Jimmy was rarely invited to birthday parties, but there was a new kid in his class whose mother had never seen him in action, so he got an invitation. At first, he just seemed a little excited, like the other kids, running around playing in the yard. At lunch he was a bit restless at the table, making funny faces and goofing around with the food. He helped himself to a third glass of soda while munching M&Ms and chips. By the time the cake and ice cream arrived, he was revved, his eyes glazed over as he babbled and jostled the kids sitting next to him. He kept ducking under the table and popping back up like a Jack-in-the-box, pausing only to stuff chunks of dessert into his mouth. His friend’s mother was kind, even when he spilled his drink. The ducking and popping got rougher until he knocked the table so hard that all the soda cups came tumbling down. As he rolled laughing on the floor, he caught a glimpse of the mother dashing for the phone to call his parents.
What happened to Jimmy? What turned him into a party monster? Was it the soda, candy, chips, sugar, artificial colors and flavors, having to sit still, overstimulation from the other children—all of the above? There are many opinions on these questions.
When we read about a scientific study showing benefits from a dietary treatment, it is important to assess the quality of the evidence. There are many ways to do a scientific study, as we have noted, and some methods produce more solid, significant, and higher-quality evidence than others. In general, studies with larger numbers of participants and those that use a randomized, double-blind, placebo-controlled method are considered to be more convincing than smaller studies that do not use a control group. (See the discussion of research evidence in Chapter 2.) Here we sort through the evidence and suggest ways to evaluate the possible impact of food on symptoms of ADHD that you and your family may be experiencing.
Dietary treatments can involve eliminating certain foods, adding foods or supplements, or both. Changing the diet of children, especially by not letting them eat the foods their friends get to enjoy, is difficult at best and sometimes disastrous. Many parents wonder if it is worth the struggle. Will this make enough of a difference to be worth the effort, the fights, the tears, the tantrums? The answer is: sometimes yes and sometimes no. Although many individuals believe that food can profoundly affect their ADHD symptoms, findings from research on elimination diets have been consistently inconclusive. However, studies are making progress investigating why certain people with ADHD are affected by specific foods, artificial food additives, and particular supplements. Whether or not you will benefit by avoiding sugar, eliminating artificial food colorings, or taking supplements probably depends upon several factors:
• Your genetic composition and polymorphism profile (see Chapter 2 for discussion of polymorphisms or genetic variants)
• Whether you have deficiencies of essential vitamins or minerals due to diet or poor absorption.
• Whether you have allergies to specific foods or food additives.
• Whether you have been/are exposed to environmental effects such as toxins, pesticides, smoking.
Here are four simple rules that may help you make decisions about whether to add dietary treatment to the burden of tasks involved in managing ADHD:
Rule 1: Observe your own reactions to food.
Rule 2: What’s good for your brain is good for your ADHD.
Conversely, what’s bad for your brain is bad for your ADHD.
Rule 3: Compare your subtype and characteristics with those that have been shown to be associated with positive responses to dietary interventions.
Rule 4: Use your common sense.
Here are some questions to consider when deciding whether to add dietary treatment to the many tasks involved in managing ADHD:
• Do I (or my child) have characteristics similar to those of people who are known to benefit from dietary changes?
• Which dietary changes are easiest to make with minimal disruption to normal eating patterns and food preferences?
• How strong is the evidence that dietary treatments really work?
• Which dietary changes or supplements would have additional health benefits to make them worth the effort and expense?
• Which supplements have been shown to help ADHD? What are the subtypes and characteristics of people most likely to benefit from these supplements?
• How do supplements work? Why are they important?
While some people swear by diets that eliminate all but a few foods, for most people, such an extreme approach is not necessary. There is some evidence that artificial food colorings, benzoate preservatives, sugars, and artificial sweeteners may cause problems in some cases. Studies suggest that approximately 50% of children may benefit from eliminating these culprits.
One characteristic of people who are most likely to benefit from dietary elimination are those who have specific food allergies or hypersensitivity to artificial food additives. This may seem obvious, but the identification of specific allergies is not. An allergy to strawberries that causes itchy hives is easy to spot, but an allergy that causes tiredness, mental fuzziness, or hyperactivity in an already hyperactive child is not. Fortunately, food allergies that exacerbate ADHD occur in only a minority of children. They are usually found in preschool children who have difficulty sleeping, irritability, atopy (allergic tendencies), asthma, allergic rhinitis, rash, behavioral problems, and sometimes high copper levels. If you suspect a food allergy, you can test it by process of elimination; that is, avoid that food for 2 weeks and see if that makes a noticeable difference, then try eating it again and see what happens. If the answer is not crystal clear, you can ask your doctor to do allergy testing.
Unfortunately, many of the studies on sugar elimination have used questionable methods. Even well-designed studies have failed to demonstrate that eating sugar worsens behavior in children with ADHD (Krummel, Seligson, & Guthrie, 1996). As a result, the issue of the role of sugar is still unresolved. It is important to understand why there is a lack of clear scientific evidence that sugar or artificial sweeteners can aggravate ADHD. It is extremely difficult to prove that one very common food component, such as sugar, causes ADHD for the following reasons:
1. It is difficult to isolate the effects of sugar because most sugary foods also contain other ingredients, such as artificial coloring and flavoring, which might contribute to the effects being observed.
2. It is impossible to totally eliminate sugar from the diet.
3. Families that allow their children to eat a lot of junk food may differ in other ways that could affect the outcome of scientific studies. For example, they could also be more lax about structuring the child’s behavior, less disciplined, less attentive to providing other forms of treatment or educational support, less able to provide a calming or predictable home environment, and so forth.
The bottom line: Since excess amounts of sugar are not particularly healthy anyway, if you find that indulging in sweets seems to aggravate ADHD symptoms, then it makes sense to curb your sweet tooth.
Neither the food industry nor our government is moving quickly enough to reduce the amount of toxic substances entering the food chain and affecting our health and the health of our children. We focus on the most common additives and the worst contaminants while offering practical ways for you to find healthier foods.
Natural food colorings from plants such as beets and carrots are available. Yet most food manufacturers prefer to use artificial dyes because they are cheaper and more durable. Food dyes are complex chemicals derived from petroleum. Many contain more than 10% impurities, including carcinogenic, genotoxic (adverse effects on DNA), and neurotoxic (adverse effects on brain cells) contaminants. The Food and Drug Administration (FDA) deals with these problems by establishing limits on the maximum amounts of these carcinogens that can be present in foods. However, these limits do not take into account the fact that a person may consume carcinogens from multiple food sources, that the number of foods containing these chemicals increases every year, and that the total amount ingested by an individual could exceed the legal limits considered “safe” (Jacobson & Kobylewski, 2010).
The British government sponsored two studies of four dyes and a preservative (sodium benzoate) that found increases in hyperactive behavior in children with and without ADHD. Based on this and other information, the government ordered food companies to eliminate these ingredients in 2009. The European Parliament followed by requiring all foods containing these additives to be labeled as follows: “May have adverse effects on activity and attention in children.” Consequently, major companies such as McDonald’s, Mars, Kraft, and PepsiCo use no artificial dyes in certain food products sold in the United Kingdom, but continue to use them in the United States. The FDA has lagged behind in banning unhealthy food additives, leaving consumers with the burden of reading food labels containing long lists of ingredients in tiny fonts and then the frustration of not being able to control access to food additives when their children have food away from home.
Let’s look at the most common offenders. Three of the dyes identified as causing allergic hypersensitivity reactions that could aggravate hyperactive behavior are Red 40 (Allura red AC), yellow 5 (tartrazine), and yellow 6 (sunset yellow). These three account for 90% of the food dyes certified by the FDA each year. In 2009, that would add up to about 13,500,000 pounds per year to brighten candies, cereals, gelatin desserts, bakery treats, and other child-oriented foods. These dyes are also used in sausages and cosmetics.
A double-blind, randomized, placebo-controlled study of 277 children found evidence that artificial food coloring and benzoate preservatives exacerbated hyperactive behavior in 3-year-old children. Although the parents noticed this effect, it was not detected by a simple clinic assessment (Bateman et al., 2004).
More recent studies suggest that people with the histamine gene polymorphism HNMT are more likely to experience increased hyperactivity in reaction to food additives, especially azo (yellow and red) dye food colorings and a preservative (sodium benzoate). We introduced this study in Chapter 2 (Stevenson et al., 2010). Stevenson’s group compared the effects of two drinks containing a mixture of artificial additives with a placebo drink (no additives) on the behavior of children who were not diagnosed with ADHD. Mix 1 contained sunset yellow, carmosine, tartrazine, ponceau 4R, and sodium benzoate; Mix 2 had sunset yellow, carmosine, quinoline yellow, Allura red, and sodium benzoate. Children with the histamine gene polymorphism HNMT showed greater increases in hyperactive behaviors when given either Mix 1 or Mix 2 for 6 weeks. Although the exact incidence of this HNMT polymorphism in the general population is not known, in the Stevenson study, about 30% of the children had this polymorphism. That translates into a huge number of children (millions), with and without a diagnosis of ADHD, who could exhibit hyperactive behaviors when they ingest these food colorings. One limitation of this study was that it did not distinguish which of the components of each drink was most responsible for the adverse effects. Ponceau 4R and quinoline yellow have been banned in the United States, but the food dyes called tartrazine (Yellow 5), sunset yellow (Yellow 6), carmosine (Red 3), and Allura red AC (Red 40) have not.
Table 4.1 Food Additives Linked to Hyperactivity
a These additives are found in some commercial brands, but not in others. Consumers should read food labels and check other resources to identify specific products that may exacerbate attentional problems in some children.
In Table 4.1 you will see examples of foods that may contain these dyes. For each food type, there are certain companies that use unhealthy dyes and others that do not. We have not identified the manufacturers whose products contain the dyes. However, you can find this type of information by reading food labels very carefully, searching websites, or by reading the Nutrition Action Health Letter (Jacobson & Kobylewski, 2010). The simplest way to avoid harmful food additives is to buy foods labeled “no artificial colorings or preservatives.”
Because artificial food additives have no nutritional value and may have adverse effects on hyperactivity, not to mention cumulative or long-term carcinogenic or neurotoxic effects, you may want to eliminate these products as much as possible. This means taking the time to read package labels and reduce your use of products containing those artificial colorings, flavorings, and preservatives that have been associated with negative effects. (You may need a magnifying glass to decipher those cryptic food labels.)
Q: What about children’s vitamins?
A: Unfortunately, many of them do contain food additives. In fact, some of the most popular and widely advertised children’s vitamins contain Red 40, Yellow 6, and Blue 2. Just read the labels carefully. What a cruel irony that we find these unhealthy additives in the supplements we give our children to stay healthy. It would be easy to eliminate these artificial colors and replace them with natural healthy vegetable dyes, such as beet juice.
Q: What can we do about the presence of artificial food additives in our food supply?
A: The first action to take is to educate ourselves and others about the widespread use of toxic additives. The second action to take is to read the labels on all the foods and supplements you buy. While writing this chapter, I remembered that the manufacturer of my calcium plus vitamin D tablets had recently changed the color from white to pink. Although I had noticed the color change, I had not given it much thought. Uh-oh! I dashed to the kitchen, flung open the cabinet, grabbed the bottle, and slowly read the label. There it was –Red 40 and Yellow 6—right there on my calcium supplements! Why did they change the tablets to pink? I guess some marketing genius decided that women prefer pink, but we don’t when it means ingesting toxic substances every day. When you consider how much calcium women take, especially when they are pregnant, breast feeding, or postmenopausal, this is deeply disturbing. But, that wasn’t all. I remembered that my multivitamins were orange. Sure enough, the label said Red 40 and Yellow 6—and I had been taking them for over 30 years—including when I was pregnant! What about those colorful antacid tablets my husband sometimes uses? Sure enough, a rainbow of carcinogens: Yellow 5, Yellow 6, and Red 40.
The third action to take is to stop buying products containing these dyes and switch to those that are free of these toxins when possible. From now on, I will use only calcium tablets that are white—the natural color of calcium—and multivitamins labeled “no artificial food colorings.” When enough consumers (1) stop buying products containing unsafe artificial food colorings, (2) write to their public representatives, and (3) confront manufacturers and store managers about the unacceptability of these toxins, perhaps there will be changes in our FDA requirements and warning labels. Meanwhile, check all the cans, boxes, and bottles in your cabinets and arm yourself with a good magnifying glass that folds in and out of its case whenever you go shopping. For more information on food additives, check the websites in the Resources section at the end of this chapter.
Rule 2: What’s bad for your brain is bad for your ADHD.
Toxic Heavy Metals
Although more research is needed on the effects of heavy metals (e.g., lead, cadmium, mercury, aluminum, or arsenic) on ADHD, there is evidence that in excess levels, they are toxic to neurons (brain cells), particularly when the brain is developing rapidly in utero and during childhood. Studies of children have shown that those with higher blood lead levels have increased risk of neurobehavioral deficits and ADHD. Studies conducted to date suggest that excess lead may reduce attention, response inhibition (control of impulsivity), and executive functions (the ability to get things done) (Roy et al., 2009). Even low-level lead exposure has been associated with increased risk of a clinical diagnosis of ADHD (Eubig, Aguiar, & Schantz, 2010). It is important to check your home for lead paint or corroding pipes, your water quality, and your neighborhood to be sure your family is not being exposed to environmental toxins.
In the United States, public health efforts have significantly reduced the incidence of lead poisoning, but people living in areas with higher industrial pollution may be at risk. If you suspect exposure to heavy metals, ask your doctor to do an evaluation. Through a careful history, physical examination, and blood tests, your doctor will be able to tell you if heavy metal levels are too high. Doctors can remove excess heavy metals from the body by prescribing oral (pills taken by mouth) chelating agents. These agents link metal ions together, forming complex structures called chelates, which are then readily eliminated from the body, primarily through urination. Beware of private clinics that do their own nonstandardized testing and offer expensive intravenous chelation regimens. If you are told that you have heavy metal poisoning and that you need chelation, get a second opinion and testing at an independent standard laboratory. Most people with ADHD do not need chelation (removal of heavy metals or pollutants from the blood) unless they have been exposed to an industrial area contaminated with heavy metals or lead paint. Chelation should be considered only when toxic levels of a heavy metal have been found in a blood sample analyzed by a standard, accredited laboratory. Chelation requires medical monitoring to minimize health risks. Adverse effects of chelation include elevated levels of liver enzymes and skin reactions (Bradberry, & Vale, 2009). Also, chelating agents can remove some of the heavy metals that your body needs such as copper and zinc, resulting in deficiencies unless supplements are provided.
Organochloride pesticides are contaminating our soil, water, and food supply. Although the FDA limits the amounts of allowable pesticides in foods, evidence is growing that certain pesticides, particularly polychlorinated biphenyl (PCB) and p,p’-dichlorodiphenyl dichloroethylene (p,p’-DDE) can cross the placenta and affect fetal neurodevelopment. A recent study by the Department of Environmental Health at Harvard School of Public Health found that increased levels of PCBs in umbilical cord blood samples were associated with a higher risk for ADHD-like behaviors in children (Sagiv et al., 2010). A study of 1,139 children, 8–15 years of age, identified 119 who met the criteria for ADHD. Those with ADHD had higher levels of organophosphate pesticides than those who did not have ADHD (Bouchard et al., 2010). Scientists are discovering more connections between pollutants such as pesticides and increased risk of developing ADHD, even if the exposure is simply from eating foods containing organic chemical pollutants (Kuehn, 2010).
While pesticides should be minimized in everyone’s diet, this is especially important for women of childbearing age, for those who are pregnant, and for children. Children 2–5 years old who ate conventional foods were found to have urinary organophosphorous pesticide levels that were six times higher than those who ate organic fruits, vegetables, and juices. Pesticide levels on conventional diets exceeded the U.S. Environmental Protection Agency (EPA) guidelines that place the children in the category of “uncertain risk,” whereas levels in children who ate organic produce were in the range of “negligible risk” (Curl, Fenske, & Elgetun, 2003).
It makes sense for everyone to reduce pesticide consumption as much as possible. This can be done by finding out which foods are most likely to contain toxins, shopping carefully, choosing organic products, and thoroughly washing or peeling all produce. Because PCBs are fat soluble, they tend to concentrate in animal fat and are found in fish, meat, and dairy products; PCB residues are also found on fruits and vegetables. Here are ways to minimize food exposure to PCBs:
1. Avoid commercial fish that are high in PCBs: Atlantic or farmed salmon, bluefish, wild striped bass, flounder, and blue crab. Prepare fish by removing the skin and trimming the fat. Broil, bake, or grill fish so that fat drips away.
2. Look for certified organic meats. Beef from grass-fed cattle is leaner.
Buy lean meats and trim off the fat before cooking. You can reduce the amount of pesticides by broiling, grilling, roasting, or pressure cooking and discarding the fat. Do not fry in lard, bacon grease, or butter. Do not make gravies from meat fats or juices unless you use certified organic meat.
3. Use organic milk and dairy products for children. If you cannot find or cannot afford organic milk products, another way to reduce pesticides is to use low-fat milk products for children age 2 and older. Because organic pesticides are fat soluble, they tend to concentrate in the fat portion of milk rather than in the protein or water soluble components.
4. Whenever possible, choose organic produce. If you cannot buy organic fruits and vegetables, careful washing and scrubbing in cold water can eliminate 50% of pesticide residues.
5. Avoid certain fruits and vegetables that tend to have the higher pesticide residues (see Table 4.2).
If you cannot afford to buy all organic produce, then you could shop strategically by choosing organic produce from primarily the high-pesticide residue group. To learn more about foods that may contain PCBs and how to avoid them, visit the website of the Institute for Agriculture and Trade Policy Food and Health Program (see Resources)
Table 4.2 Pesticide Residue Levels in fruits and vegetables
| High | Moderate | Low |
| Apples, grapes (imported), nectarines, peaches, pears, red raspberries, strawberries, bell peppers, carrots, celery, green beans, hot peppers, potatoes, spinach | Apricots, blueberries, cantaloupe, grapefruit, grapes (domestic), honeydew melons, oranges, collard greens, cucumbers, kale, lettuce, mushrooms, sweet potatoes, tomatoes, and winter squash | Apple juice, bananas, mangoes, orange juice, papaya, plums, tangerines, watermelon, asparagus, avocado, broccoli, cabbage, cauliflower, onion, sweet corn, and sweet peas |
Note. Adapted from the Institute for Agriculture and Trade Policy Food and Health Program.
Free radicals are molecules that can damage cells by breaking down essential components such as cell membranes. One of the most common sources of free radicals is the smoke inhaled from cigarettes and recreational drugs. Many people with ADHD become readily addicted to smoking cigarettes because nicotine can improve alertness and attention. So, not only are they prone to regular nicotine addiction, but they are also drawn into smoking because it improves their ability to function. Unfortunately, there are long-range consequences due to the increased risk of cancers of the mouth, throat, lungs, and stomach, ulcers, and cardiovascular disease. Moreover, the free radicals in cigarette smoke also attack brain cells causing damage to their membranes, internal structures, and DNA. Over time this accelerates brain aging. People with ADHD who smoke to obtain short-term benefits need to weigh these against the long-term health costs.
Now that we have talked about what to get rid of, let’s look at nutrients that might be worth adding. As we discuss each supplement, we note the characteristics of people most likely to benefit. Moderate levels of vitamin and mineral supplementation (not megavitamins) have been beneficial in studies of children who are deficient or who have relatively low levels of these nutrients prior to treatment. Lack of diversity in the diet, especially inadequate amounts of fresh fruits and vegetables, can contribute to deficiencies. In addition, poor absorption of nutrients due to medical conditions, age, or improper food storage and preparation can reduce vitamin levels. In general, fresher food is higher in vitamins and nutrients than food that has been sitting on a shelf in the cabinet, refrigerator, or freezer. The growth of farmers’ markets and the movement to “eat local” are making fresh foods more available. Raw food enthusiasts believe that cooking is unnecessary and only destroys nutritional value. This is not entirely true. For example, many people cannot fully digest certain raw foods and may need to cook them in order to absorb nutrients. Overcooking can also cause loss of nutrients. We recommend cooking foods until they are just done, but not overcooked. For example, green vegetables should retain their color and some firmness. Also, vitamins can be lost when vegetables are cooked in water; steaming preserves more of the nutrients. If you have a local health food store, rummage through their book section to find a guide to healthier cooking.
Tables 4.6 and 4.7 at the end of this chapter provide a summary of treatment guidelines for all of the supplements in this chapter and a list of quality products and where to find them.
Children and adults with below-normal levels of essential vitamins—B1, B6, B12, folate, C, and D—may benefit from supplementation. People with ADHD often have suboptimal diets because they either don’t have the organizational ability to shop and cook properly, or they don’t have the patience to sit and eat regular meals. Moreover, their appetite may be suppressed by stimulant medications. Very healthy eaters are more likely to have adequate vitamin levels unless they have a problem with absorption (which may not be obvious). As we get older (over age 40) our ability to digest foods and absorb nutrients may decline. If you are concerned about possible vitamin deficiencies, you may ask your doctor to run certain blood tests for the more important ones, including methylcobalamin (B12), folate, and vitamin D.
A randomized, double-blind, 3-month study of 245 children with low serum levels of vitamins B or C found that treatment with vitamin supplements reduced levels of aggression and antisocial behavior as well as improving cognitive performance compared to placebo. In 20% of the children given supplements, the mean IQ scores increased 16 points (Schoenthaler & Bier, 1999).
Folate and B vitamins, particularly B6 (pyridoxine) and B12 (methylcobalamin), are essential for normal brain development as well as for the ongoing production of neurotransmitters, including serotonin, norepinephrine, and dopamine. Many children (and adults) recoil from eating foods rich in these vitamins, particularly spinach and other dark-green leafy vegetables. When creative recipes such as spinach cookies or crunchy kale bars fail, daily vitamin supplementation may be the easiest solution.
One vitamin preparation we often use is Bio-Strath®. Derived from baker’s yeast grown on alpine antioxidant herbs, Bio-Strath is high in natural antioxidants, minerals, vitamins (particularly B vitamins), essential amino acids, and immune boosters. It does not contain any whole yeast and therefore is not a problem even for people who are prone to yeast infections. Liquid Bio-Strath contains 3% alcohol and should not be used by anyone recovering from alcoholism, even though the amount in one teaspoon is negligible (see Table 4.6 and 4.7 at end of chapter). Bio-Strath also comes in tablet form. In an open study of 18 children whose assessment on a medical questionnaire suggested ADHD, the children were given one teaspoon of Bio-Strath three times a day for 6 weeks. Compared to starting scores, computerized tests of visual and auditory attention and response control improved significantly over the 6 weeks in 12 out of 18 participants. The greatest improvements were found in attention to auditory stimuli, processing of visual stimuli, and auditory impulsiveness (König & Joller, 2006). Further studies are needed to identify who would most likely benefit from Bio-Strath.
In mineral deficiencies, supplements are also useful. Many children with ADHD have inadequate diets, so it may be worth checking with your pediatrician, who can easily test the levels of vitamins and essential minerals before starting supplements.
The micronutrient zinc is an essential cofactor in the production of dopamine and norepinephrine, two neurotransmitters that have been linked to ADHD. Low serum levels of zinc have been found to correlate with inattention, but not hyperactivity/impulsivity, in a study of American children (Arnold & DiSilvestro, 2005). In Turkey and Iran, where zinc deficiency is more prevalent, two studies showed zinc supplements to be helpful for ADHD. In a 6-week controlled study of 44 children with ADHD, 15 mg elemental zinc given daily improved the effects of methylphenidate (Ritalin) more than placebo (Akhondzadeh, Mohammadi, & Khademi, 2004). Another 12-week controlled study of 328 boys and 72 girls with ADHD found that zinc sulfate 40 mg/day significantly reduced ADHD symptoms compared with placebo (Bilici, Yildirim, Kandil, et al., 2004).
A Canadian study of 43 children with ADHD found that 66% were deficient in zinc and 23% in copper (Kiddie, Weiss, Kitts, Levy-Milne, & Wasdell, 2010). Curiously, in the Canadian study no relationship was found between children’s serum zinc levels and the amount of zinc in their food or their use of standard multivitamin–mineral supplements. This study raises several questions. For example, how do we account for the observation that the daily consumption of zinc did not determine the serum zinc levels? Do children with ADHD have lower zinc and copper levels because of poor absorption of these elements from food, or is there some genetically based difference in how these minerals are metabolized? Although taking vitamin–mineral supplements containing small amounts of zinc did not appear to increase zinc serum levels, would higher doses of zinc make a difference? The use of supplements for zinc deficiencies warrants further study. Until there is more evidence, it may be helpful to check serum zinc levels. If the level is low, it may be worthwhile to use a daily zinc supplement (rather than a standard multivitamin–multimineral supplement) for several months and recheck the serum level as well as re-evaluate ADHD symptoms to see if there is improvement.
Copper is an important micronutrient in the synthesis of dopamine and norepinephrine. The Canadian study mentioned above (Kiddie et al., 2010) found that about 23% of the children with ADHD were deficient in copper. Studies of the potential role of copper in ADHD are needed before it can be recommended as a treatment.
Iron is necessary for dopamine synthesis. Enhanced dopamine transmission is a feature of most of the medicines that are effective in treating ADHD. In one study, ferritin (a measure of iron stores) was low in 84% of 53 children with ADHD compared with 18% of 27 children who did not have ADHD. Lower ferritin levels correlated with more severe cognitive deficits and ADHD ratings (Konofal, Lecendreux, Arnulf, & Mouren, 2004). In iron-deficient adolescents, iron supplements have improved learning and memory (Bruner, Joffe, Duggan, Casella, & Brandt, 1996). In a controlled study of 23 children (ages 5–8 years) with low serum ferritin levels, iron supplementation (80 mg/day) appeared to improve ADHD symptoms (Konofal et al., 2008). Iron therapy was well tolerated. Larger studies are needed to explore the role of iron supplements in the treatment of ADHD.
Tina was a little wiggle worm. Her legs were always moving. It was cute when she was 3, but as she grew older, it became more of a problem. She was forever kicking her chair or the chair in front of her. Although she seemed to be moving constantly, she was also tired, no matter what time she was put to bed. Tina’s parents began to worry that she might have ADHD. One night, determined to find out whether Tina was sleeping or not, her mother sat in her room to watch. What she saw was that Tina’s legs kept moving, even when she appeared to be asleep. When she described this to her pediatrician, the doctor ordered a blood test. When it showed a low level of ferritin (iron), the doctor explained that restless leg syndrome (RLS) is a condition in which a person’s legs seem to keep moving when they sit or lie down. It can cause poor sleep quality and daytime tiredness. Low levels of iron and folate are among the many possible causes of RLS. Because RLS can be mistaken for hyperactivity, children with symptoms of ADHD or restless legs should be tested for iron and folate deficiencies. In most cases, RLS can be treated with supplements. This condition could also be a wakeup call for a better diet. Frequent consumption of foods that are rich in iron and folate, which include dark-green leafy vegetables (e.g., spinach, kale, collard greens), beans, and red meat, may prevent the development of deficiencies.
Q: Who should be tested for iron deficiency and possible supplementation?
A:
1. Children with RLS.
2. People with anemia (low red blood cell count).
3. People with ADHD and poor dietary habits.
4. Since ferritin levels are not checked in routine screenings, you may need to discuss getting this tested with your doctor.
The body, particularly the brain, needs polyunsaturated fatty acids (PUFAs). Our bodies are not able to produce certain PUFAs, including omega-3 and omega-6 fatty acids. In order to stay healthy, we must eat foods containing these essential fatty acids. Fish, plant oils, nuts, seeds, soy, dark-green leafy vegetables, and eggs provide most of the PUFAs in our diets. The most essential omega-3 fatty acids are eicosapentanoic acid (EPA), docosahexanoic acid (DHA), and alpha-linolenic acid (ALA). Omega-6 fatty acids are also important for metabolic functioning. Fortunately, most people get enough of them—arachidonic acid (AA), and gamma-linolenic acid (GLA)—in their diets. For a list of some foods containing PUFAs, see Table 4.3 and additional nutritional information in the Resources section at the end of the chapter.
Table 4.3 Food Sources for Essential Polyunsaturated Fatty Acids (PUFAs)
| Omega-3 Fatty Acids | Food Sources |
| Alpha-linolenic acid (ALA) | Seeds and nuts (pumpkin seeds, English black walnuts, flaxseeds, almonds); beans (navy, pinto, soy); vegetable oils (olive, soybean, rapeseed, walnut, flaxseed); leafy greens (kale, collard greens, spinach); fish (salmon, rainbow trout, catfish) |
| Eicosapentanoic acid (EPA) | Oily fish, fish oil (cod liver, herring, mackerel, salmon, sardine, albacore tuna, swordfish); microalgae; human breast milk |
| Docosahexanoic acid (DHA) | Cold-water ocean fish and fish oils, shellfish, eggs, microalgae |
| Omega-6 Fatty Acids | |
| Linolenic acid (LA) | Cooking oils (safflower, grape seed, poppy seed, sunflower, hemp, corn, wheat germ, cottonseed, soybean, walnut, sesame, rice bran, pistachio, peanut, canola, linseed); egg yolk, chicken fat, meats; fish (salmon, rainbow trout, catfish) |
| Arachidonic acid (AA) | Animal sources (meat, eggs) |
| Gamma-linolenic acid (GLA) | Vegetable oils (evening primrose, blackcurrant seed, borage, hemp seed); spirulina |
PUFAs are components of many important molecules used to build cellular structures, such as the membranes that form the outer wall of cells, nuclei, and mitochondria. Healthy, flexible cell membranes make it possible for neurons to transmit electrical impulses throughout the brain in milliseconds. PUFAs are key building blocks of these membranes. If the body lacks an adequate supply of essential fatty acids, it will substitute unhealthy fatty acids as components of the cell membranes, leading to less fluidity, less flexibility, and decreased transmission efficiency. The consequences can include problems with mood, cognitive functions, and memory. While both omega-3 and omega-6 fatty acids are important, we emphasize omega-3 fatty acids supplements because most people in the United States get plenty of omega-6 fatty acids in their diets, whereas few get enough omega-3s. Table 4.4 summarizes the contributions of omega-3 fatty acids to overall health.
Table 4.4 The Contribution of Omega-3 Fatty Acids to Neural Development and Brain Health
• Maintain membrane fluidity.
• Support membrane enzyme activities.
• Provide antioxidant defense against neuronal damage from free radicals.
• Produce anti-inflammatory molecules (e.g., prostaglandins).
• Affect gene expression in brain cells
Research has established the importance of omega-3 fatty acids, especially DHA, in neuronal development (Bourre, 2006). DHA is an essential component of cell membranes. For example, infants given omega-3-enriched formula have shown improved brain and eye development, better problem solving at 10 months, and higher scores on a mental development index (Willatts, Forsyth, DiModugno, Varma, & Colvin, 1998).
Dietary studies find deficiencies in omega-3 fatty acids (30–90% below the recommended daily allowance) in many countries, including the United States, Canada, Europe, and Australia. Changes in eating habits and food sources make it harder to fulfill daily needs for omega-3 fatty acids. With low-quality feed, the EPA and DHA contents in farm-raised salmon and trout have dwindled compared with fish living in the wild. Conversely, feeding omega-3 fatty acids to chickens pumps up the omega EPA and DHA in egg yolks by 20-fold.
Omega-3 fatty acid deficiencies have been found in a subset of boys with ADHD (Antalis et al., 2006). Further studies of essential fatty acids, particularly in patients with low serum levels of specific EPAs, are needed in ADHD to determine what level of response to expect.
Aside from the fact that omega-3 fatty acids are generally good for the brain, research is showing that different combinations of essential fatty acids, both omega-3 and omega-6 fatty acids, can have positive effects on ADHD symptoms. To add to the confusion, various combinations of essential fatty acids may produce different effects in subtypes of ADHD (inattentive, hyperactive, or mixed). So the current challenge in research is to find the best mixtures of essential fatty acids and the best match of each mix with ADHD subtypes.
Excess omega-6 fatty acids can interfere with the benefits of omega-3 fatty acids. A high proportion of omega-6 to omega-3 fatty acids in the diet shifts the body towards developing diseases: increased inflammation, cardiovascular disease, and cancer. Dietary sources of omega-6 fatty acids include poultry, eggs, avocado, nuts, cereals, whole-grain breads, most vegetable oils (palm, soybean, rapeseed or canola, sunflower, corn, safflower, and flax/linseed), evening primrose oil, pumpkin seeds, acai berry, and spirulina (Ayachi, El Abed, Dhifi, & Marzouk, 2007; Herrero, Vicente, Cifuentes, & Ibáñez, 2007). We do not recommend spirulina (a nutritional supplement made from microscopic organisms capable of photosynthesis that grow in both sea and fresh water) for children because products vary widely and may contain contaminants such as heavy metals. Products tested and shown to be free of heavy metals may be safer.
The average American diet contains more than enough omega-6 fatty acids, but tends to fall short on the omega-3 fatty acids. Therefore, it is more likely that people with ADHD will have a deficiency of omega-3 fatty acids than omega-6 fatty acids. Early studies using omega-6 fatty acids for ADHD showed minimal benefits. More recent studies have used combinations of omega-3 and omega-6 fatty acids or just omega-3 fatty acids. Using a combination of omega-3 PUFAs—containing twice as much eicosapentanoic acid (EPA) compared with docosahexanoic acid (DHA)—may be more beneficial (Parker et. al., 2006). You will find this combination in supplements marked “EPA/DHA 2:1.” However, these tend to be more expensive; you can save money by taking a larger dose of regular fish oil. Cod liver oil has been a popular remedy for generations. However, it is not the best source of omega-3 fatty acids as the following case illustrates. When it comes to cod liver oil, it may be too much of a good thing.
When Alana’s children were tested and diagnosed as having ADHD, she realized that she probably had it, too. Always juggling too many things, she kept putting off an endless list of household chores. She felt fuzzy-headed and overwhelmed most of the time. When she started taking Adderall the mental fuzziness improved by about 75%. She began to notice how certain foods affected her. For example, refined sugar and carbohydrates (found in white bread, pasta, and desserts), made her feel sluggish and sleepy. After trying numerous supplements, she found that taking two tablespoons of cod liver oil twice a day and maintaining a healthy diet, her mental clarity rose from 75 to 95%. She tested herself on her favorite brain-boosting computer games. On Adderall alone, she could not get past the intermediate level of difficulty. However, when she added cod liver oil to the Adderall, she quickly reached and handled the expert level.
Alana enjoyed the benefits of cold liver oil, but she did not read the label carefully. When I (Dr. Gerbarg) suggested that she read the label, she found that one teaspoon contained a total of 1260 mg omega-3 fatty acids plus 700 IU (international units) of vitamin A. We did the math: (700 IU/tsp) x (3 tsp per Tbsp) x (4Tbsp/day) = 8,400 IU/day. We added this to the amount of vitamin A in her multivitamin: 5,000 IU. Then we added an estimate of the amount of vitamin A she consumed on an average day from her food: 7,000 IU. The grand total was 20,400 IU of vitamin A per day! The problem is that although vitamin A is important for vision, bone growth, and immune defense, excessive amounts can increase the risk of birth defects, liver abnormalities, osteoporosis, and a variety of cancers.
The Food and Nutrition Board of the Institute of Medicine has established tolerable levels for the daily intake of vitamin A. Retinol is the form in which vitamin A is absorbed into the body. Table 4.5 shows the tolerable daily upper intake amounts for healthy individuals in IUs. These levels are for healthy individuals only. People with malnutrition or specific vitamin A deficiency may require higher daily intakes.
Alana was relieved when I proposed a compromise. She could continue taking one tablespoon a day of her favorite cod liver oil and make up the rest of her omega-3 fatty acids using a different fish oil supplement that was much lower in vitamin A.
A balanced diet is necessary for healthy brain development starting in utero. Women who are pregnant need to be conscious of eating healthy foods every day, taking supplements recommended by their doctor, and absolutely avoiding anything that may cause toxic effects on the rapidly developing brain of their baby (e.g., alcohol, cigarette smoke, illegal drugs). While vitamins, minerals, supplements, and omega-3 fatty acids should be taken by everyone during pregnancy, couples with a personal or family history of ADHD should be especially careful to supplement their diet with additional omega-3 fatty acids, which have been shown to enhance brain development. During pregnancy a large amount of omega-3 fatty acids is incorporated into the baby’s growing brain. This can deplete the mother’s store, particularly in the later stages. Supplementation is needed both to supply the needs of the fetus’s neural development as well as to maintain the health of the mother. It is vital to assure adequate levels of dietary omega-3 fatty acids, especially DHA, for women during pregnancy and breastfeeding and in infant formulas, particularly for premature infants. Some, but not all, prenatal vitamins contain omega-3 fatty acids. The product label should tell you how many milligrams of omega-3 fatty acids, EPA and DHA, are contained in each tablet.
Table 4.5 Tolerable Daily Upperefer Intake Amounts for vitamin A by Age
| Age (years) | Vitamin Aa |
| 0–1 | 2,000 IU |
| 1–3 | 2,000 IU |
| 4–8 | 3,000 IU |
| 9–13 | 5,610 IU |
| 14–18 | 9,240 IU |
| 19+ | 10,000 IU |
Note. Adapted from the Office of Dietary Supplements, National Institutes of Health (2010).
aIU = International Units
Recall that there are three subtypes of ADHD:
1. Predominantly inattentive
2. Predominantly hyperactive/impulsive
3. Combined hyperactive/impulsive and inattentive
For simplicity, as noted previously, we use ADHD to include all three subtypes and ADD to denote only the inattentive subtype.
A Swedish study of 75 boys with ADHD, ages 8–18, found that those with the inattentive subtype (ADD) responded faster to a combination of omega-3 and omega-6 fatty acids treatment. About one quarter of the children with ADD reported a 25% improvement in symptoms after 3 months, and about half of the entire group improved after taking the supplement for 6 months (Johnson, Ostlund, Fransson, Kadesjo, & Gillberg, 2009).
Oppositional defiant disorder describes children who show a pattern of negativistic, hostile, defiant behavior more frequently than is typical for children their age. These behaviors must be severe enough to cause significant impairment in social or academic functioning. Some children have both ADHD and oppositional defiant disorder. A mixture of DHA, EPA, AA, and ALA was used in a study of ADHD children. Significant improvements were found in teacher ratings of attention and parent ratings of oppositional defiant disorder, but not on measures of other symptoms (Stevens et al., 2003).
Another study—a 15-week randomized, double-blind, placebo-controlled study—compared children with different symptoms of ADHD. One group had oppositional behavior symptoms; the second group had less hyperactive/impulsive symptoms; and the third group had both oppositional behavior and less hyperactivity/impulsivity. The children were given either one capsule per day of PlusEPA (containing 500 mg EPA plus 2.7 mg DHA + 10 mg vitamin-E-mixed tocopherols) or a placebo (Gustafsson et al., 2010).
• Among those with oppositional behavior symptoms, 52% of the children given PlusEPA showed at least 25% improvement in oppositional behaviors and attention, but not in hyperactivity, on the Conners Teacher Rating Scales (CTRS), compared to 9% in the placebo group.
• 36% of children with less hyperactivity/impulsivity symptoms reported more than 25% improvement on the CTRS, but this was not statistically significant compared to the placebo group (18%).
• Children with both oppositional behavior and less hyperactivity/impulsivity had a 61% rate of response to PlusEPA, with more than 25% improvement on CTRS, compared to 11% with placebo.
Overall, children with both oppositional behavior and less hyperactive/impulsivity showed the highest rate of response to a combination of EPA, DHA, and vitamin E.
The use of purified fish oil supplements has become more appealing due to growing concerns about contaminants such as mercury and polychlorinated biphenyls (PCBs) in fish, and recommendations to limit consumption of fish to one serving per week. Nuts (particularly walnuts), flax, and dark green vegetables are also good sources of omega-3 fatty acids. However, flax contains ALA, not DHA. Although we have enzymes that convert a small amount of ALA into DHA, it is too little to meet the body’s needs. Understandably, vegetarians prefer flax to fish, but unfortunately, the ALA from flax provides far fewer physical benefits than EPA and DHA from fish oil (Nettleton, 1991).
In sorting through all this information, or waiting for a clear answer, our recommendation is to apply Rule 4: Use your common sense. Because each research study selects different groups of children and uses different combinations of essential fatty acids and vitamins, collecting enough data to predict which supplements are most likely to be effective for any individual is likely to take years. In the meantime, since the essential fatty acids are both beneficial and benign (no serious adverse effects), you can try your own mixing and matching. Remember to allow time—at least 10 weeks—for each supplement to evaluate how well it is working before adding or changing to another. In addition to assessing yourself (or your child) for changes, it helps to get feedback from others who know you (or your child) well.
S-adenosylmethionine (SAMe) is a natural substance found in all the cells of our bodies. This generous metabolite donates clumps of itself (methyl and sulfate molecular groups) to help build many of the most important molecules in the body, including neurotransmitters and our home-grown antioxidants. Always busy, SAMe participates in over 200 chemical pathways in all body organs and tissues (Brown, Gerbarg, & Bottiglieri, 2000). In short, SAMe is a super metabolite. Among the many neurotransmitters that are beholding to SAMe, dopamine is the one that needs boosting in ADHD. SAMe increases dopamine transmission and enhances the response to amphetamine stimulant medications. In other words, if you are experiencing only partial improvement from taking a stimulant such as Ritalin or Adderall, then you may get a better response by adding SAMe.
Brain waves of people with ADHD show abnormal increases in the slow frequencies: low alpha and theta. Shifting from slow alpha waves to faster alpha (alpha-2) and beta waves is associated with increased alertness, faster processing, and better behavior control (see Chapter 6 for a detailed discussion of brain-wave frequencies in ADHD). In an EEG (electroencephalographic) study of elderly subjects, SAMe increased the faster brain-wave frequencies—alpha-2 and beta. Although EEG studies of SAMe in ADHD have not yet been done, it is likely that SAMe would also improve the faster frequencies in people with ADHD. A 4-week open study of eight men with adult ADHD found that 2400 mg/day of SAMe improved ratings on measures of ADHD and mood in six out of the eight. The two who did not improve had not responded to previous trials of methylphenidate (Ritalin). Side effects were not significant (Shekim, Antun, Hanna, McCracken, & Hess, 1990). Larger and longer-term studies are needed to explore the use of SAMe in children and adults with ADHD.
SAMe is best known as an antidepressant. Many studies have shown that it is as effective as prescription antidepressants, works faster, and has fewer side effects. So, it is particularly useful in people suffering from both ADHD and depression. SAMe combines well with Rhodiola rosea to form a dynamic duo.
Many people are successfully treated for ADD in childhood or adolescence. For others, the right treatment may not come along until later, after many years of underperformance at school and failed relationships. This was the case with Jeremy, who sought help at age 27 when he was flunking out of graduate school. Jeremy had struggled with chronic low-level depression, severe dyslexia, and ADD since childhood. He told Dr. Brown that he was “never happy.” In fact, Jeremy was intensely restless, easily distressed, and filled with self-blame. It was hardly surprising that he was failing in graduate school, particularly because he chose to study history, a field requiring immense amounts of reading. Dating was also a disaster. No woman wants to sit in a restaurant trying to hold a conversation with a man who is so distracted by other people’s conversations that he can’t even listen to what she says, or who interrupts her as soon as she tries to talk. Being late or forgetting every date is also not an endearing quality. Jeremy had tried nearly every medication available for his condition—all with unbearable side effects. Finally, a course of SAMe relieved his depression. When Rhodiola rosea was added to the mix, he felt even better. Within a short time, his mood and energy improved. He was able to focus, complete his work with fewer errors and, for the first time ever, stop procrastinating. Jeremy wisely left graduate school for a good job as a salesman that capitalized on (rather than penalized) his high-energy qualities. He was even able to sustain his first long-term relationship.
Although SAMe is generally well tolerated, some people report experiencing nausea, loose stools, agitation, or transient sleepiness. SAMe is best absorbed when taken on an empty stomach about 30 minutes before breakfast and lunch. Doses range from 600 to 1200 mg twice a day. Because SAMe is rapidly oxidized when exposed to air, it should be purchased only in blister packs (each pill in a separate foil blister). Bargain brands tend to have low potency and may cause more side effects. The quality of the SAMe and the tablet manufacturing is of particular importance with this supplement. See Table 4.7 on quality supplements at the end of this chapter to find a list of high-quality brands. SAMe may be worth trying in cases with incomplete response to medications, habituation (loss of effectiveness over time) to stimulants, coexisting depression, or intolerance of prescription stimulants.
SAMe is well-tolerated by most people, but it can cause nausea, agitation, or anxiety in sensitive individuals. Although SAMe is usually taken on an empty stomach, if nausea occurs, it should be taken with a light snack to settle the stomach. People with bipolar disorder can be triggered into manic episodes by prescription antidepressants as well as by SAMe. Therefore, it should not be given to those with known bipolar disorder. If agitation, hostility, racing thoughts, or excessively elevated, inappropriate mood occur, SAMe should be discontinued because that individual may have undiagnosed bipolar disorder.
Q: Who is likely to benefit from SAMe?
A: SAMe can be very helpful for the following indications:
• A history of improving on prescription stimulants such as Ritalin or Adderall, but inability to tolerate the side effects.
• ADHD plus depression.
• Incomplete response to medications
• Habituation (loss of effectiveness over time) with stimulants
• Combines well with Rhodiola rosea (see Chapter 3) for synergistic benefits
• May enhance and accelerate response to biofeedback (see Chapter 6).
Picamilon is a combination of two natural compounds: the B vitamin niacin and a calming neurotransmitter called gamma-aminobutyric acid (GABA). One of its main effects is to increase blood flow within the brain by decreasing cerebral blood vessel tone. When blood flow increases, brain cells receive more oxygen and nutrients. This may be why picamilon can improve cognitive function as well as alertness and decrease anxiety and depression. Although Picamilon has mild stimulative properties, it reduces aggressive behavior in animal studies. In our clinical work we find that picamilon can be very helpful not only for ADHD, but also in patients with cerebral vascular disease, stroke, traumatic brain injuries, and those recovering from a stroke. People with ADHD may have difficulties remembering appointments and keeping track of time. Some are constantly late and as a result they may lose friends who interpret their lateness as a sign of unreliability or a lack of consideration. One of Dr. Brown’s patients was always late even for very important appointments.
Judy missed her first two appointments with me [Dr. Brown]. Although she was being treated for anxiety, depression, and an eating disorder, I began to think that she might also have ADHD. I called the night before to remind her of the next appointment and she managed to come, though 15 minutes late. She apologized profusely and told me tearfully that she had lost most of her friends because she always forgot to keep the dates she made with them. “People think I don’t care about them when I forget or I’m an hour late. They accuse me of being inconsiderate, but I can’t help it. I do everything I can think of to be on time, but it just slips away from me and then, when I realize, it’s too late.”
By the age of 50, Judy had been through many different antidepressants, mood stabilizers, and major tranquilizers. In the past, Provigil, a stimulant, had been more helpful than the other drugs. She was being treated by a cognitive behavior therapist.
Judy had heard about picamilon from other patients with ADHD, and she wanted to give it a try. From the first day, starting with just 100 mg, she noticed a change. At a full dose of 200 mg in the morning and 100 mg in the afternoon, she was less scattered, much more focused and organized. She was able to think more clearly. Depression, motivation, and energy all improved markedly. She cleaned her long neglected brushes, set up an easel, and took up painting again.
Picamilon is very low in side effects, even when given to elderly people. In rare instances it may lower blood pressure and cause light-headedness, dizziness, or fainting. It is best to start with 50–100 mg daily and increase gradually to a maximum of 200 mg in the morning and 100 mg in the mid-afternoon to minimize the risk of side effects.
Q: Who can benefit from picamilon?
A: Anyone with ADHD could possibly benefit from picamilon.
• Picamilon can be especially helpful for those who have ADHD with either anxiety or depression
• Picamilon can also help recovery from brain injury and stroke.
Amino acids are the building blocks of proteins. Studies of amino acid supplements, including tryptophan, phenylalanine, levodopa, and l-tyrosine, have shown only short-term benefits in ADHD with loss of effect after a few weeks. At this time we see no sufficient evidence of benefits for any significant period of time in ADHD. Vegetarians who are not getting adequate amounts of protein in their diet may need to use protein supplements with a full complement of the essential amino acids.
Q: Who should use amino acid supplements?
A: In general, we do not recommend amino acid supplements for ADHD. It is better to invest in other supplements with more proven benefits.
Acetyl-l-carnitine is a form of the natural substance, carnitine. Carnitine is made in muscle and liver tissues and is found in meat, poultry, fish, and some dairy products. Studies show that it improves cell membrane function, energy metabolism, synthesis of ATP (adenosine triphosphate, high-energy molecules) and neurotransmitters, essential fatty acid utilization, and possibly the attention component of the cholinergic system, the neuronal network that uses the neurotransmitter acetylcholine. (See Chapter 2 for a discussion of the role of acetylcholine in ADHD.)
In a 16-week randomized pilot study involving 112 children with ADHD, ages 5–12, L-carnitine given in weight-based doses from 500 to 1500 mg twice a day was compared to placebo. Although the overall group scores showed no difference, there was significant improvement in attention in ADD (the inattentive type of ADHD), but not in the combined type (ADHD with both inattention and hyperactivity/impulsivity).
Side effects have been negligible in reported studies. L-carnitine deserves further study for possible benefit in the inattentive type (Arnold et al., 2007). Carnitines are safe and have shown promise in preliminary studies. Doses range from 500 to 1500 mg twice a day. We prefer to use acetyl-L-carnitine because it is better absorbed into brain cells and therefore likely to be more effective. While waiting for further research, it would be reasonable to try acetyl-L-carnitine as a complementary treatment in the people with the inattentive subtype of ADHD.
The nootropic meclofenoxate is a combination of a dopamine booster DMAE (dimethyl-aminoethanol) and a synthetic form of a plant growth hormone called PCPA (p-chlorophenoxyacetic acid). As a cognitive enhancer meclofenoxate is well studied, inexpensive, and low in side effects. Meclofenoxate carries the DMAE rapidly into the brain where it becomes part of the nerve cell membranes. Once embedded in the membranes, DMAE scavenges free radicals to prevent them from causing damage (Zs-Nagy, 2002). DMAE increases dopamine activity and contributes to the synthesis of choline needed to produce the neurotransmitter acetylcholine.
In Chapter 2 we discussed the importance of acetylcholine for learning, short-term memory, attentional effort, and the allocation of visual attention (Klinkenberg et al., 2010). Choline and acetylcholine are essential for brain function, especially memory, but there are two problems. First of all, it is not easy to get choline into brain cells where it can be converted into acetylcholine for neurotransmission. Second, many people are now following diets that limit the amounts of foods that are richest in choline—fatty meats, organ tissues, and egg yolks. As a result, we may not be supplying enough choline for our brains to function at their best. One study found that when pregnant animals were fed a diet high in choline, they bore offspring with better cognitive function and a reduced incidence of dementia when they reached old age (Meck, Williams, Cermack, et al., 2007). Meclofenoxate improves the ability of choline to enter brain cells. Also, the herb ginkgo can enhance the cognitive effects of meclofenoxate.
Meclofenoxate has minimal side effects, unless it is given in excess doses or combined with other cholinergic agents (medications such as donepezil [Aricept] that increase acetylcholine transmission). In doses that are too high for an individual, it can cause headache, irritability, muscle tension, small muscle tremors, insomnia, agitation, or facial tics. Therapeutic doses range from 250 mg per day in children over the age of 12 to 500–2,000 mg per day in adults. Some people are sensitive and may get some side effects even on 500 mg a day. In such cases, the dose can be reduced.
Q: Who could benefit from Meclofenoxate?
A: Meclofenoxate is particularly helpful for improving memory problems associated with ADHD. Because meclofenoxate is not activating, it is more useful when the person does not need a highly stimulating agent.
We have introduced you to many wonderful natural supplements. Now what do you do with this information? Do you rush to your nearest health food store and buy one of everything? Of course not. Please take your time. If you are interested in a particular supplement, reread the section on it carefully so you are clear about how it works, what to expect, what side effects could occur, and how to use it correctly. Here are some general suggestions to help you use these treasures safely and effectively:
1. Discuss your use of supplements with your primary health care provider. It is especially important to involve your pediatrician or family practitioner before giving supplements to children.
2. Check the lists of precautions and warnings to be sure that you do not have any contraindications for using each product.
3. Be sure to get good-quality brands. This is especially important with herbs that may not be closely regulated for quality, purity, and effectiveness. Table 4.7 at the end of this chapter will guide you to some of the better brands. As we mentioned above, you can also visit websites that independently rate products.
4. Start slowly, take your time increasing the doses, and if you begin to experience mild side effects, back off to a lower dose and wait at least a week before trying to increase it again.
5. Be patient. It may take time for you to get up to a high-enough dose to see the benefits. Do not exceed the maximum doses listed in the supplement guidelines of Table 4.6. More is not always better and can cause side effects.
Natural medicines and nutrients are not magical cures, but they can often help reduce symptoms of ADHD, especially when combined carefully with other supplements and complementary treatments. Mother Nature has provided us with many natural medicines. It is up to us to use them wisely.
Table 4.6 Treatment Guidelines for Vitamins, Nutrients, and Nootropics
Note. ADHD = attention-deficit/hyperactivity disorder (includes all three subtypes); BP = blood pressure; CAM = complementary and alternative medicine; DHA = docosahexanoic acid; EPA = eicosapentanoic acid; GI = gastrointestinal; PUFA = polyunsaturated fatty acid.; mcg = micrograms; 
= decreases; mg/d = milligrams per day; tab = tablet; qd = per day; b.i.d. = twice a day; t.i.d. = three times a day; mg = milligrams, mcg = micrograms.
aThe doses in this table are meant only as guidelines. People who are more sensitive may need to use lower doses. Readers should discuss the choice of supplements and the adjustment of doses with their personal physician.
bCommon side effects are listed. There are additional rare side effects. Individuals with high blood pressure, diabetes, pregnancy (or during breastfeeding), or any chronic or serious medical condition should check with their physician before taking supplements. Patients taking anticoagulants should consult their physician before using supplements. Parents are advised to consult a qualified physician to prescribe and monitor supplements given to children.
cOne study suggests that folate with B12 and B6 may increase the risk of restenosis in cardiac stents in men only whose serum homocysteine level is greater than 15μm/L (Lang et al, 2004)
Table 4.7 Guide to Quality Vitamins, Nutrients, and Nootropics
Note. DHA = docosahexanoic acid; EPA = eicosapentanoic acid; GNC = General Nutrition Centers.
a Costs of products may vary. This table lists approximate costs at the time of publication.
Here is a list of websites, books, and journals where you may find additional information about foods, vitamins, and nutrients to help reduce symptoms of ADHD. Websites for Organizations
Agriculture and Trade Policy Food and Health Program: http://iatp.org/foodandhealth/.
Grassroots organization started in the 1980’s to save the family farm. Advocates for healthy sustainable food supply, fair trade, and human rights. Supports family farmers and rural communities.
Center for Science in the Public interest: www.csinet.org.
See the report, “Food Dyes: A Rainbow of Risks” by Kobylewski and Jacobson (2010).
ConsumerLab.com: www.consumerlab.com.
Rates many brands of herbs and supplements on some measures of quality and labeling accuracy. Does not assess for shelf life, that is, the possible loss of potency over time prior to purchase. Provides useful free information. For in-depth reports on specific supplements an annual fee is required.
Concise updated presentation of CAM, including risks and interactions.
National Center for Complementary and Alternative Medicine, National Institute of Health, National Library of Health Complementary and Alternative Medicine Specialist Library (NeLCAM): www.library.nhs.uk/cam.
Natural Medicines Comprehensive Database: www.naturaldatabase.com.
Good source for comprehensive information on herbs, but tends to overemphasize side effects.
The Research Council for Complementary Medicine: www.rccm.org.uk/default.aspx?m=o.
Aims to develop and extend the evidence base for complementary medicine in order to inform practitioners and their patients about the effectiveness of CAM treatments of specific conditions. New database: CAMEOL.
Supplement Watch: www.supplementwatch.com.
Corporation of scientist, physiologists, nutritionists, and other health professionals offers free access to a database on supplements. To obtain detailed reports on particular supplements requires a $25 annual fee.
U.S. Food and Drug Administration: www.fda.gov/medwatch.
Provides safety information, reports serious problems, and issues warnings.
Dr. Richard P. Brown and Dr. Patricia L. Gerbarg: www.haveahealthymind.com.
Provides updates and a free newsletter on Complementary and Alternative Medicine.
Vaugns’ Summaries: www.vaughns-1-pagers.com/food/artificial-food-colors.htm Information on artificial colorings in candy.
Brown, R.P., Gerbarg, P.L., & Muskin, P.R. (2009). How to Use Herbs, Nutrients, and Yoga in Mental Health Care. New York: Norton. —Balanced, well-documented information on how to use herbs, nutrients, nootropics, other supplements, and mind-body practices. Includes risks, benefits, and clinical guidelines. Covers anxiety, depression, PTSD, cognitive function, life stage issues, hormonal changes, sexual enhancement, substance abuse, schizophrenia, and medical issues.
Ernst, E., Pittler, M.H., & Wider, B. (Ed.). (2006). The Desktop Guide to Complementary and Alternative Medicine: An Evidence-Based Approach (2nd ed.). London: Mosby.
Concise, well-organized as a quick reference resource. The viewpoint is quite conservative and at times unnecessarily cautious.
Lake, J., & Spiegel, D. (2007). Complementary and Alternative Treatments in Mental Health Care. Washington, DC: American Psychiatric Association. Chapters are written by experts in different areas of CAM; for example, Chinese medicine, homeopathy, Ayurvedic treatments.
BMC Complementary and Alternative Medicine: www.biomedcentral.com.
Peer-reviewed journal publishes articles on CAM.
Evidence-Based Complementary and Alternative Medicine: www.hindawi.com.
Peer-reviewed journal publishes articles on CAM.
Herbalgram: Journal of the American Botanical Council: www.Herbalgram.org.
In depth, authoritative articles on herbs from around the world.
Journal of Complementary and Alternative Medicine: www.liebertpub.com.
Peer-reviewed journal publishes articles on CAM.