty-five child or adolescent patients diagnosed with ADHD according to DSM-IV-TR criteria. Thirty-five healthy subjects also were included in the study as controls. Venous blood samples were collected, and NO pool and MDA levels as well as SOD, GSH-Px, and CAT activities were measured. NO and MDA levels of the patients were significantly higher than the controls. GSH-Px activities of the patients were significantly lower than the controls. CAT activities of the patients were higher than the controls; however, the difference was not statistically significant. There were no significant differences in SOD activity between the patient and control groups. Remarkably high levels of NO pool and MDA oxidants as well as low GSH-Px activities suggest an oxidative imbalance in paediatric patients with ADHD. CAT activities may be increased in response to increased oxidant levels.