Janice Pellow, M.Tech (Hom), Elizabeth M. Solomon, HD, ND, DO, BA,
Candice N. Barnard, M.Tech (Hom), B.Phys.Ed
University of Johannesburg,
Department of Homeopathy,
Johannesburg, South Africa.
Attention-deficit/hyperactivity disorder (ADHD) is a commonly diagnosed childhood disorder characterized by impulsivity, inattention, and hyperactivity. ADHD affects up to 1 in 20 children in the United States. The underlying etiologies of ADHD may be heterogeneous and diverse, and many possible risk factors in the development of ADHD have been identified. Conventional treatment usually consists of behavioral accommodations and medication, with stimulant medication most commonly being prescribed.
Parents concerned about the side effects and long-term use of conventional medications are increasingly seeking alternatives to pharmacologic treatment.Complementary and alternative medicine (CAM) offers parents various treatment options for this condition, including dietary modifications, nutritional supplementation, herbal medicine, and homeopathy. CAM appears to be most effective when prescribed holistically and according to each individual’s characteristic symptoms. Possible etiologies and risk factors for the condition also need to be considered when developing a treatment plan. This article serves to highlight the latest research regarding the most commonly used CAM for children with ADHD.
|Dietary Factors and Nutrient Deficiencies|
|Hypersensitivity to foods and/or additives||Increase in inflammatory mediators and neuropeptides in the blood|
|Phospholipid deficiencies||Possible impairments in neuronal structure and function, especially during early development|
|Omega-3 fatty acid deficiency||Impaired neurotransmitter reception in brain; altered neuronal plasticity|
|Amino acid deficiencies||Decreased production of amino acid-based neurotransmitters|
|Refined carbohydrates||Abnormal glucose metabolism, causing disruptions in hormone and neurotransmitter regulation|
|Mineral deficiencies||Impaired dopaminergic transmission|
|Antioxidant deficiencies||Oxidative damage to DNA|
|Exposure to Environmental Toxins|
|Heavy metals, solvents, pesticides, neurotoxins||Disrupted neurotransmitter and neuromodulator function|
|Exposure to Electronic Media|
|Television||Over-stimulation, sensory addiction, increased stimulus-seeking behavior|
|Cell phones||Pre-and post-natal exposure linked to increase in ADHD symptoms. Exact mechanism unknown.|
|Natural light deficiency / Exposure to fluorescent lighting||Hyperactive behavior and decreased learning ability|
Numerous risk factors for ADHD have been proposed. The following potential etiological domains all appear to exacerbate existing ADHD symptoms and have a plausible neural mechanism of action,  as outlined in Table 1.
Dietary Influence and Nutritional Deficiencies
Poor diet and resultant deficiencies of various nutrients can contribute to oxidative stress and altered neuronal plasticity, both of which have an impact on children with ADHD. Deficiencies of zinc, magnesium, glutathione, and/or omega-3 fatty acids, for instance, have been linked to concentration, memory, and learning problems in children with ADHD. 
Hypersensitivity to Foods and/or Additives
A high proportion of children with ADHD tend to exhibit atopic symptoms, leading to a recent hypothesis by Pelsser et al that ADHD may comply with the criteria for hypersensitivity.  Exposure to sensitizing foods appears to increase inflammatory mediators and neuropeptides in the blood,  and hypersensitive children are likely to exhibit atopy, irritability, sleep disturbances and prominent hyperactive-impulsive symptoms.  Future research regarding a genetic atopic link is needed. Probiotic therapy has been shown to be beneficial in children with atopic conditions such as eczema,  thus may be useful for immune-mediated hypersensitivity reactions in ADHD. 
A potential link between ADHD and food additives (preservatives, artificial flavorings and colorings) has been debated for decades. [18,22] A study published in Lancet in 2007 put forward the findings that sodium benzoate and commonly used food colorings may exacerbate hyperactive behavior in 3-year- and 8/9-year-old children. 
Dissimilarities in the behavioral responses of these children when consuming additives suggested a genetic influence.  Indeed, this was confirmed in a 2010 follow-up study of the same children, which showed adverse effects of food additives on ADHD symptoms to be moderated by polymorphisms in the genes controlling histamine degradation.  A relationship between food additives and behavior is concluded to be clinically relevant for individual children, particularly those with a tendency toward hyperactivity. 
Essential Fatty Acid and Phospholipid Deficiencies
Essential fatty acids (EFAs) and phospholipids are both essential for normal neuronal structure and function and must be supplied through the diet. [4, 25, 26] The myelin sheath, which insulates every neuron in the brain, is made up of roughly 75-percent phospholipids, with each molecule having an attached saturated and unsaturated fatty acid, the latter being either an omega-3 or an omega-6 fatty acid.  The brain and nervous system depend heavily on these essential nutrients, especially during critical periods of development such as childhood, and dietary deficiency during these periods may increase the risk of developing ADHD-type symptoms. 
Omega-3 fatty acids, specifically docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), appear to improve neurotransmitter reception in the brain. DHA, in particular, protects neurons and glia from death by maintaining brain-derived neurotrophic factor (BDNF), a protein formed within the brain that aids in maintaining neuronal plasticity. [19,27] The ratio between omega-3 and omega-6 fatty acids is especially important, and our modern Western diet has produced an imbalance in this ratio, with more foods rich in omega-6 (e.g., canola oil, sunflower oil) being consumed. This imbalance is considered to be a risk factor for ADHD. [28,29] ADHD children may also have an inability to metabolize EFAs correctly.  Children with ADHD frequently manifest EFA deficiency symptoms, which may include dry hair and skin, eczema, recurrent infections, increased thirst and behavioral problems.  Correcting underlying EFA deficiencies may improve ADHD symptoms in many individuals.
Low-Protein, High-Carbohydrate Diets
Amino acids are the building blocks of proteins, as well as precursors for most of the neurotransmitters in the brain (Figure 1). Certain amino acids are considered essential, as they need to be taken in through the diet; as a result, low protein diets may foster amino acid deficiency symptoms.  Many of the amino acids needed by the body to manufacture neurotransmitters, such as phenylalanine, tyrosine, and tryptophan, are found to be low in the blood of adults and children with ADHD. [19,31,32] Deficiencies of these neurotransmitter precursors, together with their vitamin and mineral cofactors, may result in ADHD-type symptoms.  Correcting underlying metabolic imbalances through amino acid supplementation may be an important treatment strategy in individual cases where a deficiency exists.
Excessive consumption of refined carbohydrates and sugar can negatively affect learning ability and increase aggressive and restless behavior in all children, although evidence for a direct link to ADHD is lacking. In one study, comparing 17 ADHD children with nine age-matched normal children, assessing the effects of sugar ingestion on behavior, the children with ADHD displayed more inattention.  It has been suggested that these results could be due to a relative glucose intolerance occurring in ADHD sufferers; however, evidence for this is contradictory. One study conducted by Langseth and Dowd on 261 hyperactive children found that after five-hour oral glucose tolerance tests, 74 percent displayed abnormal glucose tolerance.  Other studies have failed to find differences in overall glucose metabolism between normal children and children with ADHD. [35,36] However, these studies did find significant differences in glucose metabolism within specific regions of the brain, such as the frontal lobe, where reduced metabolism was inversely correlated with symptom severity.  Reactive hypoglycemia after sugar ingestion typically causes a rise in plasma epinephrine and norepinephrine; however, the rise in ADHD children is nearly 50-percent lower than in normal children.  The data suggest that ADHD children have difficulty regulating hormones and neurotransmitters, which may be further aggravated by refined sugar consumption.
Numerous studies have shown evidence of mineral deficiencies in children with ADHD, namely, zinc, iron, calcium, magnesium, and selenium. [19,38-41] As zinc and iron are associated with dopamine metabolism, a deficiency of either of these minerals might be associated with significant impairment in dopaminergic transmission.  Consumption of certain artificial food additives can lead to various nutrient deficiencies in some individuals, in particular zinc deficiency, which can exacerbate anxiety and conduct disorder problems.  A disturbance in the zinc:copper ratio is also evident, with high levels of copper being found in many ADHD children. 
Environmental Toxins and Contaminants
Exposure to metals (lead, cadmium, mercury, aluminum), solvents, pesticides, polychlorinated biphenyls, or other environmental toxins has been linked to ADHD. [43-45] Minerals such as zinc are needed to help metabolize and eliminate heavy metals; thus, a deficiency of such nutrients can exacerbate the problem.  The vast majority of toxicants released into the environment and their effects on a child’s developing nervous system have, however, not been adequately researched. It has been proposed that prenatal and perinatal insults to the developing brain, including environmental toxins, can disturb the timetable of expression of neurotransmitters and their receptors.  If so, this might have the effect of producing permanent changes in the brain that predispose to ADHD during childhood or adolescence. Although exact mechanisms were not clear, a literature review revealed a more than two-fold increased risk of ADHD among children whose mothers smoked during pregnancy.  Other studies suggest that these contaminant s may disrupt two key sets of psychological mechanisms that are also disrupted in ADHD: higher-order executive functions and reinforcement responses.  Chelation therapy for binding heavy metals in the body may prove beneficial in cases of ADHD associated with toxic overload. In one small study conducted on children with both autism and ADHD, using chelation therapy in combination with other nutritional, behavioral, and educational approaches, all 10 children showed a significant improvement in social interaction, cognitive function, and behavior, as well as a significant reduction in urinary lead burden. 
Environment, Electronic Media, and Culture
It is a well-established theory that electronic media can influence children’s development.  Research has shown that early television watching (ages 1-3) is associated with the development of attention problems in children by age seven.  Another study showed that children who watch two or more hours of television per day had increased attention problems in adolescence, suggesting that the adverse effects of television may be cumulative.  One possible explanation for these findings is that television watching replaces other activities that encourage concentration and attention, such as reading. Also, children’s television programs may overstimulate the developing brain of a young child, leading to sensory addiction.  One result of sensory addiction is difficulty coping with slowness. In children, this can manifest as an inability to regulate their own behavior, motivating the need for more stimulus-seeking behavior. Restlessness, anxiety, and impulsivity may result from a perceived lack of stimulation.  Further studies are needed in this field for a fuller evaluation of the association between television and ADHD.  According to a study published in the journal, Epidemiology, children exposed to mobile phones prenatally and, to a lesser extent, postnatally, were 80-percent more likely to exhibit ADHD-type symptoms, such as hyperactivity and behavioral problems, at school-going age.  Although this association has yet to be substantially proven, it does raise cause for concern due to the widespread use of this technology.
Natural light deficiency has been suggested as a risk factor for ADHD.  Exposure to cool-white fluorescent lights appears to affect learning ability in children, and research suggests that it may also be linked with the incidence of attention-deficit disorder and hyperactivity. One study showed that there was a 32-percent reduction in hyperactive behavior in children when fluorescent lighting was removed from their classrooms.  As a result, it has been suggested that radio-frequency (RF)-shielded full-spectrum lighting and/or natural unfiltered daylight preferably be used.  Spending time outdoors in “green” natural settings appears to improve ADHD symptoms.  Moreover, the greener and more natural the environment compared to indoor or relatively built up outdoor settings (e.g., parking lots, downtown areas), the less severe the ADHD symptoms.