Nutrient intake, dietary patterns, and anthropometric variables of children with ADHD in comparison to healthy controls: a case-control study

Novel and complementary treatment approaches in attention-deficit/hyperactivity disorder

PURPOSE OF REVIEW

To provide an updated review of novel and complementary treatment approaches for children and adolescents with attention-deficit/hyperactivity disorder.

RECENT FINDINGS

The evidence for complementary attention-deficit/hyperactivity disorder treatments is often promising, but limited to small, unblinded studies. Recent evidence from larger, more rigorous studies reveals that most of these treatments have modest efficacy. Omega-3 polyunsaturated fatty acids, saffron, broad spectrum micronutrients, and physical exercise have potential benefits that seem to outweigh known risks. However, neurofeedback, cognitive training, and trigeminal nerve stimulation need further research to determine whether specific sub-groups of children/adolescents with attention-deficit/hyperactivity disorder would benefit long-term with their associated tolerable risks.

SUMMARY

There is not sufficient evidence for complementary treatments to be recommended as substitutes for first-line pharmacological and psychosocial treatment options. Nonetheless, some adjuvant therapies to currently recommended attention-deficit/hyperactivity disorder treatments can be safe. Physicians should be familiar with existing and emerging complementary treatments to help guide families.

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.

Short-term effects of an elimination diet and healthy diet in children with attention-deficit/hyperactivity disorder: a randomized-controlled trial

An Elimination Diet (ED) may be effective in reducing symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD), but has never been compared to an active control condition [i.e., Healthy Diet (HD)]. In a two-armed RCT, a total of N = 165 children (5-12 years) with ADHD were randomized by means of minimization (1:1) to either an ED (N = 84) or HD (N = 81) within two Dutch child and adolescent psychiatry centers. The design included a non-randomized comparator arm including N = 58 children being treated with Care as Usual (CAU). Treatment allocation was unblinded. The primary outcome was a 5-point ordinal measure of respondership based on a combination of parent and teacher ratings on ADHD and emotion regulation, determined after 5 weeks of treatment. Ordinal regression analyses were done on an intention-to-treat basis. Fewer ED (35%) than HD (51%) participants showed a partial to full response, despite overall good-to-excellent treatment adherence (> 88%) and comparable high parental prior believes. A younger age and higher problem severity predicted a better respondership. CAU-preferring participants responded more often favorably (56%) compared to ED-but not HD-participants. Small-to-medium improvements in physical health (blood pressure, heart rate, and somatic complaints) were found in response to ED/HD versus decrements in response to CAU (74% received psychostimulants). The lack of superiority of the ED versus HD suggests that for the majority of children, dietary treatment response is not rooted in food-allergies/-sensitivities. The comparable results for treatment with HD and CAU are remarkable given that CAU participants were probably 'easier to treat' than HD (and ED) participants with proportionally fewer with a (suboptimal/non-response to) prior treatment with medication (4% versus 20%). Further assessment of long-term effects is needed to evaluate the potential place of dietary treatment within clinical guidelines. The trial is closed and registered in the Dutch trial registry, number NL5324 ( https://www.onderzoekmetmensen.nl/en/trial/25997 ).

Functional contribution of the intestinal microbiome in autism spectrum disorder, attention deficit hyperactivity disorder, and Rett syndrome: a systematic review of pediatric and adult studies

Introduction

Critical phases of neurodevelopment and gut microbiota diversification occur in early life and both processes are impacted by genetic and environmental factors. Recent studies have shown the presence of gut microbiota alterations in neurodevelopmental disorders. Here we performed a systematic review of alterations of the intestinal microbiota composition and function in pediatric and adult patients affected by autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and Rett syndrome (RETT).

Methods

We searched selected keywords in the online databases of PubMed, Cochrane, and OVID (January 1980 to December 2021) with secondary review of references of eligible articles. Two reviewers independently performed critical appraisals on the included articles using the Critical Appraisal Skills Program for each study design.

Results

Our systematic review identified 18, 7, and 3 original articles describing intestinal microbiota profiles in ASD, ADHD, and RETT, respectively. Decreased Firmicutes and increased Bacteroidetes were observed in the gut microbiota of individuals affected by ASD and ADHD. Proinflammatory cytokines, short-chain fatty acids and neurotransmitter levels were altered in ASD and RETT. Constipation and visceral pain were related to changes in the gut microbiota in patients affected by ASD and RETT. Hyperactivity and impulsivity were negatively correlated with Faecalibacterium (phylum Firmicutes) and positively correlated with Bacteroides sp. (phylum Bacteroidetes) in ADHD subjects. Five studies explored microbiota-or diet-targeted interventions in ASD and ADHD. Probiotic treatments with Lactobacillus sp. and fecal microbiota transplantation from healthy donors reduced constipation and ameliorated ASD symptoms in affected children. Perinatal administration of Lactobacillus sp. prevented the onset of Asperger and ADHD symptoms in adolescence. Micronutrient supplementation improved disease symptomatology in ADHD without causing significant changes in microbiota communities' composition.

Discussion

Several discrepancies were found among the included studies, primarily due to sample size, variations in dietary practices, and a high prevalence of functional gastrointestinal symptoms. Further studies employing longitudinal study designs, larger sample sizes and multi-omics technologies are warranted to identify the functional contribution of the intestinal microbiota in developmental trajectories of the human brain and neurobehavior.

Systematic review registration

https://clinicaltrials.gov/, CRD42020158734.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

Nutrients patterns and attention deficit hyperactivity disorder among Egyptian children: a sibling and community matched case-control study

BACKGROUND

Attention Deficit Hyperactive Disorder (ADHD) diagnosis has been growing among children, with great public health concern. The relationship between nutrient intake pattern and ADHD remains unclear.

AIM

To identify the nutrient intake patterns and its association with ADHD in children.

SUBJECTS AND METHODS

The study involved 146 children with ADHD, 141 control sibling, and 146 community controls. ADHD diagnosis was confirmed using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) criteria following the assessment by the long-form Conner's Scale. Dietary intakes were assessed using a semi-quantitative food frequency questionnaire. Nutrients patterns were identified using the principal component analysis (PCA).

RESULTS

ADHD children have significantly higher mean total energy intake than community controls and siblings (8867.9, 4481.9 and 7308.2 KJ, respectively, p < 0.001). Four nutrient patterns extracted by the PCA explained 75.9% of the total variance. Lower tertiles of "predominantly calcium-phosphorus; pattern 1" and "predominantly-vitamins; pattern 3" were significantly associated with increasing odds of ADHD, compared to community controls (p for trend: 0.002 and 0.005, respectively), while the same associations were noted in "predominantly-vitamins" and "predominantly Zinc-Iron; pattern 2" when compared to siblings (p for trend: <0.001 and <0.001, respectively). However, Higher tertiles of macronutrients; pattern 4" were associated with increased ADHD odds, compared to either community controls or siblings (p for trend: 0.017 and <0.001, respectively).

CONCLUSION

Lower intakes of nutrients patterns of minerals and vitamins, and higher intakes of macronutrients were associated with increased likelihood of ADHD in children.

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.

Eating Patterns and Dietary Interventions in ADHD: A Narrative Review

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, affecting ~7% of children and adolescents. Given its adverse health outcomes and high healthcare and societal costs, other treatment options beyond pharmacotherapy have been explored. Case-control studies have shown that dietary patterns may influence the risk of ADHD, and specific dietary interventions have been proposed as coadjuvant treatments in this disorder. These include nutritional supplements, gut microbiome-targeted interventions with biotics, and elimination diets. The purpose of this review is to examine which dietary patterns are most associated with ADHD and to summarize the existing evidence for the clinical use of dietary interventions. The literature showed that non-healthy dietary patterns were positively associated with ADHD, whereas healthy patterns were negatively associated. As for nutritional supplements, only vitamin D and vitamin D + magnesium appeared to improve ADHD symptoms when baseline levels of vitamin D were insufficient/deficient. Regarding biotics, evidence was only found for Lactobacillus rhamnosus GG and for multi-species probiotic supplementation. Elimination diets have scarce evidence and lead to nutritional deficiencies, so caution is advised. Overall, more robust scientific evidence is required for these dietary interventions to be implemented as part of ADHD therapy.

The Impact of Bilateral Anodal tDCS over Left and Right DLPFC on Executive Functions in Children with ADHD

Transcranial direct current stimulation (tDCS) is increasingly used for therapeutic purposes in attention-deficit hyperactivity disorder (ADHD). The dorsolateral prefrontal cortex (DLPFC) is the most targeted region of tDCS studies in ADHD. There is limited knowledge and mixed results about the relevance of left or right DLPFCs in ADHD’s cognitive deficits. No study so far has investigated the impact of the increased excitability of both left and right DLPFC with anodal tDCS on cognitive deficits in ADHD. Here, we explored the impact of online bilateral anodal left and right DLPFC tDCS on executive dysfunction in children with ADHD. Twenty-two children with ADHD (mean age ± SD =8.86 ± 1.80) received bilateral anodal online tDCS over the left and right DLPFC (1.5 mA, 15 min) in two separate sessions in active and sham states. They underwent a battery of four neuropsychological tasks of executive functions during stimulation that measured working memory, cognitive flexibility, response inhibition, and executive control. Bilateral anodal left and right DLPFC tDCS did not improve performance on working memory, cognitive flexibility, and response inhibition. Executive control was, however, partially improved for those who received active tDCS first. The upregulation of bilateral DLPFC tDCS with anodal polarity does not improve executive dysfunction in children with ADHD. The unilateral modulation of DLPFC with anodal tDCS may be more beneficial to cognitive deficits in ADHD in light of previous works targeting only left and/or right DLPFC.