Questions & Answers

I just read your article about attention deficit hyperactivity disorder (ADHD) and was disappointed that you didn’t include anything about dietary changes that can alleviate symptoms. Can you provide more information about these?

Dietary changes generally have been much less often studied in high-quality clinical trials compared to drug treatments for ADHD. Thus, expert groups, including the American Academy of Pediatrics (AAP), do not recommend dietary changes as part of routine treatment in all children with ADHD.[1] Yet there is some evidence that certain changes to the diet can help improve ADHD symptoms in some children. These dietary approaches to treating ADHD include supplementing meals with omega-3 fatty acids and eliminating from the child’s diet artificial food coloring or foods that can cause allergies and sensitivity (including chicken egg, peanut, soy, milk, fish and wheat).[2],[3],[4],[5],[6],[7] The benefit seen with such dietary changes is typically much smaller than that seen with FDA-approved ADHD drugs.[8],[9] Nevertheless, such dietary adjustments do not cause any serious side effects, and may be used in combination with drug treatment. Dietary changes may also be a reasonable alternative for children who should not take ADHD medication, including very young children, children with mild cases of ADHD, those who have not been conclusively diagnosed with ADHD, and those with heart problems or other conditions that prevent them from taking ADHD drugs.

Your article on ADHD drugs recommended that all children be screened for heart problems before starting medication, but what does that mean?

Multiple professional groups recommend screening children for heart conditions before starting them on a regimen of ADHD medications, as these medications can cause serious heart-related side effects, including sudden death in rare cases.[11],[12] However, experts continue to debate what steps the screening should include. The American Heart Association (AHA) and the AAP both recommend that doctors ask detailed questions about whether a child has experienced any potentially heart-related symptoms, such as fainting, chest pain or seizures, and whether there is a family history of heart problems or sudden death.[13],[14] They also recommend a doctor check the child’s blood pressure and listen for an abnormal heartbeat.
The more controversial question is whether doctors should routinely do an electrocardiogram (ECG) to measure the electrical activity of the child’s heart, as this test can be expensive and may not be helpful for all patients. The AHA suggests that routine ECG screenings for all ADHD patients who are to be treated with drugs may be reasonable, whereas the AAP excludes ECGs from its screening recommendation, noting that the test should be conducted only when judged necessary for an individual patient. Because heart-related risk factors vary by individual, you should talk with your child’s doctor about his or her individual risk for heart problems and the potential need for additional screening steps, such as an ECG, before and during treatment with ADHD medications.

References

[1] Krull KR, Augustyn M, Torchia MM. Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. UpToDate. Accessed November 8, 2016.

[2] Faraone S, Antshel K. Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD. Child Adolesc Psychiatric Clin N Am. 2014;23:965-972.

[3] Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: Systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000. Epub 2011 Aug 12.

[4] Schab DW, Trinh NT. Do artificial food colors promote hyperactivity in children with hyperactive syndromes? A meta-analysis of double-blind placebo-controlled Trials. J Dev Behav Pediatr. 2004;25:423-434.

[5] Nigg JT, Lewis K, Edinger T, et al. Meta-analysis of attention-deficit/hyperactivity disorder or atten¬tion-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. J Am Acad Child Adolesc Psychiatry. 2012; 51(1): 86-97.

[6] Sonuga-Barke EJ, Brandeis D, Cortese S, et al. Nonpharmacological interventions for ADHD: Systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry. 2013; 170(3):275-289.

[7] Pelsser LM, Frankena K, Toorman J, et al. Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): A randomised controlled trial. Lancet. 2011;377(9764):494-503.

[8] Bloch MH, Qawasmi A. Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: Systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000. Epub 2011 Aug 12.

[9] Nigg JT, Lewis K, Edinger T, et al. Meta-analysis of attention-deficit/hyperactivity disorder or atten¬tion-deficit/hyperactivity disorder symptoms, restriction diet, and synthetic food color additives. J Am Acad Child Adolesc Psychiatry. 2012;51(1):86-97.

[10] Faraone S, Antshel K. Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD. Child Adolesc Psychiatric Clin N Am. 2014;23:965-972.

[11] Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: A scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117(18):2407-2423.

[12] Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management, Wolraich M, et al. ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents (Supplement). Pediatrics. 2011;128(5):1007-1022.

[13] Ibid.

[14] Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: A scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117(18):2407-2423.