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Dear Subscriber,

I hope that you are doing well.

This issue of Attention Research Update reviews a recently published study comparing fatty acid supplementation and medication treatment for children with ADHD. Fatty acid supplementation is an alternative treatment for which some positive results have been reported, but direct comparisons of this treatment approach to more conventional medication treatment are limited. As you will see below, results from this trial are encouraging.

Please feel free to forward this newsletter to others you know who may be interested - you’ll find a “Forward to a Friend” link at the end of this message. If this has been forwarded to you, and you would like to receive Attention Research Update on a regular basis, just visit http://www.helpforadd.com to subscribe.

I hope you enjoy today’s issue.

Sincerely,

David Rabiner, Ph.D.
Research Professor
Dept. of Psychology & Neuroscience
Duke University
Durham, NC 27708


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New Study of Fatty Acid Supplementation to Treat Youth with ADHD
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Although medication treatment is helpful for an estimated 70 to 90% of children with ADHD, the development of effective alternative treatments is important for several reasons. First, even when children respond well to medication, important difficulties often remain. Second, some children experience intolerable side effects that preclude the ongoing use of meds. And, many parents are reluctant to begin medication treatment for their child and some refuse to do so.

Dietary supplementation of long-chain fatty acids as an intervention for ADHD has generated considerable interest in recent years. Certain highly poly-unsaturated fatty acids (PUFAs) are known to play an important role in many aspects of physical health, and may also play a role in a wide range of neuro-developmental and psychiatric conditions. For example, children with ADHD have been shown in several studies to have low blood levels of PUFAs. Because PUFAs are important for healthy brain development and functioning, some researchers have suggested that increasing PUFA levels via dietary supplements could enhance brain functioning and reduce ADHD symptoms.

Several prior issues of Attention Research Update have reviewed studies of fatty acid supplementation as a treatment for ADHD symptoms - see http://www.helpforadd.com/2007/may.htm and http://www.helpforadd.com/2006/august.htm - and some encouraging results have been reported. And, recently published reviews of fatty acid supplementation indicate that it yields reductions in ADHD symptoms for many children; the best results have typically been obtained with the combination of Omega-3 and Omega-6 fatty acids.

Despite these overall positive findings, the benefits of fatty acid supplementation are believed to be significantly smaller than those typically provided by medication treatment. However, studies that directly compare PUFA supplementation with stimulant medication, are limited.

There has also been very limited work examining the combination of PUFA supplementation and medication treatment. Because medication and PUFAs may reduce ADHD symptoms via different mechanisms, their combination may have additive affects resulting in greater symptom reduction.

Exploring these issues was the focus of a study published recently online in the Journal of Attention Disorders [Barragab et al. (2014). Efficacy and safety of Omega-3/5 fatty acids, methylphendiate, and a combined treatment in children with ADHD. Journal of Attention Disorders, DOI: 10.1177/1087054713518239].

Participants were 90 6- to 12-year old children (60 boys) newly diagnosed with ADHD; the study was conducted in Mexico at the National Health Institute for Children in Mexico. Children were randomly assigned to 1 of 3 treatment conditions: 1) Omega-3/6 fatty acid supplementation; 2) stimulant medication treatment; and, 3) the combination of Omega-3/6 fatty acid supplementation and stimulant medication treatment.


Study Treatment

Children receiving fatty acid supplementation were given 3 capsules 2X/day corresponding to a daily dose of 558 mg EPA - eicosapentaenoic acid - 174 mg DHA - docosahexaenoic acid, and 60mg of GLA - gamma-linolenic acid. The brand name of the product used was Equazen eye q (This is available at Amazon and many other places; I have no connection whatsoever with the manufacturer).

The stimulant medication used in the study was long-acting Metadate CD, a branded version of the generic methylphenidate. Children were titrated up to a maximum dose of 1 mg/kg/day depending on their response to medication and the emergence of any adverse affects. Dose adjustments were made weekly when indicated.


Assessments

Assessments of children’s symptoms and overall illness severity were completed at baseline, 1 month, 3 months, 6 months, and 12 months. At each assessment, parents completed the ADHD Rating Scale to assess the presence of core ADHD symptoms. On this measure, parents rate the frequency that their child display each of 18 symptoms on a 0 to 3 scale; total scores can thus range from 0 to 54.

Clinician’s and parents also independently completed the Clinical Global Impressions-Severity (CGI-S) scale; this is a 7-point scale to assess the severity of an individual’s illness, ranging from 1 (normal, not ill) to 7 (among the most extremely ill patients). Thie CGI-S is commonly used to measure the efficacy of treatments. No data was collected from children’s teachers.

By collecting these measures at multiple time points over 1 year, the researchers could determine not only whether the groups differed at the end of treatment, but also whether there were differences in the pattern of change over time.

Of the 90 children who began in the study, 69 remained enrolled 12 months later. More children withdrew from the medication group (n=10) and the Omega-3/6 group (n=8) than from the combined group (n=3).


Results

The main finding from this study was that children in each groups showed marked declines in AHD symptoms and overall illness severity over the 12 months. For example, at baseline the average total score on the ADHD Rating Scale was 41.43, 40.7, and 42.03 for the Omega-3/6, medication, and combined treatment groups respectively. At the 12-month assessment, these scores had dropped to 25.83, 27.77, and 24.33 respectively; the difference between Omega-3/6 treatment and combined treatment was statistically significant.

For the CGI-S, average scores from parents declined from 6.27, 6.07, and 6.07 to 4.10, 3.63, and 3.63 for the Omega-3/6 group, the medication group, and the combined group respectively. For clinician ratings, the baseline and end-point ratings were essentially the same. Ratings of 3 on the CGI-S correspond to ‘mildly ill’ and ratings of 4 correspond to ‘moderately ill’. Thus, despite substantial improvement, important difficulties remained evident for most children.

The researchers also examined the percentage of children in each group who showed a clinically meaningful response, defined as a reduction of at least 30% on the ADHD-RS total score. This was attained by 93% of children in the combined group, 80% in the medication group, and 60% in the Omega-3/6 group. This difference in response rate was significant, with children receiving Omega-3/6 only less likely to be ‘responders’. The researchers also examined the rate of change in symptoms over time. There was a steeper decline in symptoms over the 1st month in the medication group compared to the Omega-3/6 group. Children receiving medication only tended to show a steep decline right away and then remained relatively level across the remaining 11 months. Although children receiving Omega-3/6 also made the bulk of their treatment gains in the first month, this was somewhat less pronounced and the declines in their symptoms over the year appeared somewhat more gradual. The combined group tended to fall in between the mono-treatment groups in the pace of the decline in their symptoms.

A final issue examined was whether children in the combined group were maintained on a longer dose of medication than those receiving medication only. At month 12, those in the combined group were receiving significantly lower dose of medication than children receiving medication only, i.e., .80 mg/kg/day vs. 1.0 mg/kg/day.

Adverse effects were rarely reported for Omega-3/6 supplementation; when such effects were reported, they did not persist beyond the first month.


Summary and Implications

In this randomized trial, Omega-3/6 supplementation was associated with reductions in children’s ADHD symptoms over one-year that were roughly comparable to those seen in children treated with medication. There was also evidence of better treatment adherence for children receiving combined treatment and that children receiving combined treatment required lower medication doses than those receiving medication alone. Overall, therefore, study results suggest that Omega-3/6 supplementation may be a viable alternative to medication for some children and/or that it can have value when combined with stimulant medication.

Within this generally positive backdrop, however, several cautions should be kept in mind. First, in all treatment groups, most children continued to struggl with ADHD symptoms even though those symptoms had diminished. This is an important reminder that treatment-induced symptom reduction is not the same as full normalization, and that many children with ADHD continue to struggle despite treatment.

Second, it is unfortunate that data from teachers was not collected. Documenting that Omega-3/6 supplementation yielded benefits as reported by teachers in addition to those reported by parents would have been a very important finding. This is particularly true since a prior trial of fatty acid supplementation - see http://www.helpforadd.com/2007/may.htm - found significant benefits according to parent reports but no benefits based on teacher report. Because many children with ADHD struggle at school, the absence of teacher data is a significant study limitation. One cannot assume that had teacher reports been obtained, they would have yielded similar findings - that is a question that awaits further study. Related to this concern is that no information on children’s academic functioning during treatment was obtained.

It is also the case that the study’s design may have attenuated treatment differences between Omega-3/6 supplementation and medication treatment. There are 2 main reasons for this. First, medication dose was capped at 1 mg/kg/day and it is possible that some children receiving medication would have shown additional benefits at higher doses. It is also the case that some children would have responded more strongly to a different stimulant medication, e.g., Concerta, Vyvanse, but no alternative medications were used. Thus, medication treatment was not conducted in a way to maximize benefits and Omega-3/6 supplementation may have looked relatively comparable as a result. On the other hand, the Omega-3/6 supplementation was the same for all children, which may not have maximized benefits for individual children.

Finally, it should be noted that there was no placebo group in this study. That is because for a study lasting a full year, maintaining children struggling with ADHD on placebo for such a time period would not be ethical. However, without a placebo or no-treatment comparison group, it is not possible to fully rule out that improvements reflected the natural symptom course, i.e., declining, over time. Of course, this would apply to children treated with medication as well.

In summary, although the tested combination of Omega-3/6 supplementation was slightly less effective than medication in this trial, clinically significant benefits for supplementation were obtained and combination therapy appeared to have some benefits over medication alone. And, there were no persistent adverse effects suggesting that this treatment is generally well tolerated. Future studies that address the issues noted above will hopefully confirm and extend these initially promising findings.

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Thanks again for your ongoing interest in the newsletter. I hope you enjoyed the above article and found it to be useful to you.

Sincerely,

David Rabiner, Ph.D.
Research Professor
Dept. of Psychology & Neuroscience
Duke University
Durham, NC 27708

Replies

Please provide the Journal Name.

Dear Fellow Parents,
Please be aware that the author has a financial stake in his research.  That doesn’t mean it’s not valuable, but I would be cautious about bias and financial motivation.

From his website:
Financial Disclosure - Financial support for Attention Research Update is provided by Attention Point, a company that offers an online suite of ADHD rating scales to facilitate the collection of behavioral ratings from parents and teachers for ADHD professionals.

Posted by elark on Sep 03, 2014 at 3:46pm

I can tell you with the addition of Omegas supplementation with my son’s meds, it makes his symptoms worse.

Posted by Pdxlaura on Sep 07, 2014 at 6:45pm

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