What supplements are recommended for Attention Deficit Hyperactivity Disorder (ADHD)?

Supplements for ADHD: Evidence-Based Recommendations

There are no supplements with strong enough evidence to recommend as primary treatment for ADHD; FDA-approved medications and behavioral therapy remain the first-line treatments with the strongest evidence for improving morbidity, mortality, and quality of life outcomes in ADHD. 1, 2

Evidence-Based Treatment Hierarchy for ADHD

First-Line Treatments (Strong Evidence)

• FDA-approved medications: Stimulants (methylphenidate, amphetamine derivatives) have the strongest evidence with effect sizes of approximately 1.0 1, 2
• Behavioral therapy: Especially important for preschool-aged children before medication 1, 2

Supplements with Limited Evidence

1. Zinc: Best evidence among supplements (two positive randomized controlled trials) 3

   • Consider only in patients with documented zinc deficiency
   • Not recommended as primary treatment

2. Omega-3 fatty acids: Mixed evidence but may warrant a trial 3, 4, 5

   • Combination of EPA, DHA, and GLA shows some promise
   • Effect size much smaller than medication (marginal benefits)
   • May be considered when:
     • Medication has failed
     • Parents oppose medication
     • As an adjunct to conventional treatment

3. Iron: Consider only with documented iron deficiency 4, 6

   • May enhance effectiveness of stimulant therapy when deficiency exists
   • Not recommended without confirmed deficiency

4. Magnesium: Limited evidence, consider only with documented deficiency 4

Supplements with Insufficient Evidence

• Carnitine: Mixed evidence, possibly small effect for inattention 3, 5
• Pycnogenol: Mixed evidence, more research needed 3
• Vitamins: Insufficient evidence for ADHD-specific benefits 3, 4
• Ginkgo biloba with ginseng: More research needed 3
• Dimethylaminoethanol (DMAE): Possibly small effect, limited evidence 5

Supplements Not Supported by Evidence

• St. John's Wort: No evidence to support use 3
• Tyrosine: No evidence to support use 3
• Phenylalanine: No evidence to support use 3
• Herbal supplements: Little evidence of efficacy 5

Dietary Approaches

• Artificial food dye elimination: Some controlled studies support this approach 6, 5

  • May be more applicable to general pediatric population than diagnosed ADHD
  • Consider as a low-risk intervention

• "Western pattern" diet avoidance: High in fat and refined sugars, associated with ADHD symptoms 6

  • Shift toward "healthy" diet with fiber, folate, and omega-3 fatty acids

Clinical Decision Algorithm

1. Start with proven treatments:

   • FDA-approved medications (stimulants first-line)
   • Evidence-based behavioral therapy

2. Consider supplements only when:

   • Standard treatments have failed or are unacceptable
   • Documented nutritional deficiencies exist
   • As adjunctive therapy, not replacement for proven treatments

3. Apply the SECS vs. RUDE rule 5:

   • Treatments that are Safe, Easy, Cheap, and Sensible (SECS) require less evidence
   • Those that are Risky, Unrealistic, Difficult, or Expensive (RUDE) require stronger evidence

Important Caveats

• Delaying proven treatments while trying supplements may worsen outcomes
• Benefits of supplements are much smaller than pharmacological treatments
• Supplement quality and dosing are not standardized
• Always disclose supplement use to healthcare providers due to potential interactions
• Caffeine should generally be limited to <300 mg/day in patients with ADHD 1

Remember that while some families may prefer "natural" approaches, the evidence strongly favors conventional treatments for meaningful improvement in ADHD symptoms and long-term outcomes.