Omega-3 Supplementation and ADHD: A Review

1. Omega-3 Supplementation and ADHD: A Review Jennifer M. Akullian

2. ADHD: Attention Deficit Hyperactivity Disorder

3. One of the most prevalent psychiatric illnesses of children Virtually unheard of and unnamed only 50-years ago Among most treatable of psychiatric disorders 70 percent of those diagnosed use pharmacology to reduce incapacitating Impact: - 32-40% of students with ADHD drop out of school - Only 5-10% will complete college - 50-70% have few or no friends - 70-80% will under-perform at work - 40-50% will engage in antisocial activities - More likely to experience teen pregnancy & sexually transmitted diseases - Have more accidents & speed excessively - Experience depression & personality disorders  Facts about ADHD:

4. Prevalence: • 3-6 % of school aged children (in some cities reaching 10-15%) • 1990: 902,000 US children diagnosed with ADHD • 1993: > 2 million US children diagnosed with ADHD • Currently as many as 4 million carry the ADHD diagnoses (30-50% child mental health service referrals)

5. Diagnosis and Progression of ADHD: • 6 or more inattentive symptoms • 6 of more hyperactive/impulsive symptoms • 6 or more of both • symptoms persist for 6 months or more

6. DSM-IV Diagnosis of ADHD: • symptoms must appear before the age of 7 • symptoms were present before age 7 • symptoms present in 2 or more settings • impairment in social, academic or occupational functioning • symptoms must not be secondary to another disorder

7. Attention Deficit Hyperactivity Disorder • Three essential varieties: • characterized by inattention, • another by hyperactivity, • and third combines the both

8. Often fails to give a close attention to details or makes careless mistakes in schoolwork, work, or other activities. Often has difficulty sustaining attention in tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to being obstructive or failure to understand instructions). Often has difficulty organizing tasks and activities. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools). Is often easily distracted by extraneous stimuli. Is often forgetful in daily activities. Inattention:

9. Hyperactivity-Impulsitivity: • Often fidgets with hands or feet or squirms in seat. • Often leaves his or her seat in the classroom or in other situations in which remaining seated is expected. • Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, they might be limited to subjective feelings of restlessness). • Often has difficulty playing or engaging in leisure activities quietly. • Is often on the go or often acts as if driven by a motor. • Often talks excessively. • Often blurts out answers before questions have been completed. • Often has difficulty awaiting turn. • Often interrupts or intrudes on others (American Psychiatric Association 1994).

10. ADHD Co-morbidity: • Learning Disorders • Oppositional Defiant Disorder • Other Conduct Disorders • Depression

11. Pharmacological Options:Stimulants • Ritalin-one dose lasts up to 4 hours • Metadate – Ritalin – once a day lasts up to 12 hrs • Focalin – New Ritalin derivative lasts up to 4 hours • Attenade-Newest Ritalin derivative-lasts 6 hours • Concerta- once a day lasts up to 12 hours • Dexedrine-last 4 hours • Adderall- New Dexedrine - once or twice a day (lasts longer than Ritalin) • Cylert-requires liver function testing due to history of hepatic failure with children who were on it

12. Pharmacological Options:Stimulant and Pharmacological Alternative Intervention Approaches • Catapres[R] • Tenex[R] • Parent Team • Home Modifications • Parent-Teacher Team • Consistency of parent-teacher-doctor team • Food allergies, diet and sleep regulation • AND . . .

13. Pharmacological Options: Stimulant and Pharmacological Alternative Intervention Approaches • Essential Fatty Acid Supplementation

14. Neurobiology of ADHD: • Central pathological deficits of ADHD are linked to several specific brain regions: • frontal cortical • frontal-basal ganglia • Neurotransmitters: • alteration in dopaminergic • and nonadrenergic transmitter functions

15. Dietary Supplementation and ADHD

16. Multiple vitamin-mineral supplements: • B Vitamins in Combination • Vitamin B6 • Iron • Zinc

17. Commonly grouped as the vitamin B complex are the following water-soluble vitamins: Thiamine (vitamin B 1 or antiberiberi factor) is a necessary ingredient for the biosynthesis of the coenzyme thiamine pyrophosphate; in this latter form it plays an important role in carbohydrate metabolism. Riboflavin (vitamin B 2 or lactoflavin) is used to synthesize two coenzymes that are associated with several of the respiratory enzymes of plants and animals (including humans) and is therefore important in biochemical oxidations and reductions. The B vitamins niacin (nicotinic acid) and niacinamide (nicotinamide) are commonly known as preventives of pellagra , which in 1912 was shown by American medical researcher Joseph Goldberger to result from a dietary deficiency. The molecular structure of vitamin B 12 (cobalamin), the most complex of all known vitamins Vitamin B 12 and closely related cobalamins are necessary for folic acid to fulfill its role; both are involved in the synthesis of proteins. Pantothenic acid, another B vitamin, is present in perhaps all animal and plant tissues, as well as in many microorganisms. Good sources of it include liver, kidney, eggs, and dairy products. Biotin is a B vitamin that functions as a coenzyme in the metabolism of carbohydrates, fats, and amino acids. Although it is vitally necessary to the body, only exceedingly small quantities are needed, and since biotin is synthesized by intestinal bacteria, naturally occurring biotin deficiency disease is virtually unknown Folic acid (pteroylglutamic acid, folacin, or vitamin B 9 ) occurs abundantly in green leafy vegetables, fruits (e.g., apples and oranges), dried beans, avocados, sunflower seeds, and wheat germ. B Vitamins in Combination

18. Vitamin B6 (pyridoxine) • Pyridoxine, pyridoxal, and pyridoxamine make up the vitamin B 6 group. They all combine with phosphorus in the body to form the coenzyme pyridoxal phosphate, which is necessary in the metabolism of amino acids, glucose, and fatty acids. The best sources of B 6 vitamins are liver and other organ meats, corn, whole-grain cereal, and seeds. Deficiency can result in central nervous system disturbances. The recommended dietary allowance for adults is 2.0 to 2.2 mg for men and 2 mg for women. Additional doses are required in pregnancy and by those taking oral contraceptives or the tuberculosis drug izoniazid. Severe nerve damage has been reported from megadoses.

19. Iron • metallic chemical element; symbol Fe. Because iron is a component of hemoglobin, a red oxygen-carrying pigment of the red blood cells of vertebrates, iron compounds are important in nutrition; one cause of anemia is iron deficiency.

20. Zinc • metallic chemical element; symbol Zn. Zinc is essential to the growth of many kinds of organisms, both plant and animal. It is a constituent of insulin, which is used in the treatment of diabetes. Chief sources of zinc are the sulfide ore, zinc blende, or sphalerite (called also blende or “black Jack” ); zincite, an oxide; calamine, a silicate; and smithsonite, the zinc carbonate

21. Essential Fatty Acids: What are they?

22. LA • Linoleic Acid : This EFA is called Linoleic Acid (LA) and is poly-unsaturated. You will see that LA is an 18 carbon chain fatty acid with two double bonds in the middle and is missing four hydrogen atoms, all on one side.

23. ALA • Alpha Linolenic Acid: is also polyunstaturated with an 18 carbon fatty acid with three double bonds at the 3, 6, and 9 carbon positions.  LNA is missing 6 hydrogen atoms, again all from one side. Because of the first double bond occurring at the 3rd carbon atom

24. Essential Fatty Acid Metabolism:

25. Colquhoun I, Bunday S. A lack of essential fatty acids as a possible cause of hyperactivity in children. Med Hypotheses 1981;7:673-679.

26. Mitchell EA, Aman MG, Turbott SH, et al. Clinical characteristics and serum essential fatty acid levels in hyperactive children. Clin Pediatr 1987;26:406-411.

27. Stevens LJ, Zentall SS, Deck JL, et al. Essential fatty acid metabolism in boys with attention-deficit hyperactivity disorder. Am J Clin Nutr 1995;62:761-768.

28. Aman MG, Mitchell EA, Turbot SH. The effects of essential fatty acid supplementation by Efamol in hyperactive children. J Abnorm Child Psycho 1987;15:75-90.

29. Arnold LE, Kleycamp D, Votolato NA, et al. Gamma-linolenic acid for attention deficit hyperactivity disorder: Placebo-controlled comparison to D-amphetamine. Biol Psychiatry 1989;25:222-228.

30. Role of Nutrient Deficiency in ADHD • A synapse: Omega 3s may make it easier • for signals to cross the gap between brain cells.

31. Management Options: • Psychostimulant Pharmaceuticals • Environmental/Social Interaction Changes • Nutrient and Essential Fatty Acid Supplementation

32. ADHD in the Future: • Common finding in all research = MORE RESEARCH NEEDED!!!! • Reasons for the lower proportions of LC-PUFA’s in hyperactive children is not clear. • Specific proteins and genes involved have been relatively ill-defined. • Controversy still surrounds both the identification and management of these conditions • ADHD etiology is recognized as being complex and multifactor; however, little progress has yet been made in elucidating predisposing factors at the biological level. • Current studies in line with original proposal that ADHD involves difficulty in the synthesis of HUFA • Omega-3 supplementation has shown promising effects in recent studies.

33. Questions: