It is important for mental health professionals to be familiar with emerging research findings about widely used complementary and alternative medicine (CAM) treatments of ADHD in order to provide patients with accurate information on efficacy, safety, and appropriate use.
A high percentage of children and adults who have been given a diagnosis of ADHD use alternative therapies alone or in combination with conventional pharmacological treatment.1 More than half of parents of children with ADHD treat their children’s symptoms using 1 or more CAM therapies, most commonly vitamins, dietary changes, and expressive therapies; yet only about 10% disclose use of such nonpharmacological therapies to their child’s pediatrician.2 Most nonpharmacological therapies used to treat ADHD are supported by limited evidence; however, as many as 80% of patients who use herbal preparations and other natural products regard these therapies as the primary treatment of their symptoms.2
Stimulant medications, including dextroamphetamine, methylphenidate, and related compounds, are the most widely used treatments of ADHD. The nonstimulant atomoxetine has less potential for abuse but also may be less effective than stimulants.3 SSRIs and other antidepressants are used with varying degrees of success. Behavioral modification aimed at rewarding desirable behavior and extinguishing disruptive or inappropriate behavior continues to be a mainstay of conventional treatment. Psychotherapy and psychosocial support help reduce anxiety and feelings of loss of control that frequently accompany ADHD. It is estimated that ADHD is correctly diagnosed and treated in fewer than one-fifth of adults, which results in significant social and occupational morbidity.
Limitations and risks of conventional treatment
Long-term amphetamine use in childhood is associated with delays in normal development.4 One-third of individuals of all ages who take stimulants for ADHD report significant adverse effects, including insomnia, decreased appetite, and abdominal pain.5 Cases of stimulant-induced psychosis have also been reported.6 Stimulants and other conventional treatments of ADHD in adults are probably only half as effective as they are in children.4
Adverse effects of nonstimulant drugs used to treat ADHD include hypertension, decreased appetite, nausea, fatigue, liver toxicity, insomnia, and seizures. A meta-analysis of 6 controlled trials concluded that stimulant therapy started in childhood reduces the risk of subsequent substance abuse by as much as one-half. In contrast, stimulants started in adolescence or adulthood increase the risk of future substance abuse.7 Nonstimulant medications and extended-release stimulants are less likely to be abused.8
As many as 80% of patients who use herbal preparations and other natural products regard these therapies as the primary treatment of their [ADHD] symptoms.
Dietary changes. Early studies on a highly restrictive diet that eliminates all processed foods reported promising findings in children with ADHD9; however, a review of controlled studies failed to support these findings.10 The oligoantigenic diet (OAD) is a highly restrictive elimination diet in which food colorings and additives as well as dairy products, sugar, wheat, corn, citrus, eggs, soy, yeast, nuts, and chocolate are eliminated. Numerous studies on the OAD reported significant reductions in hyperactivity in children with ADHD when specific food items were eliminated from the diet using an open-label protocol.11 In most studies, symptoms recurred when children were subsequently challenged with the eliminated food item following a placebo-controlled protocol. The significance of findings on elimination diets is limited by study design flaws, including heterogeneity of patient populations, absence of standardized outcome measures, high dropout rates and, in some studies, nonblinded raters.
Although research findings are mixed, sugar has long been suspected as an underlying causative factor in ADHD. In a 9-week placebo-controlled study, children without ADHD who were randomized to diets high in sucrose, aspartame, or saccharin showed no differences in behavior.12 The expectations of parents may bias the perceptions of their children’s behavior following the consumption of large quantities of sugar. In one controlled trial, mothers who believed their child had eaten sugar were more likely to label their child’s behavior as hyperactive.13
In their comprehensive review of nonpharmacological therapies for ADHD, Weber and Newmark14 remarked that the study design did not adequately control for fruits, juices, or other dietary sources of sugar and suggested that future studies should not focus primarily on sugar but rather on a possible link between high-glycemic-index foods and hyperactivity. Large prospective controlled studies on dietary restrictions as therapeutic interventions in ADHD have been elusive because of difficulties in controlling eating behavior in both children and adults.15
1. Bussing R, Zima BT, Gary FA, Garvan CW. Use of complementary and alternative medicine for symptoms of attention-deficit hyperactivity disorder. Psychiatr Serv. 2002;53:1096-1102.
2. Chan E, Rappaport LA, Kemper KJ. Complementary and alternative therapies in childhood attention and hyperactivity problems. J Dev Behav Pediatr. 2003; 24:4-8.
3. Findling RL. Evolution of the treatment of attentiondeficit/hyperactivity disorder in children: a review. Clin Ther. 2008;30:942-957.
4. Newcorn JH,Weiss M, Stein MA. The complexity of ADHD: diagnosis and treatment of the adult patient with comorbidities. CNS Spectr. 2007;12(8, suppl 12):1-14.
5. Schachter HM, Pham B, King J, et al. How efficacious and safe is short-acting methylphenidate for the treatment of attention-deficit disorder in children and adolescents? A meta-analysis. CMAJ. 2001;165: 1475-1488.
6. Berman SM, Kuczenski R, McCracken JT, London ED. Potential adverse effects of amphetamine treatment on brain and behavior: a review. Mol Psychiatry. 2009;14:123-142.
7. Faraone SV, Wilens T. Does stimulant treatment lead to substance use disorders? J Clin Psychiatry. 2003;64(suppl 11):9-13.
8. Upadhyaya HP. Managing attention-deficit/hyperactivity disorder in the presence of substance use disorder. J Clin Psychiatry. 2007;68(suppl 11):23-30.
9. Feingold B. Why Your Child Is Hyperactive. New York: Random House; 1975.
10. Wender EH. The food additive–free diet in the treatment of behavior disorders: a review. J Dev Behav Pediatr. 1986;7:35-42.
11. Rojas NL, Chan E. Old and new controversies in the alternative treatment of attention-deficit hyperactivity disorder. Ment Retard Dev Disabil Res Rev. 2005;11:116-130.
12. Wolraich ML, Lindgren SD, Stumbo PJ, et al. Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children. N Engl J Med. 1994;330:301-307.
13. Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interactions. J Abnorm Child Psychol. 1994;22:501-515.
14.Weber W, Newmark S. Complementary and alternative medical therapies for attention-deficit/hyperactivity disorder and autism. Pediatr Clin North Am. 2007;54:983-1006.
15. Cormier E, Elder JH. Diet and child behavior problems: fact or fiction? Pediatr Nurs. 2007;33:138-143.adults with attention deficit hyperactivity disorder. J Clin Psychol. 2005;61:621-625.
16. Butnik SM. Neurofeedback in adolescents and adults with attention deficit hyperactivity disorder. J Clin Psychol. 2005;61:621-625.
17. Monastra VJ, Monastra DM, George S.The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attentiondeficit/hyperactivity disorder. Appl Psychophysiol Biofeedback. 2002;27:231-249.
18. Monastra VJ, Lynn S, Linden M, et al. Electroencephalographic biofeedback in the treatment of attention-deficit/hyperactivity disorder. Appl Psychophysiol Biofeedback. 2005;30:95-114.
19. Ramirez PM, Desantis D, Opler LA. EEG biofeedback treatment of ADD: a viable alternative to traditional medical intervention? Ann N Y Acad Sci. 2001;931:342-358.
20. Bekaroglu M, Aslan Y, Gedik Y, et al. Relationships between serum free fatty acids and zinc, and attention deficit hyperactivity disorder: a research note. J Child Psychol Psychiatry. 1996;37:225-227.
21. Richardson AJ, Puri BK. The potential role of fatty acids in attention-deficit/hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2000;63:79-87.
22. Voigt RG, Llorente AM, Jensen CL, et al. A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder. J Pediatr. 2001;139:189-196.
23. Stevens LJ, Zentall SS, Deck J, et al. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. Am J Clin Nutr. 1995;62:761-768.
24. Sinn N, Bryan J. Effect of supplementation with polyunsaturated fatty acids and micronutrients on learning and behavior problems associated with child ADHD. J Dev Behav Pediatr. 2007;28:82-91.
25. Richardson AJ, Puri BK. A randomized doubleblind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning difficulties. Prog Neuropsychopharmacol Biol Psychiatry. 2002;26:233-239.
26. Sorgi PJ, Hallowell EM, Hutchins HL, Sears B. Effects of an open-label pilot study with high-dose EPA/DHA concentrates on plasma phospholipids and behavior in children with attention deficit hyperactivity disorder. Nutr J. 2007;6:16. http://www.nutritionj. com/content/pdf/1475-2891-6-16.pdf. Accessed April 29, 2010.
27. Lyon MR, Cline JC,Totosy de Zepetnek J, et al. Effect of the herbal extract combination Panax quinquefolium and Ginkgo biloba on attention-deficit hyperactivity disorder: a pilot study. J Psychiatry Neurosci. 2001;26:221-228.
28. Trebatická J, Kopasová S, Hradecná Z, et al.Treatment of ADHD with French maritime pine bark extract: Pycnogenol. Eur Child Adolesc Psychiatry. 2006;15:329-335.
29. Nathan PJ, Tanner S, Lloyd J, et al. Effects of a combined extract of Ginkgo biloba and Bacopa monnieri on cognitive function in healthy humans. Hum Psychopharmacol. 2004;19:91-96.
30. Yorbik O, Ozdag MF, Olgun A, et al. Potential effects of zinc on information processing in boys with attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2008;32:662-667.
31. Arnold LE, Bozzolo H, Hollway J, et al. Serum zinc correlates with parent- and teacher-rated inattention in children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2005;15:628-636.
32. Bilici M, Yildirim F, Kandil S, et al. Double-blind, placebo-controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2004;28:181-190.
33. Akhondzadeh S, Mohammadi MR, Khademi M. Zinc sulfate as an adjunct to methylphenidate for the treatment of attention deficit hyperactivity disorder in children: a double blind and randomized trial [ISRCTN64132371]. BMC Psychiatry. 2004;4:9.
34. Arnold LE, DiSilvestro RA. Zinc in attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2005;15:619-627.
35. Konofal E, Lecendreux M, Arnulf I, Mouren MC. Iron deficiency in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2004;158:1113-1115.
36. Oner O, Alkar OY, Oner P. Relation of ferritin levels with symptom ratings and cognitive performance in children with attention deficit-hyperactivity disorder. Pediatr Int. 2008;50:40-44.
37. Sever Y, Ashkenazi A, Tyano S, Weizman A. Iron treatment in children with attention deficit hyperactivity disorder: a preliminary report. Neuropsychobiology. 1997;35:178-180.
38. Van Oudheusden LJ, Scholte HR. Efficacy of carnitine in the treatment of children with attentiondeficit hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2002;67:33-38.
39. Arnold LE,Amato A, Bozzolo H, et al. Acetyl-L-carnitine (ALC) in attention-deficit/hyperactivity disorder: a multi-site, placebo-controlled pilot trial. J Child Adolesc Psychopharmacol. 2007;17:791-802.
40. Torrioli MG, Vernacotola S, Peruzzi L, et al. A double-blind, parallel, multicenter comparison of Lacetylcarnitine with placebo on the attention deficit hyperactivity disorder in fragile X syndrome boys. Am J Med Genet A. 2008;146:803-812.
41. Coulter MK, Dean ME. Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic disorder. Cochrane Database Syst Rev. 2007;(4):CD005648.
42. Frei H, Everts R, von Ammon K, et al. Randomised controlled trials of homeopathy in hyperactive children: treatment procedure leads to an unconventional study design. Experience with open-label homeopathic treatment preceding the Swiss ADHD placebo controlled, randomised, double-blind, cross-over trial. Homeopathy. 2007;96:35-41.
43. Haffner J, Roos J, Goldstein N, et al. The effectiveness of body-oriented methods of therapy in the treatment of attention-deficit hyperactivity disorder (ADHD): results of a controlled pilot study [in German]. Z Kinder Jugendpsychiatr Psychother. 2006;34:37-47.
44. Jensen PS, Kenny DT. The effects of yoga on the attention and behavior of boys with attention-deficit/ hyperactivity disorder (ADHD). J Atten Disord. 2004;7:205-216.
45. Khilnani S, Field T, Hernandez-Reif M, Schanberg S. Massage therapy improves mood and behavior of students with attention-deficit/hyperactivity disorder. Adolescence. 2003;38:623-638.
46. Kuo FE, Taylor AF. A potential natural treatment for attention-deficit/hyperactivity disorder: evidence from a national study. Am J Public Health. 2004;94:1580-1586.
47. Canu W, Gordon M. Mother nature as treatment for ADHD: overstating the benefits of green. Am J Clin Health. 2005;95:371.
48. Lake J. Attention-deficit and hyperactivity disorder (ADHD). In: Sarris J, Wardle J, eds. Clinical Naturopathy: An Evidence-Based Guide to Practice. Sydney: Elsevier Australia; 2010:693-706.
49. Rowe KS, Rowe KJ. Synthetic food coloring and behavior: a dose response effect in a double-blind, placebo-controlled, repeated-measures study. J Pediatr. 1994;125(5, pt 1):691-698.
50. Dengate S, Ruben A. Controlled trial of cumulative behavioural effects of a common bread preservative. J Paediatr Child Health. 2002;38:373-376.
51. Fuchs T, Birbaumer N, Lutzenberger W, et al. Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: a comparison with methylphenidate. Appl Psychophysiol Biofeedback. 2003;28:1-12.
52. Konofal E, Lecendreux M, Deron J, et al. Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol. 2008; 38:20-26.
53. Hamazaki T, Hirayama S. The effect of docosahexaenoic acid-containing food administration on symptoms of attention-deficit/hyperactivity disorder: a placebo-controlled double-blind study. Eur J Clin Nutr. 2004;58:838.