COMPLIMENTARY AND ALTERNATIVE TREATMENTS FOR ADHD: A REVIEW OF DIETARY APPROACHES

By Kaitlin Deason

A Senior Project submitted In partial fulfillment of the requirements for the degree of

Bachelor of Science in Nutrition

Food Science and Nutrition Department California Polytechnic State University

San Luis Obispo, CA

December 2009

Abstract

ADHD is the most common behavioral disorder seen in children and is associated with hyperactivity, an inability to focus/concentrate, and impulsive behavior. Stimulant medications are the most commonly used treatment, but they have a long list of detrimental side effects. This has created a large deal of controversy over the past thirty years about how to treat ADHD and has led to the research of complimentary and alternative treatment methods including dietary approaches. Food can influence behavior, so the thought is that different foods and nutrients may influence the symptoms of ADHD. One meta analysis, and several original research studies that looked at the use of fatty acid supplementation, zinc supplementation, and elimination diets for the treatment of ADHD were reviewed. Findings from these studies show positive results in alleviating some of the symptoms of ADHD with few side effects. There were limitations to these studies that will need to be addressed before the use of dietary treatment can be highly recommended. While more research is needed, this promising data shows dietary treatment methods to be useful in managing ADHD, and current evidence demonstrates that dietary approaches should be considered when implementing ADHD treatment plans.

1

Introduction

Attention deficit hyperactivity disorder (ADHD) affects anywhere between two to 18%

of children making it the most common behavioral disorder seen in children (Sinn, 2008).

ADHD is associated with hyperactivity, an inability to focus/concentrate, and impulsive behavior

which can play a large role in daily functioning and the overall success of an individual

(American Psychological Association [APA], 2000; Bilici, Yildirim, Kandil

2003; Schnoll, Burshteyn, & Cea-Arvena, 2003;

Schab & Trinh, 2004; Stevenson, 2006; Weber & Newmark, 2007; Sinn, 2008; Taylor, 2008;

Schuchardt, Huss, Strauss-Grabo, & Hahn, 2009). There has been a large increase in the

incidence of ADHD over the past thirty years making it a disorder of controversy and concern

(Olfson, Gameroff, Marcus, & Jensen, 2003; Paston & Reuban, 2008; Sinn, 2008;Taylor, 2008).

To date the most effective and widely accepted treatment is the use of stimulant drugs which

have proven beneficial for most individuals (USA Today, 2009). However, some people are

concerned about the safety and efficacy of these drugs due to a host of undesirable side effects

they may cause (Sinn, 2008; Bilici et al., 2003; Weber & Newmark, 2007; Schab & Trinh, 2004;

Taylor, 2008). In addition only 70% of individuals with ADHD respond to treatment from

stimulant medications (Olfson, Gameroff, Marcus, & Jensen, 2003). While this is a large percent

of individuals, some still require additional treatment options. As a result, a vast amount of

research has been put into complementary and alternative approaches to the treatment of ADHD

(Weber and Newmark, 2007). Some alternative techniques for treatment include behavioral

therapy and diet. Nutrition can have a major impact on behavior and thus has been the target for

2

research observing the impact that dietary intake can have in reducing the severity and incidence

of ADHD (Schnoll et. al., 2003; Sinn, 2008). This review of literature will discuss a variety of

approaches focusing primarily on the effects of dietary factors in the treatment of ADHD

including: essential fatty acid supplementation, zinc supplementation, food additives, and

elimination diets.

ADHD: An Overview

Definition and Diagnosis

There is no laboratory test to diagnose ADHD, and diagnosis must be determined by a

trained professional (National Institute of Mental Health [NIMH], 2008). Because ADHD

presents with symptoms similar to other mental disorders and symptoms vary among individuals,

there is potential for misdiagnoses (NIMH, 2008). ADHD is diagnosed based on criteria laid out

in the Diagnostic & Statistical Manual for Mental Disorders (DSM-IV-TR) which can be found

in Appendix A. Diagnosis is determined when an individual meets at least six of nine symptoms

of either inattention or hyperactive/impulsive behavior uncharacteristic of their developmental

stage. In addition, symptoms must cause problems in more than one location such as at school

and at home (APA, 2000).

Etiology

The exact cause of ADHD is currently unknown. There has been a vast amount of

research regarding the causes but the etiology is agreed to be complex and a result of multiple

factors (Schnoll et. al., 2003; Bilici et. al. 2003; Weber & Newmark, 2007). The areas of major

investigation to date are environmental factors, genetic factors, and altered brain function

3

(Schnoll et. al., 2003; Bilici et. al. 2003; Weber & Newmark, 2007; & Sinn, 2008).

Environmental factor such as exposure to lead, mercury, pesticides and tobacco are also being

considered possible causes of ADHD (Sinn, 2008). Dopamine receptors are one genetic factor

being studied, and studies of animal have shown that dysfunctional dopamine and

norepinephrine pathways lead to symptom similar to those seen in people with ADHD (Weber &

Newmark, 2007). In addition, a family history of ADHD is commonly observed, linking it to

genetics (Sinn, 2008). Frontal lobe abnormalities have been observed in some children diagnosed

with ADHD (Sinn, 2008). Finally, diet is known to play a role in brain function by maintaining

appropriate levels of vitamins and minerals. So, dietary influences are also being looked at as a

cause of ADHD (Schnoll et al., 2003).

Trends in US Population

Over the past 30 years there has been a significant increase in the number of individuals

diagnosed with ADHD (Olfson, et. Al., 2003; Paston & Reuban, 2008; Taylor, 2008). Between

1987 and 1997 there was an increase of around 1.7 million children being treated for ADHD

(Olfson, et. Al., 2003), and between 1997 and 2006 there was a 3% increase in the diagnosis of

ADHD (Paston & Reuban, 2008). In 2005, it was estimated that ADHD cost $36 to $52 billion

in health care costs (Paston & Reuban, 2008), and schools may be experiencing $3 billion dollars

in costs related to ADHD (Schab & Trihn, 2004). Finally, boys are at least two times more likely

than girls to have ADHD (Olfson, et. Al., 2003; Schnoll et. Al., 2003; Paston & Reuban, 2008;

Schuchardt et. al., 2009). As seen in Figure 1. The increase in diagnoses is believed by some to

be influenced by factors aside from an increase in incidence alone. There are indications that an

4

increase in diagnosis may be due to pressure from parents seeking treatment for hyperactive

children, pressure from pharmaceutical companies, and looseness of diagnoses (Taylor, 2009).

Others indicate increased access to healthcare, increase in knowledge of the disease, and parental

attitudes toward behavioral conditions (Paston & Reuban, 2008; Sinn, 2008).

Figure 1: All Diagnoses of ADHD among children 6-17 years of age, by sex: United States, 1997-2006 (Paston & Rueban, 2008).

Non Dietary Treatments

Medications

Drugs are the most common method chosen for the treatment of ADHD. Thirty nine and

a half million individuals are being prescribed ADHD medications which is a rise of 40% over

the last five years (USA Today, 2009). There are two major classes of drugs used to treat

ADHD, stimulant and non-stimulant. Stimulant medications are the most widely used class of

5

drugs and work on the central nervous system by blocking reuptake of norepinepherine and

dopamine into the presynaptic neuron (Physicians’ Desk Reference Inc. [PDR], 2008; NIMH,

2008). In clinical studies, stimulant drugs have proven more effective than non-stimulants in the

treatment of ADHD (Draughton & Kratozitochil, 2009). However, the way in which both drug

classes affect ADHD is unknown (PDR, 2008). Stimulant medications are available in two

different forms, extended release or long acting and rapid release or short acting (Draughton &

Kratozitochil, 2009; NIMH, 2008). Extended release means a given dose of medication is

released into the body over a period of time and an individual taking this form of stimulant will

only have to take one pill each day. On the other hand, rapid release stimulants provide a given

dose of medication all at once resulting in an immediate response. The time of action is shorter

and requires this type of medication to be taken multiple times throughout the day. Stimulant

drugs include amphetamines (Adderall), methylphenidate hydrochlorides (Ritalin and Conterta),

dexmethylphenidates (Focalin), and dextroamphetamine (Dexedrin) (Draughton & Kratozitochil,

2009; NIMH, 2008).

The next class of drugs is non-stimulants. Before 2002, there were no FDA approved

non-stimulant drugs, but now there are two. Atomoxetine (Strattera), was the first drug

approved, and like stimulant drugs the mechanism by which it effect ADHD is unknown, but an

effect is seen in clinical trials (Draughton & Kratozitochil, 2009). The second non-stimulant

approved in September, 2009 is Guanfacine Hydrochloride (Laughren, 2009). This medication

does have some reported side effects including, drowsiness, syncope, dizziness, dry mouth,

abdominal pain, and others, but these are not as severe as those seen with stimulant

6

medications(Laughren, 2009). However, other non-stimulant drugs that are not FDA approved

but still thought to have some effect on treating the symptoms of ADHD have been used in the

past (Draughton & Kratozitochil, 2009).

While the use of medications proves to be an effective method for the treatment ADHD,

side effects are a major concern (Bilici et. al., 2003; Schab & Trinh, 2004; Weber & Newmark,

2007; Sinn, 2008). Of the people using stimulant medications up to 30% experience side effects

(Weber & Newmark, 2007). Both stimulant and non-stimulant medications present with side

effects (PDR, 2008). The side effects vary based upon drugs but include: anorexia, decreased

appetite, weight loss, decreased growth, insomnia, nausea and vomiting, diarrhea, constipation,

dry mouth, blurred vision, vertigo, heart problems, suicidal tendencies, and many others,

including death on rare occasions (PDR, 2008). In addition, stimulant medications have a high

risk of dependence and abuse and are therefore classified as controlled substances which are

heavily regulated by prescriptions (Weber & Newmark, 2007; PDR, 2008). Non-stimulant drugs

are not dependence producing drugs, but the major side effect for concern regarding this class of

drugs is the increase in suicidal thoughts (PDR, 2008; Draughton & Kratochvil, 2009).

The use of medication has helped a number of individuals control their ADHD which is

why there has been such an extensive rise in their use. However, the side effects are a cause for

individuals to find safer methods to treat their ADHD. This is where research plays such a

valuable role in providing information about new techniques that can be utilized to help

individuals control their ADHD.

7

Behavioral Therapy

Behavioral therapy is another form of treatment used by some individuals to aid in

reducing the symptoms of ADHD. There are three widely accepted treatments addressing ADHD

which include medications (most commonly stimulant medication), behavioral therapy, and a

combination of both (American Academy of Pediatrics [AAP], 2001; Pelham et. al., 2005). A

guide to the treatment of ADHD including behavioral therapy can be observed in Appendix B.

There are a variety of aspects to behavioral therapy and most studies implement more than one

method in their treatment (Pelham et. al., 2005; Fabiano et. al., 2007; Daly, Creed,

Xanthopoulos, & Brown, 2007). Different approaches include parent training, classroom

intervention, academic intervention, and peer intervention all in order to teach behavioral

management skills to those involved with individuals diagnosed with ADHD and the individual

to better their productivity and decrease disruptive behaviors (Daly et. al., 2007). The goal of

behavioral therapy is to modify the social and physical environment in order to achieve a change

in behavior (AAP, 2001). A variety of techniques used are listed in Table 1. It is important to

note that behavioral therapy is different than psychological interventions which focus on altering

a child’s emotional status, and while seeming useful in relationship to ADHD psychological

interventions have proven mostly ineffective in clinical studies (AAP, 2001). Behavioral

modification (BMOD) alone and in combination with stimulant medications does show a

significant improvement for ADHD symptoms (Pelham et. al., 2005; Fabiano et. al., 2007). In

both studies reviewed by Pelham et. al. and Fabiano et. al., behavioral therapy intervention

consisted of a point system with daily or weekly rewards, daily report cards, time-outs, social

reinforcement or praise and other methods all within a classroom setting. The degree of BMOD

8

varied from no intervention to high intervention and also included some varying dosage of

stimulant medication ranging 15 to 60 mg or a placebo (Pelham et. al., 2005; Fabiano et. al.,

2007). The results of each of these studies showed the most effective treatment to be a

combination of BMOD with either medium or high doses of stimulant medications. BMOD

alone also showed a statistically significant reduction in most of the ADHD symptoms being

observed (Pelham et. al., 2005; Fabiano et. al., 2007). These are promising results in moving

toward alternative treatments for ADHD besides medication.

Table 1: Effective behavioral modification strategies for children with ADHD (AAP, 2001).

Dietary Treatment

Fatty Acid Supplementation

There is a growing body of evidence supporting the benefits of essential fatty acid (EFA)

supplementation in the treatment of ADHD related symptoms. Adequate levels of EFAs are

required for normal brain function (Richardson & Puri, 2002; Schnoll et al., 2003; Joshi, Lad,

Kale, Patwardhan, Mahadik, Patni, Chaudhary, Bhave, & Pandit, 2006; Sinn, 2008; Bélanger,

Vanesse, Spahis, Sylvestre, Lippé, l’Heureux, Ghadirian, Vanasse, & Levy, 2009; Schuchardt et

9

al., 2009). The human body is incapable of creating the EFAs, linoleic acid (LA) and alpha-

linoleic acid (ALA), necessary for the conversion to active forms of EFAs, eicosapentanoic acid

(EPA), docosahexaenoic acid (DHA), and arachidonic acid (AA), that the body needs, and

therefore, these must be consumed as part of the diet (Bélanger, 2009; Schuchardt et al., 2009).

In addition, the process of converting ALA to its active forms (EPA and DHA) is a slow and

inefficient process which drives toward a greater need for these long-chain polyunsaturated fatty

acids (LC-PUFAs) in the diet or as a supplement (Schuchardt et al., 2009). LC-PUFAs have a

variety of functions in the body and a close relationship to part of the brain that affects attention,

motivation and emotion (Schuchardt et al., 2009). A list of there functions can be seen in Table

2.

Table 2. Physiological functions of LC-PUFAs (AAP, 2001)..

There are differences seen in the metabolism of EFAs between males and females, most likely

due to the hormones testosterone and estrogen, and this is believed to be one reason more males

present with ADHD (Schuchardt et al., 2009). Also, conversion of EFAs to their active form is

affected by the minerals magnesium and zinc. A deficiency in these minerals results in decreased

activity of the enzyme responsible for converting LA to AA and ALA to EPA and DHA, and a

10

deficiency in EFAs has symptoms very similar to those of ADHD (Schuchardt et al., 2009). In a

study by Richardson and Puri (2002), 29 children were given either a supplement of fatty acids

(186mg EPA, 480 mg DHA, 42 mg AA, 60 IU vitamin E, 8 mg thyme oil, 864 mg cis-linoleic

-linoleic acid) or a placebo (olive oil) and were observed for 12 weeks

(Richardson & Puri, 2002). Baseline and final observations were made based on seven global

index scales and seven ADHD subscales and improvements of statistical significance were in

seven of the 14 total observation categories for those being supplemented compared to the

placebo. Improvement was observed in DSM Inattention, DSM Global Total, Conners’ Global

Total, DSM Hyperactivity-Impulsivity, Psychosomatics, Anxiousness/Shyness, and Cognitive

Problems (Richardson & Puri, 2002). A second study by Joshi et al. (2006), observed 30 subjects

with ADHD for 12 weeks and compared them to a normal, age equivalent control group (Joshi et

al., 2006). The 30 with ADHD were all given a supplement of flax oil (200 mg ALA) and 25 mg

of vitamin C. Their behavior was rated based on a parent rating scale determined by DSM-IV at

baseline and at the conclusion of the study. In addition, blood samples were taken from both

subjects and controls and compared at the baseline and conclusion of the study. At base line

there appeared to be no significant difference in blood fatty acid profiles despite the information

supporting that those with ADHD have altered or lower levels of EFAs. However, at the

conclusion of the study those being supplemented showed a significant increase in levels of AA,

DHA, and EPA compared to the control. Furthermore, a significant improvement was seen in all

aspects of behavior being evaluated on the parent rating scale (Joshi et al., 2006). Finally, in a

study done by Richardson in Sinn (2008), 117 children with developmental coordination disorder

were supplement with 552 mg EPA, 168 mg DHA, and 60 mg gamma linolenic acid or a placebo

11

(Sinn, 2008). Those being treated with the supplement displayed a significant decrease in ADHD

symptoms and improved in both reading and math compared to the placebo (Sinn, 2008). All of

these studies provide data showing the positive influence of EFA supplementation in the

treatment of ADHD. With additional studies on the effect of EFAs on the brain and ADHD the

potential for using EFA supplementation for ADHD treatment is a likely possibility especially

considering the recent nature of the studies preformed.

Zinc Supplementation

Zinc also plays an important role in brain functioning and development (Akhondzadeh,

Mohammadi & Khademi, 2004; Bilici et al., 2004; Arnold & DiSilvestro, 2005; Sinn, 2008).

Zinc is a coenzyme for a number of proteins responsible for brain function and structure and

includes direct and indirect effect impacts on protein synthesis, formation of LC-PUFAs,

formation of neurotransmitters, formation of active forms of vitamins, dopamine metabolism,

and other metabolic reactions (Arnold & DiSilvestro, 2005; Sinn, 2008). Zinc deficiency is

thought to impact those with ADHD because it is required for the production of melatonin, a

hormone responsible for the regulation of dopamine which is considered a possible causative

agent for ADHD (Akhondzadeh et al., 2004; Arnold & DiSilvestro, 2005; Sinn, 2008). In

addition, deficiencies in zinc can induce behavioral and sensory changes including altered

concentration, the jitters, and changes in taste and smell (Arnold & DiSilvestro, 2005).

Two zinc studies were reviewed to determine the impact of zinc supplementation on

ADHD. The first study was conducted by Bilici et al. (2004) and included 193 children (after

51.8% dropped out) diagnosed with ADHD (Bilici et al., 2004). The subjects were either

12

assigned a 150 mg supplement of zinc sulfate or a placebo and then assessed over a 12 week

period using an ADHD scale and blood samples to determine zinc and free fatty acid levels. In

the intervention group, a statistically important increase in zinc and free fatty acids was

determined compared to placebo. Also, scores improved on the ADHD scale for hyperactivity,

impulsivity, and socialization but not for concentration (Bilici et al., 2004). The study appeared

relatively inconclusive despite the discussion moving toward positive results. The second by

Akhondzaden et al. (2004) included 40 children with ADHD who were taking the stimulant

medication Methylphenidate (Akhondzadeh et al., 2004). The subjects were randomly assigned

to either treatment with 55 mg zinc sulfate in addition to their medication or a placebo group,

which only received methylphenidate. They were observed for six weeks and assessed based on

parent/teacher rating scales. The intervention group saw a statistically significant improvement

in both teacher and parent ratings over the placebo group (Akhondzadeh et al., 2004). While

both of the studies do show positive results for the supplementation of zinc they both appear to

have limitations that will be discussed later. Finally, the subjects in both studies reported

experiencing a metallic taste meaning that zinc supplementation is not side effect free

(Akhondzadeh et al., 2004; Bilici et al., 2004). However, this side effect is less harmful then the

many side effects noted in those taking stimulant medications.

Food Additives and Elimination Diets

Food is thought to play a major role in hyperactivity so there have been numerous studies

in the past 30 years looking at some form of elimination diet (Schnoll et al., 2003; Schab &

Trinh, 2004; McCann et al., 2007; Weber & Newmark, 2007; Sinn, 2008; Pelsser, Frankena,

13

Toorman, Savelkoul, Pereira, & Buitelaar, 2009). These have included, removing artificial food

colorings and additives (AFCAs), allowing only a select variety of foods, and eliminating

particular ingredients from the diet (Schnoll et al., 2003; Schab & Trinh, 2004; McCann et al.,

2007; Weber & Newmark, 2007; Sinn, 2008; Pelsser et al. 2009). Interest in AFCAs role in

hyperactivity and ADHD sparked when Dr. Feingold introduced his research over 30 years ago

using the Feingold Diet, which eliminated all artificial food colors, flavorings, and salicylates

among other things (Schnoll et al., 2003; Schab & Trinh, 2004; Weber & Newmark, 2007; Sinn,

2008). While he reported over 50% of his intervention group improved their behavior to reach

normal levels, the study was unable to be recreated with the same results and the reliability of

these results has been questioned ever since (Schnoll et al., 2003; Schab & Trinh, 2004; Weber

& Newmark, 2007; Sinn, 2008). In the mean time, researchers have tried to fill in the gaps by

completing studies of their own design that address the question of whether elimination diets can

affect hyperactivity.

A study by McCann et al. (2007) looks specifically at the effect of the food additives

yellow sunset, carmoisine, tartrazine, ponceau, and sodium benzonate, on the behavior of

children (McCann et al., 2007). The study was designed as a randomized, double blind, placebo

controlled, crossover where all subjects received treatment and placebo at some point in the

study. The participants were 137 three year olds and 130 eight/nine year olds. There were two

treatment interventions, the first was 65-69.98 mg of the previously mentioned additives and the

second was 75-107.4 mg of additives depending on age. The first week of the trial, the additives

being used in the study were removed from the diet to achieve a baseline. The additives were

14

also removed between active periods of treatment in order to prevent carry over from previous

treatment. During the intervention weeks (two, four and six) participants randomly received one

of the two AFCAs mixtures or the placebo. The children’s hyperactivity was scored based on a

global hyperactivity aggregate (GHA) that was composed of results from parent teacher ratings,

direct observations, and computer testing. While undergoing intervention both the three year old

and eight year old age groups experienced much higher levels of hyperactivity, but the three year

olds appeared to be the most affected by the AFCAs (McCann et al., 2007). This study definitely

shows a positive association between AFCAs and hyperactivity, but the children in this study

were not diagnosed with ADHD so the correlation is not clear.

In a study by Pelsser et al. (2009) 27 children who met the criteria for ADHD were

placed on a few foods diet in order to determine whether it would decrease symptoms of the

disorder (Pelsser et al. 2009). Of the 27 children, half were assigned to a treatment group which

consisted of a diet only containing rice, turkey, lamb, vegetables, fruit, margarine, vegetable oil,

tea, pear juice, and water. The other half was placed on a waitlist and acted as a control group

continuing with their normal diet. The intervention group was observed using a parent teacher

rating scale and an ADHD rating scale after a baseline was determined from normal eating

habits. Those involved in treatment exhibited improvement by 50% or more, and 11 out of 15, or

70%, no longer met the DSM-IV criteria for ADHD (Pelsser et al. 2009). This study shows great

potential for diet being used as a treatment for ADHD given that so many of the intervention

participants saw a reversal of ADHD.

15

Conclusion/Discussion of Limitations

After looking at a variety of research regarding the alternative treatment of ADHD it is

concluded that there is an accumulation of data supporting the efficacy and benefits from using

various alternative treatments. However, it is critical to address that while each of these studies

confirms a positive outcome, they each have some shortcomings or unfavorable aspects

influencing their results. This section will address each of the studies presented throughout this

review in order to give a more comprehensive idea about the usefulness of alternative theories.

There were some drawbacks that span the majority of the studies. First, every study that

was examined was short in duration. Nearly every study was less than four months in length.

While most of the research has provided positive results, the long-term efficacy of the various

treatments is widely unknown. In addition, the long-term side effects are also unclear. If an

improvement is seen in the short term, it would be expected to continue with further treatment,

but the point of maximum improvement is not known. Finally, to determine whether or not

treatment was effective, most studies included parent and/or teacher ratings, which are a highly

subjective method of observation and can have extremely varying results. The results from these

questionnaires should be evaluated keeping this in mind.

Medication

As stated previously, the use of medication is an accepted method of treatment for

ADHD (AAP, 2001). However, the problem here again is that medications do not help everyone

with ADHD and they have their fair share of side effects. Overall, the studies looking into the

16

effects of different medications contain a large subject base, display good methods, and over the

course of thirty years can by relied on to give accurate information regarding their benefits and

problems. The important thing to keep in mind is that stimulant medications are highly addictive

and need to be taken only under careful supervision of a physician to avoid abuse, but they play a

critical role in the treatment of ADHD for some individuals.

Behavioral Therapy

The first alternative treatment discussed was not diet related but was behavioral therapy.

Again, this is the only other accepted method for treating ADHD aside from medication (AAP,

2001). Behavioral therapy is a very difficult practice to measure because the degree of

intervention varies by individual and it is hard to make an identical plan for each individual. In

the two studies examined (Pelham et al. (2005) and Fabiano et al. (2007)), their weaknesses are

very similar so they will be addressed together. First, each has a relatively small study group and

the ratio of boys to girls is around 12:1, which is not an accurate representation of what is

observed outside of the research setting. In addition, neither study looked at the differences in

ethnicity/culture. This is an issue due to the fact that gender and ethnicity/culture can impact how

individuals may learn or respond to other forms of behavioral therapy not being represented in

the study. Next, the research was performed in a controlled classroom, which does not address

how the findings may transmit in a normal classroom setting. Additionally, these studies use a

crossover method where every child receives both treatment and placebo. This limits the study

outcomes because it does not address the lingering effects that either medication or behavioral

modification may imply. Overall, behavioral therapy definitely exhibits benefits in the treatment

17

of ADHD whether in addition to medication or on its own. This is why it is one of two generally

accepted treatment methods for ADHD.

Fatty Acid Supplementation

Three studies were used to examine the effects of fatty acid supplementation in the

treatment of ADHD. These included studies by, Richardson and Puri (2002), Joshi et al. (2006),

and Bélanger et al. (2009), and they too have limitation influencing their results. One weakness

that all three of these studies exhibited was their short duration. Another important problem to

address is that it is not known which fatty acids might play a role in reducing symptoms of

ADHD, and by choosing a placebo that contains any form of fatty acid may positively or

negatively affect the results. The studies by Richardson and Puri (2002), and Bélanger et al.

(2009), used placebo controls that included n-6 fatty acids while their treatment groups receive

n-3 (Richardson & Puri, 2002, & Bélanger et al., 2009). The problem here is that the effect of n-

6 on ADHD is unknown, so a better placebo could have been used. In the study by Joshi et al.

(2006), no placebo was included. This is not a good study method because it does not take into

account the placebo effect, which may lead to falsely positive results.

In the study by Richardson and Puri (2002), the children involved in the study were not

diagnosed with ADHD. While they did look at the effects of fatty acids on hyperactive behavior

they did not investigate the effects on those who actually have the disease. As discussed

previously, there may be fatty acid metabolism differences in those with ADHD. So, the results

of this study should be considered with some caution when applying to an ADHD population.

18

Finally, none of these studies take into account ethnicity and ethnicity may account for

differences in the metabolism of fatty acids and other factors.

While it appears that fatty acid supplementation may offer something in the way of

treatment for some individuals with ADHD, there are clearly limitations to the information

currently available. Given that deficiencies and metabolism are different for everyone, the

benefits from fatty acid supplementation may vary. However, given that there are no reported

side effects for fatty acid supplementation, it should be recommended that individuals with

ADHD try this alternative treatment since it has proven effective for some individuals.

Zinc Supplementation

Two original research studies were reviewed to determine the usefulness of zinc

supplementation for the treatment of ADHD. The first study by Bilici et al. (2004) actually

included a large study group of 400 children. However, about half of the participants dropped

out before the conclusion of the study and despite the dropout the 400 that started were all

included in some of the results, making it difficult to determine the usefulness of the outcome.

Also, the dosage of zinc given to the treatment group did not vary in strength, and was actually a

very high amount (150 mg). Therefore it is uncertain how different potencies could affect the

findings. Supplementation with zinc had two reported side effects in both studies, metallic taste

and nausea, which could be a reason for the large number of dropouts. In the second study by

Akhondzadeh et al. (2004) the study size was small including only 44 children. A major

downside to this study is that the results are only based on parent and teacher rating scales. As

19

discussed previously, these are primarily opinion based compared to objective data. This study

did not include blood serum level of zinc. So, the degree of change is not given. Finally, the

treatment of zinc was included with the stimulant medication methylphenidate which could not

clearly identify the effect of zinc supplementation alone. However, it is important to look at the

effect of both zinc supplementation with methylphenidate and without methylphenidate on the

symptoms of ADHD. As in the first study, there was only one dosage of zinc (55 mg) studied,

which may or may not be enough for different individuals.

Zinc supplementation did show improvements in some aspects of hyperactive behavior.

However, some individuals may discontinue this treatment due to the metallic taste and nausea it

causes. Therefore, it cannot be highly recommended as a treatment for ADHD. The results seem

relatively inconclusive.

Food Additives and Elimination Diets

Two original research studies were analyzed regarding food additives and elimination

diets along with one meta-analysis. The first study by McCann et al. (2007), included 300

children which is a considerably large study group. However, in this study the children did not

necessarily have ADHD. Rather, they were looking at the overall effects of food additives on

hyperactive behavior in children. Overall, this study displayed good methods. They included two

different doses of food additives and these varied based on age. There were a variety of

observation techniques that were compiled to determine the overall results. Finally, the study

includes other useful information such as socioeconomic status and parent education to

20

determine if external factors such as these plays a role in hyperactive behavior. Besides the fact

that not everyone had ADHD, the only other weakness noted was the small variance in ethnicity.

Almost every participant was white.

In the second study by Pelsser et al. (2009), only 27 children were included, but they

were all diagnosed with ADHD, which is considered a strength for this review. There was a

control group in this study but no placebo, and it would be difficult to implement a placebo given

the restriction in the diet. Everyone was aware of the intervention, causing a placebo effect.

Another issue with the degree of restriction is that it is not clear which foods are leading to

beneficial or detrimental effects. Finally, a diet with such limited food items may be hard to

maintain over a long period of time. This study was only for five weeks, which is a very short

time. Regardless of the weaknesses, it is quite remarkable that 70% of the participants on the

elimination diet no longer met ADHD criteria.

Both of these studies display strong evidence that elimination of certain foods can have a

major impact on hyperactive behavior. These are very promising results for using dietary

treatment to reduce symptoms of ADHD. However, this may have to be a very individualized

process making it more difficult to implement on a large scale. A strength of this study was the

improvement of symptoms with no side effects, and it should be considered as a possible

alternative treatment in the future.

Future Needs

All of the reviewed studies look at the efficacy of alternative treatments for ADHD.

21

However, this is an extremely controversial issue and much is still needed to determine how

various alternative methods can be used for wide scale treatment. It does appear that some time

in the future that dietary treatment may be an accepted method for reducing ADHD symptoms as

further studies are conducted.

First and foremost, before any true treatment where the mechanisms of action are truly

understood, it is vital that the causes of ADHD are determined. As of now, it is uncertain as to

what causes this mental disorder. This not only makes diagnoses difficult but treatment as well.

The more that is known about ADHD, the more that can be determined about treatment. With

advancing technology (genetic testing, brain scanning, nutrient levels, ect.) perhaps the cause of

this disorder will be discovered.

Studies of longer duration are greatly needed. All of the research reviewed was lacking in

treatment length, even for medications. This is very important in regards to long-term efficacy

and side effects. There is a need for long-term treatment for individuals with ADHD so the

effectiveness of treatment needs to be studied for longer periods of time.

Most research studies look at only one treatment method or treatment in combination

with stimulant medication. However, many people want to move away from treatment with

stimulant medications. This calls for studies that include a variety of combination treatments in

order to achieve the most beneficial results. In addition, varying strengths of medicine and

supplementations should also be looked at more closely in order to achieve the most

advantageous results with minimal doses and side effects.

22

Coexisting factors are largely ignored in the studies reviewed for this paper. Individuals

with conditions such as tourrettes, autism, mental retardation, anxiety, and others were excluded

from the research studies. As a result, there are a lot of unknowns in regards to treatment of

ADHD and co-morbid disorders and studies in the area are needed.

23

References

Akhondzadeh, S., Mohammadi, M., & Khademi, M. (2004). Zinc sulfate adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: A double blind and randomized trial. BioMed Central Psychiatry, 4. Retrieved November 1, 2009 from http://www.biomedcentral.com/1471-244X/4/9.

American Academy of Pediatrics [AAP] (2001). Clinical practice guidelines: treatment of the

school-aged child with attention-deficit/hyperactive disorder. Pediatrics, 108 (4), 1033-1044.

American Psychiatric Association [APA] (2000). Diagnostic and statistical manual of mental

disorders, fourth edition [DSM-IV]. Washington DC: American Psychiatric Association. Arnold, L.E., & DiSilvestro, R.A., (2005). Zinc and attention-deficit/hyperactivity disorder.

Journal of Child and Adolescent Psychopharmacology, 15(4), 619-627. Bélanger, S.A., Vanesse, M., Spahis, S., Sylvestre, M., Lippé, S., l’Heureux, F., Ghadirian, P.,

Vanasse, C., & Levy, E. (2009). Omega-3 fatty acid treatment of children with attention-deficit hyperactivity disorder: A randomized, double-blind, placebo-controlled study. Pediatric Child Health, 14 (2), 89-98.

Bilici, M., Yildirim, F., Kandil, S., . . ., Ülgen, M.,

Yildiran, A., & Asku, H. (2004). Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Progress in Neuro-Psychophamacological & Biological Psychiatry, 28, 181-190.

Centers for Disease Control and Prevention (2009). Attention deficit/hyperactivity disorder

(ADHD). Retrieved October 15, 2009, from http://www.cdc.gov/ncbddd/ADHD/.

Daly, B.P., Creed, T., Xanthopoulos, M., & Brown, R.T. (2007). Psychosocial treatments for children with attention deficit/hyperactivity disorder. Neuropsychological Review, 17, 73-89.

Draughton, Joan M., & Kratochvil, Christopher J. (2009) Review of ADHD pharmacotherapies:

advantages, disadvantages, and clinical pearls. The Journal of the American Academy of Child and Adolescent Psychiatry, 48(3).

Fabiano, G.A. Pelham, W.E., Gnagy, E.M., Fabiano, G.A., Burrows-MacLean, L., Coles, E.K., Chacko, A., Wymbs, B.T., Walker, K.S., Arnold, F., Garefino, A., Keenan, J., Onyango, A.N., Hoffman, M.T., Massetti, G.M., & Robb, J.A. (2007). The single and combined

24

effects of multiple intensities of behavioral modification and methylphenidate for children with attention deficit hyperactivity disorder in a classroom setting. School Psychology Review, 36 (2), 195-216.

Joshi, K., Lad, S., Kale, M., Patwardhan, B., Mahadik, S.P., Patni, B., Chaudhary, A., Bhave, S., & Pandit, A. (2006). Supplementation with flax oil and vitamin C improves the outcome of attention deficit hyperactivity disorder (ADHD). Prostoglandins, Leukotrienes and Essential Fatty Acids, 74, 17-21.

Laughren, T.P. (2009). INTUNIV™ (guanfacine) extended-release tablets. U.S. Food and Drug Administration Center for Drug Evaluation and Research. Retrieved November 10, 2009 from http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022037lbl.pdf.

McCann, D., Barrett, A., Cooper, A., Crumpler, D., Dalen, L., Grimshaw, K., Kitchin, E., Lok. K., Porteous, L., Prince, E., Sonuga-Barke, E., O Warner, J., & Stevenson, J. (2007).!Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet, 370, 1560-1567.

Multimodal Treatment Study of ADHD Cooperative Group (2004). National Institute of Mental

Health multimodal treatment study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Journal of Pediatrics, 113(4).

National Institute of Mental Health [NIMH] (2008). Attention deficit hyperactivity disorder (ADHD). Retrieved October 15, 2009, from http://www.nimh.nih.gov/health/ publications/attention-deficit-hyperactivity-disorder/complete-index.shtml.

Olfsen, Mark, Gameroff, Marc J., Marcus, Steven C., & Jensen, Peter S. (2003). National trends in the treatment of attention deficit hyperactive disorder. American Journal of Psychiatry, 160, 1071-1077.

Paston, P. N. & Reuban, C.A. (2008). Diagnosed attention deficit hyperactivity disorder and learning disabilities: United States 2004-2006. National Center for Health Statistics. Vital and Health Statistics, 10(237).

Pelham, W. E., Burrows-MacLean, L., Gnagy, E.M., Fabiano, G.A., Coles, E.K., Tresco, K.E., Chacko, A., Wymbs, B.T., Wienke, A.L., Walker, K.S. & Hoffman, M.T. (2005). Transdermal methylphenidate, behavioral, and combined treatment for children with ADHD. Experimental and Clinical Psychopharmacology, 13(2), 111-126.

Pelsser, L.M., Frankena, K., Toorman, J., Savelkoul, H.F.J., Pereira, R.R., & Buitelaar, J.K. (2009). A randomized controlled trial into the effects of food on ADHD. European Child & Adolescent Psychiatry, 18(1), 12-19.

25

Physicians’ Desk Reference Inc. [PDR] (2008). Physicians’ Desk Reference 2009. Oradell, N.J.: Medical Economics Co.

Richardson, A.J., & Puri, B.K. (2002). A randomized double-blind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning difficulties. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 26, 233-239.

Schab, David, & Trihn, Nhi-Ha (2004). Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind placebo-controlled trials. Developmental and Behavioral Pediatrics, 25 (6), 423-435.

Schnoll, Roseanne, Burshteyn, Dmitry, & Cea-Aravena, Juan (2003). Nutrition in the treatment of attention-defecit hyperactivity disorder: a neglected but important aspect. Applied Psychophysiology and Biofeedback, 28 (1), 63-75.

Schuchardt, Jan Phillip, Huss, Michael, Strauss-Grabo, Manuela, & Hahn, Andreas (2009). Significance of long-chain polyunsaturated fatty acids (PUFAs) for the development and behaviour of children. European Journal of Pediatrics.

Shire US Inc. (2009). Intuniv (guanfacine) extended-release tablets: new nonscheduled treatment for ADHD. Retrieved October 29, 2009 from http://www.intuniv.com/consumer/new-treatment-for-adhd.aspx.

Sinn, Natalie (2008). Nutritional and dietary influences on attention deficit hyperactivity disorder. Nutrition Reviews, 66 (10), 558-568.

Stevenson, Jim (2006). Dietary influences on cognitive development and behaviour in children. Proceeding of the Nutrition Society, 65, 361-365.

Taylor, Eric (2008). Developing ADHD. The Journal of Child Psychology and Psychiatry, 50 (1-2), 126-132.

USA Today (2009). New findings raise questions about use of ADHD drugs. USA Today. Retrieved October 20, 2009 from http://web.ebscohost.com.ezproxy.lib.calpoly.edu:2048/ehost/detail?vid=2&hid=103&sid=eaeeff35-0b3f-4ac9-996a-5d63d559551e%40sessionmgr111&bdata=JnNpdGU9Z Whvc3QtbGl2ZQ%3d%3d#db=afh&AN=J0E205432560209.

Weber, Wendy, & Newmark, Sanford (2007). Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatric Clinics of North America, 54, 983-1006.

Wiles, NJ., Northstone, K., Emmett, P. & Lewis, G. (2009). ‘Junk food’ and childhood behavioural problems: results from ALSPAC cohort. European Journal of Clinical

26

Nutrition, 63, 491-498.

Appendix A: DSM-IV Diagnostic Criteria for ADHD I. Either A or B: A) Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level: Inattention 1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 2) Often has trouble keeping attention on tasks or play activities. 3) Often does not seem to listen when spoken to directly. 4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). 5) Often has trouble organizing activities. 6) Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). 7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils,

books, or tools). 8) Is often easily distracted. 9) Is often forgetful in daily activities. B) Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: Hyperactivity 1) Often fidgets with hands or feet or squirms in seat. 2) Often gets up from seat when remaining in seat is expected. 3) Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). 4) Often has trouble playing or enjoying leisure activities quietly. 5) Is often "on the go" or often acts as if "driven by a motor". 6) Often talks excessively. Impulsivity 7) Often blurts out answers before questions have been finished. 8) Often has trouble waiting one’s turn. 9) Often interrupts or intrudes on others (e.g., butts into conversations or games). II. Some symptoms that cause impairment were present before age 7 years. III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home). IV. There must be clear evidence of significant impairment in social, school, or work functioning.

27

V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

1) ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months 2) ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 3) ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

28

Appendix B: Treatment Guideline for ADHD