Nutrition interventions for childhood attention-deficit hyperactivity disorder

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By Kellie Blake, RDN, LD, IFNCP

As a dietitian in a psychiatric facility, I see people of all ages and from all walks of life. By the time they are admitted to the hospital, many of my pediatric patients have already been labeled with multiple serious mental health diagnoses. I’m always curious how different their behavior and quality of life would be if they had access to the appropriate nutrition for the developing brain. While dietary changes continue to be controversial when it comes to attention deficit hyperactivity disorder (ADHD), I believe nutrition-related changes are always indicated and can lead to tremendous symptom improvement, quality of life, and long-term outcomes.

ADHD is a condition often diagnosed in childhood and persisting into adulthood. One in 10 children are affected and boys are much more likely to be diagnosed. Kids with ADHD often have on-going difficulty with paying attention and are hyperactive and impulsive. They often suffer from learning disabilities and conduct disorders and experience other mental health symptoms such as anxiety and mood disorders. Traditional treatment includes medication and psychotherapy, but without the addition of dietary intervention, ADHD is often treatment resistant.

Neurological, biochemical, and genetic factors are all a part of the pathogenesis of ADHD, but there are a number of nutrition-related factors underlying these root causes. Food sensitivities and abnormal glucose regulation, as well as deficiencies in minerals and omega-3 fatty acids, can all contribute to ADHD symptoms, but they can also be targets of nutrition therapy.

Food Sensitivities and Food Allergies

While more rigorous research is needed, food sensitivities and food allergies can contribute to ADHD symptoms in some children. Removing potential triggers with a short-term elimination diet has been shown in some studies to be effective in reducing symptoms. In addition, the link between celiac disease and childhood psychiatric disorders has been established. A 2017 cohort study concluded celiac disease is a risk factor for mood, anxiety, eating, autism spectrum and behavioral disorders, ADHD, and intellectual disability in children. Interestingly, psychiatric symptoms often precede the celiac diagnosis, so early celiac testing and a gluten-free diet may be important for preventing the development of psychiatric symptoms. But, even without celiac disease, gluten can still be problematic.

While elimination diets can be very difficult to implement and should only be continued for a few weeks, they can provide valuable information about which foods or substances may not be tolerated. One study in the journal Nutrition Metabolism described a 66 percent improvement in ADHD symptoms after an elimination diet with subsequent food challenge. The most problematic foods for kids with ADHD in this study included sugar, dyes, additives, flavors, milk, corn, chocolate, egg, wheat, potato, soy, citrus, and pork. I often recommend a four-week elimination period and then add foods back in systematically to determine individual triggers and better adapt the maintenance meal plan.  

Reactive Hypoglycemia and Refined Sugar

Poor blood sugar control, even in those without diabetes, can underly many mental health symptoms. As reported in the journal Psychiatry Research, children with ADHD experience altered blood sugar management when compared to healthy controls and following a Western-type diet high in refined carbohydrates and inflammatory fats more than doubles the risk of ADHD. Although more research is needed, refined sugar has been found to be a common culprit when it comes to ADHD symptoms and observational studies have correlated the amount of refined sugar consumed with restless, aggressive, and destructive behaviors. In addition, in a cross-sectional study, intake of fried food, sweetened desserts, and salt was associated with inattention and hyperactivity in kids with ADHD when compared to kids with a more nutritionally balanced diet. While there is no rigorous research to definitively confirm sugar as the cause of or exacerbation of ADHD behaviors, the research is clear on the effect refined sugar has on blood sugar regulation and the gut microbiome. The elimination food plan removes refined sugar, but to help maintain normal glucose regulation, I encourage routine meals containing protein, healthy fat, and fiber.

Minerals

Magnesium assists nerve cells to relax and lack of adequate magnesium can contribute to ADHD symptoms. According to a study published in the journal Child and Adolescent Psychiatric Clinics of North America, children with ADHD do have lower magnesium levels when compared to healthy controls and magnesium supplementation of six milligrams per kilogram per day, along with 0.6 milligrams per kilogram per day of vitamin B6 did improve ADHD symptoms. I prescribe high magnesium foods like dark leafy greens, beans, legumes, dark chocolate, and nuts. Getting kids to eat greens can be a challenge, so I often recommend hiding them in a green smoothie. If the diet is limited, I will encourage the addition of Epsom salts baths or topical magnesium cream.

Zinc acts as a cofactor for neurotransmitter and melatonin metabolism. Kids with ADHD have lower zinc levels than healthy controls. Zinc deficiency symptoms are like ADHD symptoms, so investigating zinc status can be helpful. Studies on the use of zinc supplementation for improving ADHD symptoms are inconclusive, but I recommend foods high in zinc such as red meat, poultry, legumes, pumpkin and hemp seeds, nuts, and seafood.

Omega-3 Fatty Acids

The Western diet is typically abundant in omega-6 fatty acids and deficient in omega-3 fatty acids. This imbalanced omega-6 to omega-3 fat ratio is implicated in neuroinflammation and could be one contributor to ADHD symptoms. In addition, cell membrane concentrations of omega-3 fatty acids have been shown to have an affect on the neurotransmission of serotonin and dopamine contributing to the development of ADHD.

Omega-3 fatty acids are also important for reducing oxidative stress, which is elevated in those with ADHD. To improve the omega-6 to omega-3 fat ratio, I teach parents and kids to reduce unhealthy sources of omega-6 fatty acids such as industrialized seed oils, like soybean, corn, sunflower, peanut, and cottonseed, and margarine, and encourage the inclusion of high-quality fatty fish twice weekly. If fish is not consumed, I recommend an omega-3 fatty acid supplement of up to 3,000 milligrams per day.

Case Study

I recently met with a patient who, during our conversations, mentioned her 11-year-old son who struggled with ADHD. He began having tantrums when he was 8 years old and was placed on medication, but continued having difficulty sitting still, poor impulse control, and a hard time making even simple decisions. My patient was hoping to find a more natural way to improve his behavior and ultimately stop the medication. Based on the needs of their family of six, we developed the following plan:

1. Full elimination diet to exclude refined sugar, common food allergens, food additives, and dyes for a period of four weeks
2. Celiac disease testing
3. Nutritional supplements to include omega-3 fish oil up to 3,000 milligrams per day, magnesium glycinate at six milligrams per kilogram per day and vitamin B6 at 0.6 milligrams per kilogram per day

At follow up, my patient reported the improvement in behavior was dramatic with the elimination meal plan. After a few weeks on the elimination plan, her son was better able to make decisions, had fewer emotional outbursts, and was more focused during school. She had spoken with his physician, who was willing to taper the ADHD medication and he is now medication-free. She added the nutritional supplements and is working with his provider to obtain Celiac disease testing. My patient described his transformation as unbelievable and said she is hopeful for continued improvement.

While ADHD can be treatment resistant, the addition of nutrition therapy can be extremely effective. Addressing food allergies and sensitivities, preventing blood sugar dysregulation, and providing the appropriate nutrients in the context of a minimally-processed, whole-foods meal plan can be life-changing for children with ADHD and their families.  

References

Bloch, M.H. and Mulqueen, J. (2014) Nutritional supplements for the treatment of ADHD. Child and Adolescent Psychiatric Clinics of North America. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/25220092/

Butwicka, A., Lichtenstein, P., Frisén, L., Almqvist, C., Larsson, H., and Ludvigsson, J.F. (2017) Celiac Disease Is Associated with Childhood Psychiatric Disorders: A Population-Based Study. The Journal of Pediatrics. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/28283256/

Cruchet, S., Lucero, Y., and Cornejo, V. (2016) Truths, Myths and Needs of Special Diets: Attention-Deficit/Hyperactivity Disorder, Autism, Non-Celiac Gluten Sensitivity, and Vegetarianism. Annals of Nutrition and Metabolism. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/27356007/

Lindblad, F., Eickhoff, M., Forslund, A.H., Isaksson, J., and Gustafsson, J. (2015) Fasting blood glucose and HbA1c in children with ADHD. Psychiatry Research. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/25747679/

Pellow, J., Solomon, E.M., and Barnard, C.N. (2011) Complementary and alternative medical therapies for children with attention-deficit/hyperactivity disorder (ADHD). Alternative Medicine Review. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/22214252/