ADHD and Complementary Health Approaches: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients:
ADHD and Complementary Health Approaches
Omega-3 Fatty Acids
Current evidence is inconclusive on whether omega-3 fatty acid supplementation could provide any benefit for the symptoms of ADHD in children and adolescents. Some randomized controlled trials have conferred modest benefits in treating ADHD; however, omega-3 fatty acid supplements are less efficacious than stimulant medications for ADHD symptoms.
Fish oil supplements, a specific source of omega-3 fatty acids, may be more beneficial than docosahexaenoic acid (DHA), according to some preliminary clinical research.
What Does the Research Show?
- A 2018 systematic review and meta-analysis of 8 studies involving a total of 628 participants found some evidence that omega-3 fatty acid supplementation monotherapy improves clinical symptoms and cognitive performances in children and adolescents with ADHD, and that these youth have a deficiency in omega-3 fatty acid levels.
- However, a 2017 systematic review of 25 randomized controlled trials found about half of the studies reporting some beneficial effect of omega-3 fatty acids on ADHD symptoms, and half reporting negative results. Of the studies included in the review, there were variations in sample size, study duration, type and dosage of supplementation, making it difficult to compare the findings and draw firm conclusions about the efficacy. Further, another 2017 systematic review with network meta-analyses of 190 randomized trials found that there is a lack of evidence for complementary health approaches, including fatty acids, for the treatment of ADHD in children and adolescents.
- A 2014 review found some evidence suggesting that omega-3 fatty acid supplementation may be useful for the treatment of ADHD. However, evidence to support the use of omega-3 fatty acid supplements in children with other primary disorders, such as dyslexia, is less clear. The review concluded: “Cumulative evidence suggests that there is currently Center for Evidence-Based Medicine (CEBM) level-1 evidence demonstrating the efficacy of omega-3 fatty acids for the treatment of ADHD.” This review included a 2011 meta-analysis of 10 trials involving 699 children with ADHD, which demonstrated a small but statistically significant benefit of omega-3 fatty acid supplementation compared with placebo. Other systematic reviews had similar results.
- However, a 2012 Cochrane review concluded that there is little evidence of benefit from polyunsaturated fatty acid supplementation for the symptoms of ADHD in children and adolescents.
- Another 2014 review of two meta-analyses examined blood levels of omega-3 fatty acids in relation to ADHD and a larger sample of randomized intervention trials in a total of 25 studies. The review found that omega-3 levels are reduced in children with ADHD, and that supplementation with omega-3 fatty acids may provide modest improvement in symptoms. However, it is not yet clear if supplementation should be confined to children with below normal blood levels.
- Omega-3 fatty acid supplements usually do not have negative side effects. When side effects do occur, they typically consist of minor gastrointestinal symptoms.
- It is uncertain whether people with fish or shellfish allergies can safely consume fish oil supplements.
- Omega-3 supplements may extend bleeding time. People who take anticoagulants or NSAIDs should use caution.
There is limited evidence from rigorous clinical trials on melatonin for sleep disorders among young people with ADHD. A 2011 review suggested a beneficial effect on sleep disorders (when administered for 4 weeks), with minimal side effects, in healthy children as well as youth with ADHD, autism, and several other populations. There is insufficient data to make conclusions about the safety and effectiveness of long-term melatonin use, although one 2009 study evaluated the efficacy and safety of long-term (mean time up to 3.7 years) treatment of melatonin for children with ADHD and insomnia, and no serious adverse events were reported.
What Does the Research Show?
- A 2017 systematic review of two randomized controlled trials and four observational studies for melatonin and behavioral insomnia in children with ADHD found improvements in sleep-onset latency and total sleep duration were reported.
- A 2014 review of two randomized, placebo-controlled trials of melatonin children with ADHD and sleep onset insomnia, along with meta-analyses of melatonin for children with sleep disorders (and without a comorbid diagnosis of ADHD) found evidence to suggest that melatonin may reduce sleep-onset latency in children with chronic sleep-onset insomnia. The review also found no evidence to suggest melatonin improves ADHD symptoms.
- A 2007 randomized controlled trial involving a total of 105 medication-free children, 6 to 12 years of age, with ADHD and chronic sleep-onset insomnia found improved sleep onset and increase in total time asleep with melatonin compared with placebo. However, no significant effect was seen on behavior, cognition, and quality of life. Reviewers of this study concluded that, “taken together, these trials and meta-analyses suggest that melatonin has Center for Evidence-Based Medicine (CEBM) level-1 evidence for reducing sleep-onset latency in children with chronic sleep-onset insomnia (regardless of a comorbid diagnosis of ADHD) but there is no evidence to suggest melatonin improves ADHD symptoms.”
- A 2006 randomized controlled trial of 27 stimulant-treated children, 6 to 14 years of age, with ADHD and initial insomnia concluded that melatonin was safe, well tolerated, and statistically and clinically superior to placebo in reducing initial insomnia. Findings suggest that a combination of sleep hygiene and melatonin is likely to improve initial insomnia.
- Melatonin appears to be safe when used short-term, but there is lack of long-term studies.
- Side effects of melatonin are uncommon but can include drowsiness, headache, dizziness, or nausea. There have been no reports of significant side effects of melatonin in children.
Pycnogenol (French Maritime Pine Bark)
There is insufficient evidence on the efficacy and safety of pycnogenol for the treatment of ADHD.
What Does the Research Show?
- A 2016 review found several studies of Pycnogenol that show its potentiality in improving ADHD symptoms. The review concluded that Pycnogenol is a promising botanical in the management of ADHD symptoms, although more studies are needed before it should be used as treatment for ADHD.
- A 2012 Cochrane review assessed the efficacy and safety of pycnogenol for several chronic disorders, including ADHD (one study in 61 children with ADHD). Although the single study included in the review found a significant reduction of hyperactivity and improved attention and concentration with pycnogenol compared with placebo, the review found that there is insufficient evidence to support the use of pycnogenol for any chronic condition.
- There is insufficient evidence on the safety of pycnogenol for ADHD, so no conclusions can be drawn.
There is insufficient evidence to support the use of ginkgo biloba for ADHD symptoms. In a single study comparing ginkgo biloba with methyphenidate, ginkgo biloba was less effective than the conventional pharmacologic treatment.
What Does the Research Show?
- In a 2010 randomized controlled trial, 50 children with ADHD received either ginkgo biloba or methylphenidate daily for 6 weeks. Findings suggest that the administration of ginkgo biloba is less efficacious than methylphenidate in the treatment of ADHD. However, those receiving ginkgo biloba had fewer adverse events than those receiving methylphenidate, regarding insomnia, headaches, and decreased appetite.
- A 2014 review concluded that although ginkgo biloba is much less effective than conventional pharmacologic interventions for ADHD, it is unclear if ginkgo biloba is any better than placebo. The review noted the potential for increased bleeding risk with ginkgo biloba and advised against its use for ADHD.
- Side effects of ginkgo biloba may include headache, nausea, gastrointestinal upset, diarrhea, dizziness, or allergic skin reactions. More severe allergic reactions have occasionally been reported.
- There are some data to suggest that ginkgo can increase bleeding risk, so people who take anticoagulant drugs, have bleeding disorders, or have scheduled surgery or dental procedures should use caution.
St. John’s Wort
Although frequently used to treat ADHD, current evidence in children suggests that St. John’s wort is no better than placebo for this condition.
What Does the Research Show?
- A 2016 review found only a few studies examining the effects of St. John’s wort on ADHD symptoms and concluded that more studies are required to determine efficacy of this herb on the treatment of ADHD.
- A 2008 randomized, double-blind, placebo-controlled trial of 54 children with ADHD, 6 to 17 years of age, found that St. John’s wort over the course of 8 weeks did not demonstrate improvement of ADHD symptoms.
- St. John’s wort is a potent inducer of both cytochrome P-450 enzymes and intestinal P-glycoprotein. Clinically significant interactions have been documented with St. John’s wort and cyclosporine, the antiretroviral agent indinavir, oral contraceptives, coumadin, digoxin, and benzodiazepines, among others.
- St. John’s wort may cause increased sensitivity to sunlight. Other side effects can include anxiety, dry mouth, dizziness, gastrointestinal symptoms, fatigue, headache, or sexual dysfunction.
- Taking St. John’s wort with certain antidepressants may lead to an increase in serotonin-related side effects, which may be potentially serious.
Other Natural Products
- Correcting mineral deficiencies such as zinc, when used in combination with conventional treatment, may provide modest improvement in some ADHD symptoms in some children. Studies of zinc for ADHD have been conducted in the Middle East, where zinc deficiencies in children are common compared to Western countries. It is unknown if zinc has any effect on ADHD symptoms in children who are not deficient, and zinc can be toxic if taken in excessive amounts.
- Dimethylamylamine (DMAA), a stimulant being used for ADHD, is promoted as an alternative to Adderall and other stimulant medications. There is no evidence on efficacy of DMAA for ADHD, but serious safety concerns. The FDA has issued a warning about the potential of DMAA to elevate blood pressure and lead to cardiovascular problems, including heart attack, shortness of breath and tightening of the chest. Given the known biological activity of DMAA, the ingredient may be particularly dangerous when used with caffeine.
- There is some evidence that suggests caffeine at high doses may provide a modest improvement of ADHD symptoms; however, high-dose caffeine in children remains controversial. Lower doses have not demonstrated any better effect than placebo for ADHD symptoms in children. Insomnia is a common adverse effect of caffeine, and side effects may be more pronounced in children than adults.
- Other natural products, including ginseng, valerian, Ningdong, bacopa, and passion flower, have been studied for their effects on ADHD symptoms, but most of these studies have been small and have had methodological issues.
Mind and Body Approaches
There is insufficient evidence to draw any conclusions about the efficacy or safety of acupuncture for ADHD in children and adolescents.
What Does the Research Show?
- A 2011 systematic review and meta-analysis of three randomized trials concluded that there is limited evidence for the effectiveness of acupuncture as a symptomatic treatment of ADHD.
- Acupuncture is generally considered safe when performed by an experienced, well-trained practitioner using sterile needles. Improperly performed acupuncture can cause serious side effects.
Meditation Therapies and Yoga
There is not enough evidence to draw firm conclusions about the efficacy of meditation for ADHD. However, short-term aerobic exercise, including yoga, has shown beneficial effects on core symptoms of ADHD such as attention, hyperactivity, and impulsivity.
What Does the Research Show?
- A 2018 systematic review of 16 studies on meditation-based therapies for ADHD found no definitive conclusions, since the methodological quality of the studies reviewed was low.
- A 2015 systematic review and meta-analysis of eight randomized controlled trials involving 249 children and adolescents found that yoga exercise suggests improvement in core symptoms of ADHD.
- A 2010 Cochrane review of four randomized controlled trials (two used mantra meditation, and two used yoga) involving 83 participants (children or adults) diagnosed with ADHD concluded that because of the limited number of studies and small sample sizes, no conclusions could be drawn about the efficacy of meditation therapy for ADHD.
- Meditation is generally considered to be safe for healthy people. However, the safety of meditation therapy has not been studied in the ADHD population. People with physical limitations may not be able to participate in certain meditative practices involving movement.
- Overall, clinical trial data in adults suggest that yoga as taught and practiced under the guidance of a skilled teacher has a low rate of minor side effects. It is not uncommon for practitioners to have some minor, transient discomfort, like in most physical activity programs. However, injuries from yoga, some of them serious, have been reported in the popular press.
- Children should work with an experienced teacher who can help modify or avoid some yoga poses, if necessary.
- as well as people with health conditions, should work with an experienced teacher who can help modify or avoid some yoga poses to prevent side effects.
Some research has suggested that neurofeedback, a technique in which people are trained to alter their brain wave patterns, may improve ADHD symptoms, but several small studies that compared the active intervention with a sham procedure did not find differences between the two treatments.
What Does the Research Show?
- A 2017 systematic review with network meta-analyses of 190 randomized trials found that there is a lack of evidence for complementary health approaches, including neurofeedback, for the treatment of ADHD in children and adolescents.
- A small 2017 randomized trial involving 13 adults investigated whether real-time fMRI neurofeedback training leads to a reduction of clinical symptoms of ADHD and improved cognitive functioning. The results showed that participants in both the neurofeedback group and control group achieved a significant increase in dorsal anterior cingulate cortex activation levels. While there was no significant difference between the neurofeedback and control group on clinical symptoms, the neurofeedback group showed stronger improvement on cognitive functioning.
- A 2018 randomized trial involving 40 children who were newly diagnosed with ADHD evaluated the effectiveness of neurofeedback versus medication (methylphenidate). The study found that teachers reported significant improvements in ADHD symptoms in the methylphenidate group compared with the neurofeedback group; however, there were no differences in ADHD symptoms or performance between the two groups on the parent report.
- A 2014 review of eight randomized controlled trials found that neurofeedback leads to significant decreases of ADHD core symptoms; however, the reviewers noted that if only probably blinded ratings are applied, these effects were reduced to a statistical trend. Therefore, current evidence is inconclusive because subsequent studies could not demonstrate the learning of self-regulation or significant effects for the best blinded assessments.
- Another 2014 review from the same year concluded that neurofeedback is not recommended for most families. Because of the lack of benefit in several sham-controlled trials, the reviewers stated that neurofeedbcak cannot be strongly recommended as a stand-alone treatment of ADHD in children at this time. However, they noted that neurofeedback “is an acceptable treatment for families with the time and money to invest in the treatment without diverting resources from other treatments or family needs.”
- The safety of neurofeedback in children or adults has not been thoroughly tested, although clinical experience suggests reasonable safety.
- Abbasi SH, Heidari S, Mohammadi MR, et al. Acetyl-L-carnitine as an adjunctive therapy in the treatment of attention-deficit/hyperactivity disorder in children and adolescents: a placebo-controlled trial. Child Psychiatry Hum Dev. 2011;42(3):367-375.
- 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(6):791-802.
- Bloch MH, Mulqueen J. Nutritional supplements for the treatment of ADHD. Child Adolesc Psychiatr Clin N Am. 2014;23(4):883-897.
- Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991–1000.
- Cerrillo-Urbina AJ, Garcia-Hermoso A, Sanchez-Lopez M, et al. The effects of physical exercise in children with attention deficit hyperactivity disorder: a systematic reviw and meta-analysis of randomized controlled trials. Child Care Health Dev. May 18, 2015. Epub ahead of print.
- Ghanizaedeh A, Berk A. Zinc for treating of children and adolescents with attention-deficit hyperactivity disorder: a systematic review of randomized controlled clinical trials. Eur J Clin Nutr. 2013;67(1):122-124.
- Gillies D, Sinn JKH, Lad SS, et al. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database of Systematic Reviews. 2012;7:CD007986.
- Hawkey E, Nigg JT. Omega-3 fatty acid and ADHD: blood level analysis and meta-analytic extension of supplementation trials. Clin Psychol Rev. 2014;34(6):496-505.
- Hoebert M, van der Heijden KB, van Geijlswijk IM, et al. Long-term follow-up of melatonin treatment in children with ADHD and chronic sleep onset insomnia. J Pineal Res. 2009;;47(1):1-7.
- Holtmann M, Sonuga-Barke E, Cortese S, et al. Neurofeedback for ADHD: a review of current evidence. Child Adolesc Psychiatr Clin N Am. 2014;23(4):789-806.
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- Salehi B, Imani R, Mohammadi MR, et al. Ginkgo biloba for attention-deficit/hyperactivity disorder in children and adolescents: a double blind, randomized controlled trial. Prog Neuropsychopharmacol Biol Psychiatry. 2010;;34(1):76-80.
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- Schoonees A, Visser J, Musekiwa, et al. Pycnogenol® (extract of French maritime pine bark) for the treatment of chronic disorders. Cochrane Database Syst Rev. 2012;4:CD008294.
- Trebatická J, Kopasová S, Hradecná Z, et al. Treatment of ADHD with French maritime pine bark extract, Pycnogenol. Eur Child Adolesc Psychiatry. 2006;15(6):329-335.
- Van der Heijden KB, Smits MG, Van Someren EJ, et al. Effect of melatonin on sleep, behavior and cognition in ADHD and chronic sleep-onset insomnia. J Am Acad Child Adolesc Psychiatry. 2007;46(2):233-241.
- Van Oudheusden LJ, Scholte HR. Efficacy of carnitine in the treatment of children with attention-deficit hyperactivity disorder. Prostaglandins Leukot Essent Fatty Acids. 2002;67(1):33-38.
- Weber W, Vander Stoep A, McCarty RL, et al. Hypericum perforatum (St John's wort) for attention-deficit/hyperactivity disorder in children and adolescents: a randomized controlled trial. JAMA. 2008;299(22):2633-2641.
- Weiss MD, Wasdell MB, Bomben MM, et al. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry. 2006;45(5):512-519.
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