ADHD and Complementary Health Approaches: What the Science Says

August 2023

Natural Products

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 2023 Cochrane systematic review (an update to a previously published review) of 37 trials with more than 2,374 participants found low-certainty evidence that polyunsaturated fatty acids (PUFA) may improve ADHD symptoms in children and adolescents in the medium term, compared with placebo; however, there was high-certainty evidence that PUFA had no effect on total parent-rated ADHD symptoms. There was also high-certainty evidence that inattention and hyperactivity/impulsivity did not differ between PUFA and placebo groups.
• A 2022 narrative review concluded that data indicate a combination of the omega-3 fatty acids eicosapentaenoic acid (EPA) and DHA with the omega-6  gamma-linolenic acid (GLA) being associated with ADHD symptom improvement. The best dosage ratio needs to be further studied, butseveral reported studies suggest a combination of a 9:3:1 ratio EPA, DHA, GLA is associated with improvement in ADHD symptoms.
• 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.

Safety

• Omega-3 fatty acid supplements usually do not have negative side effects. When side effects do occur, they typically consist of minor gastrointestinal symptoms.

Melatonin

There is limited evidence from rigorous clinical trials on melatonin for sleep disorders among young people with ADHD. One recent review found that melatonin supplementation improves sleep delay as well as extends overall sleep duration in people with ADHD. However, 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 2020 review concluded that melatonin supplementation improves sleep delay as well as extends overall sleep duration in people with ADHD.
• A 2019 review of 19 studies involving a total of 1,021 children found that, overall, melatonin was better than placebo for improving both the time to fall asleep and total sleep. The studies involving children with ADHD found that children with ADHD who took melatonin fell asleep 20 minutes earlier and slept 33 minutes longer. The effects of melatonin on behavior and daytime functioning, however, weren’t clear because the studies used different ways to measure these outcomes.

Safety

• 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 2020 Cochrane systematic review assessed the efficacy and safety of pine bark extract for various chronic disorders, including ADHD. One study involving 61 participants with ADHD was included in the review. The reviewers concluded that based on that single study, in children with ADHD, it is unknown whether pine bark extract decreases inattention and hyperactivity assessed by parent- and teacher-rating scales or increases the change in visual-motoric coordination and concentration.
• 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.

Safety

• There is insufficient evidence on the safety of Pycnogenol for ADHD, so no conclusions can be drawn.

Ginkgo Biloba

There is insufficient evidence to support the use of ginkgo biloba for ADHD symptoms. In a single study comparing ginkgo biloba with methylphenidate, 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.

Safety

• 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 biloba 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.

Safety

• 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 U.S. Food and Drug Administration 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 passionflower, 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

Acupuncture

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 for ADHD.

Safety

• 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 small-to-moderate beneficial effects on core symptoms of ADHD such as attention, hyperactivity, and impulsivity.

What Does the Research Show?

• A 2023 review found that meditation-based therapies lack rigorous, unbiased evidence to support their effects on ADHD. The wide range of approaches, heterogeneity of study designs, and high potential for bias makes it difficult to draw definitive conclusions about meditation’s effectiveness. Despite these significant limitations, the available data do suggest a relatively consistent small-to-moderate effect in children and adolescents.
• A 2023 systematic review of 10 studies evaluating yoga and meditation for ADHD in children found that yoga and meditation positively affected various symptoms in children with ADHD, including attention, hyperactivity, and impulsive behavior. The authors suggested that yoga or meditation may help supplement conventional treatment and help achieve a better quality of life. They also noted that more in-depth research is necessary with a more significant number of participants and over a more extended period of time.

Safety

• 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.

Neurofeedback

To date, evidence of the effectiveness of neurofeedback for ADHD is mixed; a growing evidence base shows moderate effectiveness for ADHD symptoms by parent report; however, the evidence is considerably less strong when considering teacher ratings, which are thought to be more effectively blinded. 

What Does the Research Show?

• A 2023 review concluded that neurofeedback is an important nonpharmacologic treatment option for people with ADHD, but that there is pervasive technical and methodological heterogeneity in the existing research, as well as factors that affect treatment efficacy such as treatment intensity, type of electroencephalogram (EEG) equipment, and person reporting (teacher vs. parent).
• A 2023 25-month follow-up of a double-blind randomized controlled trial involving 120 children aged 7 to 10 years found that theta-beta ratio neurofeedback appeared to be comparable to the evidence-based Multimodal Treatment Study of ADHD treatments, suggesting a psychotherapeutic/behavioral effect. They further suggest that improvements in ADHD found with neurofeedback studies seem to be from “nonspecific” psychological/behavioral effects rather than specifically due to brain waves training.
• A 2022 pragmatic four-arm randomized controlled trial compared two types of neurofeedback (Slow Cortical Potential and Live Z-score) and Working-memory training (WMT) with treatment as usual in 202 children and adolescents (aged 9 to 17 years) with ADHD. The study found that at posttreatment, the effects of WMT on spatial and verbal working-memory were superior to neurofeedback and treatment as usual, but the effects were only partially sustained at follow-up. No other consistent effects were observed.

Safety

• The safety of neurofeedback in children or adults has not been thoroughly tested, although clinical experience suggests reasonable safety.

Other Emerging Therapies

• A 2023 randomized controlled trial of 348 children (8 to 12 years of age) evaluated a new game-based digital therapeutic, AKL-T01, an investigational digital therapeutic designed to target attention and cognitive control delivered through a video game–like interface via at-home play for 25 minutes per day, 5 days per week for 4 weeks. The study found that compared with the control group, participants in the treatment group had improvements in Attention Performance Index scores from baseline.
• A 2019 double-blind, placebo-controlled pilot study assessed the efficacy and safety of trigeminal nerve stimulation (TNS), a noninvasive neuromodulation intervention, in 62 children (8 to 12 years of age) with ADHD. The study found that ADHD Rating Scales (ADHD-RS) and Clinical Global Impression (CGI) scales favored the TNS treatment group, and the resting-state quantitative electroencephalography showed increased spectral power in the right frontal and frontal midline frequency bands in the TNS group.

References

• Agostoni C, Nobile M, Ciappolino V, et al. The role of omega-3 fatty acids in developmental psychopathology: a systematic review on early psychosis, autism, and ADHD. International Journal of Molecular Sciences. 2017;18(12):2608.
• Ahn J, Anh HS, Cheong JH, et al. Natural product-derived treatments for attention-deficit/hyperactivity disorder: safety, efficacy, and therapeutic potential of combination therapy. Neural Plasticity. 2016;2016:1320423.
• Bloch MH, Mulqueen J. Nutritional supplements for the treatment of ADHD. Child and Adolescent Psychiatric Clinics of North America. 2014;23(4):883-897.
• Catalá-López F, Hutton B, Núñez-Beltrán A, et al. The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: a systematic review with network meta-analyses of randomised trials. PLoS One. 2017;12(7):e0180355.
• Chang J P-C, Su K-P, Mondelli V, et al. Omega-3 polyunsaturated fatty acids in youths with attention deficit hyperactivity disorder: a systematic review and meta-analysis of clinical trials and biological studies. Neuropsychopharmacology. 2018;43(3):534-545.
• D’Helft J, Caccialanza R, Derbyshire E, et al. Relevance of ω-6 GLA added to ω-3 PUFAs supplements for ADHD: a narrative review. Nutrients. 2022;14(16):3273.
• Gillies D, Leach MJ, Algorta GP. Polyunsaturated fatty acids (PUFA) for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Cochrane Database of Systematic Reviews. 2023;4(4):CD007986.
• Gonzalez NA, Sakhamuri N, Athiyaman S, et al. A systematic review of yoga and meditation for attention-deficit/hyperactivity disorder in children. Cureus. 2023;15(3):e36143.
• Hasslinger J, Jonsson U, Bölte S. Immediate and sustained effects of neurofeedback and working memory training on cognitive functions in children and adolescents with ADHD: a multi-arm pragmatic randomized controlled trial. Journal of Attention Disorders. 2022;26(11):1492-1506.
• Lee MS, Choi T-Y, Kim J-I, et al. Acupuncture for treating attention deficit hyperactivity disorder: a systematic review and meta-analysis. Chinese Journal of Integrative Medicine. 2011;17(4):257-260.
• McGough JJ, Sturm A, Cowen J. Double-blind, sham-controlled, pilot study of trigeminal nerve stimulation for attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2019; 58(4):403-411.
• Neurofeedback Collaborative Group. Neurofeedback for attention-deficit/hyperactivity disorder: 25-month follow-up of double-blind randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2023;62(4):435-446.
• Robertson NU, Schoonees A, Brand A, et al. Pine bark (Pinus spp.) extract for treating chronic disorders. Cochrane Database of Systematic Reviews. 2020;9(9):CD008294.
• Russell D, Arnold LE. Complementary and integrative treatments for attention-deficit/hyperactivity disorder in youth. Child and Adolescent Psychiatric Clinics of North America. 2023;32(2):173-192.
• Rzepka-Migut B, Paprocka J. Efficacy and safety of melatonin treatment in children with autism spectrum disorder and attention-deficit/hyperactivity disorder—a review of the literature. Brain Sciences. 2020;10(4):219.
• 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. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2010;34(1):76-80.
• 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.

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