Omega 3 Fatty Acids for ADHD: Do They Work?

Omega 3 Fatty Acids for ADHD: Do They Work?

mmm. oily fish!

“Are omega 3 fatty acids,” a savvy parent asked me the other day, “an effective alternative to medications for ADHD?”

I had recently diagnosed their child with attention deficit/hyperactivity disorder. Like many parents, they were thoughtful, had their concerns, and we were mulling the possible options.  As happens, neither parent was enthusiastic about the prospect of adding a  stimulant medication to the overall approach for their child at home or at school. Fair enough. We talked about a range of ‘med-free’ alternative approaches to ADHD, some proven, some less so. To give her a better answer about fatty acids found in fish oils and other foods, I did some digging. Here’s what I found.

Let’s get this out of the way: ‘Fatty acid’ sounds like the name of a lousy rock band. No matter.  The so-called ‘essential fatty acids’ are materials that must be consumed by humans in our diet (we can’t make our own)  to keep our nerves healthy and our cell membranes happy. EPA and DHA (known as eicosapentaenoic acid and docosahexaenoic acid, respectively) are the most desirable omega 3 fatty acids.  The more we learn, the more we like them. They are good for people.

For example, research has shown the omega-3 fatty acids exert a positive effect on the inflammation and blood circulation in the body.  Studies of populations with higher intake of omega 3s, such as the Inuit peoples of the Arctic Circle, show they reduce risk factors for heart disease, including high cholesterol and high blood pressure.  In addition, omega 3s may have benefits in adult patients for conditions such as some cancers, and arthritis. Research suggests omega 3s can help with  mental disorders, such as schizophrenia and depression.

In children, the omega 3 fatty acids, EPA and DHA, are known to assist in nerve function and formation.  In the last couple of years, DHA has been added to infant formulas, for example, to optimize babies’ brain and eye development. Does it work? Maybe. We’re still figuring out if that is entirely true.

Historically, humans met their needs through the intake of fish and seafood, where omega 3s naturally occur. Sources such as salmon, mackerel, anchovies, and tuna provide rich supplies of EPA and DHA. Certain plantstuffs—notably things kids like and eat less– such as walnuts, flaxseeds, and other seeds and grains provided other precursor materials (eg linoleic acid) that the body could process to EPA and DHA. We processed food-loving North Americans have seen a decline of our intake of the omega 3 fatty acids over time. In some quarters, there is a suspicion that this relative decline in our omega 3 levels may have a biological explanation for certain mental and mood disorders.  Maybe so again.

Research has demonstrated that children with ADHD have lower levels of omega 3s in their bodies compared to their peers. Emerging research has already been done on school-age children to see if giving supplements omega 3 ‘deficient’ children makes a difference. An oft-quoted study (among others) of children  8-12 years old given DHA and EPA supplement improved their academic performance and focus. This is promising, and certainly merits our (in)attention. I am not aware of a study that has yet revealed that giving a child omega 3 fatty acid supplements for ADHD are as or more effective than stimulant medications. For the time being, , omega 3 supplementation hasn’t become a mainstay of therapy for ADHD. Yet.

Tangent #1: For the record, omega 3s are but one nutrient whose deficiency is associated with ADHD symptoms in children. Other studies have found an association of higher rates of hyperactivity and inattentiveness for children with low iron, zinc, and magnesium.  While the studies continue they remain relatively limited in scale and have produced some conflicting results. Primary care docs (like yours truly) do not perform a blood test or screen for these nutrients as a routine workup for kids suspected with ADHD. It isn’t been proven to be cost effective.  However, giving your child a multivitamin daily is a really good idea.

Now, back to our kiddo in clinic.

Recall that attention deficit/hyperactivity disorder (aka ADHD, or ADD) is the most commonly seen mental or behavioral problems in American children. Research finds ADHD affects 8-10% of children of school age in this country, in about 4 times as many boys as girls. And, of all the kids identified, about half of them or more may continue to have ADHD-related issues into adulthood.  That’s a lot of kids (2 million), and a fair number of grownups.

ADHD is complicated. Is it overdiagnosed? Sometimes, sure. A responsible evaluation and management strategy for ADHD needs to look holistically at the child, including their age, maturity level, past medical history (premature birth? other medical condition?) strengths and areas where they struggle.

ADHD  is not a ‘one size fits all’ phenomena, and that management plans have to be tailored to the child in question.  From the research and in practice, we know that stimulant medications such as Ritalin, or Adderall can be a safe and effective part of an overall strategy plan. And, about 80% of children who use these medications for this problem realize some to great benefit.

Tangent #2: It is also critical to know that ADHD often co-travels with other emotional or cognitive problems.  Many kids have more than just ‘simple ADHD.” More than 50% of children with the diagnosis suffer from depression, conduct and anxiety disorders, and learning disabilities. No joke. It is imperative that these issues be weighed and addressed, for they may impact greatly on what treatments are considered, including supplements, alternative therapies, stimulant medications, or consulting with a mental health expert.

As noted, stimulant medications have their issues, too. Finding the right does can take time, and a few visits to work out. While they have a good safety profile as meds go, almost half of children taking stimulant medications for ADHD encounter unpleasant side effects. Many of my patients do complain about the more common problems associated with stimulants, including headache, stomach upset, loss of appetite, sleep difficulties, or moodiness. They aren’t for everybody.

So for the family that is medication-wary, or complementary/alternative therapy inclined, we return to our initial question: Is the the use of a omega 3 fatty acid supplement in a child or teen’s diet a safe and effective alternative to taking stimulant medications and their ilk for ADHD?

Safety.

For seafood lovers, eating certain fish twice a week has been recommended as a healthy, holistic approach for taking omega 3 rich fish oils. A 4 ounce serving of salmon for example, can deliver up to a gram of omega 3s. Concerns have arisen in the last few years, noting contamination of ocean fish with mercury and or dioxins. More recent research coming out of Scandanavia suggests that eating fish two, or even three times a week may not be as harmful as originally feared. For now though, parents may consider offering a fish based entrée at least once a week. Eat up, me hearties!

For vegetarians, or those with a distaste or allergy to seafood, emphasizing a diet rich in plant sources of ALA (from which EPA and DHA can be made by the body) may be another option. Flaxseed has the highest concentration of ALA, and its oil can be used in making foods or used in salad dressing.

In terms of using omega 3 dietary supplements, such as gels or capsules, there are a few issues to consider. Generally, preparations over the last decade have lessened the tendency for fish oil supplements to have a fishy taste, or to provide unhappy afterburps. And, speaking from experience, some of the flaxseed preparations don’t taste so hot either.  A clinical pearl, borrowed from Dr Kathi Kemper’s extraordinary website at Wake Forest University, suggests that chilling supplements lessens their tendency to have a strong flavor, and taking them with food reduces tummy upset associated with them.

And, dietary supplements like omega 3s have the potential of any herb or dietary supplement to exert truly pharmacologic effects upon the body. Specifically, omega 3s have a mild blood thinning effect and can interact with medications that do the same, such as aspirin, ibuprofen or other anticoagulant meds. For this reason, it is especially important for a family to disclose or discuss a child’s use of any supplement they are using with a physician or surgeon they are working with. It all matters, and it all goes on the med list!

Tangent #3: In terms of buying herbs and supplements, it is a buyer beware scenario. Put simply, the quality control over these products is not as scrupulously followed by the FDA as are the manufacture and sale of pharmaceuticals. With omega 3 and fish oil supplements,  the well-regarded ConsumerLab.com (a sort of online, subscription website version of Consumer Reports for herbs and supplements) recently reported the results of their survey of a number of omega 3 preparations.  Their e-newsletter summarized their findings here:

Laboratory tests of fish oil, krill oil, and algal oil supplements by ConsumerLab.com revealed quality problems with 7 out of 24 products selected for review. Three products contained less omega-3 fatty acids (EPA and/or DHA) than claimed.  Several products (including a children’s fish oil) were spoiled when purchased. An enteric-coated fish oil softgel released its oil too early…Seventeen of the selected omega-3 supplements passed testing as did 15 products similarly tested through ConsumerLab.com’s voluntary certification program.

So, are these supplements safe? Yes, if chosen well. Caveat emptor.

Fortunately, Dr Kemper’s website provides us with a reliable guideline (below) for well-established products to choose, and how much omega 3 to give children. Ideally, omega 3 supplements for kids should contain a combination of EPA and DHA.

Typical doses are for the COMBINATION of EPA+DHA: 500 mg for 6- 12 year olds; 1000-3000 for teens and adults

Liquid preparations:

Carlson’s (1 tsp contains 800 mg EPA + 500 mg DHA)

Or Nordic Naturals Ultimate Omega Liquid (1/2 tsp contains 813 mg EPA + 563 mg DHA)

Gel:

Coromega Omega-3 Squeeze (each packet contains 350 mg EPA + 230 mg DHA)

Capsules:

Nordic Natural EPA Xtra (2 capsules contain 1,060 mg EPA + 274 mg DHA)

or
Trader Joe’s concentrated, molecularly distilled (500 mg – 600 mg of EPA+DHA per pill)

Bottomline then, omega 3s are safe and dosing guidelines are now a bit clearer. But,are omega 3 fatty acids given via diet or via omega 3 capsules an effective alternative to stimulant medications?

No, not really. Omega 3 use for children with ADHD has a better role, in my view, as an adjunctive therapy, not as alternative to stimulant medications. I will recommend parents give DHA and EPA preparations to children to complement a broader treatment plan, including behavioral management, other potentially helpful integrative/lifestyles therapies (biofeedback, as one example) and medications, including Ritalin and others.  If people use omega 3s supplements with their children, let your primary care doc know. It matters, they might help, and we all may learn something. These omega 3s may have other salutary effects as well. Food for thought, eh?

Nice links:

photo above by SurelyFishingTV

Cartoon below by me

Omega 3 Fatty Acids for ADHD: Do They Work?

Jack Maypole, MD has plenty of material to work from. He is director of Pediatrics at the South End Community Health Center and he is director of the Comprehensive Care Program at Boston Medical Cent ...read more

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