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Fish Oil and ADHD: What is The Evidence?

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We’ve all heard claims about fish oil “curing” ADHD, but what does the latest research show? Mixed results, at best, though further study is warranted.

Make no mistake:  The human brain needs essential fatty acids to function properly; so does the rest of the body. But the question is this: Does fish oil supplementation actually diminish ADHD symptoms?

Following the last post on diet and ADHD, David Rabiner, Ph.D., explains the latest research on ADHD and fish oil, below.  (To subscribe to his free newsletter, Attention Research Update, click here.) Reprinted here with Dr. Rabiner’s permission. Cartoon reproduced under paid license from Cartoon Stock.

New findings: Does fatty acid supplementation help children with ADHD

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 neuro-developmental 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 and http:www.helpforadd.com/2007/may.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, 1540-1549].

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 were reported.

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 symptoms.

- Results -

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. It is possible, of course, that other types of fatty acid supplementation 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. 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 ADHD.

–David Rabiner, Ph.D., Attention Research Update

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  1. Kevin’s avatar

    Thanks for providing more research on the benefits of omega 3 fish oils on ADHD. I believe a larger portion of the research should focus on determining if there exists a therapeutic level of omega 3 fatty acids and the effects on ADHD.

    Many of the studies I’ve looked at used different amounts of EPA and DHA with mixed results. I believe that EPA and DHA dosages play a large role in the benefits one can derive from omega 3 fatty acids; particularly in regards to their possible effects on mental and emotional health.

    Reply

    1. Gina Pera’s avatar

      Thanks for your comment, Kevin.

      I’m looking at a big ol’ stack of studies I picked up last year at a conference from the OmegaBrite people. I got a little concerned, though, when I saw Barry Sears as a co-investigator on one study. I used to think he was solid….until I researched his background. Now I’m more alarmed when I see his name attached to it.

      I think we’re decades away from understanding the delicate dance that each individual’s physiology does with the environment, including nutrients like omega-3s, Vitamin D, all the vitamins and minerals. So many genetic and epigenetic factors.

      In the meantime, I try to follow the generally agreed upon guidelines vis a vis Omega-3s and hope for the best. ;-)

  2. Robin Schwartz’s avatar

    Thank you. I was debating between giving this treatment to my child. You explained the study well.

    Reply

    1. Gina Pera’s avatar

      Thanks for your comment, Robin. You know, we all need omega-3s for a variety of reasons. So, you want to make sure your child has enough — but not too much. Too much can be as bad as not enough. best, g

  3. Ruth Pinnell’s avatar

    Ms. Pera – regarding your comment to Robin above – how much is enough? My son (6 yrs, ADHD) has been on the label-recommended dose of Nordic Naturals Children’s DHA since he was weaned. I believe that now that he is older, I should switch him to a formula that has a higher EPA to DHA ratio. But I can’t figure out what that is because of all the conflicting information on the web! I’m leaning to switching to the Nordic Naturals Ultimate Omega Jr or Children’s 3-6-9 formula.

    Do you have a recommendation level for the amount of Omega-3s that is “not too much”? (I don’t expect this to be an ADHD treatment, just want him to get the nutrients he needs).

    Thank you so much!!

    Reply

    1. Gina Pera’s avatar

      Hi Ruth,

      Excellent question.

      Several of my psychiatrist acquaintances use Omega-Brite brand of fish oil. So, I can point you to their FAQs as being one of the more reliable sources of information on fish oil, no matter which brand you choose.

      http://omegabrite.com/why/faqs.html

      best
      g

  4. Linda Rackley’s avatar

    Mrs. Pera,

    I have a 9yr old son that is ADHD. His father is suggesting he takes a creame called Barleans Organic Fish oil, My son is also taking his flintstone vitamins when he is at his dad’s as well (we are divorced) My son showed a dramitic improvment when I took him into the Dr. and she started him on Adderall XR. I’m not against trying other things to help with his ADHD, but with everything I have read I am not on board with the fish oil theroy just yet, although it seems like there may be some advantages for it. I have a few questions for you:

    What is your take on the adderall xr?

    How do you feel about the fish oil and vitamins together, and what would be a good dosegae for a 9 yr old who weights 80 lbs???

    What are your thoughts on the Barleans Organic Fish oil??

    Thank you,
    Linda

    Reply

    1. Gina Pera’s avatar

      Hi Linda,

      I appreciate your question.

      Here is the summary from the study explained in the post (What is the Evidence for Fish Oil?):

      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.

      To summarize the findings further:

      1. Fish oil supplementation is NOT a helpful treatment for ADHD.
      2. There is suggestive evidence that if the child with ADHD is also highly oppositional AND blood levels of EPA (fish oil) are low, there might be benefit in attention problems and oppositional behavior. But nearly half of this group did not benefit significantly.

      In other words:

      1. We all need sufficient levels of essential fatty acids. That is required for health (not just brain health). So, your child should be getting this through food or supplementation.
      2. Fish oil is not going to “treat” most cases of ADHD, especially if the child doesn’t have low levels of EPA and is not oppositional.
      3. You do NOT want to over-supplement fish oil; that poses health risks.
      4. Fish oil is not going to take the place of medication for many people with ADHD.

      To answer your specific questions:

      1. I’ve heard that Barleans is a respected brand, so you’re probably okay there. And, you should go by the manufacturer’s suggestions on dosage.
      2. Most of us need a multi-vitamin/mineral, and that includes children. Make sure it’s a quality brand.
      3. I’m not the biggest fan of Adderall XR, though I acknowledge it works well for some people. I encourage you to try other Rx first before settling on that one, such as Vyvanse, Concerta or the patch form of methylphenidate (ritalin): Daytrana.

      Good luck! If you see your child doing well on medication, I hope you can convince his father to go along and see the benefit to his son. This is sometimes a problem and a matter of “denial.”

      Gina

  5. Elisabeth’s avatar

    Hi Ms. Pera,

    I have a highly oppositional boy who is now 11 years old. He has been on Ritalin LA since he was 6, and it has been a life saver. He can now attend school without disrupting the class. He is also much happier than he used to be.

    4 weeks ago I put him on Nordic Naturals EPA formula. This has 850 mg EPA, 200 mg DHA. The research I did pointed to EPA as being the factor for reducing ADHD/oppositional behavior. I think it is helping slightly, but not enough to stop taking the Ritalin, at least yet. I have left him off Ritalin the last 2 days and his lack of focus and some of his oppositional tendencies returned. I will keep using it though and will write back if I start to see great improvement. I do think it is helping a little and I hope it will help more over time.

    Thank you very much for posting!
    Elisabeth

    Reply

    1. Gina Pera’s avatar

      I’m glad you found the information helpful, Elisabeth. Your son is lucky to have such a diligent mom!

      best to you both,
      g

  6. paulina’s avatar

    my son was diagnose with adhd but it is not sever. I had him on medication but he was having really bad side affects. He was come home from school from his head aches and he felt his heart was going to burst out of his chest. Next i switch him to the aderall xr but that that had him cry non stop all day. It seem like he had no control of his emotions. I decided to go the natural way and trying out omegabrite give it a chance see if it helps him out. It killed me so much to see what he was going through with the meds. he was taking. Honestly i feel just being more patient and finding out different way to help your child will benefit him in school. Sports and lots of outside play also helps my son. Daily routines and timers seems to also have a benefit in school.

    Reply

    1. Gina Pera’s avatar

      HI Paulina,

      Half of all children and adults have a co-existing condition, such as anxiety or depression. If those are not treated along with the ADHD, the medication might cause more adverse side effects.

      Yet, even without these co-existing conditions, it’s important to try a few different medications, beginning at a LOW dose and slowly working up. To make sure the child is eating well, has no nutritional deficiencies, and gets good sleep.

      Fish oil is NOT a treatment for ADHD – please read the piece on which you are commenting – but we all need essential fatty acids for good brain/body health.

      And yes, all children should have daily routines, but especially children with ADHd.

      best,
      g

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