Some recent studies provide new information about nonpharmacological treatments for ADHD, course of ADHD in preschoolers, solar intensity and ADHD, and age and stimulant use.
Parents of children with ADHD frequently ask whether there are nonmedication treatments that are effective for managing their children’s symptoms of ADHD. A recent meta-analysis provides an answer to this clinically important question.1 This meta-analysis sought to evaluate the effects of dietary and psychological treatments for symptoms of ADHD in children and adolescents. The studies were randomized controlled trials published in peer-reviewed journals that included youths aged 3 to 18 years who had a diagnosis of ADHD or who met symptom criteria based on ADHD rating scales.
Three dietary interventions were included in these analyses: restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation. The restricted elimination diet studies included antigenic foods, general elimination diets, oligoantigenic diets, and elimination of specific provoking foods. The artificial food color exclusion had trials that excluded certified food colors, tartrazine, and unspecified food colors or that implemented a Feingold-type diet. The free fatty acid supplementation included trials of omega-3 supplements and/or omega-6 supplements.
The psychological treatments included cognitive training, neurofeedback, and behavioral interventions. The cognitive training included studies of either attention training or working memory training. The neurofeedback included studies of theta-beta training, training of slow cortical potential, and individualized frequency band training. The behavioral interventions included parent training; combination of child and parent training; combination of parent, child, and teacher training; and child training only.
The outcome measure was pretreatment to posttreatment change in total ADHD symptom severity. The investigators conducted 2 analyses: outcome measure assessment by a rater closest to the therapeutic assessment setting (most likely a parent) and outcome measure assessment by a blinded rater. When assessments were done by an individual such as a parent, both dietary and psychological interventions showed statistically significant effects. However, when assessments where done in blinded conditions, only free fatty acid supplementation and artificial food color exclusion showed statistically significant effects. Neurofeedback, cognitive training, and restrictive elimination diets did not elicit a significant decrease in children’s symptoms of ADHD under blinded conditions.
What are the implications of these findings for treatment of ADHD in youths? In studies of medication treatment for children and adolescents with ADHD, standardized mean differences in pretreatment and posttreatment are approximately 0.9. Mean difference found for free fatty acid supplementation was 0.16 and artificial food color exclusion was 0.42: both are substantially below that found for medication treatment. The authors conclude that it is important to identify more effective nonpharmacological treatments for children and adolescents who have ADHD.
Polyunsaturated fatty acids added to stimulants
Another question posed by parents is whether adding fatty acids to stimulant treatment will further diminish ADHD symptoms. The addition of polyunsaturated fatty acids to stimulant treatment for children aged 6 to 12 years with ADHD was investigated.2 In this double-blind, placebo-controlled, 10-week trial, 40 children were randomized to either methylphenidate or methylphenidate plus polyunsaturated fatty acids (430-mg capsules containing 241 mg of docosahexaenoic acid, 33 mg of eicosapentaenoic acid [EPA], and 180 mg of omega-6). The outcome measure was a 25% decrease in ADHD symptoms on the Parent ADHD Rating Scale.
No significant differences were found in rates of inattention, hyperactivity, and impulsivity between the two groups. These investigators conclude that the addition of polyunsaturated fatty acids to stimulants affords no clinical benefit. However, the dose of EPA was low, which may have partially accounted for lack of improvement.
Dr Wagner is the Marie B. Gale Centennial Professor and Vice Chair in the department of psychiatry and behavioral sciences and Director of Child and Adolescent Psychiatry at the University of Texas Medical Branch at Galveston.
1. Sonuga-Barke EJ, Brandeis D, Cortese S, et al; European ADHD Guidelines Group. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry. 2013;170:275-289.
2. Assareh M, Davari Ashtiani R, Khademi M, et al. Efficacy of polyunsaturated fatty acids (PUFA) in the treatment of attention deficit hyperactivity disorder: a randomized, double-blind, placebo-controlled clinical trial. J Atten Disord. 2012 Nov 15; [Epub ahead of print].
3. Riddle MA, Yershova K, Lazzaretto D, et al. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. J Am Acad Child Adolesc Psychiatry. 2013;52:264-278.e2.
4. Arns M, van der Heijden KB, Arnold LE, Kenemans JL. Geographic variation in the prevalence of attention-deficit/hyperactivity disorder: the sunny perspective. Biol Psychiatry. 2013 Mar 20; [Epub ahead of print].
5. Zoëga H, Valdimarsdóttir UA, Hernández-Díaz S. Age, academic performance, and stimulant prescribing for ADHD: a nationwide cohort study. Pediatrics. 2012;130:1012-1018.