What is the best diet for ADHD ?

What is ADHD

Attention deficit hyperactivity disorder (ADHD) is a mental disorder in which children are especially inattentive, impulsive or hyperactive ⁴⁾.

ADHD is a disorder that has three different types of symptoms ⁵⁾:

1. Inattentive: Difficulty paying attention or focusing on certain tasks and are easily distracted.
2. Hyperactive: Being overactive (or hyperactive) describes children who are restless or constantly fidgeting – for instance, they may not be able to sit still during school lessons, and get up and walk around the classroom a lot instead.
3. Impulsive: Acting on impulse (without thinking) children act in a way that is extremely rash, inconsiderate, careless or impatient for their age.

Attention deficit hyperactivity disorder (ADHD) is not just a childhood disorder ⁶⁾. Although the symptoms of ADHD begin in childhood, ADHD can continue through adolescence and adulthood. Even though hyperactivity tends to improve as a child becomes a teen, problems with inattention, disorganization, and poor impulse control often continue through the teen years and into adulthood.

Attention deficit and hyperactivity disorders are very common. Surveys estimate that as many as 9 percent of American children and 4 percent of adults have ADHD ⁷⁾. About 4 to 5 out of 100 children are diagnosed with ADHD in Germany ⁸⁾. However, one representative study on the prevalence of ADHD in Germany shows that only 1 to 2 out of 100 children meet the actual criteria for diagnosis, and that it is twice as common in boys as in girls. This implies that some children are wrongly diagnosed with ADHD ⁹⁾. But there are also some children who have ADHD and are never diagnosed with it. It is not known exactly how often this happens. Children may first develop ADHD symptoms at an early age (between 3 and 6 years old). However, ADHD is most often found and treated in elementary school (between 7 and 9 years old) ¹⁰⁾.

Children or teens with ADHD may:

• Get distracted easily and forget things often
• Switch too quickly from one activity to the next
• Have trouble following directions
• Daydream too much
• Have trouble finishing tasks like homework or chores
• Lose toys, books, school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones often
• Fidget and squirm a lot
• Talk nonstop and interrupt people
• Run around a lot
• Touch and play with everything they see
• Be very impatient
• Blurt out inappropriate comments
• Have trouble controlling their emotion
• Overlook or miss details, make careless mistakes in schoolwork, at work, or during other activities
• Have problems sustaining attention in tasks or play, including conversations, lectures, or lengthy reading
• Seem to not listen when spoken to directly
• Fail to not follow through on instructions, fail to finish schoolwork, chores, or duties in the workplace, or start tasks but quickly lose focus and get easily sidetracked
• Have problems organizing tasks and activities, such as doing tasks in sequence, keeping materials and belongings in order, keeping work organized, managing time, and meeting deadlines
• Avoid or dislike tasks that require sustained mental effort, such as schoolwork or homework, or for teens and older adults, preparing reports, completing forms, or reviewing lengthy papers
• Become easily distracted by unrelated thoughts or stimuli
• Forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments.

Signs of hyperactivity and impulsivity may include:

• Fidgeting and squirming while seated
• Getting up and moving around in situations when staying seated is expected, such as in the classroom or in the office
• Running or dashing around or climbing in situations where it is inappropriate, or, in teens and adults, often feeling restless
• Being unable to play or engage in hobbies quietly
• Being constantly in motion or “on the go,” or acting as if “driven by a motor”
• Talking nonstop
• Blurting out an answer before a question has been completed, finishing other people’s sentences, or speaking without waiting for a turn in conversation
• Having trouble waiting his or her turn
• Interrupting or intruding on others, for example in conversations, games, or activities

Showing these signs and symptoms does not necessarily mean a person has ADHD. Many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms. If you are concerned about whether you or your child might have ADHD, the first step is to talk with a health care professional to find out if the symptoms fit the diagnosis. The diagnosis can be made by a mental health professional, like a psychiatrist or clinical psychologist, primary care provider, or pediatrician.

The severity of ADHD and which of the behaviors is more pronounced can vary between boys and girls and from child to child. Some children may be more affected by inattentiveness and often appear to be daydreaming. Other children are especially impulsive and hyperactive. Depending on which of these behaviors is more obvious, children with ADHD can be divided into two groups: primarily inattentive or primarily hyperactive-impulsive. Children who are extremely inattentive, but not hyperactive, are also described as having attention deficit disorder (ADD).

Severe ADHD can cause major problems in the life and everyday routine of both the child and their parents and brothers and sisters: Because children with ADHD behave differently than expected, they often cause trouble. They need a lot of attention. They find it more difficult to learn because of their short attention span. ADHD may also be accompanied by other kinds of mental disorders.

The number of children being diagnosed with ADHD has increased in recent years. Some people are wary of this development and doubt that ADHD is really that common. They are worried that a lot of children who are diagnosed with ADHD are simply a little overactive, but otherwise healthy. A wrong diagnosis may lead to unnecessary treatment. Being wrongly labelled as mentally ill may also affect a child’s self-esteem.

But there are also children and teenagers who actually have ADHD but are not diagnosed with it. This can also have a negative effect, because they may not get treatment that could help them. So it is very important to take the time to look into things so ADHD can be ruled out or diagnosed.

Effects of ADHD

Children and teenagers with ADHD have more accidents, hurt themselves more often, and have more problems at school ¹¹⁾. They tend to have more conflicts with their peers and go against the rules, or behave defiantly and even aggressively. Teenagers with ADHD are more likely to smoke, drink alcohol or use other drugs, which may make other problems worse. They are also more frequently involved in crimes than other people their age who do not have ADHD. Developmental problems may arise too, such as difficulties with language development or reading and writing.

Children with ADHD may also have other emotional problems or disorders, including things like depression or anxiety disorders. Some children with ADHD have a tic disorder as well.

When adults have ADHD it usually causes problems in relationships or at work. Especially adults who were very hyperactive and impulsive as children are sometimes inconsiderate of others: They find it difficult to attend to their responsibilities, tell the truth, or respect their partner.

Causes and risk factors for ADHD

The causes of ADHD are not fully understood, but causes of ADHD and the modifiers of its course are multifactorial ¹²⁾.

Current research suggests ADHD may be caused by interactions between genes and environmental or non-genetic factors. Like many other illnesses, a number of factors may contribute to ADHD such as ¹³⁾:

• Genes
• Cigarette smoking, alcohol use, or drug use during pregnancy
• Exposure to environmental toxins during pregnancy
• Exposure to environmental toxins, such as high levels of lead, at a young age
• Low birth weight
• Brain injuries

Research has shown that, in children with ADHD, the chemical messenger dopamine is transported differently between the nerve cells of the brain, especially in the regions that are used for memory and learning. And there are other physical differences that may be involved in the development of ADHD. Genes play an important role.

Some experts disagree with the view that ADHD is only linked to physical or genetic factors. Instead, they consider changes in our society to be just as important. They believe that ADHD symptoms also result from overstimulation coupled with lack of exercise, modern society’s emphasis on achievement, and changes in a child’s family situation. Hardly any good-quality studies have tested these theories, though.

It is also not clear what factors might play a role in the risk of developing ADHD. Individual studies have shown that children are at greater risk if their mothers smoked, drank alcohol or consumed other drugs while pregnant. There is also a possible link between ADHD and very low birth weight or other childbirth-related problems like a lack of oxygen at birth.

Certain foods are often associated with ADHD too ¹⁴⁾. Some research actually suggests that children who often eat foods containing artificial colors and preservatives are more likely to develop abnormal behavior ¹⁵⁾. But nutrition appears to play a very small role at most. If you think it may be a factor, you can test whether changing a child’s diet helps.

Outlook for ADHD

ADHD usually first develops in childhood. In adulthood the symptoms are generally much less severe or may have disappeared completely.

About 50 out of 100 children who have ADHD show at least some symptoms as adults. About 15 out of 100 still fulfill all of the criteria for an ADHD diagnosis when they are adults.

But the symptoms often change as people age. For instance, teenagers and adults with ADHD are usually less hyperactive than they were as children, but often feel restless.

How is ADHD Diagnosed ?

It is best to have ADHD diagnosed by specialists who are very familiar with the disorder. These may include doctors, psychiatrists or psychotherapists who specialize in treating children and teenagers.

An in-depth talk and physical examination are important for ruling out other possible causes of the abnormal behavior. Things like sleep disorders, problems with vision or hearing, or an overactive thyroid gland might also lead to concentration problems, problems at school or hyperactivity.

The talk can also help to rule out other mental disorders as possible causes, and to diagnose any additional medical conditions. Your doctor or therapist may ask you questions like these:

• Is your child forgetful, easily distracted or unfocused?
• Does your child frequently climb up on things, disrupt others, or have rage attacks?
• Does the behavior occur both at school and at home?
• How long have you observed this kind of behavior in your child?
• Does your child’s performance at school suffer as a result, or does your child have difficulty findings friends because of their behavior, and are they unhappy about it?

Psychological tests and questionnaires are used to approach the diagnosis in a structured way. The child’s teachers or preschool teachers may also be asked to describe the child’s behavior in school or preschool.

Treatment for ADHD

Although there is no cure for ADHD, currently available treatments may help reduce symptoms and improve functioning.

Before any treatment is started, the doctor will talk about what ADHD is and how everyone can best cope with it. As well as the parents and their child, teachers and preschool teachers may also be there too. It may then turn out that there is no urgent need for treatment. When deciding whether or not treatment is necessary, it is important to consider how much of a problem the behavior is for the child and their parents, and whether things like their performance at school are suffering as a result.

If a child only has a mild form of ADHD that does not affect his or her life too much, it might be enough to complete a parent training and education program on dealing with ADHD ¹⁶⁾. These programs can be taken as a class with an instructor or done on your own using written material.

If a child has moderate or severe ADHD that is causing problems at school and in their social environment, it may be helpful to try interventions at school or have family or behavioral therapy ¹⁷⁾. The type of help that will be most effective will depend on the child’s age, whether they tend to be more inattentive or more hyperactive, and what areas of their life the ADHD has the greatest impact on.

Researchers found that, helping parents acquire new skills to help improve their child’s behavior (parental behavior training) reduces ADHD symptoms and disruptive behavior disorders in children under 6 with ADHD ¹⁸⁾. Improvements in disruptive behavior lasted as long as 2 years in some studies. Parents who attend more parental behavior training sessions see more improvement in their child’s behavior.

Medication can relieve ADHD symptoms ¹⁹⁾. It is mainly considered for the treatment of more severe ADHD when psychological and educational approaches are not effective enough. Medicine containing the drug methylphenidate is the most commonly used medication. If methylphenidate does not work or cannot be used for other reasons, the drugs atomoxetine, dexamfetamine or lisdexamfetamine may be used instead.

Treatment at a psychosomatic or psychiatric hospital for children and teenagers may be a good idea for children who are extremely hyperactive and impulsive and have great difficulty coping in daily life, or can no longer cope at all ²⁰⁾. Hospital treatment may also be needed if the child has other severe mental disorders too.

Parental Behavior Training ²¹⁾

• Parental behavior training programs teach parents better ways to help their child or teen.
• Often, parents and their child attend behavior training sessions together.
• Usually one of the first things the programs focus on is creating a healthy bond between the parents and the child.
• Programs teach parents how to understand their child’s behavior. Parents learn skills to help their child avoid behavior problems before they start.
• Parents can learn how to organize tasks in a way that makes it easier for their child or teen to complete them.
• Parental behavior training programs teach parents how to create a system of rewards and consequences.
• Program sessions usually take place in an office, and there may be weekly sessions for several weeks or months.
• These programs usually charge a fee. Some of these costs may be covered by your insurance.

Psychosocial Therapy ²²⁾

• A trained therapist can talk with your child and other family members about controlling behaviors and emotions and improving social skills.
• Therapy sessions usually take place in an office. The therapist may suggest weekly sessions for several weeks, months, or years, depending on the child’s needs.
• Therapists usually charge a fee for each hour of therapy. Some of these costs may be covered by your insurance.

School-Based Programs ²³⁾

• The Individuals with Disabilities Education Act (IDEA) requires public schools to offer special education services to the children who qualify. Children with ADHD are often included.
• Education specialists at schools help students with ADHD succeed in learning and academics. They can work with the child, the parents, and teachers to make adjustments to the classroom, learning activities, or homework assignments.
• An individual education plan (IEP) is created with education specialists, teachers, and parents. The IEP outlines the actions taken at the school to help the child succeed. These plans are reviewed at the end of the year and should be passed on to the child’s next teacher.
• These services may be free of charge for families living within the school district.

Diet for ADHD

The specific hypothesis that synthetic food colorings influence ADHD (at that time, hyperkinetic reaction), via either allergenic or pharmacologic mechanisms, was introduced in the 1970s by Feingold ²⁴⁾. Feingold was an allergist, so his predisposition was to evaluate for potential allergens in patients. He suggested initially that children who are allergic to aspirin (which contains salicylates) may be reactive to synthetic food colors as well as naturally occurring salicylates, although he later focused in particular on food color additives. He proposed a diet free of foods with a natural salicylate radical and all synthetic colors and flavors to treat hyperactivity. This diet is also referred to as the Kaiser Permanente diet. A narrower approach simply restricts synthetic food colors, although these are sometimes also restricted as part of more general diets. Despite much research, the role of foods and food ingredients (such as color additives) in ADHD remains controversial ²⁵⁾. Some evidence suggests that only a small number of people with ADHD are affected by substances in food, and that different individuals may react to different foods or food components.

The ketogenic diet (keto diet) has been used in treatment-resistant epilepsy since the 1920s ²⁶⁾. Keto diet consists of a rigidly controlled high-fat, low-protein, and low-carbohydrate diet usually with a 4:1 lipid:non-lipid ratio (fat to protein and carbohydrate ratio) ²⁷⁾. Keto diet has been proven an effective treatment in difficult-to-control seizures with its use primarily in children with epilepsy ²⁸⁾, ²⁹⁾, particularly those with epileptic encephalopathies whereby epileptic activity may contribute to severe neurological and cognitive impairments ³⁰⁾. The finding that keto diet is beneficial for epilepsy was supported by a systematic review ³¹⁾, meta-analysis ³²⁾, and a Cochrane review ³³⁾. Keto diet and related diets have been proven useful in pharmacoresistant childhood epilepsy ³⁴⁾. Despite its long history in epilepsy, the role of keto diet in mental disorders is unclear. Currently, there is insufficient evidence for the use of ketogenic diet (keto diet) in mental disorders, and it is not a recommended treatment option ³⁵⁾.

Celiac disease is an autoimmune disorder that damages the small intestine and inhibits absorption of nutrients. People with celiac disease cannot tolerate gluten, a protein in wheat, rye, barley, and in some products such as medicines, vitamins, and lip balms. When affected people eat food with gluten, or use a product with gluten, the immune system reacts by damaging tiny parts of the lining of the small intestine called villi. Treatment is a lifelong, gluten-free diet ³⁶⁾. If you are concerned about celiac disease, you are strongly discouraged from starting a gluten-free diet without having had a firm diagnosis by your medical doctor. And if you change your diet to the gluten free diet, even for as little as a month, can complicate the diagnostic process. This is because all celiac disease blood tests require that you be on a gluten-containing diet to be accurate. Celiac disease is markedly overrepresented among patients presenting with ADHD. A gluten-free diet significantly improved ADHD symptoms in patients with celiac disease in this study ³⁷⁾. The results further suggest that celiac disease should be included in the ADHD symptom checklist. However children with ADHD and without a diagnosis of Celiac disease should avoid going on a gluten free diet, because a gluten-free diet isn’t always a healthy diet. For instance, a gluten-free diet may not provide enough of the nutrients, vitamins, and minerals the growing children body needs, such as fiber, iron, and calcium. Plus some gluten-free products can be high in calories and sugar too.

If you’re interested in trying a special diet, consult your health care provider and consider getting guidance from a registered dietitian. Planning, evaluating, and following special diets can be challenging, and it is important to ensure that the diet meets nutritional needs.

Various dietary effects have been of long-standing interest. Among the dietary theories, the hypothesis that allergies or else hypersensitivity to certain foods or ingredients cause learning and behavior problems entered the literature as early as the 1920s ³⁸⁾. A specific hypothesis that food additives, which include synthetic food colorings and flavors, influence ADHD (at that time, hyperkinetic reaction), via either allergenic or pharmacologic mechanisms, was introduced in the 1970s by Feingold ³⁹⁾. He suggested initially that children who are allergic to aspirin are susceptible to synthetic food colors as well as naturally occurring salicylates, but he later focused on food color additives. To treat this reaction, Feingold proposed a diet free of foods with a natural salicylate radical and all synthetic colors and flavors ⁴⁰⁾.

The topic of synthetic color additives and hyperactivity was heavily studied in the 1970s and 1980s. In 1982, the National Institutes of Health convened a consensus development conference on defined diets and childhood hyperactivity, which recommended further study. A 19839 meta-analysis included 23 studies regarding the efficacy of the Feingold diet; the authors concluded that the composite effect size was too small to be important, setting the tone for two decades of professional skepticism as to the value of dietary intervention in ADHD. In a more recent meta-analysis, Schab and Trinh ⁴¹⁾ reviewed 15 double-blind, placebo-controlled studies, plus six others for their supplemental analysis. They concluded that there was a reliable effect linking synthetic colors to ADHD symptoms in parent ratings, but not in teacher or observer ratings, and that the effect was carried by individuals preselected to be diet responsive. The effects seemed to be similar whether or not children were initially selected to be hyperactive. That report helped revive scientific interest in the role of synthetic food colors and has provoked periodic controversy for nearly 40 years between the relationship of food color additives to ADHD.

Overall, from recent meta-analysis of ADHD and synthetic food color additives ⁴²⁾ has provided mixed results. The confidence in or generalizability of the food color findings is limited by the lack of consistency in the findings across information sources, small pooled samples for studies restricted only to FDA-approved colors and for the psychometric test data, outdated studies in the United States, and vulnerability to publication bias of findings from parent studies. Artificial food colors (AFCs) have not been established as the main cause of attention-deficit hyperactivity disorder (ADHD), but accumulated evidence suggests that a subgroup shows significant symptom improvement when consuming an artificial food colors-free diet and reacts with ADHD-type symptoms on challenge with artificial food colors ⁴³⁾.  A widely publicized population-based study conducted in England ⁴⁴⁾ concluded that food additives contribute to hyperactivity, prompting the European Union Parliament recently to require warning labels on foods containing 6 colors, not all of which are approved for use in the United States by the US Food and Drug Administration, FDA ⁴⁵⁾.

In conclusion, artificial food colors are not a main cause of ADHD, but they may contribute significantly to some cases, and in some cases may additively push a youngster over the diagnostic threshold ⁴⁶⁾. The current status of evidence is inconclusive “but too substantial to dismiss” ⁴⁷⁾. Until safety can be better determined, researchers suggest minimizing children’s exposure to artificial food colors. With the current concerns about childhood obesity, there appears to be no need to make food look more attractive than its natural color. Approximately 33% of children with ADHD may respond to a dietary intervention ⁴⁸⁾. Although as many as 8% may have symptoms related to food colors, the source of most of this dietary response remains unclear ⁴⁹⁾. Researchers thus conclude that dietary effects on and treatments of ADHD, including food additives and colors, deserve renewed investigation ⁵⁰⁾.

According to the British Food Standards Agency ⁵¹⁾: “research funded by the FSA has suggested that consumption of mixes of certain artificial food colours and the preservative sodium benzoate could be linked to increased hyperactivity in some children.”

The artificial colours are ⁵²⁾:

• sunset yellow FCF (E110)
• quinoline yellow (E104)
• carmoisine (E122)
• allura red (E129)
• tartrazine (E102)
• ponceau 4R (E124)

A European Union-wide mandatory warning must be put on any food and drink (except drinks with more than 1.2% alcohol) that contains any of the six colours. The label must carry the warning “may have an adverse effect on activity and attention in children” ⁵³⁾.

The Food Standards Agency is publicising the product ranges to encourage the food industry to participate in the voluntary ban ⁵⁴⁾. The Food Standards Agency is encouraging manufacturers to work towards finding alternatives to these colours. Some manufacturers and retailers have already taken action to remove them.

Elimination Diets

The concept of an elimination diet to improve health was first proposed by Albert Rowe ⁵⁵⁾ in 1926 in regards to food allergies and spelled out in his subsequent book. The focus of elimination diets is to remove specific foods from the diet in an effort to eliminate potential allergens that occur naturally in food (eg, eggs, wheat, dairy, soy) or artificial ingredients that may have allergenic or even toxicant effects (eg, synthetic food additives: artificial colors, flavors, sweeteners, as well as flavor enhancers [like monosodium glutamate (MSG)] and preservatives). These diets are used to attempt to diagnose and treat food allergies and intolerances ⁵⁶⁾.

Food elimination diets vary in their specific content, but take 3 main forms:

• A single food exclusion diet excludes one suspected food, such as eggs.
• A multifood exclusion diet, such as the 6-food elimination diet, eliminates the most common food allergens: cow-milk protein, soy, wheat, eggs, peanuts, and seafood.
• A “few foods diet” (also called an oligoantigenic diet) restricts a person’s diet to only a few less commonly consumed foods (eg, lamb/venison, quinoa/rice, pear, and others with low allergenic potential).

The “few foods diet” must be overseen by a properly qualified professional (eg, dietitian) to avoid nutritional deficiency, but is effective at identifying multiple food allergies in an individual ⁵⁷⁾. Much of the use of these diets in the medical literature is targeted at single specific food allergies (eg, cow’s milk ⁵⁸⁾ or physical symptoms thought to potentially be related to food allergies, such as esophagitis) ⁵⁹⁾, ⁶⁰⁾.

Other specific elimination diets exist, such as a gluten-free diet and the Kaiser Per-manente (or Feingold) diet. The gluten-free diet is currently the only successful treatment for patients with Celiac disease ⁶¹⁾ and is also being used to treat nonceliac gluten sensitivity ⁶²⁾. Gluten is the protein found in wheat, rye, and barley, and thus, any item in the diet containing these grains (including some food additives) must be removed. A gluten and casein-free diet is also being tested in autism ⁶³⁾. The Feingold diet eliminates food colorings and sometimes certain preservatives and foods with naturally occurring salicylates ⁶⁴⁾. The Feingold diet was later adapted to only exclude artificial colorings and preservatives, which Feingold came to think were the pertinent factors in ADHD.

All elimination diets use the same 2-step process, wherein the diet is followed for a period of time; then, if symptoms remit, foods (or food additives) are reintroduced one at a time to test for a return of symptoms. When using the “few foods diet,” this process is lengthy, because many foods must be tested until enough foods have been identified to reinstate a healthy balanced diet without allergens. When food allergy is suspected, skin prick allergy testing can accompany dietary treatment. More commonly, the dietary intervention is purely “empirical” in that foods are eliminated and reintroduced while symptoms are monitored.

Allergists define food allergy as an immunologic response in the body after exposure to a food item. Common manifestations of food allergy include skin responses (uticaria), sensitivity/swelling in the mouth, rhinitis, breathing difficulties, and gastrointestinal issues ranging from vomiting to diarrhea; less well-known neurologic symptoms, like headache, anxiety, confusion, nervousness, and lethargy, have also been reported ⁶⁵⁾.

On the other hand, food intolerance is defined by allergists as a nonimmunological (ie, nonallergic) response to a food item, which may be due to enzyme deficiency (eg, lactose intolerance) or another nonimmunological hypersensitivity reaction such as to food additives ⁶⁶⁾. Food intolerances can also cause gastrointestinal difficulties, but often also result in other symptoms, which can range from headache and blurred vision to mood changes, fatigue, and pain. Pelsser and colleagues ⁶⁷⁾ hypothesized that ADHD involves food hypersensitivity (intolerance). This type of food intolerance is often considered to be a toxicologic or pharmacologic response to chemicals found in food. However, intolerance is difficult to verify because the idea of intolerance proposes that reaction may occur after a substantial time period; furthermore, the mechanisms of such intolerance are not necessarily demonstrated for most additives.

Summary:

Use of elimination diets to treat attention deficit and hyperactivity disorder (ADHD) has been proposed and studied for nearly 40 years and frequently reviewed and discussed. A consensus has emerged among most reviewers that an elimination diet produces a small aggregate effect but may have greater benefit among some children.

An elimination diet has a chance of success between 0% and 50%, with the best guess being a 10% to 30% chance of successful completion and positive response ⁶⁸⁾. Furthermore, cultural and national differences in food content are significant, such that results in one nation may not generalize to another. For example, the number of food additives approved for use varies considerably between countries. Canada ⁶⁹⁾ and the European Union ⁷⁰⁾ both have less than 500 food additives approved for use. Contrast this with the United States, which has over 3000 food additives allowed to be used in food ⁷¹⁾, although there is as yet no evidence that the prevalence of ADHD differs among these nations.

Given that Celiac disease is markedly overrepresented among patients presenting with ADHD. If you are concerned about celiac disease, you are strongly discouraged from starting a gluten-free diet without having had a firm diagnosis by your medical doctor. And if you change your diet to the gluten free diet, even for as little as a month, can complicate the diagnostic process. This is because all celiac disease blood tests require that you be on a gluten-containing diet to be accurate. A gluten-free diet may significantly improved ADHD symptoms. However be aware that a gluten-free diet isn’t always a healthy diet. For instance, a gluten-free diet may not provide enough of the nutrients, vitamins, and minerals the body needs, such as fiber, iron, and calcium. Some gluten-free products can be high in calories and sugar.

Food additives to avoid:

• All artificial colors.
• All artificial flavors.
• All artificial sweeteners, including aspartame, acesulfame K, neotame, saccharin, sucralose.
• Sodium benzoate.
• Butylated hydroxyanisole and Butylated hydroxytoluene.
• Carrageenan.
• Monosodium or monopotassium glutamate.
• Any hydrolyzed, textured, or modified protein.

Dietary supplements

Although conventional treatment has been proven helpful for ADHD symptoms in children and adults, complementary approaches have not ⁷²⁾. Complementary health approaches studied for ADHD include the following:

• The possibility that omega-3 fatty acids (fish oil supplementation) could be helpful for ADHD is being investigated, but the evidence is inconclusive. This 2012 Cochrane Review ⁷³⁾, showed there is little evidence that polyunsaturated fatty acids (PUFA) supplementation provides any benefit for the symptoms of ADHD in children and adolescents. The majority of data showed no benefit of polyunsaturated fatty acids (PUFA) supplementation, although there were some limited data that did show an improvement with combined omega‐3 and omega‐6 supplementation ⁷⁴⁾.

• Correcting deficiencies in the minerals zinc, iron, or magnesium may improve ADHD symptoms, but this does not mean that supplements of these minerals would be helpful for people with ADHD who are not deficient, and all three minerals can be toxic if taken in excessive amounts.

• Melatonin has not been shown to relieve ADHD symptoms, but it may help children with ADHD who have sleep problems to fall asleep sooner.

• Research on L-carnitine/acetyl-L-carnitine and various herbs, such as St. John’s wort, French maritime pine bark extract (also known as Pycnogenol), and Ginkgo biloba, has not demonstrated that these supplements are helpful for ADHD.

Neurofeedback

Some research has suggested that neurofeedback, a technique in which people are trained to alter their brain wave patterns, may improve ADHD symptoms, but several small studies that compared neurofeedback with a simulated (sham) version of the procedure did not find differences between the two treatments.

Other complementary health approaches

An assessment of research on homeopathy concluded that there is no evidence that it is helpful for ADHD symptoms. Several mind and body practices, including acupuncture, chiropractic care, massage therapy, meditation, and yoga, have been studied for ADHD. However, the amount of evidence on each of these practices is small, and no conclusions can be reached about whether they are helpful.