Although medication treatment benefits an estimated 70 to 90% of children
with ADHD, effective alternative treatments are needed for several reasons.
First, even for children who respond well to medication, difficulties that
need to be addressed often remain. Second, some children experience side effects
that preclude the ongoing use of meds. Finally, most studies of stimulant
medication treatment are relatively short-term, and data showing that stimulant
medication improves long-term outcomes remain scarce.
One alternative treatment that has been studied in recent years is dietary
supplementation of long-chain fatty acids. Certain long chain fatty acids
play an important role in many aspects of physical health, and may also influence
a wide range of neurodevelopmental and psychiatric conditions. For example,
children with ADHD have been shown to have low blood levels of certain long
chain fatty acids, particularly omega-3 fatty acids. Because omega-3 fatty
acids have been linked to several neurodevelopmental and psychiatric disorders,
it has been suggested that increasing omega-3 levels via dietary supplements
may enhance brain functioning and reduce ADHD symptoms.
In prior issues of Attention Research Update (see http://www.helpforadd.com/2006/august.htm
) I reviewed studies that obtained promising findings for fatty acid supplementation
in youth with ADHD symptoms. These studies had several limitations that
made it difficult to draw clear conclusions about the potential benefits of
this intervention approach, however. A more recent study of fatty acid supplementation
addresses many of these limitations and provides important new information
on the value of fatty acid supplementation as a treatment for ADHD
[Gustafsson et al. (2010). EPA supplementation improves teacher-rated behavior
and oppositional symptoms in children with ADHD. Acta Paediatrica, 99
Participants were 92 7-12 year old Swedish children diagnosed with ADHD;
none were receiving stimulant medication. Children were randomly assigned
to receive either 15 weeks of fatty acid supplementation with a formulation
called PlusEPA, or, to the control condition where they received an identically
appearing placebo capsule. Each PlusEPA capsule contained 500 mg of EPA (EPA
stands for Eicosapentaenoic acid and is an omega-3 fatty acid) + 2.7mg of
DHA (DHA stands for Docosahexaenoic acid and is another type of omega-3 fatty
acid) and 10 mg of vitamin E. No adverse effects of EPA supplementation
Parents and teachers completed the short version of the Conners Rating Scale
- a widely used measure of ADHD symptoms and oppositional behavior - at baseline
and after 15 weeks of treatment. Comparing ratings for the treatment and control
groups enabled the researchers to learn whether PlusEPA treatment yielded
significant reductions in ADHD symptoms and oppositional behavior. EPA
blood levels were taken at baseline and after 15 weeks so the researchers
could learn whether change in blood levels was associated with change in ADHD
The primary outcome measure selected by the authors was the sum of children's
scores on the parent and teacher versions of the Conners Rating Scale.
On this primary outcome measure, there was absolutely no evidence that children
receiving EPA supplementation were doing any better than controls.
The authors next tested for differences on the hyperactive, inattentive
and oppositional scales within the parent and teachers measures separately.
For the parent ratings, there was no evidence of any treatment effect for
any of these scales. For the teacher measure, children receiving EPA
supplementation had lower ratings of inattention after 15 weeks than control
children. Although this difference was statistically significant, it
was relatively small in magnitude.
Finally, the researchers examined the impact of supplementation in children
who were identified as being highly oppositional at baseline. Within
this subgroup of highly oppositional children, results indicated that supplementation
was associated with significant declines in teachers' ratings of attention
problems and oppositional behavior but not in hyperactivity. Just over
50% of oppositional children treated with EPA had a clinically meaningful
decline in teacher ratings compared to just 9% of children who received placebo.
- Relation between EPA blood levels and treatment response
The researchers compared EPA blood levels among children within the oppositional
group to see whether they differed between those who responded to EPA supplementation
and those who did not. Results indicated that responders had significantly
lower levels at baseline compared to nonresponders. Differences at the
end of treatment were not significant.
- Summary and implications
Results from this well-conducted study provide clear evidence that EPA supplementation
is not a helpful treatment for a general sample of children with ADHD.
This conclusion is based on the finding that the primary outcome examined
by the researchers - the sum of parent and teacher ratings on the Conners
rating scale - showed absolutely no difference between treatment and control
groups. There is thus no basis for recommending EPA supplementation
as a general treatment approach for youth with ADHD.
However, follow-up analyses offer suggestive evidence that EPA supplementation
may benefit youth with ADHD who are highly oppositional, especially if their
normal blood levels of EPA are low. Among this subgroup, treatment with
EPA was associated with significant reductions in teacher ratings of attention
problems and oppositional behavior. Even within this subgroup, however,
nearly 50% did not realize significant benefits and improvements in hyperactivity
were not evident overall.
While results obtained for this subgroup of ADHD youth are promising, the
authors acknowledge that the subgroup was not clearly specified apriori, but
was instead constructed in an exploratory post-hoc analysis. This is
a completely appropriate thing to do, but when significant treatment effects
are obtained in post-hoc analyses, it is especially important to replicate
the findings in a new sample to be more confident that it was not a chance
effect. Thus, before too much credence is placed in this result, it
would be important to conduct a new study of EPA supplementation in children
with ADHD who are highly oppositional, and see whether the positive findings
are replicated. If so, it would provide a reasonable basis for recommending
this approach with such children.
In the meantime, this study does argue against EPA supplementation as a
general treatment recommendation for children with ADHD. There are
two important caveats to that conclusion. First, the dose used in this
study was relatively low and it is possible that treatment with a higher
dose would have yielded more positive findings overall. Second, it
is also possible that other types of fatty acid supplementation than that
used in the current study would yield more positive findings, and it is important
to recognize that the negative result reported in this study does not mean
that other types of supplementation regimes may not be helpful.
Hopefully, additional randomized-controlled trials that examine the impact
of different doses and supplement regimes will be available shortly.
In the meantime, however, these findings do provide an important caution regarding
the general efficacy of this approach and highlight the value of carefully
conducted trials in establishing the efficacy of alternative treatments for