Attention-deficit hyperactivity disorder (ADHD) and attention-deficit disorder (ADD) refer to a range of problem behaviours generally associated with poor attention span. In general, ADHD is a persisting disorder, with many children continuing to have significant difficulties in adulthood. ADHD is thought to affect about 3–9% of school-age children and young people in the UK, and about 2% of adults worldwide.
Attention-deficit hyperactivity disorder (ADHD) is an increasingly common condition and associated behavioural issues can easily be blamed on the ‘condition’, however there is much that can be done to support a child with ADHD. Natural therapies can help to retrain a child in how they think and act in certain situations, and diet can play an important role in providing fatty acids, amino acids and other essential nutrients to support proper functioning of the brain. Supplements may also offer the much-needed additional support for children who, for various reasons, may be deficient in specific nutrients.
Core symptoms include an inability to remain attentive or to concentrate, the tendency to become very easily distracted, as well as hyperactivity and impulsivity. The activity is sometimes characterised by fidgeting and general restlessness; the impulsivity can present itself as inappropriate speech (i.e. blurting out words when it is not suitable to do so) or hitting out.
Children with ADHD may be unable to sit still or pay attention in the classroom, for example, which can often lead to problems with academic achievement, in terms of both language and literacy skills, as well as a reduced ability to cope with certain social situations.
A diagnosis of ADHD is given to children who consistently present these symptoms. It is perfectly normal for a child to display one or more of these symptoms on occasion, and therefore infrequent misbehaviour does not warrant a diagnosis of ADHD.
The causes of ADHD are still somewhat unclear, although it is believed that a combination of genetic, environmental and dietary factors all contribute to risk.
In order to determine the genetic factors, scientists will often use twin studies to evaluate genetic links to many disorders and diseases. For example, if one identical twin has ADHD, it is more likely that the other will have, or later develop, symptoms as well. Whilst this genetic link is becoming clearer, it is unlikely that one gene alone is responsible, but that ADHD is caused in part by several genes, which all make a small contribution to the onset of this disorder.
ADHD is a condition that falls within a class of disorders termed ‘neurodevelopmental disorders’. Simply put, neurodevelopmental disorders are due to an impairment of the growth and development of the brain or central nervous system. Some of the genes that are thought to contribute to the development of ADHD are those that control certain types of neurotransmitters (chemicals involved in sending messages between nerve cells in the brain). Defects in one or more of these genes may contribute to a greater risk of developing ADHD. Two well-studied genes are those that control the production of dopamine and noradrenaline, levels of which are often low in ADHD. Both of these neurotransmitters are heavily involved in behaviour. It’s not all about our genes, of course. It appears that people with ADHD can have abnormalities in certain areas of the brain that control activities associated with self-control and result in the core symptoms of ADHD – hyperactivity, impulsiveness and inattention. To summarise, it is thought that an imbalance of some of the neurotransmitter chemicals in the brain and changes in the structure of areas of the brain play a key role in ADHD.
Environmental factors may also play a role in the development of ADHD. These are factors that are associated with a higher risk of ADHD, but do not involve our genes – in other words, not an inherited increased disposition. Environmental factors in ADHD could include complications during pregnancy, at birth or shortly after birth. Increased exposure to toxic chemicals is also thought to play a role in ADHD risk: smoking, drinking alcohol or use of drugs during pregnancy, or even high levels of stress whilst pregnant, can all affect the development of the baby’s brain.
Diet is not considered to be a direct cause of ADHD, though an inadequate diet may be an aggravating factor of the symptoms. Dietary needs vary significantly for one child compared to another, so dietary requirements of certain nutrients may be much higher for children with ADHD to support their needs. Understanding common deficiencies and nutritional needs of children with ADHD is therefore important when looking for ways to improve their symptoms.
Dietary changes can result in a significant reduction of symptoms in children with ADHD. The brain requires adequate nutrition to be able to function properly, so ensuring that a child with ADHD has optimal nutrition should be a key priority.
Amino acids are the building blocks of protein and help to support the synthesis and function of the neurotransmitters. As children with ADHD have low levels of neurotransmitters such as dopamine and serotonin, including a protein-rich diet from foods such as meat, fish, eggs, lentils, beans, cheese, yoghurt, nuts and seeds may help to support learning, motivation and memory. Try to include a source of protein with each meal.
Omega-3 fatty acids
Blood levels of omega-3 fatty acids, particularly EPA, are particularly low in children with ADHD. The brain requires omega-3 fatty acids to support synthesis and function of neurotransmitters, so an omega-3 deficiency may cause additional problems in those with ADHD. As these fatty acids are also required for structure and development of the brain, low levels of fatty acids in children with ADHD also correlates with a reduced volume of areas in the brain responsible for controlling memory, movement, learning and attention. EPA is an omega-3 fatty acid found in oily fish such as mackerel, herring and anchovies. It may also be beneficial to include other types of omega-3 fatty acid from nuts and seeds.
Nutrient-dense foods for the brain
Certain vitamins and minerals including zinc, magnesium and vitamin B6 are particularly important for the function of the brain, supporting neurotransmitter function, balancing mood and supporting sleep. Zinc-rich foods include beef, wheat germ and pumpkin seeds and pure cocoa powder. Good sources of magnesium include nuts and seeds, dark green leafy vegetables, beans and lentils. Vitamin B6 can be found in fish, nuts, seeds and spices.
Probiotics and prebiotics
If your child complains about digestive symptoms such as bloating and discomfort, this may be due to undigested food passing through the intestinal wall, resulting in an immune response. Such an issue is very common in children with neurodevelopmental problems and can be helped by supporting the balance of bacteria in the gut. Probiotics found in live yoghurts and supplements can increase the beneficial bacteria, which in turn support healthy digestion and immune function. Sugar may have the opposite effect by feeding harmful bacteria, increasing symptoms of bloating. In addition to probiotics, prebiotics found in foods such as onions, garlic, artichoke and asparagus help to feed the beneficial bacteria.
Foods to avoid
Certain foods have been shown to aggravate symptoms of ADHD in some children, so it may be worth doing a trial period excluding these foods and recording symptoms.
Sugar and refined carbohydrates, such as foods containing white flour, can cause blood sugar to rise and then fall very quickly, leading to the release of stress hormones, high and low energy levels and increased inflammation. Such changes in the body can lead to mood alterations and reduced concentration. Refined carbohydrates are also low in nutrients and can influence behaviour and anxiety. With so many negative effects of refined carbohydrates, it may be beneficial for the majority of children to include lower glycaemic index (GI) carbohydrates such as whole grains, vegetables and pulses, which release energy more slowly, thereby avoiding those detrimental rapid highs and lows.
Although whole grains may be fine for most children, it must be considered that some may have some sensitivity to gluten, found in wheat, barley and rye. Casein is another common allergen found in milk, which can cause digestive problems in some children. Not only do these proteins cause digestive discomfort for some individuals, it is considered that as a result of undigested gluten and casein crossing the blood barrier, opioid peptides can form, resulting in emotional and behavioural changes. This effect is only evident in a small proportion of children, so only try cutting these foods out of your child’s diet if other dietary changes have not helped with their condition.
It is generally a good idea to avoid anything artificial added to foods. Synthetic food colour additives, in particular, have been shown to affect some children with ADHD, especially those who are prone to other food allergies. Eating fresh real food is the best way to avoid such ingredients.
The omega-3 fatty acid EPA is the most important supplement to consider for neurodevelopmental conditions, as clinical trials have consistently shown EPA to improve ADHD symptoms. Fatty acids are fundamental to our health and wellbeing as they are essential constituents of every living cell in the human body.
Omega-3 EPA derived from oily fish and omega-6 GLA derived from virgin evening primrose oil help to release hormone-like substances in the body, which reduce inflammation. Certain types of omega-6 fatty acids can lead to inflammation if taken in excess, but the combination of omega-6 GLA and omega-3 EPA, with a high ratio of EPA to GLA, is powerfully anti-inflammatory. High levels of inflammation in the body can cause significant damage to cells and can negatively impact various aspects of our health, so keeping inflammation levels low is important, particularly for brain health.
The omega-3 fatty acids EPA and DHA are also essential for proper communication between the cells, thus deficiencies could impact the functions of neurotransmitters such as dopamine, which, consequently, can affect attention and concentration – both being fundamental factors in ADHD. As low omega-3 levels are associated with low levels of dopamine, supplementing with EPA may improve behavioural and learning difficulties associated with the condition by increasing dopamine levels. Studies support this approach, with results suggesting that by supplementing the diet of a child with ADHD with purified fish oil (specifically EPA), improvements are seen in relation to inattention, hyperactivity and impulsivity, when compared to a placebo.
Omega-3 EPA or DHA?
EPA and DHA are both important fatty acids required for brain health, but increasing evidence shows that they have distinct roles in brain function. DHA is the dominant omega-3 fat in the brain and thus, historically, assumptions were made about DHA being most important for brain function. In recent years, however, research suggests that EPA is the key omega-3 fat for cognition and function because it supports neurotransmitter production and cell communication, whilst DHA is essential for brain structure and development.
Recent meta-analyses show that it is EPA, rather than DHA, that is the most effective omega-3 fatty acid in supporting the symptoms of ADHD.
Focusing on EPA as the active ingredient within fish oils that supports cognition has helped clarify why several studies using fish oil in ADHD have failed to show statistically significant benefits. Most fish oil supplements targeted for brain function have been formulated to contain rich amounts of DHA (unfortunately, based on out-dated understanding). It is therefore not surprising that such confusion surrounds the effectiveness of fish oils in ADHD. Those studies where EPA is the dominant fatty acid given to children with ADHD, however, do show extremely beneficial and statistically significant benefits across a variety of measures.
Recent studies also show that the addition of the anti-inflammatory omega-6 fatty acid GLA found in evening primrose oil may further enhance the actions of EPA, offering further potential for a natural treatment regime. Whilst there are several fish oil supplements containing EPA omega-3 and GLA omega-6, most of these are still standard strength fish oils with a higher ratio of DHA and insufficient doses of EPA. The concentration and dose of EPA in any omega-3 fatty acid supplement is paramount for the effectiveness of treatment in ADHD. Standard fish oil provides only 18% concentration of EPA, whereas supplements offering 70% concentration and above offer much more active doses. The higher the ratio of EPA to DHA, the more effective the supplement is likely to be for ADHD.
Fatty acid deficiencies in children with ADHD
Some studies have found that children with ADHD have lower levels of long-chain fatty acids, including the omega-3 EPA, than other children. To explain such deficiencies, it is suggested that individuals with ADHD may simply not obtain sufficient levels from food, or otherwise they may lack the enzyme that converts short-chain fatty acids from foods we eat (found in plant-based foods such as nuts and seeds) to the important anti-inflammatory fatty acids EPA and DHA. To support the functioning of these enzymes, zinc, magnesium and vitamin B6 are required. Another hypothesis is that the turnover of long-chain fatty acids EPA and DHA is elevated and the body cannot replenish them at a fast enough rate. Direct supplementation is therefore a sensible way to overcome both possibilities: either an inability to produce them physiologically or an increase in their turnover necessitates higher intake of these essential nutrients.
The evidence for combined EPA and GLA supplementation
A double-blind, randomised, placebo-controlled clinical trial published in the Journal of Child Neurology used our patented supplement Vegepa E-EPA 70 and demonstrated positive outcomes across 10 out of 11 measures in children with ADHD. The recruited 94 children were clinically diagnosed with ADHD were all resistant to treatment with methylphenidate, commonly known as methylphenidate. Having taken methylphenidate for six months or more, together with standard behaviour therapy, the children had no reported improvement in behaviour or academic learning.
These treatment-resistant children were then randomly assigned to receive supplementation with either two daily capsules of Vegepa E-EPA 70 (providing 560 mg of marine EPA and 18 mg of GLA) or a placebo. All children continued to take methylphenidate daily. Of those children taking Vegepa E-EPA 70, 81.2% showed statistically significant improvements in restlessness, 87.5% in aggressiveness and 70.8% in anger control. Furthermore, 83.3% showed statistically significant improvements in cooperation with parents and teachers, with 77.1% of children showing improved educational functioning and academic performance.
Whilst some improvements were observed within three months, the most marked improvements were observed after six months of supplementation, demonstrating the critical importance of length of treatment regime. Overall, however, the study reported significant improvements in 10 out of 11-item subscales and found Vegepa E-EPA 70 to be effective in reducing both behavioural and educational difficulties in ADHD-diagnosed children unresponsive to methylphenidate alone.
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