3 Dietary Interventions that Can Help Children with ADHD (especially when properly monitored)

3 Dietary Interventions that Can Help Children with ADHD (especially when properly monitored)

3 Dietary Interventions that Can Help Children with ADHD (especially when properly monitored)

Are dietary inter­ven­tions effec­tive for treat­ing ADHD? For many par­ents and pro­fes­sion­als, try­ing to parse through the dif­fer­ent claims has been chal­leng­ing and confusing.

Are dietary inter­ven­tions effec­tive for treat­ing ADHD? For many par­ents and pro­fes­sion­als, try­ing to parse through the dif­fer­ent claims about the impact of diet on ADHD has been chal­leng­ing and confusing.

At this point, sub­stan­tial research on how dietary inter­ven­tions impact ADHD has accu­mu­lated and sev­eral meta-analyses of this work have been pub­lished. Recently, a review of sev­eral meta-analyses of dietary inter­ven­tions for ADHD was pub­lished [Research review: The role of diet in the treat­ment of attention-deficit/hyper­ac­tiv­ity dis­or­der — an appraisal of the evi­dence on effi­cacy and rec­om­men­da­tions on the design of future stud­ies]. In this paper, the authors sum­ma­rize find­ings across 6 dif­fer­ent meta-analyses of the impact of diet on ADHD to pro­vide a high level sum­mary of the best avail­able evi­dence to date.

Types of dietary interventions

Three types of dietary inter­ven­tions were reviewed — Restricted Elim­i­na­tion Diets (RED), Arti­fi­cial food col­or­ing exclu­sion (AFCE), and sup­ple­men­ta­tion with free fatty acids (SFFA). Although other types of sup­ple­ments beyond free fatty acids have been inves­ti­gated, the authors felt there was not suf­fi­cient research on any sin­gle approach to include in their summary.

1. Restricted elim­i­na­tion diets (RED) — There are 2 dif­fer­ent approaches to imple­ment­ing this diet. In one approach, the child is placed on an extremely restricted diet, e.g., rice, turkey, a range of veg­eta­bles (let­tuce, car­rots, cau­li­flower, cab­bage, beets), pears and water; this is some­times referred to as the Few Food Diet. When a reduc­tion in ADHD behav­iors results — this would gen­er­ally occur within 2–3 weeks if the diet is going to have a pos­i­tive effect — new foods can be added back one at a time to see if they are well-tolerated or lead to an increase in prob­lem behav­iors. Alter­na­tively, par­tic­u­lar foods that are sus­pected to exac­er­bate a child’s symp­toms may be removed one at a time to see if the child’s behav­ior improves.

2. Arti­fi­cial food col­or­ing exclu­sion (AFCE)- As the title indi­cates, this involves efforts to remove all arti­fi­cial food col­or­ings from a child’s diet, e.g.,Yellow #6, Yel­low #5, Sodium Ben­zoate, Blue #2, etc., and observ­ing whether this is asso­ci­ated with a reduc­tion in ADHD behav­iors. Care­fully con­ducted tri­als have demon­strated that AFC’s – in amounts chil­dren could typ­i­cally con­sume – can increase ADHD symp­toms in many children.

3. Essen­tial fatty acid sup­ple­men­ta­tion — Cer­tain fatty acids, e.g., Omega 3 and Omega 6, pro­mote neural func­tion­ing. These fatty acids are called essen­tial because they are not syn­the­sized in the body and must be ingested. Chil­dren with ADHD may have lower lev­els of essen­tial fatty acids rel­a­tive to peers and sev­eral stud­ies have demon­strated a link between low lev­els of EFAs and the sever­ity of ADHD symp­toms. Stud­ies inves­ti­gat­ing the ben­e­fits of fatty acid sup­ple­men­ta­tion for youth with ADHD raise fatty acid lev­els by admin­is­ter­ing cap­sules con­tain­ing the fatty acids or some­times by intro­duc­ing diets rich in fish products.

Are these inter­ven­tions effective?

RED — Three dif­fer­ent meta-analyses exam­in­ing the impact of RED on chil­dren with ADHD reported sig­nif­i­cant pos­i­tive effects. At this point, I believe the most rea­son­able con­clu­sion to be drawn from avail­able data is that restricted elim­i­na­tion diets, if imple­mented prop­erly, have a sig­nif­i­cant effect that is likely to be in the small to mod­er­ate range. An aver­age effect in the small to mod­er­ate range reflects the fact that some chil­dren are likely to show sub­stan­tial ben­e­fits while many oth­ers may show no ben­e­fits at all.

AFCE — Small but sig­nif­i­cant effects of elim­i­nat­ing AFC’s from children’s diet have been reported. When stud­ies have been restricted to chil­dren with diag­nosed ADHD, sig­nif­i­cant and slightly larger benefts are reported. As with RED, a rea­son­able con­clu­sion at this time is that, on aver­age, chil­dren with ADHD will derive mod­est ben­e­fits when AFCs are removed from their diet. Some chil­dren may show large reduc­tions in ADHD symp­toms while oth­ers may show no dis­cernible reduc­tions at all.

Fatty acid sup­ple­men­ta­tion — Results from mul­ti­ple meta-analyses con­verge on their being a mod­est but sig­nif­i­cant ben­e­fit of fatty acid sup­ple­men­ta­tion on ADHD symp­toms. As with RED and AFCE, some chil­dren are likely to dis­play sub­stan­tial ben­e­fits from this approach while for oth­ers, the impact on ADHD symp­toms will be min­i­mal or non-existent. Even in these cases, how­ever, there are gen­eral health ben­e­fits that may accrue from fatty acid supplementation.

How should these find­ings be used to guide intervention?

Exist­ing evi­dence points towards mod­est but sta­tis­ti­cally sig­nif­i­cant ben­e­fits of each dietary inter­ven­tion on ADHD. As indi­cated above, mod­est aver­age ben­e­fits can obscure the fact that some chil­dren show sub­stan­tial gains. If that hap­pens to be your child, the fact that most chil­dren may not real­ize large ben­e­fits would be less relevant.

Are dietary inter­ven­tions some­thing that par­ents should try and that pro­fes­sion­als should rec­om­mend? In think­ing about this, sev­eral issues are impor­tant to con­sider. First, the eas­i­est of the 3 dietary inter­ven­tions to imple­ment would be fatty acid sup­ple­men­ta­tion. This does not requir­ing restrict­ing children’s food intake in any spe­cific way, can have gen­eral health ben­e­fits regard­less of how it impacts ADHD behav­iors, and places much more lim­ited demands on chil­dren and par­ents. When known food allergies/sensitivities are not present, this approach seems as likely to be help­ful as restric­tive diets that are more dif­fi­cult to imple­ment. It thus seems like a rea­son­able ini­tial alternative.

It is impor­tant to rec­og­nize that restricted elim­i­na­tion diets can be dif­fi­cult to imple­ment and sus­tain — efforts to sig­nif­i­cantly limit the foods a child eats may lead to con­flicts that cre­ate impor­tant prob­lems in their own right. Unless food aller­gies are present, a diet restrict­ing only AFCs may be a bet­ter choice as this would be eas­ier to imple­ment than a few foods diet. How­ever, given the ubiq­ui­tous nature of arti­fi­cial food col­or­ings and dyes, this can also be challenging.

Although par­ents might try to imple­ment such diets on their own, dietary inter­ven­tions should be car­ried out under the super­vi­sion of a nutri­tion­ist or other pro­fes­sional who is expe­ri­enced in these approaches. In par­tic­u­lar, restricted elim­i­na­tion diets, e.g., few foods diet, should be over­seen by a prop­erly qual­i­fied pro­fes­sional to avoid nutri­tional defi­ciency. Such a pro­fes­sional should also be able to assist in iden­ti­fy­ing pos­si­ble food allergies/sensitivities that would both increase the chances of a pos­i­tive out­come and help deter­mine which foods are most impor­tant to avoid.

Because par­ents ini­ti­at­ing dietary inter­ven­tion may have strong expec­ta­tions of ben­e­fit, and the placebo effect may also be oper­at­ing, there should be a sys­tem­atic plan in place to mon­i­tor children’s response. Ide­ally, behav­ior rat­ings would be obtained weekly from par­ents and teach­ers that would include assess­ments of ADHD symp­toms, other behav­ior prob­lems, and the quan­tity and qual­ity of school work com­pleted. If the teacher can be kept unaware of the inter­ven­tion, so much the bet­ter as this would remove a poten­tial source of bias in his/her ratings.

Obtain­ing these rat­ings should begin sev­eral weeks before start­ing treat­ment so that a reli­able base­line can be estab­lished; once the inter­ven­tion begins they should be col­lected weekly. Review of these rat­ings reg­u­larly by the pro­fes­sional over­see­ing the treat­ment is the best way to learn whether things really are get­ting bet­ter, and even if they are, what prob­lems are per­sist­ing that need to be addressed via other means. If the diet — or fatty acid sup­ple­men­ta­tion — has been care­fully fol­lowed for at least 4 weeks and no reli­able ben­e­fits are dis­cerned, it would be time to con­sider other treat­ments. This type of mon­i­tor­ing approach is not spe­cific to dietary inter­ven­tions but is an impor­tant com­po­nent of any treat­ment for ADHD.

One uncom­pli­cated and sen­si­ble inter­ven­tion that all par­ents can imple­ment is mak­ing sure their child eats a good break­fast that has ade­quate amounts of pro­tein. Research has shown that this can play an impor­tant role in help­ing all chil­dren — not just those with ADHD — main­tain bet­ter atten­tion lev­els across the morning.

-- Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. Alvaro Fer­nan­dez, named a Young Global Leader by the World Eco­nomic Forum, is the co-author of The Sharp­Brains Guide to Brain Fit­ness. They have part­nered to offer the upcom­ing online course How to Nav­i­gate Con­ven­tional and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment. (Starts on May 12th; reg­is­tra­tion open)

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